eMedicine Specialties > Orthopedic Surgery > Shoulder

Osteonecrosis, Shoulder: Treatment

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

Treatment

Medical Therapy

Removal of the offending agent, if possible, is the first line of treatment. Nonsurgical options often are more successful in cases of shoulder osteonecrosis because the shoulder is a non–weightbearing joint. Physical therapy that include modalities for pain control and ROM exercises with subsequent strengthening is helpful in all stages, particularly in stage I and stage II.

Studies have shown that treatment with alendronate can possibly prevent a collapse of the femoral head caused by osteonecrosis; however, no research has been published regarding its effectiveness in treating osteonecrosis of the shoulder.

Surgical Therapy

  • Core decompression: A central core of bone is removed or drilled from the humeral head into the necrotic zone.7
  • Arthroscopy: Arthroscopic debridement of chondral lesions is performed.
  • Hemiarthroplasty: Humeral head prosthetic replacement is performed (see Image 3).8,9,10
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.

  • Total shoulder arthroplasty: The humeral head is replaced with glenoid resurfacing.8,10

Preoperative Details

The decision for a given surgical procedure is based on preoperative staging. Core decompression, muscle pedicle grafting, and arthroscopy are indicated in cases prior to collapse of the humeral head. These procedures can be helpful in stage I, stage II, and stage III disease. Once irregularity of the joint surface occurs, arthroplasty is most beneficial.

Intraoperative Details

  • Core decompression: Place the patient in the beach-chair position with the arm over the edge of the table. Perform core decompression with the use of image intensification. Make a small incision in the lateral deltoid. Place a Kirschner wire (K-wire) into the necrotic lesion, and use a cannulated drill to take a core of bone.
  • Hemiarthroplasty: Place a humeral head prosthesis, usually through a long deltopectoral incision. For idiopathic osteonecrosis, the procedure is technically easier to perform than hemiarthroplasty for advanced arthritis, as there is usually minimal-to-no soft-tissue contracture and head deformity. By using the excised head as a sizer, near-perfect replacement of the articular surface can be achieved.
  • Total shoulder arthroplasty: Multiple prostheses are available. The glenoid is resurfaced, usually with an all-polyethylene component. Total shoulder arthroplasty is indicated in individuals with stage IV disease.

Postoperative Details

  • Core decompression and muscle pedicle grafting: Immediate ROM exercises can be initiated. Some limitations on ROM may be placed in cases of muscle pedicle grafting. Patients with core decompression are started on immediate passive ROM exercises, with active ROM as tolerated. Once full ROM is achieved, strengthening exercises can be initiated.
  • Hemiarthroplasty and shoulder arthroplasty: Immediate passive ROM is initiated, with limitation of external rotation to 45° for 6 weeks to allow for repair of the subscapularis from the surgical approach. Active ROM can be started as tolerated, with the same limitation in the absence of rotator cuff repair, which is rare. Strengthening usually is initiated at 6 weeks postsurgery.

Follow-up

  • Core decompression: Studies of core decompression have shown good and excellent results in up to 90% of cases of stage I and stage II disease.11,12 Core decompression also can be successful in stage III disease, with a 30% failure rate requiring subsequent arthroplasty. Failure occurs in all cases of stage IV or V disease; the procedure is palliative only.7
  • Muscle pedicle grafting: Limited experience with this procedure has shown no significant difference from core decompression alone, with increased morbidity. Further studies are required.13
  • Arthroscopy: Limited studies are available for review. Arthroscopy has no effect on the disease process, but it may be helpful in dealing with mechanical symptoms.
  • Arthroplasty: A 90% success rate has been reported in advanced-stage disease, with most patients regaining full ROM.8,10

Complications

Common surgical complications include infection and neurovascular injuries, which are particularly rare in these procedures.

When performing core decompression, care must be taken to avoid the axillary nerve anteriorly. Avoidance of penetration of the humeral head during core decompression is key.

The cephalic vein is at risk during the approach for arthroplasty. Problems with arthroplasty include prosthetic loosening, dislocation, and intraoperative fracture. Fortunately, these problems are rare in avascular necrosis.

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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