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

Avascular necrosis of the humeral head after shoulder arthroscopy

Arthroscopic rotator cuff repair usually provides pain relief after surgery. In the early postoperative period, tendon re-rupture can trigger the pain again, and this rupture is usually confirmed by ultrasound. In this case report, we present a case of tendon re-rupture with concomitant rapid-onset avascular necrosis after arthroscopic rotator cuff repair. In an early stage, avascular necrosis can only be confirmed using MRI, and ultrasound may confound the diagnosis. Therefore, it is important to suspect this postoperative complication in female patients presenting with pain despite initial improvements after rotator cuff repair. Early diagnosis helps manage symptoms and control disease progression. In this case, a reverse shoulder arthroplasty provided pain relief and an acceptable range of motion.

The role of sagittal axis in biceps tenodesis for superior capsular reconstruction in massive irreparable rotator cuff tears

BACKGROUND

This study aims to compare histopathological results following a 6-week postoperative follow-up of biceps tenodesis (BT) at 1/3 median, 1/3 posterior, and 1/3 anterior locations to the rotator cuff footprint (RCF) in cases of massive irreparable rotator cuff tears (MIRCT).

MATERIALS AND METHODS

Thirty rabbits were assigned to three groups. BT for superior capsular reconstruction (SCR) was performed on rabbits 1-10 at the 1/3 median part of the RCF along the sagittal axis using a transosseous reinforced suture with the modified Mason-Allen technique, maintaining consistent pressure in the groove (Group 1). In rabbits 11-20 (Group 2), tenodesis was performed 1/3 posterior to the RCF, while rabbits 21-30 (Group 3) underwent tenodesis 1/3 anterior to the RCF. Following the 6-week follow-up, the shoulders were excised en bloc, and histopathological evaluation was conducted using a modified Bonar's scale. Results were statistically compared among the groups.

RESULTS

The level of cell morphology was significantly lower in Group 2 compared to the other groups (p < 0.05). The extracellular matrix level was also significantly lower in Group 2 compared to the others (p < 0.05). There were no statistically significant differences in collagen levels across Groups 1, 2, and 3 (p > 0.05), nor in cellularity levels among the groups (p > 0.05). General score evaluation levels were significantly lower in Group 2 than in the other groups (p < 0.05).

DICSUSSION

BT performed on the 1/3 posterior part of the RCF demonstrated greater success compared to procedures conducted at the 1/3 median and 1/3 anterior locations for MIRCT.

Novel surgical safety zones on bony-en-face view of humeral greater tuberosity: a fresh cadaveric dissection study

BACKGROUND

The neurovascular alignment in the humeral greater tuberosity (HGT) region has not been thoroughly investigated. However, many studies have documented the vascular-nerve architecture of the proximal humerus. The purpose of this study was to identify novel safety zones on the bony-en-face view of the HGT for surgical procedures.

METHODS

Eighteen complete adult fresh frozen cadavers (36 paired shoulders) were dissected in this study (12 males and 6 females; mean age of 69.39 years). Five landmarks-A, B, C, D, and E-were established to define the boundary of the HGT. Point A was the intersection of the superior facet of HGT and the intertubercular groove of the long head of the biceps tendon. Point B was the junction of the attachment point between the supraspinatus and the infraspinatus muscle. Point C was the intersection of the infraspinatus and the teres minor muscle and point D was the lowest foot point of the teres minor muscle. Point E was on a vertical intersection line from point D to point A. Next, we segmented the individualized pentagon ABCDE into 15 zones. First, we drew line BF to ensure it was perpendicular to DE. Then, we designated points H, J, and M as the midpoints of the supraspinatus, infraspinatus, and teres minor, respectively, with H and J perpendicular to DE and M perpendicular to EA. Finally, we drew perpendicular lines from points J, C, and M to EA, which intersected at points K, G, and L, respectively. The neurovascular structures in each zone were identified to enable the calculation of percentages, allowing for the definition of safe and dangerous zones.

RESULTS

We have identified the specific ranking of the safe zones for branches of the circumflex humeral artery as follows: 1a (19.44%, meaning blood vessels were observed in 7 of 36 shoulders, accounting for 19.44% of the total); 3a (25%); 2a (47.22%); 7 (66.66%); 2b (75%); 1b (77.77%); 3b (80.55%); 4, 10, and 11 (all 88.88%); 6 and 8 (both 91.67%); and 5, 9, and 12 (all 100%). The specific zone ranking of vascular-branch numbers is as follows: 1a < 3a < 2a < 7 < 2b < 1b < 10 < 3b < 4 < 6 < 11 < 8 < 9 < 12 < 5. The specific ranking of the dangerous zones for the anterior branches of the axillary nerve is 8 (5.55%), 11 (8.33%), 10 (38.88%), and 9 (66.66%).

CONCLUSION

We demonstrate the neurovascular distribution in the 15 zones on the bony-en-face view of the HGT, clearly highlighting both safe and dangerous zones. We recommend following clinical suggestions based on our anatomical findings: (1) selection of safe insert points from zones 1a, 3a, 2a, or 7 for screw fixation (Liu-Gang type I & II) and (2) avoidance of neurovascular dangerous zones 8, 11, 10, and 9 for plate fixation. However, we should keep in mind that this technique cannot prevent vascular disruption in these areas.

Osteonecrosis of the Humeral Head Following Arthroscopic Repair of Rotator Cuff Tears: A Case Report

Introduction

The osteonecrosis and the collapse of the humeral head may have many risk factors such as trauma, alcoholism, metabolic diseases, and corticosteroid therapy. Otherwise, it was described as a rare complication of shoulder arthroscopy in the past few years.

Case Report

We report the case of a 65-year-old right-handed woman who had a rotator cuff tear of the right shoulder. She underwent a double-row arthroscopic repair. Six months later she had an intense shoulder pain, with radiological and MRI signs of humeral head osteonecrosis. The patient had a reverse total shoulder arthroplasty.

Conclusion

The aim of this case report is to underline the diagnostic particularities of this complication, and to shed light on the pathogenesis of the interruption of blood supply in the humeral head following rotator cuff repair. We also discuss the management of this complication with reverse total shoulder arthroplasty.

Comparison between osteonecrosis of the humeral and femoral heads - epidemiological analysis of the surgical trend using the nationwide claims database of the republic of Korea

BACKGROUNDS

The humeral head is the second most common site of osteonecrosis, after the femoral head. However, compared to osteonecrosis of the femoral head (ONFH), epidemiological information on osteonecrosis of the humeral head (ONHH) is scarce. We hypothesised that different biomechanical properties of the shoulder from the hip joint might present different epidemiological characteristics of ONHH from those of the ONFH. To evaluate epidemiological differences, we compared trends in the surgical treatment of ONHH and ONFH using the nationwide medical claims database of the Republic of Korea (ROK).

METHODS

We analysed epidemiological data from the Health Insurance Review and Assessment (HIRA) database of the ROK between 2008 and 2018. HIRA database contains almost all medical information in an anonymised form, including demographics, diagnoses, and types of surgical procedures, generated through healthcare practices in ROK. The annual incidence rates of ONHH and ONFH were calculated based on the total number of the general population. Demographics, annual incidence, and the proportion of post-traumatic osteonecrosis and surgical procedures were compared according to the anatomical site and the affected year.

RESULTS

The total number of patients treated for ONHH and ONFH during the study period was 1,028 and 66,260, respectively. Although the incidence of ONHH increased, it is a relatively rare disease compared to ONFH. ONHH occurred more frequently in females, while ONFH occurred predominantly in male patients (p < 0.001). Surgical treatment for ONHH was most frequently performed in older patients (63.7%), whereas middle-aged patients had the largest proportion of ONFH (48.9%, p < 0.001). The proportion of post-traumatic osteonecrosis was significantly higher in the ONHH (5.1%) than in the ONFH (1.9%, p < 0.001). Arthroplasty was performed more frequently in the ONHH (96.0%) than in the ONFH (92.9%, p < 0.001).

CONCLUSION

Despite the anatomical similarities between the hip and shoulder joints, the different biomechanical properties, such as weight-bearing functions, might cause epidemiological differences between ONHH and ONFH.

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.

Unusual Vascular Distribution in the Third Segment of the Axillary Artery

The third segment of the axillary artery (TSAA) is the main vascular supply to the muscles of the upper limb. Numerous studies have reported atypical branching patterns of the TSAA, which can complicate operative interventions involving structures supplied by this segment of the artery. Our current study evaluated a previously undescribed branching pattern in the TSAA, in which the subscapular artery gave rise to an unusual posterior humeral circumflex artery, and a second subscapular artery. In addition, a third variant was found in the origin of the thoracodorsal artery: two collateral horizontal arteries supplying the deep medial surface of the latissimus dorsi muscle. Vascular anatomical variants may affect the classical upper limb interventions requiring modification of the traditional surgical approaches. This case report aims to evaluate these variants from a clinical perspective regarding the management of upper limb trauma, axillary, breast, and muscle flap surgery.

[Effectiveness analysis of proximal humerus internal locking system plate combined with rotator cuff reinforcement suture in treatment of Neer type Ⅳ proximal humerus fracture]

Objective

To investigate the effectiveness of proximal humerus internal locking system (PHILOS) plate combined with rotator cuff reinforcement suture in the treatment of Neer type Ⅳ proximal humerus fracture.

Methods

The clinical data of 48 patients with proximal humeral fractures admitted between January 2016 and December 2020 were retrospectively analyzed, including 18 males and 30 females. The age ranged from 28 to 69 years (mean, 56.3 years). The causes of injury included falling in 39 cases and traffic accident in 9 cases. The time from injury to operation was 2-5 days (mean, 2.8 days). All of them were Neer type Ⅳ proximal humerus fractures, including 11 patients with dislocation. All patients underwent internal fixation with a PHILOS plate after anatomical reduction of the greater nodule, and the rotator cuff was sutured to the plate to reinforce fixation. The operation time was recorded, the wound healing, fracture healing, and complications were observed. The visual analogue scale (VAS) score, Constant-Murley shoulder score, University of California Los Angeles (UCLA) score, and American Shoulder and Elbow Surgeons (ASES) score were used to evaluate shoulder function before operation, at 3 months after operation, and at last follow-up.

Results

The operation time ranged from 65 to 90 minutes (mean, 76.9 minutes). All incisions healed by first intention. All patients were followed up 9-16 months (mean, 12 months). Fracture reduction was good and all fractures healed, the healing time was 2-6 months (mean, 4.6 months). There was no complication such as subacromial impingement, fracture redisplacement, and screw removal during follow-up. One patient had humeral head necrosis, but the basic function of the shoulder joint was acceptable, the symptoms were mild, and no treatment was performed. At 3 months after operation, the upper limb function of the patients basically recovered. The VAS score, Constant-Murley score, UCLA score, and ASES score significantly improved at 3 months after operation and at last follow-up when compared with preoperative, and further improved at last follow-up than at 3 months after operation ( P<0.05).

Conclusion

PHILOS plate combined with rotator cuff reinforcement suture in the treatment of Neer type Ⅳ proximal humerus fracture has the advantages of promoting early postoperative rehabilitation exercise, improving postoperative function of shoulder joint, and reducing complications.

Diagnosis and treatment of avascular necrosis of the humeral head: Current concepts

Avascular necrosis (AVN) of the humeral head is an uncommon clinical entity which can result in significant morbidity for patients. There is a paucity of literature concerning humeral head AVN, which may be due to the relatively rarity of the condition and poorly understood nature. Despite being first described decades ago, the underlying pathophysiology leading to humeral head AVN is still poorly defined. While the staging of humeral head AVN is well described, not much is known about prognosticating factors to predict the eventual course. Most of the management options are based on that of femoral head AVN, and even so, there is a paucity of good quality clinical trials in the literature. This current concepts paper describes what is known about humeral head AVN and proposes a management algorithm to guide clinicians.

Rapidly destructive osteonecrosis of the humeral head after arthroscopic rotator cuff repair: a case report

Background

Cases of rapidly destructive osteonecrosis (RDON) of the humeral head after arthroscopic rotator cuff repair (RCR) have rarely been reported, which has prevented a clear consensus on the cause of osteonecrosis.

Case presentation

A 63-year-old woman without a history of trauma underwent arthroscopic RCR after being diagnosed with a medium-sized full-thickness rotator cuff tear for symptoms of left shoulder pain for six months. The patient had no medical history other than hypertension, and no other potential cause was found for osteonecrosis of the left shoulder prior to surgery. Four months after surgery, pain and range of motion improved. Six months after surgery, the patient complained of an increase in shoulder pain. While follow-up ultrasonography did not show a re-tear of the repaired tendon, osteonecrosis of the humeral head could not be confirmed as plain radiography was not performed. Follow up MRI performed a year after surgery revealed RDON of the humeral head. Despite mild improvement in the shoulder pain, the Shoulder Rating Scale of the University of California at Los Angeles (UCLA) and Constant score were poor at 23 and 69, respectively. In the present case, the arthroscopic RCR was performed using two anchors; for the repair of the anterior of the supraspinatus and the rotator interval, a 2.8-mm all-suture anchor was inserted into the upper part of the intertubercular groove. The cause of RDON is presumed to be the damage to the anterolateral and intraosseous branches of the anterior humeral circumflex artery (AHCA) for anchor positioning and insertion.

Conclusions

A poor outcome was obtained in the case of RDON, despite the integrity of the repaired rotator cuff tendon after arthroscopic RCR was intact. Although the cause of RDON has not been clearly established, care should be taken not to damage the anterolateral and intraosseous branches of the AHCA regarding the insertion location of the suture anchor, and to prepare the anchor in the vicinity of the intertubercular groove.

Pegs not superior to screws for fixation of fractures of the proximal humerus

Background

Angular stable plates were introduced two decades ago as a promising treatment for fixation of displaced fractures of the proximal humerus (PHF). However, high rates of adverse events and reoperations have been reported. One frequent reason is secondary penetration of screws into the glenohumeral joint, due to sinking of the fracture or avascular head necrosis. To prevent joint penetrations angular stable plates with smooth locking pegs instead of locking screws have been developed. The aim of the present study was to investigate whether blunt pegs instead of pointed screws reduced the risk of secondary penetration into the glenohumeral joint during fracture healing after operatively treated PHFs.

Methods

From two different patient cohorts with displaced PHFs (60 treated with PHILOS plate with screws and 50 with ALPS-PHP plate with pegs), two groups were matched according to fracture type AO/OTA 11-B2 and 11-C2 and age (55–85 years). They were followed up at 3, 6 and 12 months. Primary outcome was radiographic signs of peg or screw penetrations into the glenohumeral joint at 12 months. Secondary outcomes were Oxford shoulder score (OSS) and Constant Score (CS) and radiographic signs of avascular humeral head necrosis (AVN).

Results

Eighteen PHILOS patients with B2 and C2 fractures could be matched with a corresponding group of 18 operated with ALPS-PHP with pegs. The number of penetrations of pegs and screws were equal between the two groups and the development of avascular head necrosis did not differ either. The functional outcomes for both OSS and CS at 12 months was clearly in favor of patients without joint penetrations in both groups.

Conclusion

We found no differences in the number of screw or peg penetrations in the PHILOS and ALPS-PHP group and the occurrence of AVN was equal. Joint penetrations led to inferior functional outcomes at 1 year.

The ClinicalTrials.gov identifier 20/11/12 prospectively for the Philos Group is NCT01737060, and for the ALPS group 11/03/20 retrospectively is NCT04622852.