Rapidly Progressive Osteonecrosis of the Humeral Head after Arthroscopic Bankart and Rotator Cuff Repair in a 66-Year Old Woman: A Case Report

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.

Rapid destruction of shoulder joint by pigmented villonodular synovitis treated by hemiarthroplasty: A case report

INTRODUCTION

Pigmented villous nodular synovitis is an uncommon proliferative disease of the joints, and rarely reported in the shoulder. It can become symptomatic when proliferating soft tissue infiltrates a joint, causing arthritic changes including bone erosion. The literature has described the disease progression as indolent. Here we report on a case of PVNS of the shoulder joint which rapidly lead to significant bone damage and was subsequently treated by shoulder arthroplasty.

PRESENTATION OF CASE

We report here on a 71-year old female patient who presented with a 6 month history of aggravating shoulder pain. Radiography imaging over a one month period indicated rapid joint destruction. Magnetic resonance imaging suggested the presence of PVNS of the shoulder joint and significant bone erosion. The patient was subsequently treated by shoulder arthroplasty performed by authors. Histological examination confirmed the PVNS diagnosis. Shoulder pain significantly decreased during the follow up period, and the patient was able to resume daily activities.

DISCUSSION

Comparing to Milwaukee shoulder syndrome or a joint infection, PVNS is known to progress indolently. However, our case clearly showed that PVNS could also cause radical destruction of the joint. Previous reports showed the high recurrence rate of PVNS after joint preserving surgery. In our experience hemiarthroplasty could be the choice of treatment with the low recurrence rate and high functional outcome.

CONCLUSIONS

Physicians should include PVNS in the differential diagnosis when they are presented with evidence of rapid destruction of the shoulder joint. Hemiarthroplasty could be treatment option for PVNS of shoulder joint.

An anatomical investigation into the blood supply of the proximal humerus: surgical considerations for rotator cuff repair

Background

The purpose of this study was to investigate the blood supply of the humeral head (HH) originating from the anterior (ACHA) and posterior circumflex humeral arteries (PCHA).

Methods

Formalin preserved specimens were used to measure ACHA length, ACHA length in the bicipital groove (BG), the length of the ascending branch of the ACHA, the penetration point of the ascending branch of the ACHA at the greater tuberosity (GT), and the penetration point of the ascending branch PCHA at the GT. Fresh specimens were used to identify the intraosseous vascular network by both the ACHA and PCHA by injecting a contrast medium using a high-resolution microfocus computed tomography. Specimens were then dissected to expose where the branches of the ACHA and PCHA penetrate the bone, and a small section of the medial head was removed to visualize dye penetration of the cancellous bone.

Results

Seven variations for the course of the ACHA were observed. In 36%, the ACHA runs posterior to the BG and posterior to the long head of biceps tendon, and splits into the anterolateral ascending and descending branch. The ascending branch enters the medial wall of the GT. Microfocus computed tomography demonstrated that the intraosseous branch of the ascending branch of the ACHA runs within the GT in a medial direction from its penetration point just along the lateral edge of the BG. Intraosseous accumulation of contrast within the GT supply occurs more toward the inferior aspect of the HH, and the anterior-superior and superior-medial aspect of the HH is not perfused. This region is a high-risk zone for avascular necrosis.

Conclusion

The results of this study suggest that 7 variations for the course of the ACHA exist. These variations and the interruption of the intraosseous arterial network in the GT with surgery and suture anchor placement result in a high-risk zone in the superomedial aspect of the humeral head overlapping with the area where early aseptic necrosis is identified.

Editorial Commentary: "Just When I Thought I'd Seen Everything That Could Go Wrong?" (Often Overheard in the Surgeon's Lounge): Osteonecrosis of the Humeral Head After Arthroscopic Rotator Cuff Surgery

Osteonecrosis occurs postoperatively after rotator cuff repair, but is there a cause-and-effect relation?