Glenoid Side Research Articles

Arthroscopic Knot Removal for Failed Superior Labrum Anterior-Posterior Repair Secondary to Knot-Induced Pain

Background: Studies on failed superior labrum anterior-posterior (SLAP) repair are increasing. However, the number of reports on treatment options for failed SLAP repair remains quite low, and the clinical results vary between different study groups. Purpose: To describe the clinical presentation of failed SLAP repair due to knot-induced pain and evaluate the efficacy of arthroscopic knot removal. Study Design: Case series; Level of evidence, 4. Methods: The authors retrospectively reviewed records of 11 patients (mean age, 24.6 ± 8.6 years; range, 17-43 years) with stable, healed SLAP lesions with knot-induced pain after arthroscopic fixation of unstable type II SLAP lesions. All patients demonstrated a positive compression-rotation test before knot removal. The mean follow-up duration after knot removal was 48.0 ± 37.4 months (range, 24-156 months). The mean duration between primary fixation and knot removal was 21.2 ± 14.7 months (range, 8-56 months). Results: Sharp pain (100%) and clicking (64%) were the most common symptoms. The knot was positioned on the glenoid side in 5 patients and the labral side in 6 patients. The knots on the glenoid side had associated humeral head cartilage damage. The mean University of California at Los Angeles score significantly improved from 15.2 points to 31.7 points after knot removal (P = .003) Additionally, the mean Constant score greatly improved from a mean of 56.5 points to 89.8 points (P = .003). At a mean of 3 weeks after surgery, we observed dramatic pain relief. Six weeks after surgery, the compression-rotation test was negative in all patients. Conclusion: The most common symptom of knot-induced pain after SLAP repair was persistent sharp pain followed by clicking. The knot appears to be a cause of pain in failed SLAP repairs, and arthroscopic knot removal can provide dramatic pain relief and significant improvement of clinical outcomes.

Resurfacing Total Shoulder Replacement With Both Humeral and Glenoid-sided Biological Fixation: The Cage Match

Resurfacing humeral heads have several advantages over stemmed total shoulder replacement including bone preservation and the potential for more anatomic humeral reconstruction. With a systematic approach to glenoid exposure including complete release of the anterior, inferior, and posterior capsules, these advantages can be realized in the setting of total shoulder arthroplasty. The Cage Match technique describes such a combination using the Equinoxe Resurfacing Humeral head in combination with the Equinoxe Cage Glenoid. This combined technique provides biological fixation on both the humeral and glenoid side by bone ingrowth into the porous-coated titanium cage that is part of both the resurfacing prosthesis and glenoid component. These advantages render the Cage Match and attractive solution for end-stage shoulder arthritis is younger patients and those who remain physically active. In addition, they lend themselves to all cases of total shoulder arthroplasty by virtue of the potential for less blood loss, shorter operative time, and the potential for improved postoperative function given an anatomic reconstruction.

Dislocation of the Shoulder Joint - Radiographic Analysis of Osseous Abnormalities.

Radiography remains pivotal to the workup of instability lesions of the shoulder, both in the acute as well as the chronic settings. The goal of radiography is to detect osseous abnormalities and locate them in order to determine the direction of instability. In antero-inferior instability, Hill-Sachs lesions are often visible at radiography and should not be confused with various differential diagnoses, which are usually more laterally located. Bankart lesions are more difficult to detect on conventional radiography, but there are less false positives than for Hill-Sachs lesions. The Garth view represents an excellent radiographic view to detect antero-inferior instability impaction fractures at both the humeral and glenoid sides. Accurate quantification of bony abnormalities and detection of lesions to the soft-tissue stabilizers of the shoulder however require advanced cross-sectional imaging techniques.

Paper #35 - 2D/3D image registration to determine host bone coverage of glenoid side reverse shoulder implants

Paper #35 - 2D/3D image registration to determine host bone coverage of glenoid side reverse shoulder implants

Reverse arthroplasty for patients with chronic locked dislocation of the shoulder (type 2 fracture sequela)

The aim of this multicenter study was to analyze the clinical and radiographic outcome and to report on the types of complications in patients with chronic locked shoulder dislocation treated with reverse shoulder arthroplasty. Twenty-two patients with a mean age of 71 years were included. The mean duration of follow-up was 3.5 years. Preoperatively, computed tomography or magnetic resonance imaging scans were performed and analyzed for bone defects and the status of the rotator cuff. Radiographs in 2 planes were obtained before arthroplasty and at final follow-up (mean, 3.5 years; range, 2-9 years). The Constant-Murley score was documented, together with active shoulder flexion, external rotation, and internal rotation. There was a significant increase in mean Constant-Murley score from 13.6 points preoperatively to 47.4 points postoperatively (P < .001). Mean shoulder flexion was 37.7° before arthroplasty and 103° thereafter (P < .001). External rotation increased from -0.5° to 14.7° (P < .003). There were 7 complications (32%), leading to revision surgery in 6 cases (27%). The most common reason for revision surgery was failure of the glenoid component due to bone defects on the glenoid side. Eight patients rated their subjective result as very good, 5 as good, 5 as satisfactory, and 4 as unsatisfactory. Reverse shoulder arthroplasty may be a viable treatment option for chronic locked shoulder dislocations with concomitant rotator cuff lesions and an intact glenoid. However, improvement in function is only fair and in this series, there was a high percentage of complications requiring re-operation.

Predictive Value and Clinical Validation of the “On-Track” vs. “Off-Track” Concept in Bipolar Bone Loss in Anterior Glenohumeral Instability

Objectives:Bone loss is a well-described risk factor for failure with arthroscopic stabilization. The isolated importance of bone loss on both the glenoid and humeral side has been increasingly studied. A more recent evolution considers how both the glenoid and humeral bone loss interact to determine whether their combination results in an “on-track” or “off-track” lesion, which may be more predictive of recurrent instability than looking at either side individually. While the biomechanics of this concept have been elucidated, no study has tested this theory in a clinical population. The purpose of this study is to compare a series of arthroscopic Bankart reconstructions stratified by whether they are “on-track” or “off-track” with regard to bipolar bone loss and to compare their rates of recurrence and functional outcome scores.Methods:Over a two year period, all isolated, primary Bankart reconstructions performed at a single facility by one of three fellowship trained Orthopaedic Sports Surgeons were included in this study. All patients had preoperative advanced imaging and had postoperative outcome measures including SANE and WOSI scores, as well as data return to work status. Glenoid bone loss, Hill-Sachs lesion size and location, as well as a radiographic measurement of the glenoid track were measured. Patients were stratified according to whether they sustained a subsequent recurrence of their instability, and these groups were analyzed according to their bone loss status, specifically whether they were “on-track” or “off-track”.Results:57 shoulders met inclusion criteria. The average age was 25.5 years (range 20-42) at the time of surgery. Average follow up was 28.4 mos. There were 10 recurrences (18%). Patients in the recurrent group had WOSI and SANE scores that were roughly half as good as the group that did not recur (p=0.003 and p=0.002 respectively). Of the 49 on-track patients, 4 (8.2%) failed. Conversely, of the 8 off-track patients, 6 (75%) failed (p=0.0001). Six of the 10 (60%) of the patients who sustained a recurrence of their instability after arthroscopic stabilization were off-track at the time of their surgery. In contrast, in the 47 patients who remained stable at latest follow-up, only 2 (4.3%) were off-track (p=0.0001). Eight of 47 patients (17%) in the non-recurrent group had glenoid bone loss greater than 20%; two of 47 stable patients (4%) were off-track. The positive predictive value (PPV) of the off-track measurement was 75% which was significantly higher than the predictive value of glenoid bone loss >20% (PPV=43%, p=0.02).Conclusion:This is the first study to apply the on-track vs. off-track assessment of bipolar bone loss to a clinical population. In this study, being off-track was a significant predictor of recurrent instability after isolated Bankart reconstruction, correctly predicting failure in 75% of cases. This was superior to the predictive value of glenoid bone loss >20% alone, which correctly predicted failure 43% of the time. Recurrence correlated with worse functional outcomes scores. Bipolar bone loss as measured by the track method is quite accurate in predicting success and failure after arthroscopic Bankart reconstruction in a clinical population. This method of assessment is encouraged as a routine part of the preoperative evaluation of all patients under consideration for arthroscopic anterior stabilization.

Deltopectoral approach for shoulder arthroplasty: anatomic basis.

The deltopectoral approach is a common surgical procedure for shoulder arthroplasty. Many surgeons are familiar with this procedure, but certain steps are still controversial. This is the case for the management of subscapularis, where surgeons must choose between tenotomy and the lesser tuberosity osteotomy. This article is conceived as a toolkit for the inexperienced surgeons, describing our tips and tricks to facilitate final exposure of the glenoid. For experienced surgeons, we analysed the tricky portions of the deltopectoral approach, comparing them with what is classically reported in the literature. We describe an original technic for subscapularis reattachment after lesser tuberosity osteotomy in order to improve its stability. The medial part of the fragment is secondarily sculpted to obtain a step shape, which will be applied against the base of the prosthetic cup in a sort of "corner buttress". Our work, based on our personal experience, confirms that there is no preferred single deltopectoral approach but, rather, multiple options. When embarking on this "shoulder highway", we encourage surgeons to respect the successive anatomic planes, which we believe is the only way to ensure easy and atraumatic dissection. - The safe plane for going around the humeral head and positioning retractors is the plane of the subacromial deltoid bursa. - Always stay close to the bone during capsule release, whether on the humeral or glenoid side. - Never go medially to the conjoint tendon or its deep face.

Long-term survival of the glenoid components in total shoulder replacement for arthritis.

Aseptic glenoid component loosening remains a common problem in total shoulder arthroplasty (TSA). This study presents long-term prospective follow-up after implantation of a glenoid component using the "cancellous compaction technique" and its effect on clinical outcome and presence and progression of radiolucent lines (RLLs). Thirty-nine TSAs were performed for primary osteoarthritis by one surgeon using the same technique. For the glenoid side, a keeled, polyethylene, convex-backed component was implanted using the "cancellous compaction technique" consisting of minimal reaming, compaction bone grafting of the glenoid and minimal addition of cement. Postoperative clinical outcome was analysed using Constant scores and patient's subjective evaluation. Independent observers evaluated postoperative X-rays for radiolucent lines (RLL) around the base plate and keel. At an average follow-up of 8.5years (range 4.7-12.5), the Constant score improved from 33.5 to 73.0 points (P < 0.0001). Active anterior elevation improved from an average 95 ° to 140° (P < 0.0001), and active external rotation improved from 20° to 45° (P < 0.0001). Pain score improved from 3.1 to 13.6 (P < 0.0001). Radiologically, the RLL score increased from 1.09 (range, 0-3) postoperative to 5.7 (range, 0-18) (P < 0.0001) at final follow-up. The occurrence of definite radiological glenoid loosening was 15.5%. Constant scores deteriorated with the progression of RLLs (P = 0.006). The rate of revision surgery for glenoid loosening was 2.5%. This study showed highly satisfactory clinical outcomes and low rates of revision for glenoid loosening using a bone-saving compaction technique for implantation of an all-polyethylene glenoid component.

Severe glenoid retroversion is best treated with asymmetric reaming in total shoulder arthroplasty–Opposes

Degenerative arthritis of the shoulder is a common orthopaedic condition, and the number of total shoulder arthroplasty procedures is increasing with the aging population. During total shoulder arthroplasty, reconstruction of the glenoid side of the joint can be particularly difficult in the face of posterior wear or excessive retroversion. Treatment options for posterior wear or excessive retroversion of the glenoid include asymmetric reaming of the high anterior side, bone grafting, or posterior augmentation of the glenoid component. A posterior augmented glenoid component allows the surgeon to maintain bone stock while correcting the posterior deficiency of the glenoid and avoiding the potential for medialization of the humeral component with anterior high side reaming. Bone grafting can be beneficial but relies on graft healing to successfully obtain stability.

A Method for Predicting Collagen Fiber Realignment in Non-Planar Tissue Surfaces as Applied to Glenohumeral Capsule During Clinically Relevant Deformation

Previously developed experimental methods to characterize micro-structural tissue changes under planar mechanical loading may not be applicable for clinically relevant cases. Such limitation stems from the fact that soft tissues, represented by two-dimensional surfaces, generally do not undergo planar deformations in vivo. To address the problem, a method was developed to directly predict changes in the collagen fiber distribution of nonplanar tissue surfaces following 3D deformation. Assuming that the collagen fiber distribution was known in the un-deformed configuration via experimental methods, changes in the fiber distribution were predicted using 3D deformation. As this method was solely based on kinematics and did not require solving the stress balance equations, the computational efforts were much reduced. In other words, with the assumption of affine deformation, the deformed collagen fiber distribution was calculated using only the deformation gradient tensor (obtained via an in-plane convective curvilinear coordinate system) and the associated un-deformed collagen fiber distribution. The new method was then applied to the glenohumeral capsule during simulated clinical exams. To quantify deformation, positional markers were attached to the capsule and their 3D coordinates were recorded in the reference position and three clinically relevant joint positions. Our results showed that at 60deg of external rotation, the glenoid side of the posterior axillary pouch had significant changes in fiber distribution in comparison to the other sub-regions. The larger degree of collagen fiber alignment on the glenoid side suggests that this region is more prone to injury. It also compares well with previous experimental and clinical studies indicating maximum principle strains to be greater on the glenoid compared to the humeral side. An advantage of the new method is that it can also be easily applied to map experimentally measured collagen fiber distribution (obtained via methods that require flattening of tissue) to their in vivo nonplanar configuration. Thus, the new method could be applied to many other nonplanar fibrous tissues such as the ocular shell, heart valves, and blood vessels.

Evaluation of the role of glenosphere design and humeral component retroversion in avoiding scapular notching during reverse shoulder arthroplasty

Scapular notching is a common observation during radiological follow-up of reverse shoulder arthroplasty. The purpose of this study was to evaluate the effect of glenosphere design and humeral component retroversion on movement amplitude in the scapular plane and inferior scapular impingement. The Aequalis Reversed Shoulder Prosthesis (Tornier) was implanted into 40 cadaver shoulders. On the glenoid side, 8 different combinations were tested: 36-mm glenosphere: centered (standard), eccentric, with an inferior tilt, or with the center of rotation (COR) lateralized by 5 or 7 mm; and 42-mm centered glenosphere: used alone or with the COR lateralized by 7 or 10 mm. The humeral component was positioned in 0°, 10°, 20°, 30°, and 40° of retroversion. Maximum adduction and abduction were measured when inferior impingement and superior impingement, respectively, were detected. The average increase in abduction amplitude was 10° and inferior impingement occurred 18° later with a 42-mm glenosphere, especially when it was lateralized by 10 mm, relative to a 36-mm centered glenosphere (P < .05). These 2 combinations provided a 28° increase in the movement amplitude in the scapular plane. Positioning of the humeral component in 10° or 20° of retroversion or in anatomical retroversion was most effective at avoiding inferior impingement but had less effect on abduction range of motion (except with the 42-mm glenosphere). Our study confirmed published results with various glenosphere designs but was unique in describing the effect of humeral retroversion on scapular impingement. Inferior scapular notching can be most effectively prevented by using large-diameter glenospheres with lateralized COR and by making sure to replicate the patient's native humeral retroversion.

Injury to the anteroinferior glenohumeral capsule during anterior dislocation

BackgroundGlenohumeral dislocation commonly results in permanent deformation of the glenohumeral capsule. Knowing the location and extent of tissue damage may aid in improving diagnostic and repair procedures for shoulder dislocations. Therefore, the objectives of this study were to determine: (1) the strain in the anteroinferior capsule at dislocation and (2) the location and extent of injury to the anteroinferior capsule due to dislocation by quantifying the resulting non-recoverable strain. MethodsA robotic/universal force–moment sensor testing system was used to anteriorly dislocate six cadaveric shoulders. The magnitude of the maximum principle strain at dislocation and the resulting non-recoverable strain due to dislocation in the anteroinferior capsule were measured by tracking the change in the location of a grid of strain markers from a reference position. FindingsThe glenoid side of the capsule experienced higher strains at dislocation than the humeral side. The greatest strains at dislocation were found on the glenoid side of the anterior band (strain ratio of 0.60), but the greatest non-recoverable strains were found in the posterior axillary pouch (strain ratio of 0.34 on the glenoid side and 0.31 on the humeral side). InterpretationThese findings suggest that even though the glenoid side of the anterior band undergoes more deformation during anterior dislocation, the most permanent deformation occurs in the posterior axillary pouch, and surgeons should consider also plicating the posterior axillary pouch when performing repair procedures following anterior dislocation. In the future, the mechanical properties of the normal and injured glenohumeral capsules will be compared.

Circumferential Arthroscopic Capsular Release: Reflections and a Historical Perspective

Circumferential Arthroscopic Capsular Release: Reflections and a Historical Perspective

Chronic anterior glenohumeral instability in soccer players: results for a series of 28 shoulders treated with the Latarjet procedure.

BackgroundGlenohumeral instability is a common problem in young and active patients. Both open and arthroscopic procedures have proven to be effective options. In cases with large bone defects on the glenoid side or on the humeral head or in contact sports, arthroscopy leads to a high risk of recurrence. We report the results of the modified Latarjet procedure in a population of 26 soccer players affected by chronic anterior instability. To our knowledge there are no previous reports on the results of this procedure when used in a homogeneous group of sportsmen.Materials and methodsTwenty-six patients (28 shoulders) were retrospectively reviewed. We analyzed the roles of the players, the levels at which they played, and the average amount of hours that they trained before their injury and after surgery. Moreover, the type of bone loss detected on a preoperative imaging study and its relevance to the patient’s sporting comeback was recorded.ResultsEight-five months after surgery the mean Duplay score was 89.3; most of the players came back to the play at the same sporting level. Ninety-three percent of the patients were happy or very happy with their functional results. One patient underwent a redislocation.ConclusionsOur series is the first in the literature to refer to a homogeneous group of soccer players. According to our results, and other series, the Latarjet procedure seems to be the gold standard in the treatment of chronic anterior instability in patients with large bone defects and in sportsmen playing contact sports.

Clinical results of revision shoulder arthroplasty using the reverse prosthesis

Success of revision shoulder arthroplasty using an unconstrained prosthesis depends on an intact rotator cuff and satisfactory bone quantity. However, the reverse shoulder arthroplasty can stabilize a glenohumeral joint even in patients with rotator cuff deficiency and bone deficits, resulting in improved outcomes. Thirty shoulders in 28 patients with a failed arthroplasty were investigated consecutively between 2005 and 2008. All shoulders had significant rotator cuff deficiency without glenoid bone loss. Revision arthroplasty using the reverse prosthesis was performed with a minimum of 2 years of follow-up. Concomitant glenoid reconstructions with tricortical iliac crest bone grafting were necessary in 12 shoulders. The average adjusted Constant score improved from 24% to 65% and the American Shoulder and Elbow Surgeons (ASES) score improved from 55 to 72 (P < .0001). Average active forward flexion increased from 42° to 106° (P < .0001). The average ASES pain score improved from 6.6 to 1.6 (P < .0001). The overall complication rate was 50%, and 7 patients (23%) required reoperation. Overall, 24 of 30 shoulders (80%) were very satisfied or satisfied. Reverse shoulder arthroplasty can be an efficacious salvage procedure in the management of failed arthroplasty due to rotator cuff-related instability or bone defects, or both. Structural bone grafting on the glenoid side is successful at managing large defects, producing similar or better clinical outcomes compared with patients without bone loss. Although the operation is associated with a considerable complication rate, 80% of patients were satisfied with the results of the procedure, and 29 of 30 shoulders had a stable prosthesis.

Principles of glenoid component design and strategies for managing glenoid bone loss in revision shoulder arthroplasty in the absence of infection and rotator cuff tear

The number of total shoulder arthroplasty (TSA) cases continues to grow each year. With the increasing number of procedures being performed, there, in turn, will exist a greater need for revision procedures. Failure of a shoulder arthroplasty can result from soft-tissue problems, bony deficiencies, infection, and component wear or loosening. Component loosening and osseous deficiencies may occur on the humeral and/or glenoid side. Multiple studies have identified glenoid component loosening as one of the more common causes necessitating revision after TSA. Glenohumeral joint instability in the setting of rotator cuff deficiency is also a common cause of glenoid loosening. Eccentric loading of the glenoid from proximal humeral migration leads to increased stress at the bonecement or bone-implant interface, commonly referred to as the ‘‘rocking horse phenomenon.’’ Eccentric loading, instability, and glenoid loosening may also result from incomplete glenoid seating, glenoid or humeral component malpositioning, or tuberosity malunion. The importance of glenoid implantation becomes evident when one considers

Finding consistent strain distributions in the glenohumeral capsule between two subjects: Implications for development of physical examinations

The anterior-inferior glenohumeral capsule is the primary passive stabilizer to the glenohumeral joint during anterior dislocation. Physical examinations following dislocation are crucial for proper diagnosis of capsule pathology; however, they are not standardized for joint position which may lead to misdiagnoses and poor outcomes. To suggest joint positions for physical examinations where the stability provided by the capsule may be consistent among patients, the objective of this study was to evaluate the distribution of maximum principal strain on the anterior-inferior capsule using two validated subject-specific finite element models of the glenohumeral joint at clinically relevant joint positions. The joint positions with 25N anterior load applied at 60° of glenohumeral abduction and 10°, 20°, 30° and 40° of external rotation resulted in distributions of strain that were similar between shoulders (r2≥0.7). Furthermore, those positions with 20–40° of external rotation resulted in capsule strains on the glenoid side of the anterior band of the inferior glenohumeral ligament that were significantly greater than in all other capsule regions. These findings suggest that anterior stability provided by the anterior-inferior capsule may be consistent among subjects at joint positions with 60° of glenohumeral abduction and a mid-range (20–40°) of external rotation, and that the glenoid side has the greatest contribution to stability at these joint positions. Therefore, it may be possible to establish standard joint positions for physical examinations that clinicians can use to effectively diagnose pathology in the anterior-inferior capsule following dislocation and lead to improved outcomes.

Finite element modelling of the glenohumeral capsule can help assess the tested region during a clinical exam

The objective of this research was to examine the efficacy of evaluating the region of the glenohumeral capsule being tested by clinical exams for shoulder instability using finite element (FE) models of the glenohumeral joint. Specifically, the regions of high capsule strain produced by glenohumeral joint positions commonly used during a clinical exam were identified. Kinematics that simulated a simple translation test with an anterior load at three external rotation angles were applied to a validated, subject-specific FE model of the glenohumeral joint at 60° of abduction. Maximum principal strains on the glenoid side of the inferior glenohumeral ligament (IGHL) were significantly higher than the maximum principal strains on the humeral side, for all three regions of the IGHL at 30° and 60° of external rotation. These regions of localised strain indicate that these joint positions might be used to test the glenoid side of the IGHL during this clinical exam, but are not useful for assessing the humeral side of the IGHL. The use of FE models will facilitate the search for additional joint positions that isolate high strains to other IGHL regions, including the humeral side of the IGHL.

Arthroscopic Remplissage with Bankart Repair for the Treatment of Glenohumeral Instability with Hill Sachs Defects (SS-14)

Arthroscopic Remplissage with Bankart Repair for the Treatment of Glenohumeral Instability with Hill Sachs Defects (SS-14)

La prothèse d’épaule en 2010 : prothèse anatomique ou prothèse inversée ? Indications et contre-indications

Three different types of shoulder arthoplasty are currently used. Anatomical total shoulder arthroplasty, composed of two implants, which replicate normal anatomy: a humeral metallic stem ended with a hemisphere, which articulates with a concave polyethylene glenoid implant. Indications are arthropathies with functional rotator cuff: osteoarthritis, inflammatory arthropathies, aseptic osteonecrosis (grade 4 and 5 of Ficat-Arlet classification) and minor post-traumatic malunions. In those indications and without complication, pain relief is achieved in more than 90% of cases and active elevation reach in average 130°. Contra-indications are non-functional rotator cuff, insufficiency of glenoid bone stock and permanent glenohumeral instability. Reversed total shoulder arthroplasty, composed of a concave humeral implant, which articulates with a hemispherical glenoid implant. It is semi-constrained and indications are mainly cuff tear arthropathy, major post-traumatic malunions and the majority of prosthetic revisions. Results are in average excellent for pain relief, good for active elevation, more variable on internal rotation and active external rotation. Reverse arthroplasty offers solutions on previously unsolved problems. Some indications are not yet validated, as inflammatory arthropathies with deficient cuff and comminuted osteoporotic fractures in elderly patients. Contra-indication is non-functional deltoid. Excepted for particular cases, follow-up is currently too short to recommend reverse arthroplasty before 70 years. Hemiarthroplasty, which is the humeral part of the total anatomical prosthesis, articulates directly with glenoid cartilage or glenoid bone. It is indicated if glenoid side is intact as in aseptic osteonecrosis stage 2 or 3 in Ficat-Arlet classification or post-traumatic osteonecrosis. Humeral head fracture, very comminuted or with an important risk of necrosis, may be treated with a special hemiarthroplasty characterized by a large window, which helps for fixation and healing of tuberosities around the stem: this major goal is not always achieved, explaining very variable results in this indication. Hemiarthroplasty may be also a solution if conversely, glenoid bone stock is not sufficient to accept an implant, as in end stages of rheumatoid arthritis or end stage of cuff tear arthropathy: the goal is here only for pain relief.