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

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.

Steroid-induced osteonecrosis of the humeral head in a 20-year-old man treated with an osteochondral autograft: A case report

To our knowledge, only one previous report described the treatment of osteochondral autograft for steroid-induced osteonecrosis of the humeral head (ONHH) in a middle-aged patient. The present report describes a 20-year-old man who was found to have avascular osteonecrosis of the right humeral head after corticosteroid pulse treatment, followed by oral corticosteroid therapy. The patient complained of serious right shoulder pain and limited range of motion (ROM). Anteroposterior (AP) radiographs of the right shoulder revealed a crescent sign at the humeral head, indicating subchondral bone collapse with a linear sclerotic change and normal articular surface of the glenoid. The case was categorized as Stage 3 according to the Cruess classification. In general, Cruess classification Stage 3 is treated with humeral head replacement and shoulder arthroplasty. The patient underwent surgical treatment involving osteochondral autograft transplantation. Autografts were harvested from the right knee. At the 1.5-year follow-up, the patient was pain-free and showed an improved active ROM. Furthermore, AP radiographs demonstrated that the glenohumeral joint space was maintained, and no progression of humeral head collapse was observed. This case may be helpful in decision-making if young patients with ONHH require surgical treatment. Furthermore, osteochondral autograft transplantation may be an effective treatment for ONHH.

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.

[Post-traumatic necrosis of the humeral head-Endoprosthesis or joint preservation]

BACKGROUND

Humerus fractures play a major role in daily clinical routine, and subsequent osteonecrosis is common after osteosyntheses.

OBJECTIVES

The current paper highlights the incidence and cause of osteonecrosis after proximal humerus fractures, with respect to presentation of anatomy and risk factors.

METHODS

Display of the literature and therapy options for humerus fracture and subsequent necrosis.

RESULTS

Humerus fractures are the seventh most frequent fractures in humans. The complication rate is 40%, and the described rate of necrosis is up to 34%. Accordingly, the surgical revision rate is at 19% according to recent literature.

CONCLUSION

The treatment of humerus head fracture must consider numerous variables. The individual type of fracture and the current individual situation of the patient must be included in the process of choosing the right treatment. Modern implants with screw locking features should be used, and for certain circumstances the direct implantation of a prosthesis should be considered. Thereby the expectations of the patient with respect to the postoperative activity level play a major role.

Survivorship of total shoulder arthroplasty vs. hemiarthroplasty for the treatment of avascular necrosis at greater than 10-year follow-up

BACKGROUND

Avascular necrosis (AVN) of the humeral head is a debilitating pathology that can be managed with an array of treatments depending on disease staging. Humeral head arthroplasty for AVN has demonstrated good short-term improvements in pain and range of motion, but the published long-term outcomes data are limited. The objective of this study was to report long-term survivorship and outcomes for patients undergoing hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) for the treatment of AVN of the humeral head.

METHODS

The practice of one fellowship-trained shoulder surgeon was queried for the surgical treatment of AVN of the humeral head via appropriate International Classification of Diseases, Ninth and Tenth Revision, codes. Sixteen shoulders that met inclusion criteria were identified. Demographics included the radiographic stage, age, sex, American Society of Anesthesiologists (ASA) score, and body mass index. The primary endpoint was survivorship of the implant. Secondary endpoints were range of motion in forward elevation, internal and external rotation, visual analog scale for pain, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, and the Simple Shoulder Test score.

RESULTS

Of the 16 shoulders included in the study, 10 underwent HA and 6 underwent TSA. The TSA cohort was significantly older (mean 60.5 vs. 44.2, P = .005), with a higher mean ASA score (mean 3.0 vs. 2.13, P = .02) than the HA group. The 10-year survivorship rates were 88.9% for HA and 80% for TSA with no significant difference between groups. Survivorship data were available for a mean 13.0 ± 5.6 years' follow-up in the HA group and 13.8 ± 4.8 years in the TSA group. When compared to one another, the results between HA and TSA only differed in internal rotation, which was statistically significantly improved in the TSA group compared with HA (2.3 ± 2.6 compared with -3.0 ± 5.0, P = .03).

CONCLUSION

The survivorship of both TSA and HA for the treatment of AVN was at least 80% at 10 years. Secondary endpoints, such as range of motion, pain, and shoulder function, improved significantly postoperatively in each cohort and were similar between the 2 groups, except for internal rotation, which had improved significantly more in the TSA group than in HA. Both TSA and HA are viable options for the treatment of AVN, each with durable long-term survival.

Midterm results of pyrocarbon interposition shoulder arthroplasty: good outcomes after posttraumatic osteonecrosis without malunion of the tuberosities

Background

In vitro data demonstrate the potential benefits of the pyrocarbon as a bearing material against cartilage or bone. And pyrocarbon-free interposition arthroplasty has been used with positive outcomes for over 10 years for hand and wrist joint replacements. This study reports the midterm results of a Pyrocarbon Interposition Shoulder Arthroplasty (PISA) in primary and secondary glenohumeral osteoarthritis and in avascular osteonecrosis.

Methods

This prospective noncontrolled, multicenter study included 67 consecutive patients who underwent PISA in France and Sweden.

Results

A cohort of 48 patients, aged 50 ± 12 years, was available for clinical assessment at a mean follow-up of 67.6 ± 9.3 months. A favorable change was reported with a mean absolute Constant score improvement of 32 ± 20 points. The highest Constant score improvement was observed in patients with avascular osteonecrosis (42 ± 18 points; P ≤ .0001). Between the earliest and the latest follow-up, radiographic analyses revealed only 2 major glenoid erosions and 4 tuberosity thinnings and thus that 86.4% of 44 shoulders remained stable with no or minor radiologic evolutions. The survival rate was 84 % at 65 months of follow-up considering all causes of revision.

Conclusion

The radiographic findings seem to confirm the interest of pyrocarbon in preserving bony surfaces. But the risk of tuberosity thinning suggests considering the use of PISA with caution in most degenerative glenohumeral joint pathologies, although the midterm outcomes highlight PISA as a suitable solution for patients presenting with posttraumatic osteonecrosis without malunion of the tuberosities and with an intact rotator cuff.

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.

Outcomes and complications after arthroplasty in patients with osteonecrosis of humeral head- systematic review

BACKGROUND

The purpose of this study was to investigate the outcomes and complications of hemiarthroplasty (HA) and total shoulder arthroplasty (TSA) in patients of osteonecrosis of humeral head (ONHH) through systematic review.

METHODS

PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines were followed by utilizing the PubMed, EMBASE, Scopus, Ovid, and Cochrane Library databases. Keywords included ONHH, avascular necrosis, head replacement, hemiarthroplasty, or total shoulder arthroplasty. Methodological Index for Nonrandomized Studies (MINORS) was used for quality assessment.

RESULTS

Ten studies (416 shoulders) were finally eligible and mean MINORS score was 11.9 (ranges, 8-16). HA was performed in 255 shoulders (61.3%) and TSA in 161 (38.7%). Mean age of the patients at the time of surgery was 50.6 years and mean follow-up period was 73.1 months. All clinical scores with range of motion were significantly improved after surgery. Overall complication rate was 20.0% with 10.1% in HA and 17.5% in TSA (p = 0.077). Overall reoperation rate was 11.2% with 7.0% in HA and 15.0% in TSA (p = 0.046). Overall revision rate was 6.4% with 5.7% in HA and 9.2% in TSA (p = 0.349).

CONCLUSIONS

Both HA and TSA in patients with ONHH yielded functional improvement with pain relief, but TSA had higher reoperation rate compared to HA.

Treatment of avascular necrosis of the humeral head - Postoperative results and a proposed modification of the classification

BACKGROUND

Avascular necrosis of the humeral head after proximal humeral fracture i.e. type 1 fracture sequelae (FS) according to the Boileau classification is a rare, often painful condition and treatment still remains a challenge. This study evaluates the treatment of FS type 1 with anatomic and reverse shoulder arthroplasty and a new subclassification is proposed.

METHODS

This single-center, retrospective, comparative study, included all consecutive patients with a proximal humeral FS type 1 treated surgically in a four-year period. All patients were classified according to the proposed 3 different subtypes. Constant score (CS), Quick DASH score, subjective shoulder value (SSV) as well as revision and complication rate were analyzed. In the preoperative radiographs the acromio-humeral interval (AHI) and greater tuberosity resorption were examined.

RESULTS

Of 27 with a FS type 1, 17 patients (63%) with a mean age of 64 ± 11 years were available for follow-up at 24 ± 10 months. 7 patients were treated with anatomic and 10 with reverse shoulder arthroplasty. CS improved significantly from 16 ± 7 points to 61 ± 19 points (p < 0.0001). At final follow-up the mean Quick DASH Score was 21 ± 21 and the mean SSV was 73 ± 21 points. The mean preoperative AHI was 9 ± 3 mm, however, 8 cases presented an AHI < 7 mm. 4 cases had complete greater tuberosity resorption. The complication and revision rate was 19%; implant survival was 88%.

CONCLUSION

By using the adequate surgical technique good clinical short-term results with a relatively low complication rate can be achieved in FS type 1. The Boileau classification should be extended for fracture sequelae type 1 and the general recommendation for treatment with hemiarthroplasty or total shoulder arthroplasty has to be relativized. Special attention should be paid to a decreased AHI and/or resorption of the greater tuberosity as indirect signs for dysfunction of the rotator cuff. To facilitate the choice of the adequate prosthetic treatment method the suggested subclassification system should be applied.

Management of Posttraumatic Avascular Necrosis of the Proximal Humerus

The etiology of avascular necrosis (AVN) of the proximal humerus can be classified as idiopathic or posttraumatic, the latter being mainly due to proximal humerus fractures. Evidence suggests that posttraumatic AVN may require surgical intervention more often than idiopathic AVN of the proximal humerus. This article provides a comprehensive review of the management of posttraumatic AVN of the proximal humerus. Early stage AVN (stages 1 to 3) is commonly treated with nonoperative intervention or core decompression of the humeral head, whereas later stage disease (stages 4 and 5) may require hemiarthroplasty or total shoulder arthroplasty to restore function. [Orthopedics. 2021;44(6):367-375.].

Clinical and Radiological Results of Hemiarthroplasty and Total Shoulder Arthroplasty for Primary Avascular Necrosis of the Humeral Head in Patients Less Than 60 Years Old

Background: Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) have shown good clinical outcomes in primary avascular necrosis of the humeral head (PANHH) both in short and long terms. The purpose of this study was to assess the complications, the clinical and radiological outcomes of shoulder arthroplasty in young patients with PANHH. Methods: One hundred and twenty-seven patients aged under 60 years old and suffering from PANHH were operated with arthroplasty. Patients were assessed clinically and radiographically before surgery with a minimum of 2 years of follow up (FU). Results: HA was performed on 108 patients (85%). Two patients were revised for painful glenoid wear after 2 and 4 years. TSA was performed on 19 patients (15%). Five TSA had to be revised for glenoid loosening (n = 4) or instability (n = 1). Revision rate was 26% with TSA and 2% with HA. There were no significant differences between HA and TSA in terms of clinical outcomes. Conclusions: With a mean FU of 8 years, HA and TSA improved clinical outcomes of patients with PANHH. HA revisions for painful glenoid wear were rare (2%). The revision rate was excessively high with TSA (26%).

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.

Arthroscopically Assisted Surgical Decompression and Fibular Strut Grafting for Proximal Humerus Avascular Necrosis: Surgical Technique

Avascular necrosis is a relatively common entity that affects the proximal humerus and can lead to substantial morbidity. It often occurs in younger patients for whom the traditional treatment of shoulder arthroplasty is not optimal. Fibular strut grafting to prevent humeral head collapse has been described as a viable treatment option. However, it is technically challenging to direct the fibular strut graft into the center of the bony infarct, where it will be most effective. This paper describes a technique of arthroscopically assisted fibular strut grafting for avascular necrosis of the humerus. This is a minimally invasive technique with low morbidity and an accurate way of placing the graft into the infarcted segment.

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.

Progressive glenoid bone loss caused by erosion in humeral head resurfacing

BACKGROUND

Cementless surface replacement of the shoulder represents an alternative to conventional stemmed anatomic prostheses. Glenoid erosion is a well-known complication in hemiarthroplasty. However, there is limited data concerning radiographic evaluation and prognostic factors for this phenomenon.

OBJECTIVES

The aim of our study was to determine the development of glenoid erosion following shoulder resurfacing using a new measurement technique and detect potential prognostic factors.

MATERIALS AND METHODS

We performed a retrospective analysis on 38 shoulders undergoing humeral head resurfacing with a mean follow-up of 65.4 ± 43 months. Clinical and radiographic evaluation followed a standardized protocol including pre- and postoperative Constant score, active range of motion, and X‑rays in true anteroposterior view. Three independent observers performed measurements of glenoid erosion.

RESULTS

We found good interobserver reliability for glenoid erosion measurements (intraclass correlation coefficient [ICC] 0.74-0.78). Progressive glenoid erosion was present in all cases, averaging 5.5 ± 3.9 mm at more than 5 years' follow-up. Male patients demonstrated increased glenoid bone loss within the first 5 years (p < 0.04). The mean Constant score improved to 55.4 ± 23.6 points at the latest follow-up. Younger age was correlated to increased functional outcome. Revision rate due to painful glenoid erosion was 37%.

CONCLUSIONS

Glenoid erosion can be routinely expected in patients undergoing humeral head resurfacing. Painful glenoid erosion leads to deterioration in functional outcome and necessitates revision surgery in a high percentage of cases.

Outcomes of shoulder replacement in humeral head avascular necrosis

BACKGROUND

This retrospective review evaluated 25 patients with 29 shoulders treated with arthroplasty for humeral head avascular necrosis (HHAVN) between 2004 and 2015. We hypothesized that regardless of implant, radiographic stage, or etiology, patients would appreciate significant improvement in pain, range of motion, and shoulder functionality after surgical intervention.

METHODS

Data were obtained by record review on all patients meeting inclusion criteria. Outcomes were evaluated using Simple Shoulder Test, Modified Constant Score, University of California Los Angeles Shoulder Rating Scale, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. The data were assessed by all patients and subcategories (treatment, avascular necrosis stage, and underlying cause).

RESULTS

At a mean follow-up of 3.9 years (range, 1-8.5 years), all patients who underwent operative intervention for HHAVN showed statistically significant improvement in functionality measurements (P < .01). Patients who underwent total shoulder arthroplasty (TSA) noted higher median outcome scores and greater improvement in all scoring methods compared with their hemiarthroplasty counterparts. The high-stage disease shoulders showed similar trends over low-stage counterparts. The shoulders in the trauma causal group had the highest scores in 3 of 4 outcome measures and favorable change in all scoring methods. These differences were not statistically significant (P > .05). No revision arthroplasties were required. Minor complications (suture abscess and intraoperative calcar fracture requiring cabling) occurred in 2 TSA patients.

CONCLUSIONS

Our outcomes demonstrate that in the short- to midterm follow-up, TSA or hemiarthroplasty is a safe and equally effective treatment for patients diagnosed with HHAVN regardless of etiology and radiographic staging.

The staged management of gleno-humeral joint osteonecrosis in patients with haematological-induced disease-a cohort review

PURPOSE

A formalised, universally accepted, radiological staging system of gleno-humeral joint osteonecrosis (ON) is lacking. Consequently, there is absence of a standardised management strategy. The aim is to propose a simple radiological staging system of gleno-humeral joint ON based on principles of the Association Research Circulation Osseous (ARCO) Society and review of clinical practice.

METHODS

A radiographic and clinical review of 45 patients with haematological-induced gleno-humeral ON was performed. The related management plans were analysed and categorised.

RESULTS

Analysis divided the disease into stages 0-4. Non-interventional management was the first-line treatment in stages 1-2. If unsuccessful, arthroscopic core decompression was performed. Patients with stages 3-4 were initially managed conservatively. If unsuccessful, in younger patients, arthroscopic joint debridement and capsular release was trialled. In older patients, or where this approach failed, shoulder arthroplasty was advised.

CONCLUSION

The simple radiological classification assessed is useful to the provision of a standardised staged management strategy of gleno-humeral ON.

Cementless humeral head resurfacing for degenerative glenohumeral osteoarthritis fails at a high rate

Purpose

The aim of the study was to examine clinical and radiographic results of a cementless humeral surface and to evaluate prognostic parameters for implant failure.

Methods

34 shoulders were examined preoperatively and after a mean 2.7 years. Radiographic parameters, Constant scores (CS) and complications were recorded.

Results

The mean CS improved from 27 to 51 points. Eight patients (24%) had an implant revision for secondary glenoid erosion. In the revision group was an increase of the LGHO of 8.4%.

Conclusions

The study shows a high revision-rate (24%). Predictor for an implant failure was an operative changing of the LGHO.

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.

Radiological and functional 24-month outcomes of resurfacing versus stemmed anatomic total shoulder arthroplasty

PURPOSE

This study compared clinical and radiographic outcomes of patients undergoing resurfacing total shoulder arthroplasty (TSA) with those treated with a stemmed TSA.

METHODS

Patients with primary osteoarthritis who underwent humeral resurfacing (RES) or stemmed (STA) TSA were identified in our shoulder arthroplasty register for retrospective analysis. Standard radiographs and clinical/patient-rated assessments were made up to 24 months post-surgery. Implant revisions were assessed. Patients were frequency-matched in a 1:1 (RES:STA) ratio based on gender and age, and compared with regard to operation time and shoulder function (Constant, SPADI and Quick DASH scores). Mixed models with statistical adjustments were applied.

RESULTS

From 2006 to 2014, 44 RES and 137 STA operations were performed in 157 patients; one and two revisions were recorded in the RES and STA group, respectively. The final matched cohort included a total of 69 patients and 37 operations per treatment group. Resurfacing TSA was 17 min shorter (95%CI: 5-28) compared to the stemmed procedure (p = 0.005). RES and STA patients showed significant functional improvement six months post-implantation, yet all measured scores did not differ between the groups at 2 years (p ≥ 0.131). The status of static centering of the humeral head, acromiohumeral distance, and a lack of signs of implant loosening were also similar between treatments.

CONCLUSION

Similar 24-month post-operative radiological and functional outcome is achieved by RES and STA patients, even with a shorter RES surgery time. Larger cohorts and longer follow-up are required to better assess implant survival.

Core decompression and arthroplasty outcomes for atraumatic osteonecrosis of the humeral head

BACKGROUND

Humeral head osteonecrosis treatment varies depending on the stage and symptoms. Successful outcomes for humeral head core decompression for stage I/II disease in chronic steroid-induced (CSI) osteonecrosis have been reported, but fewer data exist for sickle cell disease (SCD) etiology. Resurfacing and hemiarthroplasty or total shoulder arthroplasty (TSA) are common for advanced collapse, with mixed results.

METHODS

We evaluate radiographic and functional outcomes after procedures for humeral head atraumatic avascular necrosis (HAAVN), decompression efficacy in CSI and SCD populations, and report outcomes of advanced disease requiring arthroplasty. Twenty-five shoulders were treated surgically for HAAVN. Post-traumatic AVN patients were excluded. Stage I/II disease received core decompression and ultrasound bone stimulation. Stage III received surface replacement or hemiarthroplasty, and arthroplasty was performed for stage IV/V. Radiographs and clinical scores were recorded preoperatively and postoperatively.

RESULTS

Included were 25 HAAVN shoulders (13 SCD and 12 CSI). Eleven shoulders (stage I/II disease) underwent core decompression. Seven of 8 shoulders (88%) progressed to stage III/IV after decompression. All SCD patients progressed to collapse. The procedure in 19 shoulders was surface replacement, hemiarthroplasty, or TSA. Constant, American Shoulder and Elbow Surgeons, Simple Shoulder Test-12, and University of California Los Angeles Shoulder scores were significantly higher at 1- and 2-year follow-up with arthroplasty; 13 of 16 arthroplasty patients (81%) had satisfactory to excellent results. One surface replacement was revised to reverse TSA.

CONCLUSIONS

Results suggest core decompression for AVN in SCD patients does not alter osteonecrosis progression and humeral head collapse. Resurfacing and hemiarthroplasty are viable treatment options for stage III, whereas shoulder replacement for stage IV/V disease appears to offer better functional results.

Shoulder joint replacement can improve quality of life and outcome in patients with dysmelia: a case series

Background

Arthroplasty is a proven treatment option for glenohumeral osteoarthritis. Common indications include primary or posttraumatic osteoarthritis, avascular necrosis of the humeral head, rotator cuff tear arthropathy and rheumatoid osteoarthritis. Arthroplasty is rarely performed among patients with glenohumeral dysmelia. An overuse of the upper limb in patients with thalidomide-induced phocomelia and people with similar congenital deformities like dysmelia results in premature wear of the shoulder joint. This study aims to evaluate our experience with cases of glenohumeral osteoarthritis caused by dysmelia and treated with arthroplasty. To date, few reports on the outcome of shoulder arthroplasty exist on this particular patient group.

Case presentation

We included four dysmelic patients (five shoulders) with substantial glenoid dysplasia in a prospective database after approval by the local ethics committee. Once conservative treatment options had been exhausted, the patients were treated with shoulder arthroplasty and assessed clinically and radiographically before and after surgery. The mean patient age at the time of surgery was 50.4 years. The minimum follow-up time was 24 months (24–91 months). All patients experienced a considerable improvement of range of motion (ROM) and a relief of pain. No intra- or postoperative complications appeared.

Conclusion

Patients with dysmelia have acceptable short and mid-term results with resurfacing hemiarthroplasty. It is an effective although somewhat complicated method to relieve pain and improve movement. Long-term performance of arthroplasty in patients with dysmelia remains to be seen, particularly with regard to the remaining problem of the altered and often deficient glenoid.

Post-traumatic osteonecrosis of the proximal humerus

Post-traumatic osteonecrosis of the proximal humerus represents a challenging problem to the surgeon. It is commonly seen following multi-fragmentary fractures of the proximal humerus which may affect the long-term functional recovery after such injuries. This review summarises the current evidence on risk factors, reasons why estimating its epidemiology is difficult, the vascular supply of the humeral head, classification, and management options.

Results of cementless humeral head resurfacing with cemented glenoid components

PURPOSE

The aim of this study was to analyse the short- and medium-term clinical and radiographic results of cementless humeral head resurfacing in combination with a cemented glenoid component.

METHODS

Thirty-five patients with a mean age of 65 years (range 42-84) and a mean follow-up of three years (two to six) were followed up. The Constant score with its subgroups as well as shoulder motions and complications were recorded. Radiographs in two planes were analysed for loosening of the components.

RESULTS

Mean Constant score improved from 29 points (6-63) to 70 points (41-89; p < 0.001). Mean shoulder flexion increased from 89° (20-170) to 158° (100-180) and mean external rotation from 10° (-10-30) to 39° (10-80). Satisfaction rate was 94 % at final follow-up. None of the components was found to be loose. There were three neurological complications, probably related to increased forces on the humeral head retractor during glenoid preparation. Two of them resolved completely; in one patient hyposensitivity remained.

CONCLUSION

Cementless humeral surface replacement arthroplasty in combination with a cemented glenoid component leads to an overall satisfactory clinical outcome. However, the high rate of neurological complications found in this study, probably related to difficult glenoid exposure, led us to discontinue this implant configuration.

Stress-shielding induced bone remodeling in cementless shoulder resurfacing arthroplasty: a finite element analysis and in vivo results

Cementless surface replacement arthroplasty (CSRA) of the shoulder was designed to preserve the individual anatomy and humeral bone stock. A matter of concern in resurfacing implants remains the stress shielding and bone remodeling processes. The bone remodeling processes of two different CSRA fixation designs, conical-crown (Epoca RH) and central-stem (Copeland), were studied by three-dimensional (3-D) finite element analysis (FEA) as well as evaluation of contact radiographs from human CSRA retrievals. FEA included one native humerus model with a normal and one with a reduced bone stock quality. Compressive strains were evaluated before and after virtual CSRA implantation and the results were then compared to the bone remodeling and stress-shielding pattern of eight human CSRA retrievals (Epoca RH n=4 and Copeland n=4). FEA revealed for both bone stock models increased compressive strains at the stem and outer implant rim for both CSRA designs indicating an increased bone formation at those locations. Unloading of the bone was seen for both designs under the central implant shell (conical-crown 50-85%, central-stem 31-93%) indicating high bone resorption. Those effects appeared more pronounced for the reduced than for the normal bone stock model. The assumptions of the FEA were confirmed in the CSRA retrieval analysis which showed bone apposition at the outer implant rim and stems with highly reduced bone stock below the central implant shell. Overall, clear signs of stress shielding were observed for both CSRAs designs in the in vitro FEA and human retrieval analysis. Especially in the central part of both implant designs the bone stock was highly resorbed. The impact of these bone remodeling processes on the clinical outcome as well as long-term stability requires further evaluation.

Durability of partial humeral head resurfacing

BACKGROUND

Partial humeral head resurfacing arthroplasty uses a stemless device, which conserves bone and restores normal anatomy. We hypothesized that this does not offer a reasonable alternative to full resurfacing or total shoulder arthroplasty.

METHODS

We performed a retrospective study of 39 shoulders with focal chondral defects of the humeral head treated with partial resurfacing arthroplasty. A minimum of 2 years' follow-up was reported, unless failure and operative intervention superseded this duration. The mean follow-up period was 51.3 months. The mean age was 45.6 years (range, 27-76 years). Preoperative and postoperative evaluation included history, physical examination, radiographs, and clinical scoring with the American Shoulder and Elbow Surgeons Shoulder Score Index and Subjective Shoulder Value.

RESULTS

Of the 39 shoulders, 25 (64.1%) showed functional improvement and decreased pain. Significant mean improvements were observed in forward flexion (121° to 152°, P = .002), external rotation (37° to 58°, P = .0003), mean Subjective Shoulder Value (31% to 74%, P < .0001), and ASES score (29 to 70, P < .0001). However, at a mean of 26.6 months' follow-up, the failure group included 6 patients (15.3%) who underwent revision and another 4 (10.2%) who were recommended to undergo revision. Patients with no prior or concomitant procedures were rare (n = 5) but had the most reliable outcomes with partial resurfacing, with no failures in that group. Of the 24 patients with prior procedures, 5 had undergone revision, and the clinical outcome scores for the remaining patients were consistently lower than those seen in patients without prior procedures.

CONCLUSION

Concomitant pathology and prior or concomitant surgical procedures potentially impair the outcome of the resurfacing procedure and could be a contraindication. Long-term success remains guarded with this treatment modality, especially in patients whose chondral injury is not an isolated finding.

Outcome of Copeland shoulder resurfacing arthroplasty with a 4-year mean follow-up

BACKGROUND

Published data on the outcome of Copeland shoulder resurfacing arthroplasty (CSRA) are limited. This observational case series study reports the functional and radiological outcome of CSRA during a mean follow-up of 4 years and highlights the correlation between key outcome measures.

METHODS

One-hundred two consecutive patients with osteoarthritis (OA-47.1%), rheumatoid arthritis (RA-40.2%), rotator cuff arthropathy (RCA-8.8%), and avascular necrosis (AVN-3.9%) underwent CSRA. The outcome assessment included pain and satisfaction, physical limitation, Oxford Shoulder score (OSS), Constant score (CS), and SF-12. Imaging was reviewed for glenoid morphology (Walch classification) and humeral head (HH) migration.

RESULTS

Highest patient satisfaction and lowest pain levels were related to the primary pathology with AVN best followed by OA, RA, and with RCA having the poorest outcome. Comparing the two largest groups the CS was significantly higher in OA (61 ± 21.3) than RA (44 ± 20.5). OSS showed a significant correlation with CS and physical subscale of SF-12. Walch type A (67.6%) and HH migration (47%) were the commonest radiographic observations. OSS, CS, pain, and satisfaction were significantly different between migration and nonmigration groups.

CONCLUSION

The CSRA resulted in satisfactory outcome in many patients. AVN and OA were associated with the best and RCA with the poorest results. The CSRA was associated with glenoid erosion and HH migration particularly in RCA. CSRA remains an option in the treatment of arthritic conditions of the shoulder but its future use may be limited to younger patients where implanting a glenoid may be regarded as problematic.

Thermal damage during humeral reaming in total shoulder resurfacing

INTRODUCTION

Total shoulder resurfacing (TSR) provides a reliable solution for the treatment of glenohumeral arthritis. It confers a number of advantages over traditional joint replacement with stemmed humeral components, in terms of bone preservation and improved joint kinematics. This study aimed to determine if humeral reaming instruments produce a thermal insult to subchondral bone during TSR.

PATIENTS AND METHODS

This was tested in vivo on 13 patients (8 with rheumatoid arthritis and 5 with osteoarthritis) with a single reaming system and in vitro with three different humeral reaming systems on saw bone models. Real-time infrared thermal video imaging was used to assess the temperatures generated.

RESULTS

Synthes (Epoca) instruments generated average temperatures of 40.7°C (SD 0.9°C) in the rheumatoid group and 56.5°C (SD 0.87°C) in the osteoarthritis group (P = 0.001). Irrigation with room temperature saline cooled the humeral head to 30°C (SD 1.2°C). Saw bone analysis generated temperatures of 58.2°C (SD 0.79°C) in the Synthes (Epoca) 59.9°C (SD 0.81°C) in Biomet (Copeland) and 58.4°C (SD 0.88°C) in the Depuy Conservative Anatomic Prosthesis (CAP) reamers (P = 0.12).

CONCLUSION

Humeral reaming with power driven instruments generates considerable temperatures both in vivo and in vitro. This paper demonstrates that a significant thermal effect beyond the 47°C threshold needed to induce osteonecrosis is observed with humeral reamers, with little variation seen between manufacturers. Irrigation with room temperature saline cools the reamed bone to physiological levels and should be performed regularly during this step in TSR.

Prognostic factors and limitations of anatomic shoulder arthroplasty for the treatment of posttraumatic cephalic collapse or necrosis (type-1 proximal humeral fracture sequelae)

BACKGROUND

The aim of this study was to evaluate the prognostic factors and limitations of anatomic unconstrained shoulder arthroplasty, performed without tuberosity osteotomy, for the treatment of secondary glenohumeral arthritis following posttraumatic cephalic collapse or necrosis of the humeral head, defined as type-1 fracture sequelae.

METHODS

Fifty-five patients with type-1 fracture sequelae treated with anatomic shoulder arthroplasty were included in this retrospective single-center cohort study. All anatomic humeral prostheses were implanted without performing a greater tuberosity osteotomy. Glenoid resurfacing was performed in forty-four patients (80%). Clinical and radiographic analysis was performed at a mean of fifty-two months (range, twenty-four to 180 months) postoperatively.

RESULTS

Four reoperations (7%) were performed, including two revisions in patients who required glenoid resurfacing because of glenoid erosion after hemiarthroplasty. At the time of the latest follow-up, 93% of patients were satisfied or very satisfied, and the mean Subjective Shoulder Value (SSV) was 81%. There were significant improvements in the mean Constant score (from 32 to 69 points), active anterior elevation (from 88° to 141°), external rotation (from 6° to 34°), and internal rotation (from the buttock to L3). Significantly poorer results were associated with proximal humeral deformity in varus and with fatty infiltration of the rotator cuff muscles. Patients with proximal humeral deformity, specifically varus or valgus malunion of the greater tuberosity, had a mean Constant score that was 10 points lower and active elevation that was almost 20° less than patients with no such deformity. The poorest results were observed in patients with varus malunion.

CONCLUSIONS

Our study confirmed that the outcomes of anatomic shoulder arthroplasty for the treatment of type-1 fracture sequelae are good and predictable when deformation of the proximal humerus is acceptable(i.e., when no greater tuberosity osteotomy is necessary). The results were negatively affected by proximal humeral varus deformity and by fatty infiltration of the rotator cuff on imaging studies. In such cases, reverse shoulder arthroplasty may be more appropriate, especially in elderly patients.

Geometrical analysis results of 42 resurfacing shoulder prostheses: A CT scan study

BACKGROUND

Shoulder resurfacing arthroplasty was introduced in Scandinavia in the early 1980s then developed by SA Copeland.

HYPOTHESIS

Resurfacing prostheses restore the normal anatomy of the proximal humerus. Here, our objective was to evaluate humeral resurfacing prosthesis position on radiographs and computed tomography (CT) images.

MATERIALS AND METHODS

We retrospectively reviewed 42 consecutive cases seen at a single centre between 2004 and 2009. Mean patient age was 65 years. CT was performed routinely before prosthesis implantation and at re-evaluation. The Copeland Mark III(®) (Biomet France SARL, 26903 Valence, France) implant was used in 32 cases and the Aequalis Resurfacing Head(®) (Tornier France, 38334 Saint-Ismier, France) in 10 cases. The post-implantation CT images were used to measure the angle of inclination, medial humeral offset, lateral glenohumeral offset, and version of the implant.

RESULTS

Mean follow-up was 18 months. Compared to baseline, no significant changes were found at re-evaluation for the angle of inclination or lateral glenohumeral offset. In contrast, medial humeral offset increased by 3.47mm, and excessive anteversion of 4.23° compared to the bicondylar line was noted.

DISCUSSION

Humeral head resurfacing prostheses restore the overall anatomy of the proximal humeral head. Our CT scan evaluation protocol seems reproducible and enables an evaluation of implant geometry. In our experience, resurfacing arthroplasty restored the native humeral offset. Inadequate retroversion was noted and was probably related to insufficient exposure during surgery.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Humeral head resurfacing in central bone defects: in vitro stability of different implants with increasing defect size

We examined the rotary motions of two distinct cementless surface replacement arthroplasties of the shoulder that were implanted on humeri with central spherical bone defects of 8%, 17%, and 37% of the head volume (n = 5 each). Rotary motions were measured under a cyclic torque application and translated into relative micromotions. Implant A with a perforated central crown had micromotions < 150 µm in all bony defects and during all simulated shoulder activities. Implant B with a central tapered tri-fin pin had no micromotions > 150 µm in defects of 0% and 8% during a strenuous activity like lifting 10 kg, but did exhibit micromotion > 150 µm in 40% of the experiments in defects of 17% and 37%, which could impair bony ingrowth. Implant B displayed a significant increase in micromotions for defects of 8% and 17% (p < 0.05). Our results suggest that implant A could be used without risk in spherical head defects up to 37% of volume, even in strenuous shoulder activities immediately after its implantation. Implant B, however, is recommended in spherical defects starting from 8% and only during light shoulder activities until bony integration of the implant has occurred.

Humeral surface replacement for the sequelae of fractures of the proximal humerus

Fractures of the proximal humerus can lead to malalignment of the humeral head, necrosis and post-traumatic osteoarthritis. In such cases surface replacement might be a promising option. A total of 28 shoulders with glenohumeral arthritis subsequent to a fracture underwent surface replacement arthroplasty of the humeral head in patients with a mean age of 60 years (35 to 83). On the basis of the inclination of the impacted head, post-traumatic arthritis was divided into three types: type 1, an impacted fracture of the head in an anatomical position (seven cases); type 2, a valgus impacted fracture (13 cases); type 3, a varus impacted fracture (eight cases). The outcome was measured by means of the Constant score. According to the Boileau classification of the sequelae of fractures of the proximal humerus, all 28 patients had a final result of intra-capsular category 1. The mean Constant score for the 28 shoulders increased from 23.2 points (2 to 45) pre-operatively to 55.1 points (20 to 89) at a mean of 31 months (24 to 66) post-operatively. Valgus impacted fractures had significantly better results (p < 0.039). Surface replacement arthroplasty can provide good results for patients with post-traumatic osteoarthritis of the shoulder. Their use avoids post-operative complications of the humeral shaft, such as peri-prosthetic fractures. Further surgery can be undertaken more easily as the bone stock is preserved.

Complications in shoulder arthroplasty: an analysis of 485 cases

The aim of this study was to analyse the complication rates of six different shoulder arthroplasty concepts for different diagnoses in the short and midterm. The study included 485 primary shoulder arthroplasties. The mean follow-up of the cohort was 3.5 (1-10) years. Complications were classified into three categories: (1) without reoperation, (2) soft tissue revision and (3) implant revision. In total, 56 complications were recorded (11.6%): 34 (7%) were category 1 complications, 11 (2.3%) were category 2 and 11 (2.3%) were category 3. For the whole cohort the median follow-up was 1.6 years (1-10 years) and the survival rate without any complication was 90.5% (95% CI: 87.9-93.1). Patients rated the result of their surgery in 270 (55.7%) cases as very satisfied, in 148 (30.5%) as satisfied, in 43 (8.9%) as somewhat disappointed and in 24 (4.9%) as disappointed. A relatively low complication rate was found in this study. Long-term observations are necessary to confirm these results.