Osteonecrosis of the Humeral Head

Management of osteonecrosis of the humeral head in the pediatric population: A systematic review

Purpose

Humeral head osteonecrosis in the pediatric patients most often occurs in patients with underlying hemoglobinopathies, exposure to chronic corticosteroids, or after trauma. The purpose of this study was to perform a systematic review evaluating the prevalence, clinical characteristics, and management of humeral head osteonecrosis in the pediatric population.

Methods

PubMed, Ovid MEDLINE, and Scopus were screened with the terms "osteonecrosis," "avascular necrosis," "pediatric," and "proximal humerus" on January 10, 2024. A total of 218 studies were screened, and 74 studies were evaluated for eligibility. Studies that reported on the prevalence and/or management of pediatric humeral head osteonecrosis were included. The systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines.

Results

Twelve studies met inclusion criteria: four retrospective case series, three prospective case series, one retrospective cohort study, one retrospective case-control study, and three case reports. A majority of the studies (67%) discussed chemotherapy-induced osteonecrosis of the humeral head. A total of 77 patients (106 shoulders) with humeral head osteonecrosis were identified. The overall prevalence of osteonecrosis of the humeral head across eight studies examining at-risk populations (underlying hemoglobinopathies or undergoing chemotherapy) was 2%. Intra-articular steroid injections, physical therapy, and activity modification are effective conservative management strategies. Additionally, core decompression and hemiarthroplasty are surgical treatment options.

Conclusions

The prevalence of osteonecrosis of the humeral head is low even among at-risk populations with associated medical conditions. A variety of conservative and surgical treatment options have been described, but no comparative evaluations of these modalities has been conducted.

Level of evidence

IV.

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.

Osteoradionecrosis of the Hip, a Troublesome Complication of Radiation Therapy: Case Series and Systematic Review

Background

Osteoradionecrosis of the hip is a serious complication of radiotherapy that is easily overlooked by physicians and patients in the early stages. There are relatively few reports on this subject, so there is no clear scientific consensus for the pathogenesis, early diagnosis, and clinical treatment of hip osteoradionecrosis. In this paper, we report two cases of hip osteoradionecrosis and systematically review the related literature.

Case Presentation

We report two cases of hip osteoradionecrosis. One patient successfully underwent total hip arthroplasty in our hospital and recovered well postoperatively. Another patient although we offered a variety of surgical options for this patient, the patient was worried that the bone loss would lead to poor prosthesis fixation, resulting in prosthesis loosening and infection, and therefore ultimately refused surgical treatment.

Conclusion

With the development of radiological techniques, the incidence of hip osteoradionecrosis is decreasing year by year, but early diagnosis and rational treatment remain challenging. The effects of non-surgical treatment are limited. Early prevention, early detection, and early intervention are crucial to delay or prevent the emergence of more serious complications.

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.

Aseptic osteonecrosis of the shoulder: Etiologies, diagnosis and medical management

Aseptic osteonecrosis of the humeral head is a multifactorial entity in which the final common pathway results in disrupted blood supply, increased intraosseous pressure, and bone death. It follows a pathologic and radiographic pattern of progression similar to that seen at the hip. Much of the information regarding the disease has been extrapolated from findings in the femoral head. In addition, many treatment modalities have been adapted from techniques used in the hip. The causative underlying factors seem to be multifactorial and can be traumatic or non-traumatic. Although clinical symptoms and the underlying cause of the disease influence the treatment of each patient, staging is the most objective criterion in determining the most appropriate treatment. Earlier identification of osteonecrosis should facilitate the management. MRI is important for asymptomatic humeral head osteonecrosis in patients with poor clinical symptom and risk factor. Conservative treatment can be effective in stages I and II, When symptoms persist and there are signs of collapse despite conservative treatment, surgical intervention is advocated.

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.

Effect of surgical treatment on the quality of life in patients with non-traumatic avascular necrosis of the femoral head

Objective

Avascular necrosis of the hip is a common debilitating disease during the fourth and fifth decades of life. This study attempted to evaluate quality of life in patients with avascular necrosis of the hip joint before and after surgery.

Methods

In this study, 40 patients with avascular necrosis of the hip who underwent total hip arthroplasty, bipolar surgery, or cord compression were examined during 2006–2013. Harris Hip Score was used to assess the hip joint function and quality of life before and after surgery. The mean scores and standard deviation were used to describe data for quantitative variables, while frequency percentage was used to describe qualitative variables. Data were analyzed through SPSS v.19 and paired t-test. p < 0.05 was considered significant.

Results

This study involved 40 subjects with a mean age of 32 ± 7.38 years, ranging from 21 to 45 years old. The mean Harris Hip Score for patients before and after surgery were 20.36 and 96.15, respectively, showing a statistically significant difference (p < 0.001). The average patient activity scores before and after surgery (8.9 and 44.2, respectively), non-deformity (1.6 and 3.9), and movement (3.6 and 4.9) indicated significant differences (p < 0.001). Furthermore, 80% of patients felt no hip joint pain six months after surgery, while 92.5% patients did not use any assistive device to walk.

Conclusions

The results of this study demonstrated that surgery substantially contributed to relieving pain and improving hip function in patients with osteonecrosis of the hip joint in the short term.

Treatment of Articular Cartilage Injuries in the Glenohumeral Joint

Articular cartilage injuries in the glenohumeral joint present a unique and difficult problem for the patient and surgeon alike. Various etiologies exist for the development of these cartilage lesions; therefore, treatment options are vast and must be chosen thoughtfully, especially in the young, active patient. Across all treatment modalities, the goal is for the patient to regain lasting function and mobility while decreasing pain.

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.

Osteonecrosis

Younger patients are affected more often by osteonecrosis than by osteoarthritis, and osteonecrosis has significantly greater long-term morbidity.

Corticosteroids are the most common cause of nontraumatic osteonecrosis.

The femoral head is the most common site of osteonecrosis.

In rare instances, osteonecrosis of the jaw has been associated with bisphosphonate exposure. This phenomenon is more common with repeated intravenous infusions of bisphosphonates.

Case reports of osteonecrosis of the jaw in association with other medications, such as denosumab, have been reported.

The final common pathway in the pathogenesis of osteonecrosis is disruption of blood supply to a segment of bone.

Abnormalities in lipid metabolism, bone homeostasis, regulation of apoptosis, coagulopathies, innate immunity, and oxidative stress may play a role in the pathogenesis of osteonecrosis.

Epigenetics may alter the predisposition to develop osteonecrosis.

MRI is currently the optimal test for early diagnosis and identification of the extent of osteonecrosis.

Nonsurgical treatment of osteonecrosis does not change the natural history of the disease.

Although surgical treatment of femoral head osteonecrosis has many variations, most symptomatic patients eventually require total hip arthroplasty.

Knowledge of risk factors and early detection are crucial to the successful management of osteonecrosis.

Because of the lack of successful treatment options, new modes of management focus on the prevention of osteonecrosis.

Rate of avascular necrosis and time to surgery in proximal humerus fractures

PURPOSE

Avascular necrosis (AVN) of the humeral head is a devastating complication of proximal humeral fracture (PHF) that often results in long-term morbidity for the patient. Rates of AVN depend on the number of fracture fragments and are highly variable. The literature suggests that timely stable and anatomic reduction may decrease the rate at which AVN develops after PHF. To our knowledge, there is no literature published investigating a temporal relationship between the timing of PHF fixation and rates of AVN.

METHODS

Operative records of one orthopedic trauma surgeon were used to identify patients that underwent open reduction internal fixation for PHF at our institution between 2007 and 2012. Radiographs at presentation were reviewed and used to classify the fractures into two, three or four parts. Date and time of the initial radiograph were recorded as were the date and time of available intra-operative fluoroscopic images. The time from presentation radiograph to operative fixation was calculated (hours). Available follow-up plain films were then reviewed and evaluated for the presence or absence of humeral head AVN.

RESULTS

Time to surgery (less than or greater than 72 h) and patient age did not correlate with development of AVN after PHF (p > 0.26). Notably, the number of fracture fragments did influence the rate of AVN identified in patients with PHF (p = 0.002).

CONCLUSION

Early operative intervention does not appear to decrease the rate of development of avascular necrosis after PHF.

Locked Posterior Shoulder Dislocation Associated With Isolated Fractures of the Lesser Tuberosity: A Clinical Study of 22 Cases With a Minimum of 2-Year Follow-up

OBJECTIVES

To evaluate the clinical and radiographic outcomes of 2-part lesser tuberosity fracture with a locked posterior dislocation.

DESIGN

Retrospective case series study.

SETTING

Beijing Jishuitan Hospital ("first-level teaching hospital").

PATIENTS/PARTICIPANTS

Between April 2003 and June 2010, 29 patients received surgical treatment for 2-part lesser tuberosity fractures with an associated locked posterior shoulder dislocation. At the final follow-up, 22 of these patients were available for evaluation.

INTERVENTION

Open reduction and internal fixation.

MAIN OUTCOME MEASUREMENTS

The shoulder range of motion and visual analog scale pain score were recorded. The postoperative outcomes were evaluated using Score of University of California in Los Angeles (UCLA), Constant, and American Shoulder and Elbow Surgeons (ASES) Scale score. The degree of humeral head necrosis was analyzed according to plain radiographs. The effects of patients' age, dominant-side involvement, as well as time from initial injury to surgery (TFIS) on clinical outcomes and the degree of humeral head necrosis were evaluated.

RESULTS

There were 21 men and 1 woman. The average age was 41.7 years. The dominant side was involved in 12 of 22 cases (54.5%). The average TFIS was 49.5 (range, 4-148) days. The mean follow-up period was 38.1 months. The TFIS was identified as the only risk factor regarding postoperative shoulder outcome scores.

CONCLUSIONS

Acceptable outcomes can be achieved with surgical treatment for 2-part lesser tuberosity fracture with locked posterior shoulder dislocations. The TFIS has a negative impact on the final outcome.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

Osteonecrosis

Osteonecrosis affects younger patients more often than osteoarthritis and has significantly greater long-term morbidity.

Corticosteroids constitute the most common cause of nontraumatic osteonecrosis.

The femoral head is the most common site of osteonecrosis.

Bisphosphonate use is associated with osteonecrosis of the jaw.

The final common pathway in the pathogenesis of osteonecrosis is disruption of blood supply to a segment of bone.

Abnormalities in lipid metabolism, bone homeostasis, regulation of apoptosis, coagulopathies, and oxidative stress may play a role in the pathogenesis of osteonecrosis.

Magnetic resonance imaging is currently the optimal test for early diagnosis and identification of the extent of osteonecrosis.

Nonsurgical treatment of osteonecrosis does not change the natural history of the disease.

Although there are many variations on surgical treatment of femoral head osteonecrosis, most patients eventually require total hip arthroplasty.

Knowledge of risk factors and early detection are crucial to the successful management of osteonecrosis.

Due to the lack of successful treatment options, new modes focus on prevention of osteonecrosis.

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.

Radiotherapy induced hip joint avascular necrosis-Two cases report

BACKGROUND

Avascular necrosis (AVN) refers to the death of osteocytes and osteoblasts. Sites such as the femoral head, the head of the humerus and the mandibula with restricted access to local blood supply are particularly vulnerable to osteonecrosis. A COMBINATION OF SEVERAL FACTORS IS RESPONSIBLE FOR ISCHAEMIA AND IS ASSOCIATED WITH AVN: corticosteroids, alcohol abuse, Cushing's syndrome, SLE, systemic vasculitis, RA, scleroderma, haemoglobinopathies, radiotherapy. Management is based on proper diagnosis and treatment - conservative, pharmacological or surgical. Radiotherapy has become an integral part of the therapeutic programme of cancer patients. However, early and late after-effects of irradiation still constitute a significant issue in clinical practice.

AIM

The aim of this report is to present two cases of acetabular protrusion and femoral head deformities after a therapeutic pelvic irradiation and draw physicians' attention to that clinical problem which continues to be underestimated.

MATERIALS AND METHODS

This report documents two cases of acetabular protrusion and femoral head deformities after a therapeutic pelvic radiation.

RESULTS

Avascular necrosis (AVN) constitutes a severe and challenging long-term complication in radiation oncology.

CONCLUSION

It is necessary to take into account bone structures among organ at risk (OAR) involved in irradiation fields. The detailed analysis of the dose distribution and the use of collimators allow to decrease the total dose to OAR. An adequate management, early diagnosis and prompt, proper treatment may protect patients from long-term morbidities.

Humeral head osteonecrosis following arthroscopic rotator cuff repair

Humeral head chondrolysis and osteonecrosis of the glenoid have been reported; however, there is no report to date about humeral head osteonecrosis following arthroscopic shoulder procedure. We report a case of osteonecrosis of the humeral head following arthroscopic rotator cuff repair what we believe is probably secondary to disruption of its blood supply after placement of multiple metallic suture anchors. The surgical records were also reviewed in an attempt to identify the cause of the humeral head osteonecrosis.

Hemiarthroplasty and total shoulder arthroplasty for avascular necrosis of the humeral head

The purpose of this study was to review the outcome of patients with osteonecrosis of the humeral head, based on etiology and treatment with either hemiarthroplasty or total shoulder arthroplasty (TSA). Sixty-four shoulders, with an average age of 57 years, were evaluated at a mean of 4.8 years. Outcomes included L'Insalata and American Shoulder and Elbow Surgeons (ASES) scores, as well as range of motion (ROM). The overall ASES score was 67, average flexion was 127 degrees, and external rotation was 49 degrees. Outcomes did not differ based on etiology, but ROM was decreased with post-traumatic osteonecrosis. There was no difference in outcome or ROM between hemiarthroplasty and TSA. The complication rate was significantly higher with TSA (22%) than with hemiarthroplasty (8%). Achieving ROM in patients with post-traumatic osteonecrosis remains difficult. TSA was associated with a higher complication rate and decreased mobility and should be reserved for patients with stage V osteonecrosis.

Rehabilitation following reverse total shoulder arthroplasty

Reverse or inverse total shoulder arthroplasty (rTSA) is becoming a widely accepted surgical intervention. This procedure is specifically designed for the treatment of glenohumeral (GH) joint arthritis or complex fractures, when associated with irreparable rotator cuff (RC) damage or in the presence of RC arthropathy. Additionally, rTSA is an option for the revision of a previously failed conventional total shoulder arthroplasty (TSA) or hemiarthroplasty (HA) in the RC-deficient shoulder. The physical therapist, surgeon, and patient must take into consideration that the postoperative course for a patient following rTSA should be different than the rehabilitation following a traditional TSA. rTSA has only recently been approved by the Food and Drug Administration in the United States; however, nearly a 20-year history of its use exists in Europe. To date, we are aware of no peer-reviewed published descriptions of the postoperative rehabilitation for patients having undergone this procedure. The purpose of this paper is to review the indications for rTSA, focusing on underlying pathology, and to outline a rehabilitation protocol founded on basic science principles and our experience working with patients following rTSA.

Rehabilitation following total shoulder arthroplasty

Total shoulder arthroplasty (TSA) is a standard operative treatment for a variety of disorders of the glenohumeral joint. Patients, who have continued shoulder pain and loss of function in the presence of advanced joint pathology, despite conservative management, are often managed by undergoing a TSA. The overall outcomes that are reported after surgical intervention are quite good and appear to be primarily determined by the underlying pathology and the tissue quality of the rotator cuff. The current Neer protocol for postoperative TSA rehabilitation is widely used and based on tradition and the basic science of soft tissue and bone healing. The purpose of this paper is to review the indications for TSA, focusing on the underlying pathologies, and to describe the variables that impact the rehabilitation program of individuals who have had a TSA. A postoperative TSA rehabilitation protocol and algorithm, founded on basic science principles and tailored toward the specific clinical condition, are presented.

Pathogenesis and treatment of osteonecrosis of the shoulder

Osteonecrosis of the humeral head is an uncommon condition that occurs when bone vascularity is impaired. The causes underlying osteonecrosis of the humeral head seem to be multifactorial and can be traumatic or nontraumatic. Although clinical symptoms and causative factors affect the treatment of each patient, staging is the most objective criterion in deciding on the most appropriate treatment. Conservative treatment can be effective in stages I and II. Surgical intervention is advocated when symptoms are persistent and signs of collapse are evident. The surgical options include arthroscopic débridement, core decompression, vascularized bone grafting, and shoulder arthroplasty.

Shoulder arthroplasty in nontraumatic osteonecrosis of the humeral head

Twelve patients (thirteen shoulders) treated with arthroplasty for nontraumatic osteonecrosis of the humeral head were prospectively evaluated. At a mean follow-up of 30.2 months (range, 14-49 months), shoulder function assessed by the Constant score improved from 18 (adjusted score, 24%) to 51 (adjusted score, 69%; P <.001). Patients older than 65 years obtained lower adjusted scores than patients younger than 65 years (P =.02). The radiographs at follow-up showed radiolucent lines in 2 patients with no evidence of implant migration. Progressive glenoid erosion was identified in 2 patients treated with hemiarthroplasty. The subjective assessment revealed good and excellent results in 4 of 13 patients (numeric rating scale [NRS] 1 and 2). Three patients were unsatisfied with the final outcome (NRS 5). All three patients had abnormal findings with regard to the glenoid, either preoperatively with subtotal destruction of the glenoid or postoperatively with glenoid erosion after hemiarthroplasty or radiolucency around the glenoid component after total joint replacement. Contrary to previously published retrospective studies, we recommend a more cautious prediction of midterm results, especially in patients older than 65 years.

Nontraumatic osteonecrosis of the humeral head

The humeral head is the second most common site for nontraumatic osteonecrosis after the femoral head, yet it has attracted relatively little attention. Osteonecrosis is associated with many conditions, such as corticosteroid use, sickle-cell disease, alcoholism, dysbarism (or caisson disease), Gaucher's disease, and other systemic conditions. The diagnosis is a clinical and radiographic one, the latter forming the basis for its staging. Treatment depends on the chronicity and severity of symptoms, as well as the degree of clinical and radiographic progression. Surgical treatment includes arthroscopic debridement and core decompression for early osteonecrosis and hemiarthroplasty or total shoulder arthroplasty for more advanced disease. This report reviews osteonecrosis of the humeral head, with an emphasis on current treatment options.