eMedicine Specialties > Orthopedic Surgery > Shoulder

Osteonecrosis, Shoulder: Workup

Author: Michael Levine, MD, Chairman, Department of Orthopedic Surgery, Western Pennsylvania Hospital
Coauthor(s): Amar Rajadhyaksha, MD, Resident, Department of Orthopedic Surgery, New York Medical College; Michael Mont, MD, Associate Professor, Department of Orthopaedic Surgery, Johns Hopkins Medical Institution
Contributor Information and Disclosures

Updated: Mar 24, 2009

Workup

Laboratory Studies

  • Laboratory studies are typically not indicated in the diagnosis of osteonecrosis. Tests can be utilized to identify inciting factors, such as the following:
    • Sickle cell disease in African Americans
    • Lipid profile to reveal if there is underlying hyperlipidemia
    • Coagulopathies - Protein S and protein C deficiencies, factor V Leiden disease

Imaging Studies

  • Radiographs help establish the diagnosis in most cases. Essential radiographic views include the following:
    • Anteroposterior (AP)
    • True AP
    • Axillary
Shoulder osteonecrosis stage II disease.

Shoulder osteonecrosis stage II disease.

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Shoulder osteonecrosis stage II disease.

Shoulder osteonecrosis stage II disease.


Shoulder osteonecrosis stage IV disease.

Shoulder osteonecrosis stage IV disease.

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Shoulder osteonecrosis stage IV disease.

Shoulder osteonecrosis stage IV disease.


Shoulder hemiarthroplasty in a patient with shoul...

Shoulder hemiarthroplasty in a patient with shoulder osteonecrosis.

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Shoulder hemiarthroplasty in a patient with shoul...

Shoulder hemiarthroplasty in a patient with shoulder osteonecrosis.

  • Bone scan4
    • Can be helpful when disease is suggested but not apparent on radiographs
    • Not commonly used because of the increased success rates of MRI
  • MRI4
    • Diagnostic modality of choice in the face of normal radiographs and clinical suspicion
    • Sensitivity and specificity greater than 98%
    • Extent of humeral head necrosis a good predictor of future collapse5
  • Tomography - Helpful in stage II disease to further define lesion

Other Tests

  • Biopsy can be performed at the time of surgery (eg, core decompression), but the diagnosis usually is based on clinical and radiographic findings.
  • Venography
  • Intraosseous pressure measurements

Histologic Findings

The first phases involve cell and marrow necrosis. The reparative phase occurs as the dead bone is removed and replaced by healthy bone. During this period, the bone is weak and subject to subchondral collapse. Following collapse of the subchondral plate, damage to the articular cartilage occurs with resultant arthritic changes to the joint.

Staging

Osteonecrosis of the humeral head has been staged by Ficat and Arlet (modified for the shoulder).6

  • Stage I - Normal
  • Stage II - Cystic and/or osteosclerotic lesions; normal contour of humeral head (see Image 1)
Shoulder osteonecrosis stage II disease.

Shoulder osteonecrosis stage II disease.

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Shoulder osteonecrosis stage II disease.

Shoulder osteonecrosis stage II disease.


Shoulder osteonecrosis stage IV disease.

Shoulder osteonecrosis stage IV disease.

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Shoulder osteonecrosis stage IV disease.

Shoulder osteonecrosis stage IV disease.

  • Stage III - Subchondral collapse or crescent sign
  • Stage IV - Narrowing of joint space; secondary osteoarthritic changes of the glenoid fossa and the glenohumeral head, such as cysts, marginal osteophytes, and destruction of cartilage (see Image 2)

More on Osteonecrosis, Shoulder

Overview: Osteonecrosis, Shoulder
Workup: Osteonecrosis, Shoulder
Treatment: Osteonecrosis, Shoulder
Follow-up: Osteonecrosis, Shoulder
Multimedia: Osteonecrosis, Shoulder
References
Further Reading
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References

  1. Cruess RL. Steroid-induced avascular necrosis of the head of the humerus. Natural history and management. J Bone Joint Surg Br. Aug 1976;58(3):313-7. [Medline].

  2. Cruess RL. Experience with steroid-induced avascular necrosis of the shoulder and etiologic considerations regarding osteonecrosis of the hip. Clin Orthop Relat Res. Jan-Feb 1978;86-93. [Medline].

  3. Cushner MA, Friedman RJ. Osteonecrosis of the Humeral Head. J Am Acad Orthop Surg. Nov 1997;5(6):339-346. [Medline].

  4. Mont MA, Ulrich SD, Seyler TM, Smith JM, Marker DR, McGrath MS, et al. Bone scanning of limited value for diagnosis of symptomatic oligofocal and multifocal osteonecrosis. J Rheumatol. Aug 2008;35(8):1629-34. [Medline].

  5. Sakai T, Sugano N, Nishii T, Hananouchi T, Yoshikawa H. Extent of osteonecrosis on MRI predicts humeral head collapse. Clin Orthop Relat Res. May 2008;466(5):1074-80. [Medline].

  6. Ficat RP, Arlet J. Necrosis of the femoral head. In: Hungerford DS. Ischemia and necrosis of bone. Baltimore, MD: Williams & Wilkins; 1980:171-82.

  7. Soohoo NF, Vyas S, Manunga J, Sharifi H, Kominski G, Lieberman JR. Cost-effectiveness analysis of core decompression. J Arthroplasty. Aug 2006;21(5):670-81. [Medline].

  8. Feeley BT, Fealy S, Dines DM, Warren RF, Craig EV. Hemiarthroplasty and total shoulder arthroplasty for avascular necrosis of the humeral head. J Shoulder Elbow Surg. Sep-Oct 2008;17(5):689-94. [Medline].

  9. Smith RG, Sperling JW, Cofield RH, Hattrup SJ, Schleck CD. Shoulder hemiarthroplasty for steroid-associated osteonecrosis. J Shoulder Elbow Surg. Sep-Oct 2008;17(5):685-8. [Medline].

  10. Tauber M, Karpik S, Matis N, Schwartz M, Resch H. Shoulder arthroplasty for traumatic avascular necrosis: predictors of outcome. Clin Orthop Relat Res. Dec 2007;465:208-14. [Medline].

  11. LaPorte DM, Mont MA, Mohan V, Pierre-Jacques H, Jones LC, Hungerford DS. Osteonecrosis of the humeral head treated by core decompression. Clin Orthop Relat Res. Oct 1998;254-60. [Medline].

  12. Mont MA, Maar DC, Urquhart MW, Lennox D, Hungerford DS. Avascular necrosis of the humeral head treated by core decompression. A retrospective review. J Bone Joint Surg Br. Sep 1993;75(5):785-8. [Medline].

  13. Kawamura K, Kawate K, Yajima H, Kobata Y, Takakura Y. Vascularized scapular grafting for treatment of osteonecrosis of the humeral head. J Reconstr Microsurg. Nov 2008;24(8):559-64. [Medline].

  14. Basmania CJ, Jaramillo JC, Wirth MA. Treatment of posttraumatic versus atraumatic avascular necrosis of the shoulder [abstract]. J Bone Joint Surg Orthop Trans. 1997;11:277.

  15. Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg Br. Jan 1985;67(1):3-9. [Medline].

  16. Iannotti JP, Williams GR. Osteonecrosis: Pathophysiology, classification and pathoanatomy. In: Disorders of the Shoulder: Diagnosis and Management. Lippincott Williams and Wilkins;1999:439-46.

  17. Loebenberg MI, Plate AM, Zuckerman JD. Osteonecrosis of the humeral head. In: Zuckerman JD. Instructional course lectures. Rosemont: American Academy of Orthopaedic Surgeons;1999: 349-58.

  18. Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. Mar 1995;77(3):459-74. [Medline].

  19. Neer CS. Avascular necrosis of the humeral head. In: Shoulder Reconstruction. WB Saunders;1990:194-9.

  20. Petri M, Baker J, Goldman D. Risk factors for osteonecrosis in SLE [abstract]. Arthritis Rheum. 1992;35 Suppl:S110.

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Keywords

shoulder osteonecrosis, aseptic necrosis, avascular necrosis, osteonecrosis of the humeral head

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Contributor Information and Disclosures

Author

Michael Levine, MD, Chairman, Department of Orthopedic Surgery, Western Pennsylvania Hospital
Michael Levine, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, American Medical Association, Orthopaedic Research Society, Pennsylvania Medical Society, Pennsylvania Orthopaedic Society, and Phi Beta Kappa
Disclosure: encore medical Consulting fee Consulting; glaxo smith kline Honoraria Speaking and teaching

Coauthor(s)

Amar Rajadhyaksha, MD, Resident, Department of Orthopedic Surgery, New York Medical College
Disclosure: Nothing to disclose.

Michael Mont, MD, Associate Professor, Department of Orthopaedic Surgery, Johns Hopkins Medical Institution
Michael Mont, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Stryker Orthopaedics Consulting fee Consulting; Wright Medical Technology, Inc. Consulting fee Consulting

Medical Editor

Mark D Lazarus, MD, Associate Professor of Orthopedic Surgery, Medical College of Pennsylvania-Hahnemann University, Chief of Shoulder and Elbow Service, Department of Orthopedic Surgery, Hahnemann University Hospital
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Pekka A Mooar, MD, Associate Professor, Department of Orthopedic Surgery, Temple University School of Medicine
Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania
Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association
Disclosure: Nothing to disclose.

 
 
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