Total shoulder arthroplasty versus hemiarthroplasty for humeral head avascular necrosis: a meta-analysis

Background: Avascular necrosis (AVN) of the humeral head can progress to joint collapse and marked functional limitation, often requiring surgical treatment. Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) are the main surgical treatment options, but their comparative clinical value remains a topic of debate. In particular, uncertainty persists regarding how functional benefit, complication risk, and implant durability should be balanced in contemporary practice. In this meta-analysis, we compared functional outcomes, complication rates, and revision risk between TSA and HA in patients with humeral head AVN. Methods: We performed a systematic search of PubMed, Scopus, Cochrane Library, Embase, and Google Scholar from database inception through November 2025. Nine comparative studies were included. Pooled mean difference (MD) and risk ratio (RR) were calculated using fixed- or random-effects models. Results: HA was associated with significantly higher patient-reported function as measured by American Shoulder and Elbow Surgeons (ASES) scores compared with TSA (MD, 17.12; P<0.00001), whereas TSA resulted in greater external rotation (MD, -10.23°; P=0.02). HA was also associated with a significantly lower overall complication rate compared with TSA (RR, 0.33; P<0.0001). Reported complications included suture abscess, periprosthetic fracture, rotator cuff pathology, postoperative stiffness, and dislocation. Visual analog scale pain score, Simple Shoulder Test score, internal rotation, and revision rates did not differ significantly between procedures (all P>0.05). Conclusions: In humeral head AVN, HA yields higher ASES scores and fewer complications, whereas TSA results in greater external rotation. Pain and revision rates are comparable, supporting the choice of individualized procedure selection based on glenoid status and patient goals. Level of evidence: III.