Osteonecrosis of the humeral head: Relationship of disease stage, extent, and cause to natural history

doi:10.1016/S1058-2746(99)90089-7

Journal of Shoulder and Elbow Surgery

Volume 8, Issue 6, November–December 1999, Pages 559-564

https://doi.org/10.1016/S1058-2746(99)90089-7 Get rights and content

Abstract

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.

References (26)

M Govoni et al.
Humeral head osteonecrosis caused by electrical injury: a case report
J Emerg Med
(1993)
DS Hungerford et al.
The importance of increased intraosseous pressure in the development of osteonecrosis of the femoral head: implications for treatment
Orthop Clin North Am
(1985)
GH Leventhal et al.
Aseptic necrosis of bone in systemic lupus erythematosus
Semin Arthritis Rheum
(1974)
RK Ryu
Arthroscopic subacromial decompression: a clinical review
Arthroscopy
(1992)
RL Cruess
Experience with steroid-induced avascular necrosis of the shoulder and etiologic considerations regarding osteonecrosis of the hip
Clin Orthop
(1978)
RL Cruess
Steroid-induced avascular necrosis of the head of the humerus. Natural history and management
J Bone Joint Surg Br
(1976)
RL Cruess
Steroid-induced osteonecrosis: a review
Can J Surg
(1981)
HG David et al.
The shoulder in sickle-cell disease
J Bone Joint Surg Br
(1993)
RP Ficat
Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment
J Bone Joint Surg Br
(1985)
C Gerber
The arterial vascularization of the humeral head
J Bone Joint Surg Am
(1990)

J Golblatt et al.

Total hip arthroplasty in Gaucher's disease. Long term prognosis

Clin Orthop

(1988)

DS Hungerford et al.

Alcoholism associated ischemic necrosis of the femoral head: early diagnosis and treatment

Clin Orthop

(1978)

B Jacobs

Alcoholism-induced bone necrosis

NY State Med

(1992)

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Osteonecrosis of the humeral head is an uncommon condition, and treatment options are controversial. The shoulder is the second most common location for osteonecrosis, typically presenting between the second and fifth decades of life. Early diagnosis and treatment are essential because osteonecrosis may progress and lead to significant pain and loss of function. Nonoperative options are limited and are based on addressing the cause of the osteonecrosis. Multiple surgical treatments have been described, and these techniques continue to evolve. Open core decompression of the humeral head has been found to be an effective surgical option to restore blood supply and stimulate new bone formation. The evolution of arthroscopic techniques combined with biological adjuncts allows a minimally invasive approach with potential to accelerate revascularization and bone growth. We describe our technique for arthroscopic-assisted intraosseous bioplasty of the humeral head for the treatment of osteonecrosis.
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Citation Excerpt :
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A Delphi exercise was implemented with an international panel of experienced shoulder trauma surgeons self-selected after invitation of all AO Trauma members. Using open questions participants recommended the type and timing of desired diagnostic images, and formulated definitions for the imaging parameters they considered most important. Formulated recommendations for the type and timing of radiological fracture monitoring and clarification of the definitions of the proposed radiological parameter set were subjected to further survey. Consensus for each factor was considered to have been reached when there was at least a two-thirds agreement in the survey participants.
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Our work confirmed the need for clear definitions of radiological features that should be considered in the follow-up of proximal humeral fractures. It has resulted in the development of an international consensus monitoring protocol for PHF treatment with a structured core set of radiological parameters. Clinical application and validation of the monitoring process are needed.
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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.
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Original articleOsteonecrosis of the humeral head: Relationship of disease stage, extent, and cause to natural history

Abstract

J Emerg Med

Orthop Clin North Am

Semin Arthritis Rheum

Arthroscopy

Experience with steroid-induced avascular necrosis of the shoulder and etiologic considerations regarding osteonecrosis of the hip

Clin Orthop

Steroid-induced avascular necrosis of the head of the humerus. Natural history and management

J Bone Joint Surg Br

Steroid-induced osteonecrosis: a review

Can J Surg

The shoulder in sickle-cell disease

J Bone Joint Surg Br

Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment

J Bone Joint Surg Br

The arterial vascularization of the humeral head

J Bone Joint Surg Am

Total hip arthroplasty in Gaucher's disease. Long term prognosis

Clin Orthop

Alcoholism associated ischemic necrosis of the femoral head: early diagnosis and treatment

Clin Orthop

Alcoholism-induced bone necrosis

NY State Med

Original article
Osteonecrosis of the humeral head: Relationship of disease stage, extent, and cause to natural history