Hemiarthroplasty: Hip and Shoulder Partial Joint Replacement — Cost, Top Hospitals & Success Rates | MyMedicPlus

Hemiarthroplasty replaces only one articular surface of a joint — the femoral head in the hip, or the humeral head in the shoulder — leaving the native socket (acetabulum or glenoid) intact. It occupies a precise therapeutic niche between internal fixation (which preserves the native head) and total joint replacement (which resurfaces both sides of the joint).

In hip surgery, hemiarthroplasty is the procedure of choice for displaced intracapsular femoral neck fractures in elderly patients, where the blood supply to the femoral head is disrupted at the time of injury, making avascular necrosis after internal fixation highly likely. The procedure replaces the femoral head and neck with a prosthetic femoral component that articulates against the native acetabular cartilage.

Hip hemiarthroplasty implants are classified as unipolar or bipolar. Unipolar designs (Austin Moore, Thompson) consist of a single metallic femoral head that moves directly against the acetabular cartilage. Bipolar designs add an inner polyethylene liner between the metallic head and an outer cup, creating two articulation interfaces — the inner bearing moves during activities of daily living, theoretically reducing wear at the acetabular cartilage surface. Long-term follow-up data show bipolar designs reduce the rate of protrusio acetabuli (acetabular erosion) and conversion to THA, though the clinical magnitude of benefit remains debated.

In shoulder surgery, hemiarthroplasty has historically been used for complex proximal humerus fractures, avascular necrosis of the humeral head, and glenohumeral arthritis with an intact rotator cuff. The landscape has shifted considerably, with reverse shoulder arthroplasty (RSA) now preferred for most elderly patients with proximal humerus fractures due to consistently superior functional outcomes and reduced revision rates compared to hemiarthroplasty in randomised data.

Femoral neck fractures — the primary hip indication: The Garden classification is the standard clinical tool for displaced intracapsular fractures. Garden I (incomplete/valgus-impacted) and II (complete, non-displaced) fractures retain some capsular blood supply and may be suitable for internal fixation with cannulated screws or a dynamic hip screw, particularly in physiologically young patients. Garden III (complete fracture, partial displacement) and IV (complete displacement, loss of trabecular alignment) fractures severely disrupt the femoral head blood supply; avascular necrosis occurs in 20–30% after internal fixation — making hemiarthroplasty or total hip arthroplasty the preferred surgical option in most cases.

Avascular necrosis (AVN) of the femoral head: Classified by the Ficat-Arlet system (Stages I–IV). Stage I (normal radiograph, MRI positive) and II (sclerosis or cyst formation) may respond to core decompression with bone grafting. Stage III (subchondral collapse — "crescent sign") and IV (secondary acetabular involvement and osteoarthritis) represent end-stage disease requiring joint replacement. Hemiarthroplasty is appropriate for Stage III AVN with a preserved acetabulum in elderly, low-demand patients; THA is preferred when the acetabulum is also damaged (Stage IV).

Proximal humerus fractures: The Neer classification divides the proximal humerus into four segments: the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft. Three- and four-part fractures with tuberosity comminution, head-splitting patterns, or fracture-dislocation in elderly patients traditionally indicated hemiarthroplasty. The PROFHER trial (UK, 2015) demonstrated no significant functional difference between hemiarthroplasty and non-operative management for displaced proximal humerus fractures — profoundly influencing practice. Reverse shoulder arthroplasty has since largely supplanted hemiarthroplasty for elderly patients with proximal humerus fractures, achieving better forward elevation and patient satisfaction.

Other indications include glenohumeral osteoarthritis with intact rotator cuff and preserved glenoid bone stock (humeral head resurfacing — a bone-conserving hemiarthroplasty variant), and acute fracture-dislocation not amenable to open reduction and internal fixation.

Patient selection for hemiarthroplasty — versus internal fixation on one side, or total joint replacement on the other — requires careful consideration of fracture morphology, patient age, physiological reserve, cognitive function, pre-injury mobility, and acetabular/glenoid cartilage status.

Hip hemiarthroplasty is preferred over internal fixation for Garden III/IV femoral neck fractures in patients over 60–65 years, in those with pre-existing ipsilateral hip pathology (arthritis, previous hip surgery), in cognitively impaired patients where rehabilitation compliance is limited, and whenever the fracture pattern does not permit stable reduction.

Total hip arthroplasty (THA) vs hemiarthroplasty: The FAITH-2 and PROFHER hip trials, along with the broader Cochrane review of THA vs hemiarthroplasty for displaced femoral neck fractures, demonstrate that THA produces superior functional outcomes (Oxford Hip Score, Harris Hip Score, 5–10 year patient-reported outcomes) in active, cognitively intact patients under 75 years. However, THA carries higher perioperative complication rates — increased dislocation risk, longer operative time, and greater blood loss. The 30-day mortality after hip fracture surgery is similar between THA and hemiarthroplasty in matched populations. NICE guidelines (NG111, 2023 update) recommend THA for patients with displaced femoral neck fractures who: (a) were able to walk independently before injury, (b) have no significant cognitive impairment, and (c) are medically fit for a longer procedure.

Shoulder hemiarthroplasty eligibility has narrowed with the rise of RSA; it remains appropriate for younger patients (<65 years) with anatomic head preservation needs, glenohumeral arthritis with intact rotator cuff, and selected AVN cases where glenoid resurfacing is not required.

Unipolar hemiarthroplasty: The Austin Moore prosthesis (press-fit, self-locking stem with fenestrations for bone ingrowth) and the Thompson prosthesis (cemented stem with smooth collar) are the two classic unipolar designs. The Austin Moore is used primarily without cement in patients with good bone stock; the Thompson is typically cemented. Both allow the metallic femoral head to articulate directly against the acetabular cartilage. Unipolar implants are technically simpler, less expensive, and appropriate for lower-demand patients.

Bipolar hemiarthroplasty: Bipolar implants consist of a standard modular femoral stem (titanium, cobalt-chrome, or polished stainless steel), a femoral head of variable size, a polyethylene inner liner, and an outer metal shell that articulates with the acetabulum. The inner bearing (metal head against poly liner) absorbs most motion; the outer bearing (shell against native acetabulum) moves less. This design aims to reduce acetabular erosion. Modern modular bipolar systems (e.g., Stryker Exeter bipolar, DePuy Corail bipolar) use the same stems as total hip systems, facilitating conversion to THA if required.

Cemented vs uncemented femoral fixation — HEALTH Trial: The HEALTH (Hip fracture Evaluation with Alternatives of Total Hip arthroplasty versus Hemi-Arthroplasty) trial (NEJM 2019) randomised 1,495 patients with displaced femoral neck fractures to hemiarthroplasty vs THA. Within the hemiarthroplasty arm, both cemented stems (Exeter polished tapered — the gold standard for cemented fixation) and uncemented stems were included. Cemented fixation provides immediate post-operative stability and is preferred by most high-volume arthroplasty surgeons; uncemented fixation risks intra-operative fracture (calcar crack) but avoids bone cement implantation syndrome (BCIS) — a rare but potentially fatal haemodynamic event during cement pressurisation in frail patients. Current BOAST/NICE guidance recommends cemented fixation for femoral neck fracture hemiarthroplasty, accepting the small BCIS risk with anaesthetic precautions.

Surgical approach: The posterior (Moore) approach provides excellent femoral head exposure and is most widely used, with a 2–3% dislocation risk (reduced by capsular repair). The anterolateral (Hardinge) and direct anterior approaches provide reduced dislocation risk but limit surgical exposure in complex cases. All hip fracture hemiarthroplasties should be performed by or under direct supervision of a consultant orthopaedic surgeon, as stated in BOAST 1 guidance.

Shoulder hemiarthroplasty technique: Performed through a deltopectoral approach. The fractured humeral head is excised; a modular humeral stem is inserted with the head component sized to match the resected native head. Tuberosity fragments must be repaired anatomically around the prosthesis — tuberosity malunion or non-union is the leading cause of poor outcomes after shoulder hemiarthroplasty, occurring in 30–50% of cases and explaining the functional variability seen in clinical trials.

Hemiarthroplasty for displaced femoral neck fracture provides early mobilisation, reliable pain relief, and avoidance of the high AVN and revision rates associated with internal fixation in this fracture pattern and demographic.

In the landmark HEALTH trial, hemiarthroplasty patients achieved earlier weight-bearing and lower 24-month revision rates than THA (randomised trial setting); THA patients had superior functional scores at 24 months but higher dislocation rates. In clinical practice, selecting hemiarthroplasty for lower-demand or cognitively impaired patients and THA for active, independent patients optimises outcomes for both groups.

For hip fracture patients, the primary benefit is immediate full weight-bearing — reducing the risks of prolonged bed rest (pressure sores, pneumonia, venous thromboembolism, muscle atrophy) that accompany conservative management. Early mobilisation within 24 hours of surgery is the standard of care per the National Hip Fracture Database (NHFD) best practice tariff criteria.

Bipolar designs specifically reduce the rate of protrusio acetabuli requiring conversion surgery at 5–10 years — a meaningful long-term benefit in patients with sufficient life expectancy.

For shoulder pathology, hemiarthroplasty reliably eliminates pain from AVN and glenohumeral arthritis, restoring adequate function for activities of daily living in the majority of patients. Where anatomy and muscle function are preserved, outcomes approach those of total shoulder arthroplasty.

Perioperative risks (hip hemiarthroplasty): The 30-day mortality after hip fracture surgery is approximately 5–8% in national registry data — reflecting the frail, elderly population rather than the surgical procedure itself. Cardiopulmonary complications (myocardial infarction, pneumonia, cardiac failure) dominate perioperative mortality. Bone cement implantation syndrome (BCIS) — haemodynamic instability during cement pressurisation — occurs in 0.5–1% of cemented fixations; risk is mitigated by anaesthetic vigilance, high-viscosity cement techniques, and thorough canal lavage before cementation.

Dislocation: Posterior approach hemiarthroplasty carries a 2–4% dislocation risk, reduced to <1% with capsular repair, combined anteversion technique, and patient education on precautions. Closed reduction under sedation is effective for most acute dislocations; recurrent dislocation may require acetabular augmentation or conversion to constrained liner or THA.

Acetabular erosion (protrusio acetabuli): The native acetabular cartilage erodes over time against the metallic femoral head, occurring in 5–20% of unipolar hemiarthroplasties at 10 years. This causes groin pain, reduced hip mobility, and ultimately requires conversion to THA. Bipolar designs reduce but do not eliminate this risk.

Periprosthetic fracture: Occurs in 1–3% at 5–10 years, particularly at the tip of uncemented stems. Requires surgical stabilisation (ORIF or stem revision).

Infection: Periprosthetic joint infection (PJI) occurs in 0.5–2% of primary hemiarthroplasties. Hip fracture patients have higher infection risk due to skin compromise, urinary catheterisation, and malnutrition. MSIS criteria are used to diagnose PJI; management involves debridement, antibiotics and implant retention (DAIR) for acute infections, or two-stage revision for chronic infections.

Shoulder-specific risks: Tuberosity non-union (30–50%), causing loss of active elevation and rotator cuff function. Stem subsidence or loosening (5% at 10 years). Pain from glenoid erosion requiring revision to total or reverse shoulder arthroplasty.

Post-operative rehabilitation is critical to achieving the functional potential of hemiarthroplasty and reducing complication rates — particularly in elderly hip fracture patients where early mobilisation directly reduces mortality.

Hip hemiarthroplasty — inpatient phase: Full weight-bearing mobilisation on day 1 post-operatively is the standard of care per the National Hip Fracture Database (NHFD) best practice tariff. Physiotherapy focuses on safe transfers, stair climbing, and hip precautions (particularly for the posterior approach — no combined hip flexion beyond 90° with internal rotation). Deep vein thrombosis prophylaxis with low molecular weight heparin or direct oral anticoagulants (DOACs) is continued for 28–35 days. Secondary prevention of falls and optimisation of bone health (calcium, vitamin D, anti-resorptive therapy for osteoporosis) are mandatory components of hip fracture care.

Outpatient follow-up: Radiograph at 6 weeks to assess stem position and acetabular integrity. Oxford Hip Score and EQ-5D at 4 months and 12 months (NHFD standard). Patients are monitored for signs of acetabular erosion on annual radiographs in the medium term. Worsening groin pain, new-onset limp, or reduced hip mobility prompts urgent re-imaging and orthopaedic review.

Shoulder hemiarthroplasty rehabilitation: Sling immobilisation for 4–6 weeks to protect tuberosity repair. Passive range-of-motion commences at 2–3 weeks; active-assisted exercises at 6–8 weeks when tuberosity healing is confirmed radiographically. Active strengthening begins at 10–12 weeks. Final functional assessment at 12 months. Patients with rotator cuff compromise or poor tuberosity healing often require physiotherapy for 12–18 months.

Conversion to THA is required in approximately 10–15% of hip hemiarthroplasties within 10 years, most commonly for acetabular pain and erosion. Early identification and appropriate patient selection reduces this revision burden.

Hemiarthroplasty costs vary by country, implant type, cementing technique, inpatient stay duration, and rehabilitation requirements. For elective cases (AVN, glenohumeral arthritis), medical tourism offers substantial cost savings.

Indicative cost comparison (USD, elective hemiarthroplasty):

• United States: USD 18,000–35,000 (hip); USD 20,000–40,000 (shoulder)
• United Kingdom (private): GBP 8,000–16,000 (hip); GBP 10,000–18,000 (shoulder)
• India (JCI-accredited centres): USD 3,500–7,000 (hip bipolar); USD 4,000–8,000 (shoulder) — 75–85% savings vs US
• Thailand: USD 7,000–13,000 (hip); USD 8,000–14,000 (shoulder)
• Turkey: USD 5,000–10,000 (hip); USD 6,000–11,000 (shoulder)

Implant cost is a major driver: Unipolar Austin Moore implants are significantly cheaper than modular bipolar systems or reverse shoulder arthroplasty components. Premium cemented stems (Exeter, Charnley) add implant cost but are the evidence-based recommendation. Patients considering implant substitution for cost savings should discuss specific implant registry data with their surgeon.

For acute hip fracture cases, medical tourism is generally not appropriate — surgery should be performed within 36 hours of admission at the nearest capable centre. Elective hemiarthroplasty for AVN or chronic shoulder pathology is suitable for international treatment planning. Patients should arrange pre-operative workup (MRI, blood tests, cardiopulmonary assessment) in their home country to streamline the overseas admission.

The choice between hemiarthroplasty and available alternatives depends on fracture severity, patient age and activity level, and the status of the native articular surface.

Internal fixation: For Garden I/II (non-displaced or valgus-impacted) femoral neck fractures — cannulated screws (parallel or inverted triangle configuration) or a dynamic hip screw with anti-rotation screw preserves the native femoral head. In young patients (under 60 years) with Garden III/IV fractures, attempted internal fixation is still considered, accepting the 20–30% risk of AVN, because the long-term consequences of arthroplasty at young age (wear, loosening, revision) are substantial.

Total hip arthroplasty (THA): Superior functional outcomes in active, independent patients with femoral neck fracture or end-stage hip AVN with acetabular involvement. THA replaces both femoral head and acetabulum, eliminating the risk of acetabular erosion and providing better long-term function. Requires slightly longer surgery and carries a 5–10% dislocation risk in fracture cases (vs 2–4% for hemiarthroplasty); constrained liners or dual-mobility cups reduce dislocation risk in high-risk patients.

Reverse shoulder arthroplasty (RSA): For proximal humerus fractures in patients over 65–70 years, RSA has demonstrated superior forward elevation, abduction, and patient satisfaction compared to hemiarthroplasty in multiple RCTs and meta-analyses. RSA does not rely on rotator cuff integrity — the deltoid drives the joint — making outcomes independent of tuberosity healing. It has largely supplanted hemiarthroplasty as the preferred replacement option for complex proximal humerus fractures in elderly patients.

Core decompression (for early AVN): For Ficat-Arlet Stage I/II AVN without subchondral collapse, core decompression with or without vascularised fibular grafting or bone marrow concentrate injection may slow or halt disease progression, potentially averting the need for arthroplasty. Success rates are highest in early-stage, small lesions with identifiable reversible aetiology (e.g., steroid cessation, alcohol abstinence).

Non-operative management: Reserved for patients with severe medical comorbidity making any surgery prohibitively high risk, or those with minimal functional demand. Conservatively managed femoral neck fractures carry high rates of varus malunion, non-union, and permanent disability, with no advantage in mortality over surgically managed cohorts.