Shoulder arthroplasty in nontraumatic osteonecrosis of the humeral head

Twelve patients (thirteen shoulders) treated with arthroplasty for nontraumatic osteonecrosis of the humeral head were prospectively evaluated. At a mean follow-up of 30.2 months (range, 14-49 months), shoulder function assessed by the Constant score improved from 18 (adjusted score, 24%) to 51 (adjusted score, 69%; P <.001). Patients older than 65 years obtained lower adjusted scores than patients younger than 65 years (P =.02). The radiographs at follow-up showed radiolucent lines in 2 patients with no evidence of implant migration. Progressive glenoid erosion was identified in 2 patients treated with hemiarthroplasty. The subjective assessment revealed good and excellent results in 4 of 13 patients (numeric rating scale [NRS] 1 and 2). Three patients were unsatisfied with the final outcome (NRS 5). All three patients had abnormal findings with regard to the glenoid, either preoperatively with subtotal destruction of the glenoid or postoperatively with glenoid erosion after hemiarthroplasty or radiolucency around the glenoid component after total joint replacement. Contrary to previously published retrospective studies, we recommend a more cautious prediction of midterm results, especially in patients older than 65 years.     

Core decompression for nontraumatic osteonecrosis of the humeral head: a technique article

Core decompression may used in the management of early stage, precollapse nontraumatic osteonecrosis of the humeral head. We propose a technique without risk of complications associated with injury to the biceps tendon or the blood supply to the humeral head.     

Nontraumatic osteonecrosis of the humeral head

The humeral head is the second most common site for nontraumatic osteonecrosis after the femoral head, yet it has attracted relatively little attention. Osteonecrosis is associated with many conditions, such as corticosteroid use, sickle-cell disease, alcoholism, dysbarism (or caisson disease), Gaucher's disease, and other systemic conditions. The diagnosis is a clinical and radiographic one, the latter forming the basis for its staging. Treatment depends on the chronicity and severity of symptoms, as well as the degree of clinical and radiographic progression. Surgical treatment includes arthroscopic debridement and core decompression for early osteonecrosis and hemiarthroplasty or total shoulder arthroplasty for more advanced disease. This report reviews osteonecrosis of the humeral head, with an emphasis on current treatment options.     

Thorough debridement of the humeral head for osteonecrosis

Osteonecrosis of the shoulder is a devastating disease, particularly in the young patient. Published data is replete with vascularized and nonvascularized bone grafting procedures for joint preservation of the hip; however, these same techniques have not been applied to the shoulder. When treating osteonecrosis of the shoulder, endoscopically-guided thorough debridement of the necrotic bone may promote good outcomes by ensuring that the bone graft, vascularized or nonvascularized, is stabilized against a viable host bed. In addition, this new technique facilitates access to the subchondral plate from the osseous side, thereby fully debriding the intraosseous fracture and allowing elevation of the articular surface if needed. When collapse is present, stage 3 disease secondary articular-sided changes may be present and should be addressed during concomitant arthroscopy. This article presents a case of endoscopically-guided thorough debridement of the humeral head combined with nonvascularized bone grafting of the residual cavity and stabilization, and concomitant arthroscopy for a 30-year-old woman with steroid-associated osteonecrosis.     

Shoulder hemiarthroplasty in the management of humeral head fractures

The results of hemiarthroplasty for shoulder fracture were evaluated in 26 patients, 20 women and 6 men with a mean age of 64.7 +/- 8.2 years. The follow-up period was 2 to 7 years. Cofield prostheses were used for the first 10 patients and subsequently 9 Global and 7 Aequalis prostheses were implanted, all cemented. The clinical outcome was assessed using the Constant-Murley scale. The mean score, at the last follow-up, was 70.4 +/- 16.4 (39-96). Mean forward elevation of the arm was 150 degrees (300-175 degrees), mean abduction was 145 degrees (30 degrees -170 degrees), and mean external rotation was 30 degrees (10 degrees-45 degrees). In most of the cases internal rotation corresponded with a position of the dorsum of the hand at the L3 vertebrae. The patients in our series achieved their optimal clinical result within the first 6 months after operation. Shoulder hemiarthroplasty is a worthwhile procedure, giving predictable results provided the patients have been carefully selected, the individual anatomy of the shoulder is restored and an aggressive rehabilitation program is implemented during the first six months after surgery.     

Studies of nontraumatic osteonecrosis. The role of core decompression in the treatment of nontraumatic osteonecrosis of the femoral head

This study reports a five-year experience with core decompression for treatment of nontraumatic osteonecrosis of the femoral head. There were 25 patients (39 hips) with predominantly steroid-associated osteonecrosis followed postoperatively for a minimum of two years. All patients were evaluated functionally, roentgenographically, histologically, and hemodynamically. At latest follow-up examination, two of 12 hips (17%) with Stage I disease, seven of 12 hips (58%) with Stage IIA disease, four of four hips with Stage IIB disease, and nine of 11 hips (82%) with Stage III disease have progressed roentgenographically and/or clinically. A lack of correlation between pressure manometrics, venography, and clinical outcome in this study suggests that mechanisms other than progressive ischemia may be involved. Current indications for core decompression are Ficat Stage 0, I, and IIA (sclerotic predominant) disease.     

Results of transtrochanteric rotational osteotomy for nontraumatic osteonecrosis of the femoral head

From 1976 to 1985, transtrochanteric rotational osteotomy was applied to 58 hips of nontraumatic necrosis of the femoral head. Of these, 52 hips were available for the present study. The follow-up periods ranged from one to ten years (average, 5.1 years). Satisfactory results were obtained in 69%, as there was no evidence of progressive collapse of the head. Hips that had had no collapse or slight collapse before osteotomy had a significantly better prognosis, compared with those that had marked collapse of the head. The extent of the lesion as depicted on the preoperative lateral roentgenogram also influenced the eventual function. Patient satisfaction was significantly greater when these lesions were less than 70% (31/37), compared with greater than 70% (5/15).     

Risk factors for nontraumatic osteonecrosis of the femoral head after renal transplantation

We investigated risk factors for osteonecrosis of the femoral head (ONF) in renal transplant recipients, who are susceptible to the disease. Among 287 renal transplant recipients, 18 ONF patients with enough data were included, and 18 age- and sex-matched recipients without ONF were nominated as reference cases. Risk factors were analyzed using a conditional logistic regression method. There were no differences between the ONF patients and the reference cases regarding the types of immunosuppressant or the donor (living or cadaveric, father or mother, matching blood type and human leukocyte antigens). The daily oral steroid dosage (prednisolone 25.0mg/day or more) and blood urea nitrogen level 2 months after transplantation were the only factors with relevance to the occurrence of ONF. We propose that oral steroid dosages should be low or reduced after renal transplantation, and acute rejection should be controlled with pulsed therapy.     

Relevance of the restoration of humeral length and retroversion in hemiarthroplasty for humeral head fractures

Sixteen patients, with a fracture of the upper humerus treated with hemiarthroplasty, were followed-up for 45.7 +/- 15.1 (20-72) months after surgery. The results were assessed using the Constant-Murley scale. The mean score was 75.8 +/- 15.7 (54-96) points out of a possible maximum of 100. At the time of their last follow-up they underwent CT of the fractured and contralateral humerus. Humeral length and retroversion were measured and evaluated. A very good final outcome (Constant score more than 71) was achieved in patients with a difference in retroversion less than 10 degrees and a difference in length less than 14 mm, between fractured and sound humerus. The mean difference in retroversion was 8.7 degrees and the mean difference in length was 0.65 cm, between fractured and sound humerus. We attribute the very good clinical outcome in our series to the quality of the anatomical reconstruction that was performed.     

肱骨头置换治疗老年人肱骨头粉碎性骨折

目的探讨人工肱骨头置换治疗老年人肱骨头粉碎性骨折的疗效。方法对13例肱骨头粉碎性骨折老年患者（〉75岁）均采用骨水泥型柄的非限制性人工肱骨头置换术。结果13例均获随访,时间3～25（12±4．5）个月。3例基本达到骨折前的状况,10例生活基本自理。结论人工肱骨头置换治疗肱骨头粉碎性骨折老年患者,可早期进行功能锻炼,减少并发症,改善生活质量,疗效满意。     

Comparison between bipolar hemiarthroplasty and THA for osteonecrosis of the femoral head

It is controversial whether bipolar hemiarthroplasty or total hip arthroplasty should be done for Ficat Stage III osteonecrosis of the femoral head. A prospective comparative study was done using the same cementless femoral components for both procedures. Forty cementless bipolar hemiarthroplasties and 31 cementless total hip arthroplasties were done in 54 patients with Ficat Stage III osteonecrosis of the femoral head. Age, gender, and followup were matched between patients having bipolar hemiarthroplasty and total hip arthroplasty. Treatment with total hip arthroplasty increased the total hip score more than treatment with bipolar hemiarthroplasty. The final pain score especially showed a significant difference between patients who had a bipolar hemiarthroplasty (5.5) and patients who had a total hip arthroplasty (5.9). Thigh pain occurred in four patients (four hips) from the bipolar hemiarthroplasty group and in six patients (six hips) from the total hip arthroplasty group. In the bipolar hemiarthroplasty group, gluteal pain occurred in six patients (six hips, 15%) and groin pain occurred in eight patients (eight hips, 20%). Dislocation occurred in two hips (two patients) in each group. The outer head migrated superiorly in nine hips (nine patients) (23%) from the bipolar hemiarthroplasty group. Because of the incidence of gluteal and groin pain and migration, total hip arthroplasty is a better procedure than bipolar hemiarthroplasty for patients with Ficat Stage III osteonecrosis of the femoral head.     

Reconstruction of humeral length and centering of the prosthetic head in hemiarthroplasty for proximal humeral fractures

Anatomic reconstruction of humeral length in hemiarthroplasty for complex proximal humeral fractures is difficult because reliable surgical landmarks are missing or are destroyed by the fracture. The pectoralis major tendon is a reliable landmark to determine prosthetic height intraoperatively. This study analyzed the clinical outcome, reconstruction of humeral length, centering of the prosthetic head in the glenoid, and tuberosity positioning and healing, using the pectoralis major tendon as a reference intraoperatively. The study included 30 patients. In 21 patients (group 1), humeral length reconstruction was performed using the pectoralis major tendon as a reference; in 9 (group 2), this reference was not used. Patients underwent a clinical and radiologic evaluation at a mean of 22.7 months. Group 1 showed significantly better results in clinical and radiologic values, especially in anatomic reconstruction of humeral length, than group 2. Clinical outcome depended significantly on greater tuberosity healing and centering of the prosthetic head in the glenoid.     

Perioperative fracture-dislocation of the humeral head during a resurfacing hemiarthroplasty

We report a case of perioperative fracture-dislocation of the humeral head produced during the reaming for a resurfacing replacement hemiarthroplasty (RRH) in a 79-year old woman. This is a surgical complication not previously described in the literature for this type of prosthesis design. Resurfacing humeral head implant has been noted as a useful treatment for glenohumeral arthropathies, also in elderly people, with a very low incidence of complications. However, as we report, they are possible.It is advisable that conventional stemmed implants could be available when RRH is performed.     

Vascularized scapular grafting for treatment of osteonecrosis of the humeral head

Eight dissections in four embalmed cadavers were performed to investigate the possibility of vascularized scapular grafting for osteonecrosis of the humeral head. When the angular branch was used as the nutrient vessel, the mean length of the vascular pedicle was 12.4 cm, which was sufficient for transferring the scapula into the humeral head. Based on the anatomical study, a 27-year-old man with corticosteroid-induced osteonecrosis of the right humeral head was treated by vascularized scapular grafting. The pedicled vascularized scapula was successfully transferred into the humeral head using the angular branch. The patient's right shoulder pain disappeared following surgical recovery. He had no limitations of right shoulder motion 3 years after the surgery. Magnetic resonance imaging at 1 year after the surgery indicated revascularization of the humeral head. The humeral head did not collapse during a 3-year follow-up with radiographic evaluation. This procedure has the potential to be a new joint-preserving procedure for osteonecrosis of the humeral head.     

Arthroscopic treatment of steroid-induced osteonecrosis of the humeral head

Shoulder arthroscopy was performed on a 52-year-old man for the treatment of steroid-induced osteonecrosis of the humeral head. The removal of loose bodies and joint debridement has successfully improved the patient's functional status through relief of pain, improved range of motion, and elimination of locking. This case suggests another use of arthroscopy in the treatment of shoulder pathology.     

Predictive factors for vascularized iliac bone graft for nontraumatic osteonecrosis of the femoral head

We reviewed the results of 35 operations performed on 29 patients with osteonecrosis of the femoral head in which a pedicle iliac bone was utilized. The average age was 35 years (17–62). There were 28 patients of stage 2 and 7 of stage 3; there were 17 type C-1 hips and 18 type C-2 hips. The pedicle bone was inserted in the anterolateral direction of the femoral head. The average follow-up period was 8 years and 7 months. Collapse of the femoral head occurred in 19 hip joints. Although 16 of 28 stage 2 hips showed collapse, all 7 stage 3 hips resulted in collapse. Thirteen of 17 hips did not show collapse in patients with type C-1 necrosis, whereas 15 of 18 hips developed collapse in patients with type C-2 necrosis. When the bone graft was inserted in the anterolateral direction of the femoral head, incidence of collapse was reduced. These results indicate that deep circumflex iliac pedicle bone graft may be indicated for stage 2 type C-1 necrosis, and that the penetration of the graft into the anterolateral aspect of the lesion is essential for the procedure to succeed.     

精确匹配的半髋表面置换术治疗股骨头缺血性坏死

目的评价精确匹配的半髋表面置换术治疗股骨头缺血性坏死的疗效。方法回顾性分析41例(48髋)股骨头缺血性坏死患者的临床资料。其中男30例,女11例;年龄29～49岁,平均37岁。其中FicatⅢ期35髋,FicatⅣ期13髋,髋臼相对正常。41例患者(48髋)均采用金属半髋表面置换术。结果全部病例均获得随访,随访时间平均5.2年。平均UCLA髋关节功能评分明显改善(P=0.001),疼痛由术前的3.1分提高到9.1分;步行由4.4分提高到9.2分;活动由5.5分提高到7.1分。按UCLA评分标准,FicatⅢ期35髋术后的满意率为88.6%;FicatⅣ期13髋术后的满意率为69.2%(P=0.25)。8髋疗效差,UCLA髋关节功能评分无明显改善,术后X线检查发现7髋呈髋内翻植入了假体(插入的短柄与股骨轴线的夹角均小于130°)。假体的5年生存率为83.0%。结论在严格掌握手术适应证、提高手术技术的前提下,精确匹配的半髋表面置换术治疗股骨头缺血性坏死的疗效满意。     

Arthroscopic treatment of bilateral humeral head osteonecrosis.

A 37-year-old woman with a renal transplant was treated by arthroscopic debridement for bilateral steroid-induced humeral head osteonecrosis. Radiologically, the right shoulder had been categorized as stage III and the left as stage IV according to Arlet and Ficat. Relief of pain and improved range of motion were obtained especially on the right shoulder. Arthroscopy is an efficient procedure for treatment of humeral head osteonecrosis in the renal transplant recipient including radiological stages III with episodes of locking.