Pathogenesis and treatment of osteonecrosis of the shoulder

Untwining the intertwined: a comprehensive review on differentiating pathologies of the shoulder and spine

Background

The anatomic interplay and overlap between the cervical spine and the shoulder constitutes a challenge for shoulder and spine surgeons, as symptoms of spine and shoulder pathologies are often similar and may lead to entity misdiagnosis.

Methods

PubMed, Cochrane, and Google Scholar (page 1-20) searches were updated to October 2023 in search of the qualified papers. Boolean Operators were used with a combination of the keywords "spine" OR "neck" And "Shoulder". Furthermore, reference lists from papers were also searched to find literature.

Results

It is of pivotal importance to conduct comprehensive preoperative clinical investigation to appropriately evaluate and assess the source of the pathology and the leading causes behind it. Certain markers can help guide surgeons towards etiologies, and these include areas of pain and physical exam findings with the arm squeeze test having the highest sensitivity and specificity for diagnosing cervical radiculopathy. As for the shoulder, despite its low sensitivity, the Yergason test had the highest specificity for diagnosing subacromial impingement. Local anesthetic injection can help as well in the diagnostic approach. Moreover, the interplay between these anatomic locations is not solely related to preoperative diagnosis. Studies have shown that previous surgery for cervical spine pathology may negatively affect the outcomes of shoulder procedures like arthroplasties.

Conclusion

Shoulder and spine surgeons should be wary and vigilant of accurately diagnosing the etiology of the presenting symptoms to ensure proper management and optimize prognosis.

Osteolytic Lesions in a Sub-Adult Loggerhead Sea Turtle (Caretta caretta): A Case Report

Osteolytic lesions in loggerhead sea turtles (Caretta caretta) during rehabilitation are attributed to multiple causes, including gas embolism, hypothermia, and osteomyelitis due to bacterial or fungal infection. This study reports the appearance of osteolytic lesions in a sub-adult loggerhead sea turtle with involvement of the right fore and hind flippers, visible swelling of the elbow and knee joints, and accompanied by lameness after 45 days of rehabilitation. Radiographs and computed tomography revealed multiple lytic bone lesions. This was the fourth rehabilitation admission of the turtle after being accidentally captured by trawler ships (bycatch) in 2019, 2020, 2022, and 2023. Potential causes were dysbaric osteonecrosis due to a past decompression sickness event and hypothermia with osteomyelitis from bacterial infection. Blood cultures and antibiotic susceptibility testing led to the isolation of Ewingella americana responsive to enrofloxacin. This study investigates extensive fore and hind flipper involvement in a sub-adult loggerhead turtle, aiming to determine causes and risk factors. The pathogenesis and significance of these lesions is discussed.

Surgical treatment of subchondral osteonecrosis of the humeral head: A case report and literature review

BACKGROUND

Osteonecrosis of the humeral head is an uncommon subchondral bone disease with many etiologies, and there is currently no definite evidence to support an optimal surgical treatment plan. We report a case of surgical treatment of left humeral head necrosis. To the best of our knowledge, this is the youngest patient with non-drug-induced humeral head necrosis and the largest collapsed area.

CASE PRESENTATION

The case involved a 16-year-old male who injured his left shoulder 1 year ago. The patient was admitted to the hospital because of shoulder pain after activity in the year following the injury. During the physical examination, the left glenohumeral joint space was tender, the pain was obvious when the shoulder joint was rotated and squeezed, and the active and passive range of motion was normal. X-ray, magnetic resonance imaging, and computed tomography + 3D computed tomography scans all showed subchondral osteonecrosis of the left humeral head. Left humeral head lesion removal and autologous osteochondral transplantation were performed, and the patient was followed up.

CONCLUSION

Non-drug-induced humeral head necrosis is rare. Autologous osteochondral transplantation is currently one of the most mature and effective treatment methods. The short-term curative effect in this patient is satisfactory, but the patient is young and has a large collapsed area, so long-term follow-up is worthwhile.

Reverse Shoulder Arthroplasty Associated With Unnoticed Glenohumeral Dislocation: A Case Report

Osteonecrosis of the humeral head is seen in rare cases of anterior shoulder dislocations. There are many different surgical procedures that have been developed to repair inveterate anterior glenohumeral dislocation. Reverse shoulder arthroplasty (RSA) is a type of surgery that has been shown to be very effective in patients with cuff tear arthropathy. A 63-year-old female came to our service with an inveterate glenohumeral dislocation. We identified the osteonecrosis of the humeral head and decided to treat her with a reverse shoulder arthroplasty. Osteonecrosis following a glenohumeral dislocation is a rare condition. Treatment with a reverse shoulder arthroplasty allows a fast recovery, good functional results, and a better quality of life.

Humeral Head Avascular Necrosis: Pathophysiology, Work-up, and Treatment Options

» Avascular necrosis (AVN) of the humeral head is the result of ischemic injury to the epiphyseal bone leading to humeral head collapse and arthritis.» Common causes include trauma, chronic corticosteroid use, or systemic disease processes, such as sickle cell disease, systemic lupus erythematosus, or alcohol abuse.» Nonoperative treatment consists of risk factor management, physical therapy, anti-inflammatory medications, and activity modification.» Surgical treatment options include arthroscopic debridement, core decompression, vascularized bone grafts, and shoulder arthroplasty.

Atraumatic osteonecrosis of the humeral head: pathophysiology and current concepts of evaluation and treatment

The humeral head is considered the second most common site for osteonecrosis to occur after the femoral head. As seen in the femoral head, the circulatory implications characteristic of this condition are attributable to the interaction between a genetic predisposition and the exposure to certain risk factors. There is no consensus regarding the pathogenesis of osteonecrosis, yet the final common pathway results in disrupted blood supply, increased intraosseous pressure, and bone death. Disease staging using radiography and magnetic resonance imaging is predictive of disease progression and can help the orthopedic surgeon to guide treatment. Although there is a myriad of treatment modalities, there is a lack of high-quality evidence to conclude what is the most appropriate treatment option for each stage of humeral head osteonecrosis. Nonoperative treatment is the preferred option in early-stage disease, and it may prevent disease progression. Nonetheless, in some cases, disease progression occurs despite nonoperative measures, and surgical treatment is required. The purpose of this article is to provide an updated review of the available evidence on risk factors, diagnosis, and treatment of atraumatic humeral head osteonecrosis.

Risk factors for fracture-related infection after open reduction and internal fixation of proximal humerus fractures: A multicenter retrospective study of 496 fractures (TRON group study)

INTRODUCTION

One of the complications of the surgical therapy for proximal humerus fractures is fracture-related infection (FRI). This multicenter study aimed to investigate the incidence of FRI and clarify the risk factors associated with FRI in patients receiving open reduction and internal fixation for proximal humerus fracture.

MATERIAL AND METHODS

Among 684 patients diagnosed as having proximal humerus fracture and who were treated by surgical therapy in 13 institutions (named TRON group) from 2015 through 2020, 496 patients (men, n = 134, women, n = 362; mean [SD] age, 68.5 [14.5] years; mean [SD] body mass index [BMI], 23.0 [4.4] kg/m²) were included as subjects. Excluded were 188 patients due to less than 12 month's follow-up, patients who underwent osteosynthesis using neither plate nor nail and those with open fracture. We extracted the following as risk factors of FRI: sex, BMI, smoking status, diabetes, glenohumeral fracture dislocation, fracture classification, approach, implant, waiting period, type of anesthesia, operative time and blood loss during surgery. We conducted logistic regression analysis to investigate the risk factors of FRI using these extracted items as explanatory variables and the presence or absence of FRI as the response variable.

RESULT

FRI occurred after surgery for proximal humerus fracture in 9 of the 496 patients (1.8%). The causative organism was methicillin-susceptible Staphylococcus aureus in 4 patients, Pseudomonas aeruginosa in one patient and Enterococcus faecalis in one patient. In the other 3 patients, causative organisms were not detected. The univariate analysis showed significant differences for present of glenohumeral fracture dislocation (p = 0.004). Logistic regression analysis showed glenohumeral fracture dislocation to be the significant explanatory factor for FRI (odds ratio 12.3, p = 0.0375).

CONCLUSION

This study revealed an infection rate following open reduction and internal fixation of proximal humerus fracture of 1.8% (9 patients) and that Staphylococcus was the most frequent causative organism. Glenohumeral fracture dislocation is a significant risk for postoperative FRI.

The humeral head: A review of the blood supply and possible link to osteonecrosis following rotator cuff repair

Trauma, corticosteroid therapy and metabolic diseases are well established aetiologies of humeral head osteonecrosis; however, there is increasing evidence that arthroscopic rotator cuff surgery may be another possible cause. One of the reasons is that there may be inadvertent damage to the arterial blood supply to the humeral head during surgical intervention. The blood supply to the humeral head displays large amounts of variation with regard to origin, course and distribution. Therefore, to shed light on the pathogenesis, the blood supply of the humeral head is reviewed together with a summary of all reported cases of osteonecrosis of the humeral head that occurred following rotator cuff repair. Inconsistencies with regard to terminologies used and contradictions concerning arterial contributions from the anterior circumflex humeral artery and the posterior circumflex humeral artery towards humeral head supply are addressed. Moreover, variations in the course of the anterior circumflex humeral artery and its branches are summarized. The vascular anatomy of the humeral head is clinically relevant due to the close relationship of these blood vessels with the surgical repair sites for rotator cuff surgery and biceps tenotomies or tenodesis procedures. Potential sites of disruption of blood supply following arthroscopic rotator cuff surgery are discussed. Detailed knowledge of the course of the arteries supplying the humeral head may help to minimize the risk of vascular injury and subsequent osteonecrosis. Given the great interindividual variations of vascular anatomy, imaging procedures preceding arthroscopic rotator cuff surgery may be advisable.

Surgical treatments of atraumatic avascular necrosis of the shoulder

Humeral head atraumatic avascular necrosis is a rare diagnosis. It concerns young patients with a high functional demand. The treatments are mostly surgical. The radiographic classification of Cruess assesses the severity of the humeral head avascular necrosis and guides surgical indications. This chapter reports a review of the literature based on meta-analyses and clinical series. Surgical treatments may be conservative or prosthetic. Conservative treatments include core decompression, bone grafting and arthroscopic debridement. Prosthetic replacements are performed by resurfacing, hemiarthroplasty or total arthroplasty. For low-grade asvascular necrosis, core decompression may be functionally effective and doesn't impair later surgical procedures. For high grades, prosthetic replacements achieve good functional outcomes. Hemiarthroplasty should be preferred if the glenoid cartilage is intact, with low rates of wear complications and better long-term outcome than shoulder arthroplasty.

Glenohumeral Osteoarthritis: The Role for Orthobiologic Therapies: Platelet-Rich Plasma and Cell Therapies

The glenohumeral (GH) joint ranks third on the list of the large joints that are most commonly affected by osteoarthritis, after the knee and the hip. General nonsurgical modalities, including changes in daily activities, physical therapy, pharmacotherapy, and corticosteroid injections, constitute the mainstay of treatment. Most of these options, however, have shown moderate and short-term effectiveness. Arthroplasty techniques have proven to be successful for elderly patients. Nevertheless, replacement options are not optimal for younger patients because their functional demands are higher and prostheses have a finite life span. This has led to the search for new nonoperative treatment options to target this subgroup of patients. It has been suggested that orthobiologic therapies, including platelet-rich plasma (PRP) and cell therapies, present great promise and opportunity for the treatment of GH osteoarthritis. Despite the promising results that have been shown by cell therapies and PRP for treating degenerative joint conditions, additional studies are needed to provide more definitive conclusions.

Dysbaric osteonecrosis in technical divers: The new 'at-risk' group?

INTRODUCTION

Dysbaric osteonecrosis (DON) in people working under increased atmospheric pressure is well documented. It is generally less common in military and commercial divers than in caisson workers, except in some high-risk groups, such as in many indigenous diving industries where workers have little or no understanding of decompression principles. With the increasing popularity within the recreational diving community of deep air and mixed-gas decompression diving ('technical diving'), it is likely that diving physicians may see an increase in the prevalence of DON in this group in the future.

METHODS

The case report is presented of a technical diving instructor, with a 30-year history of deep diving, who developed bilateral humeral head DON and required a right shoulder hemi-arthroplasty. A focused literature search was also undertaken to identify published cases of DON in recreational divers.

RESULTS

The frequency, duration and depth of exposure to pressure, inadequate decompression, the occurrence of DCS and increasing age have been common features associated with DON in both divers and caisson workers. Many of these features were present in this technical diver.

CONCLUSIONS

Whilst DON is uncommon in recreational air scuba divers, all the above risk factors are present to a greater degree in technical diving. It is suggested that medical review for DON is merited from time to time in this potentially high-risk group of recreational divers.

Avascular Necrosis of the Humeral Head in a Patient with Methylenetetrahydrofolate Reductase 1 Gene Polymorphism: A Case Report

CASE

Atraumatic avascular necrosis (AVN) of the humeral head is a debilitating condition with an insidious onset and progressively worsening pain. We report a case of a woman who presented with left shoulder pain with a medical history of a rare genetic polymorphism in the methylenetetrahydrofolate reductase (MTHFR) gene. Advanced imaging demonstrated focal AVN of her humeral head. Treatment varies based on the stage of the disease, which, in this case, included an ultrasound-guided intra-articular corticosteroid injection and oral methylated supplementation.

CONCLUSION

In patients with no other known risk factors presenting with AVN of the humeral head, MTHFR polymorphism should be strongly considered a possible cause of AVN.

Idiopathic humeral head osteonecrosis mimicking rotator cuff disorders: Two challenging diagnostic case reports

RATIONALE

Shoulder pain is a common complaint among patients, and rotator cuff disorders are the most common diagnoses. Humeral head osteonecrosis is easily masked by other more common diagnoses and concomitant conditions.

PATIENT CONCERNS

This challenging diagnostic report consists of 2 cases. Case 1 was that of a 59-year-old man who presented with right shoulder pain that had lasted for >1 year. Case 2 was that of a 52-year-old man who complained of right shoulder pain lasting for 6 months. They both presented with chronic right shoulder pain without relevant trauma history, and the physical examination showed a tenderness point over the right greater tuberosity.

DIAGNOSIS

These 2 patients were diagnosed with osteonecrosis involving the right greater tuberosity region via magnetic resonance imaging.

INTERVENTIONS

In case 1, the patient underwent cord decompression and artificial bone grafting with C-arm guidance. In case 2, the patient refused surgical intervention and decided to continue receiving physical therapy for symptom control.

OUTCOMES

In case 1, the patient responded well to cord decompression and artificial bone grafting. After the surgery, the active range of motion was restored and the pain in the right shoulder diminished further. In case 2, conservative treatment helped alleviate the patient's shoulder pain but did not entirely eliminate it.

LESSONS

Physicians should always have a high index of suspicion for osteonecrosis, especially when treating chronic shoulder pain, regardless of whether there are typical symptoms/known risk factors or not.

Bisphosphonate combination therapy for non-femoral avascular necrosis

Background

Avascular necrosis at sites other than femoral head (AVNOFH)/Non-Femoral AVN is a rare entity. No standard of treatment still exists for treating early stages of AVNOFH with most of the cases eventually progressing to a late arthritic stage needing surgical intervention. Bisphosphonates have been shown to prevent disease progression, bone collapse, and the requirement for surgery in avascular necrosis of femoral head. The present study is conducted to evaluate the response of bisphosphonates in the non-surgical management of the early stages of AVNOFH.

Materials and methods

Prospectively collected data of 20 patients diagnosed with an early stage of AVNOFH and treated with the combination of oral alendronate 70 mg weekly and intravenous zolendronic acid (ZA) for 1 year, between Jan 2009 to Dec 2015, was evaluated retrospectively. Clinical evaluation was done using the visual analogue scale (VAS), mean analgesic requirement, and range of motion. Radiographs and magnetic resonance imaging (MRI) were taken to classify the stage of AVN, monitor radiological collapse, and evaluate radiological progression and bone marrow edema changes.

Results

In our analysis of 18 patients (2 lost to follow-up), 5 patients had AVN of the humeral head, 4 patients of the talus, 3 of the lunate, and 2 each of the scaphoid, medial tibial plateau, and second metatarsal head. Pain relief with the drop in VAS score was seen at a mean duration of 4.3 weeks (range 3–13 weeks) after the start of therapy. A 50% reduction in mean analgesic requirement was achieved in the first 6 weeks (2-11 weeks). MRI showed complete resolution of BME in 13 patients at 6 months and in 17 patients (94.4%) at 1 year. Radiological collapse was seen in 6 out of 18 patients at a mean follow-up of 35.3 months (range 14–56 months). Only one out of 18 patients enrolled required surgery.

Conclusion

A combination of oral alendronate and intravenous zolendronic acid provides a pragmatic solution to this rare entity of AVNOFH, where no standard treatment exists.

Etiology of Shoulder Arthritis in Young Patients

The manifestation of glenohumeral arthritis in the young adult is a devastating occurrence that can be difficult to manage. This review details the many underlying etiologies including genetic causes, congenital abnormalities, glenohumeral instability, posttraumatic lesions, postcapsulorraphy arthropathy, osteonecrosis, intraarticular pain pump postoperative use, radiofrequency/thermal capsulorraphy treatments, septic arthritis/infection, and inflammatory arthropathies. Although each of these potential causes have been well-studied, their contributions to the development of glenohumeral arthritis in the young person has not been described extensively.

Shoulder Arthroplasty for Humeral Head Avascular Necrosis Is Associated With Increased Postoperative Complications

BACKGROUND

Humeral head avascular necrosis (AVN) of differing etiologies may lead to shoulder arthroplasty due to subchondral bone collapse and deformity of the articular surface. There have been no large studies evaluating the complications for these patients after they undergo total shoulder arthroplasty (TSA).

QUESTIONS/PURPOSES

The first objective of this study is to evaluate the complication rate after TSA in patients with humeral head AVN. The secondary objective is to compare the complication rates among the different etiologies of the AVN.

METHODS

Patients who underwent TSA were identified in the PearlDiver database using ICD-9 codes. Patients who underwent shoulder arthroplasty for humeral head AVN were identified using ICD-9 codes and were subclassified according to AVN etiology (posttraumatic, alcohol use, chronic steroid use, and idiopathic). Complications evaluated included postoperative infection within 6 months, dislocation within 1 year, revision shoulder arthroplasty up to 8 years postoperatively, shoulder stiffness within 1 year, and periprosthetic fracture within 1 year and systemic complications within 3 months. Postoperative complication rates were compared to controls.

RESULTS

The study cohorts included 4129 TSA patients with AVN with 141,778 control TSA patients. Patients with posttraumatic AVN were significantly more likely to have a postoperative infection (OR 2.47, P < 0.001), dislocation (OR 1.45, P = 0.029), revision surgery (OR 1.53, P = 0.001), stiffness (OR 1.24, P = 0.042), and systemic complication (OR 1.49, P < 0.001). Steroid-associated AVN was associated with a significantly increased risk for a postoperative infection (OR 1.72, P = 0.004), revision surgery (OR 1.33, P = 0.040), fracture (OR 2.76, P = 0.002), and systemic complication (OR 1.59, P < 0.001). Idiopathic and alcohol-associated AVN were not significantly associated with any of the postoperative evaluated complications.

CONCLUSIONS

TSA in patients with humeral head AVN is associated with significantly increased rates of numerous postoperative complications compared to patients without a diagnosis of AVN, including infection, dislocation, revision arthroplasty, stiffness, periprosthetic fracture, and medical complications. Specifically, AVN due to steroid use or from a posttraumatic cause appears to be associated with the statistically highest rates of postoperative TSA complications. Given these findings, orthopedic surgeons should be increasingly aware of this association, which should influence the shared decision-making process of undergoing TSA in patients with humeral head AVN.

Surgical management of osteonecrosis of the humeral head: a systematic review

PURPOSE

Osteonecrosis of the humeral head is a rare diagnosis. The aim of this systematic review was to identify published studies and analyse the best clinical evidence available related to the surgical management of osteonecrosis of the humeral head.

METHODS

A systematic electronic search was performed using the PubMed (MEDLINE), EMBASE and Cochrane Library databases. Published studies that reported the outcomes for adult patients treated surgically for osteonecrosis of the humeral head were included. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was followed.

RESULTS

Twelve studies were included: five prospective case series and seven retrospective case series. A total of 309 patients, comprising 382 shoulders, were included. Three main surgical procedures were evaluated: core decompression, hemi-arthroplasty and total shoulder arthroplasty.

CONCLUSIONS

Based on the current available data, core decompression is a safe and effective option for treating low-grade osteonecrosis of the humeral head, while hemi-arthroplasty and total shoulder arthroplasty should be considered for high-grade osteonecrosis. More studies and better-designed trials are needed in order to enrich the evidence and enable researchers to draw stronger conclusions. Since osteonecrosis is an uncommon, though challenging disease, a proper knowledge of its treatment is needed.

LEVEL OF EVIDENCE

IV.

Autologous Concentrated Bone Marrow Grafting for the Treatment of Osteonecrosis of the Humeral Head: A Report of Five Shoulders in Four Cases

Five shoulders in four patients affected by advanced osteonecrosis of the humeral head were treated with autologous concentrated bone marrow grafting. Bone marrow sample was aspirated from the iliac crests, concentrated by a centrifugation technique, and injected into the necrotic site. The shoulders were evaluated radiologically with X-ray scoring and clinically with measurement of range of motion and pain score (visual analogue scale, VAS). The mean follow-up period was 49.4 (range, 24–73) months. The concentration ratio of nucleated cells was calculated and the number of transplanted mesenchymal stem cells (MSC) was estimated by a colony-forming assay. All four shoulders with stage 3 disease achieved joint sparing. One shoulder with stage 4 disease required replacement surgery. Clinical evaluation of the spared joints showed improvement in range of motion in two cases and deterioration in two cases. VAS scores were 0 after surgery in three cases. The mean concentration ratio was 2.73, and the mean number of transplanted MSC was 1125. The outcomes of autologous concentrated bone marrow grafting for advanced osteonecrosis of the humeral head were varied. Further research is needed to determine the effectiveness and the indications of the present surgery.

Shoulder arthroplasty for post-traumatic osteonecrosis of the humeral head

BACKGROUND

Osteonecrosis (ON) of the humeral head is a known complication of proximal humeral trauma. Prosthetic replacement may be the last option to treat the associated pain. Depending on the condition of the glenoid, hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) can be considered. To date, the peer reviewed literature offers limited direction on the better treatment for this population.

METHODS

Between 1973 and 2010, 93 arthroplasties were performed for post-traumatic ON of the humeral head after conservative treatments failed. Of these, 37 HAs and 46 TSAs were monitored for a minimum of 2 years (mean, 8.9 years) or until reoperation.

RESULTS

The HA and TSA groups showed improvements in pain (P < .001), elevation (P < .01), and external rotation (P < .01). The TSA group had less pain at follow-up than the HA group (2.1 vs 3.0, P = .001). TSA led to better satisfaction (70% vs 56%) and more excellent/satisfactory Neer ratings (57% vs 41%) compared with HA. Nine HA patients and 5 TSA patients underwent reoperation. The most common causes for reoperation were painful glenoid arthrosis (n = 8) in HA and rotator cuff failure (n = 4) in TSA. The estimated 15-year survivorship was 79.5% for HA and 83% for TSA.

DISCUSSION

In patients with post-traumatic ON of the humeral head, shoulder arthroplasty provides improvements in range of motion. However, TSA provides superior pain relief, with better patient-reported satisfaction. TSA should be strongly considered in patients with post-traumatic ON of the humeral head with damage to the glenoid cartilage.

Shoulder arthroplasty for atraumatic osteonecrosis of the humeral head

BACKGROUND

Osteonecrosis (ON) of the humeral head represents <5% of the shoulder arthroplasty population. Depending on the stage of disease, surgeons must decide between hemiarthroplasty (HA) and total shoulder arthroplasty (TSA). To date, the peer-reviewed literature offers minimal insight into the best form of treatment of this population of patients.

METHODS

Between August 1973 and November 2010, 141 shoulder arthroplasties were performed for operatively confirmed ON of the humeral head; 67 HAs and 71 TSAs were observed for at least 2 years (mean, 9.3 years) or until reoperation. Indications for surgery included imaging-confirmed ON in a patient who had failed to respond to conservative treatment modalities.

RESULTS

Shoulder arthroplasty provided significant improvements in pain scores (P < .001), elevation (P < .01), and external rotation (P < .01) for both the HA and TSA populations. Both groups showed similar patient-reported satisfaction (>75%) and excellent/satisfactory Neer ratings (>65%). Eleven percent of HAs had moderate to severe glenoid erosion at follow-up, and 25% of glenoid components were radiographically at risk. Eight HAs and 11 TSAs underwent reoperation. The most common cause for reoperation was painful glenoid arthrosis in the HA group (7) and aseptic loosening (4) in the TSA group. The estimated 20-year survivorship of HA and TSA was 87% and 79%, respectively.

CONCLUSIONS

In patients with atraumatic ON of the humeral head, both HA and TSA can be expected to provide lasting pain relief and improved range of motion, with HA having longer follow-up. HA should be strongly considered in patients with atraumatic ON of the humeral head and preserved glenoid cartilage.

The stiff shoulder; A case study

Clinicians working in outpatient departments and advanced practitioner clinics frequently encounter patients presenting with multidirectional stiffness of the glenohumeral joint. This case report describes the assessment and treatment of a patient presenting with glenohumeral joint stiffness and describes the possible differential diagnoses. The evidence base used to inform the decision-making process is presented and the use of radiology that helped to ultimately establish the diagnosis is discussed. The clinical reasoning process of applying knowledge and experience to identify patient problems and to make appropriate decisions that result in positive patient outcomes is discussed. The case report highlights the importance of early diagnosis.

Focal anatomic resurfacing implantation for bilateral humeral and femoral heads' avascular necrosis in a patient with Hodgkin's lymphoma and literature review

INTRODUCTION

The femoral and humeral heads are among the most common sites of osteonecrosis. The aims of this case report was to report three years' results for sequential treatment of bilateral, concomitant involvement of humeral and femoral heads with focal anatomic resurfacing implantation in a single patient with Hodgkin's lymphoma and to review the relevant literature, which is relatively scarce.

PRESENTATION OF CASE

We present a 48-year-old male patient with concomitant, bilateral femoral and humeral head avascular necrosis. He was diagnosed as Hodgkin's lymphoma in 1984. He had bilateral groin and shoulder pain, lasting for three years and aggravated by joint motions. Radiological evaluations demonstrated bilateral focal osteonecrosis of femoral heads and humeral heads, respectively. Despite conservative treatment, he did not obtain any symptomatic relief. Following the common decision, he was treated with sequential implantations with the HemiCAP(®) device for both bilateral pathologies, by a single surgeon and standard surgical approaches. Neither intraoperative nor postoperative complication was encountered. After the follow-up period of 36 months after the last surgery, he was symptomless and with normal range of motion for all four joints.

DISCUSSION

The bilateral, concomitant involvement of humeral and femoral head in the setting of avascular necrosis is relatively rare. Moreover, the optimal treatment method at earlier stages, in young patients has not been established yet.

CONCLUSION

This study is the first report to present the three-years' clinical result of a single, relevant case, who was treated with sequential focal anatomic resurfacing implantations (HemiCAP(®)) in four aforementioned joints.

Rapid progressive atypical atraumatic osteonecrosis of humeral head: a case report

Osteonecrosis of the humeral head is an uncommon and slow progressive condition. This condition is difficult to be recognized because its initial symptoms are nonspecific. Simple radiography is the standard tool to stage disease progression. However, plain radiographic findings of osteonecrosis are nearly normal in the initial stage. We report a case of 74 years old female patient who have suffered from painful limitation of the shoulder joint. She had no trauma history and no specific predisposing factors for osteonecrosis of the humeral head. To confirm, follow up radiography and shoulder magnetic resonance imaging were performed.

Progressive osteolysis and surface chondrolysis of the proximal humerus following influenza vaccination

Influenza vaccination is a common annual event among individuals in the United States. Complications, although infrequent, are usually mild and self-limiting. This article describes the case of a 46-year-old man who experienced progressive osteolysis and surface chondrolysis of the proximal humerus following routine influenza vaccination. The patient presented with shoulder pain and limited range of motion 3 weeks following vaccination in the deltoid area. No skin changes were noted, inflammatory markers were normal, and the patient's pain and disability persisted despite nonsteroidal anti-inflammatory drugs and occupational therapy. Plain radiographs revealed a small lytic area involving the greater tuberosity of the humeral head. Magnetic resonance imaging (MRI) showed abnormal uptake and cystic changes involving the greater tuberosity of the humeral head; repeat MRI at 5 months showed progression in the cystic changes. Diagnostic arthroscopy of the shoulder revealed a hyperemic joint capsule and extensive, full-thickness chondrolysis of the humeral head. Cystic biopsy demonstrated inflammatory cells and granulation tissue, consistent with foreign body response. Cultures were negative. Surgical debridement of the cystic areas and resurfacing of the humeral head yielded a good outcome. To our knowledge, this is the first reported complication of influenza vaccination requiring surgical intervention. Physicians need to be aware of the potential for osteolysis and chondrolysis, which may require aggressive forms of management.

Atraumatic osteonecrosis of the distal radius and ulna: case series and review

PURPOSE

Atraumatic multifocal osteonecrosis is defined as the occurrence of atraumatic osteonecrosis in 3 or more anatomic locations, and it is rare. We identified 6 patients with osteonecrotic lesions in the distal ulna, radius, or both. The purposes of this study were to describe the clinical manifestations of atraumatic multifocal osteonecrosis affecting these bones, to identify risk factors for developing the disease in these locations, and to evaluate the success of treatment by percutaneous drilling.

METHODS

A total of 10 wrists in 6 women with a mean age of 41 years had symptomatic osteonecrosis. Patients were treated by percutaneous drilling after they had failed nonoperative modalities. Clinical evaluation included preoperative and postoperative Michigan Hand Questionnaire scores plain radiographs, and MRI evaluations were performed to characterize the disease. The incidence of risk factors was recorded.

RESULTS

There was disease occurrence in the radius in all 10 wrists and in the ulnas of 4 wrists. All patients presented with symptomatic osteonecrosis of the large joints (primarily knee or hip), presumably secondary to corticosteroid use. These patients later developed symptomatic pain in the distal ulna, radius, or both that impaired daily activities. Other risk factors included alcohol or tobacco use, blood dyscrasias, and systemic lupus erythematosus. Treatment consisted of percutaneous drilling of the distal radius (and ulna when affected). One patient required additional bilateral drillings and had further improvement in her Michigan Hand Questionnaire scores. At a mean follow up of 35 months, there was no disease progression as evident radiographically.

CONCLUSIONS

The distal radius and ulna are rare sites of osteonecrosis associated with multifocal disease. The clinical presentation and risk factors are similar to osteonecrosis in the large joints. Magnetic resonance imaging identifies necrotic lesions. The present study suggests that disease in these sites can be safely and effectively treated with percutaneous drilling.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Atraumatic osteonecrosis of the humeral head after influenza A-(H1N1) v-2009 vaccination

In the recent pandemic influenza A-(H1N1) v-2009 vaccination campaign, adjuvanted vaccines have been used because of their antigen-sparing effect. According to available reports, the rate of severe vaccination reactions has not increased, as compared with previous seasonal influenza vaccinations. Here we describe an adult female patient who was vaccinated with an AS03 adjuvanted split-virus vaccine injected into the left arm. She experienced a prolonged and painful local reaction for 4 weeks. During this time, persistent incapacitating pain shifted into the left shoulder. Magnetic resonance imaging (MRI) at the injection site detected atraumatic humeral head osteonecrosis in conjunction with bursitis of the rotator cuff region. Clinical and laboratory examination revealed no other underlying disease. Using analgetic medication and physical therapy, resting pain completely remitted within the following 14 weeks. Pain on exertion declined within the following 6 months. Atraumatic osteonecrosis, a relatively rare disorder which initially presents non-specific clinical symptoms, has never been associated with parenteral influenza vaccination. Although the available data cannot establish a causal relationship, our patient's clinical course - with a continuous transition from increased local post-vaccination reactions to symptoms of a severe shoulder lesion with osteonecrosis - raises the question of a pathogenetic link. Considering the vascular pathogenesis of osteonecrosis, we hypothesize that our patient's enhanced local immunologic reaction may have led to regional vasculitis as the cause of bone destruction. As mild forms of osteonecrosis may have escaped previous clinical attention, it is the purpose of our report to increase awareness of this exceptional event as a possible side effect of parenteral adjuvanted vaccination.

Thorough debridement of the humeral head for osteonecrosis

Osteonecrosis of the shoulder is a devastating disease, particularly in the young patient. Published data is replete with vascularized and nonvascularized bone grafting procedures for joint preservation of the hip; however, these same techniques have not been applied to the shoulder. When treating osteonecrosis of the shoulder, endoscopically-guided thorough debridement of the necrotic bone may promote good outcomes by ensuring that the bone graft, vascularized or nonvascularized, is stabilized against a viable host bed. In addition, this new technique facilitates access to the subchondral plate from the osseous side, thereby fully debriding the intraosseous fracture and allowing elevation of the articular surface if needed. When collapse is present, stage 3 disease secondary articular-sided changes may be present and should be addressed during concomitant arthroscopy. This article presents a case of endoscopically-guided thorough debridement of the humeral head combined with nonvascularized bone grafting of the residual cavity and stabilization, and concomitant arthroscopy for a 30-year-old woman with steroid-associated osteonecrosis.

Osteonecrosis of the humeral head

Osteonecrosis of the humeral head is considerably less common than osteonecrosis of the hip. However, as in the hip, the interaction between a genetic predisposition and certain risk factors may lead to increased intraosseous pressure, loss of circulation, and eventual bone death. The most common risk factor remains corticosteroid use, which accounts for most reported cases. Radiographic staging and measurement of lesion size are predictive of disease progression and can be used to determine appropriate intervention. Recent studies have reported the use of various treatment modalities such as pharmacologics, core decompression with small-diameter drilling, arthroscopic-assisted core decompression, and bone grafting. Prospective, randomized studies are needed to determine the efficacy of these joint-preserving procedures. Newer resurfacing techniques have a role in treating articular surface loss. Hemiarthroplasty and total shoulder arthroplasty are recommended for patients with end-stage disease.

A case report of atypical magnetic resonance images of the hindfoot following cocaine injection in the foot and a review of osteonecrosis in calcaneus

Osteonecrosis in bones with a rich vascular supply, such as the calcaneus, is uncommon. The magnetic resonance imaging (MRI) showed an isolated lesion in the calcaneus in the few cases of calcaneal osteonecrosis reported in the literature. Presented here is a hitherto unreported pattern of multiple serpigenous osteonecrotic lesions in the hindfoot on MRI, in a patient who injected cocaine in his foot.

Treatment of osteonecrosis of the humeral head with cementless surface replacement arthroplasty

BACKGROUND

Osteonecrosis of the humeral head is a disabling condition that can lead to joint destruction with persistent pain and dysfunction. The aim of the present study was to examine cementless humeral surface replacement arthroplasty as a treatment option for posttraumatic and nontraumatic osteonecrosis.

METHODS

Between 2002 and 2005, seventeen shoulders with posttraumatic (n = 8) or nontraumatic (n = 9) osteonecrosis of the humeral head were treated with cementless humeral replacement arthroplasty. The mean proportion of the humeral head that was occupied by necrotic bone was 18.6% (range, 8.9% to 30.9%). The mean duration of follow-up was three years. Constant scores, patient satisfaction, and complications were recorded. Volumetric measurements of the necrotic areas and signs of implant loosening were analyzed with use of standardized radiographs.

RESULTS

The mean Constant score for the entire cohort improved significantly from 31 to 62 points (34% to 75% when adjusted by age and sex) (p < 0.0001). There were also significant improvements in mean shoulder flexion (from 87 degrees to 139 degrees), abduction (from 64 degrees to 120 degrees), and external rotation (from 2 degrees to 27 degrees). The final values for the Constant score, abduction, and power were significantly higher for the nontraumatic group than for the posttraumatic group. Fourteen patients (fifteen shoulders) were very satisfied (eleven shoulders) or satisfied (four shoulders), and two patients (two shoulders) were somewhat disappointed with the postoperative result. Signs of implant loosening were not observed. One patient had a wound infection that required surgical débridement and antibiotic therapy. To date, no implant revisions have been necessary.

CONCLUSIONS

Cementless humeral surface replacement arthroplasty is a potentially bone-preserving option for patients with posttraumatic and nontraumatic osteonecrosis of the humeral head. Even in the presence of bone loss of as much as 31% of the humeral head, implant loosening was not observed. Good functional results and relief of pain in combination with a low complication rate can be achieved in the short term.

Shoulder hemiarthroplasty for steroid-associated osteonecrosis

Currently, there is little information on the outcome of humeral head replacement for steroid-associated osteonecrosis of the humeral head. The purpose of this study was to evaluate the outcome of patients who underwent humeral head replacement for steroid-associated osteonecrosis to determine the results, risk factors for an unsatisfactory outcome, and rates of revision surgery. Between 1980 and 2000, 32 shoulder hemiarthroplasties were performed for steroid-associated osteonecrosis. We included 31 hemiarthroplasties in 25 patients with a minimum 2-year follow-up (mean, 12.0 years) in the study. The mean age of the 23 female and 9 male patients was 49.4 years at the time of surgery (range, 25-86 years). Overall, mean pain scores decreased from 4.6 to 2.6 (P < .0001). However, moderate or severe pain was reported in 12 shoulders (38%) at the most recent follow-up, 2 of them requiring implant revision. The mean preoperative to postoperative active elevation increased from 92 degrees to 139 degrees (P < .0001), and external rotation increased from 36 degrees to 65 degrees (P < .0001). According to a modified Neer result rating system, there were 13 excellent results (42%), 4 satisfactory results (13%), and 14 unsatisfactory results (45%). Improvement in pain and function most often occurred after hemiarthroplasty as a treatment for steroid-associated osteonecrosis of the humeral head. However, there are a large number of unsatisfactory results related to glenoid cartilage wear over time.

Osteochondritis dissecans of the humeral head

Osteochondritis dissecans (OCD), although common in other regions, is exceptional in the shoulder. We present a rare case of OCD of the humeral head in a young patient that remained undiagnosed for a 3-year period.

Expression of the angiomatrix and angiogenic proteins CYR61, CTGF, and VEGF in osteonecrosis of the femoral head

Angiogenesis and bone repair are closely linked processes. VEGF, CYR61, and CTGF have been identified as signaling factors that control angiogenesis and could be important in fracture healing. The purpose of this study was to investigate the expression of these signaling factors in osteonecrosis of the femoral head. Twenty-one bone cylinders were retrieved from hips of patients with osteonecrosis of the femoral head at different ARCO stages. Immunohistochemistry for CD34, CYR61, CTGF, and VEGF expression was done on each bone cylinder representing the different regions of osteonecrosis (necrosis, fibrosis, transition zone, and edematous area). VEGF, CYR61, and CTGF were expressed in samples with osteonecrosis. Particularly VEGF and CYR61 were highly expressed in the edematous area. CYR61 was also highly expressed in the transition zone. CTGF was expressed mainly in the area of marrow fibrosis and edema. CYR61, CTGF, and VEGF are expressed to different degrees in the different repair zones of osteonecrosis. Particularly, the high expression of VEGF and CYR61 in the edematous area may represent a consequence of hypoxia and indicate a role of these proteins in the repair processes ongoing in osteonecrosis.