Arch Fam Med 2000 Jun;Mar;9(3):291-4
Trinity Lutheran Family Medicine Center, Kansas City, Mo., USA. cwolfe@stormontrail.org
We describe a patient with avascular necrosis in both shoulders. Confirmatory testing in making the diagnosis included plain radiography, bone scan, and magnetic resonance imaging. The pathogenesis and staging of the disease by radiography are presented in the article. Treatment options include a conservative regimen of shoulder range of motion exercises and nonsteroidal anti-inflammatory agents or surgery (arthroplasty or core decompression). The patient's risk factors include long-term corticosteroid use, smoking, and alcohol consumption. Other known risk factors include sickle cell disease, Gaucher disease, chemotherapy, lymphoma, dysbaric conditions, and trauma. This literature search shows that prevention and early diagnosis lend the best outcomes for the diagnosis of avascular necrosis.
J Shoulder Elbow Surg 1999 Nov-Dec;8(6):559-64
Department of Orthopedic Surgery, Mayo Clinic, Scottsdale, Ariz. 85259, USA
One hundred fifty-one patients with 200 shoulders affected with osteonecrosis of the humeral head were evaluated for associated factors, the need for prosthetic replacement surgery, the state of the unoperated shoulder, and the existence of prognostic factors. Associated factors included corticosteroid use in 112 shoulders, trauma in 37, Gaucher's disease in 3, sickle cell disease in 3, and radiation necrosis in 1. No cause was evident in 44 shoulders. Ninety-seven shoulders had replacement surgery. The need for replacement surgery was found to be related to extent and stage of humeral head involvement and to diagnosis. Shoulders with a traumatic cause of osteonecrosis required surgery more often (cumulative rate of 77.8% by 3 years). Advancing stage of disease was also related to the need for surgery. By 3 years the cumulative replacement rate was performed in 42% for shoulders with stage 2 disease, 29% with stage 3 disease, 55% with stage 4 disease, and 79% with stage 5 disease. In a similar manner, surgical frequency increased with increasing extent of humeral head involvement. In 60 shoulders not surgically treated that were monitored an average of 8.6 years (range 3.4 to 14.5 years), there was none to occasional moderate pain in 46 and moderate to severe pain in 14. The mean American Shoulder and Elbow Surgeons score was 64.8.
Clin Orthop 1998 Oct;(355):254-60
Department of Orthopaedic Surgery, Good Samaritan Hospital, Johns Hopkins University School of Medicine, Baltimore, MD 21239, USA.
Core decompression is one treatment used for symptomatic osteonecrosis of the humeral head. The purpose of this report was to examine the long term outcome of this procedure. Sixty-three shoulders in 43 patients who underwent a core decompression for humeral head osteonecrosis were followed up from 2 to 20 years (mean, 10 years). None of these patients had responded to nonoperative treatment before core decompression. Results of core decompression according to preoperative Ficat and Arlet stage revealed Stage I disease had 15 of 16 (94%) successful outcomes and Stage II had 15 of 17 (88%) successful outcomes. Stage III had 16 of 23 (70%) successful results and Stage IV had one of seven (14%) successful result. Core decompression of the shoulder is a safe procedure with few recognized complications and can be performed on an outpatient basis. The procedure has been successful for Stages I, II, and III osteonecrosis in terms of early relief of pain and increased function.
J Shoulder Elbow Surg 1998 Nov-Dec;7(6):586-90
Department of Orthopaedics, University of Berne, Inselspital, Switzerland
Twenty-five patients with a partial or complete collapse of the humeral head caused by post-traumatic avascular necrosis underwent clinical and radiologic evaluation at an average of 7.5 years (range 2.3 to 17.6 years) after having an underlying proximal humeral fracture. Posttraumatic humeral head necrosis was always associated with disability. The overall shoulder function as assessed with the Constant score was 46 points, corresponding to a functional shoulder value of 51% of an age- and sex-matched normal control group. The clinical outcome was significantly related to the anatomic alignment of the fragments of the humerus by the time of healing. In 13 patients (group 1) treatment resulted in an anatomic or nearly anatomic healing of the fracture, and in 12 other patients (group 2) avascular necrosis and collapse ensued in addition to malunion of 1 or more of the fracture fragments. Subjective overall outcome (P < .0001) and pain (P < .0001) were significantly better in group 1. Active anterior elevation averaged 125 degrees in group 1 and 80 degrees in group 2 (P = .0007), and abduction averaged 110 degrees in group 1 and 63 degrees in group 2 (P = .007). The relative shoulder score according to Constant was 65% of an age- and sex-matched normal population for group 1 and 41% for group 2 (P = .001). The results obtained in group 1 were comparable to those reported after hemiarthroplasty for complex humeral fractures. A proximal humeral fracture that is at risk for avascular necrosis has to be reduced anatomically if joint-preserving treatment is selected. If anatomic reduction cannot be obtained, other treatment options such as arthroplasty should be considered.
Aktuelle Radiol 1997 Jan;7(1):41-4
Radiologische Universitatsklinik Bonn
A 14-year old female patient was treated with chemotherapy including cortisone for malignant T-cell lymphoma. After chemotherapy she complained of pain in both hips and shoulders. Bone scintigraphy and conventional radiography failed to show any abnormality. However, bilateral femoral and humeral head necrosis was seen with MR imaging, which was also useful for follow up.
J Shoulder Elbow Surg 1996 Sep-Oct;5(5):355-61
Department of Orthopaedic Surgery, Hospital for Special Surgery, Cornell University Medical Center, New York, New York, USA.
Forty-two patients (65 shoulders) with osteonecrosis of the humeral head were reviewed. Minimal follow-up was 2 years or until shoulder arthroplasty was performed for persistent severe pain and disability not responsive to conservative treatment. Thirteen shoulders had surgery shortly after presentation, whereas 22 others initially treated conservatively required surgery. Thirty shoulders in 20 patients have been treated without surgery and were evaluated at an average of 10 years after initial presentation. Fifteen shoulders are doing satisfactorily, whereas 15 others are doing poorly. Overall, 37 (71%) shoulders had clinical progression of disease requiring shoulder arthroplasty or resulting in severe pain and disability. All had radiographic stage III, IV, or V, and 41 (85%) had articular surface incongruity of 2 mm or greater. Humeral head drilling was not effective in preventing clinical or radiographic progression in stage III.disease. Radiographic stages of III or greater and documented radiographic disease progression were significantly associated with a poor outcome.
J South Orthop Assoc 1996 Summer;5(2):101-7
Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston 29425, USA.
To determine the effects of sickle cell disease on the glenohumeral joint, 28 shoulders in 14 patients with SS sickle cell hemoglobinopathy were studied clinically and roentgenographically. patients were randomly selected; their mean age was 46 years (range, 22 to 63 years). Pain, stability, and function of the shoulders were assessed, and roentgenograms were evaluated for osteonecrosis. All 28 shoulders had some degree of pain with activity, but functional range of motion was maintained despite symptoms. Seventy-one percent of the patients had had total hip arthroplasty and 21% had had total knee arthroplasty for osteonecrosis; there was a mean of 1.5 previous joint implants per patient. Our study results show that, in patients with sickle cell hemoglobinopathy, symptoms of humeral head osteonecrosis are better tolerated than those of osteonecrosis in the lower extremities, delaying the need for surgical intervention. With severe pain and functional limitations, shoulder arthroplasty is the procedure of choice in this patient population. However, the risks are greater for patients with sickle cell disease than for other patients who have humeral head osteonecrosis, and thorough preoperative medical and anesthesia evaluations are necessary. These patients require perioperative transfusion or plasmapheresis and sufficient intraoperative hydration and oxygenation to avoid precipitating a sickle cell crisis; in addition, use of methyl methacrylate should be avoided.
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