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Avascular Necrosis of the Humeral Head M87.029 733.41

avascular necrosis humerus xray 

avascular necrosis humerus xray

avascular necrosis humerus mri

x-ream pro-stim

synonyms: avascular necrosis of the humeral head, shoulder avn, shoulder osteonecrosis

Osteonecrosis of the Humeral Head ICD-10

  • M87.021 - Idiopathic aseptic necrosis of right humerus
  • M87.022 - Idiopathic aseptic necrosis of left humerus
  • M87.029 - Idiopathic aseptic necrosis of unspecified humerus

Osteonecrosis of the Humeral Head ICD-9

  • 733.41(shoulder) asceptic necrosis of bone-humeral head

Osteonecrosis of the Humeral Head Etiology / Epidemiology / Natural History

  • Can be posttraumatic or nontraumatic.
  • Postraumatic: generally after proximal humerus fracture with disruption of blood supply to humeral head
  • Nontrauamtic: associated with sickle cell anemia, corticosteriod use ,
  • Most commonly adults 20-50yrs old
  • Etiology: EtOH or prolonged high dose steriods.  Other risk factors: sickle cell, dysbarism, Gaucher's disease, trauma, high-dose radiation, thrombophilia, protein S & C defiencies, hypofibrinolysis.
  • Thought to be due to altered circulating lipids and coagulation mechanisms.
  • Marrow death occurs 6-12 hrs after ischemia, radiographic changes appear after 3 months, articular collapse within 6-12 months in 80% of patients with clinical AVN.

Osteonecrosis of the Humeral Head Anatomy

Osteonecrosis of the Humeral Head Clinical Evaluation

  • Gradually progressive shoulder pain.
  • Progessive stiffness and loss of motion.
  • Generally normal strength

Osteonecrosis of the Humeral Head Xray / Diagnositc Tests

  • AP, scapular lateral and axillary views. See Shoulder Xray.
  • MRI: If suspected but not seen or if only in one shoulder MRI is indicated.  MRI sensitivity and specificiaty=95% for early AVN. Not good for estimating the extent of lesion.
  • CT is the best technique to determine area of bone death.
  • Bone scans are sensitive but have large number of false positives and have no advantage over MRI
  • Evaluation should include lipid levels and possible screening for decreased levels of protein C and S and antithrombin III and increased levles of plasminogen activatoter inhibitor-1.

Osteonecrosis of the Humeral Head Classification / Treatment

  • Cruess Classification (Cruess RL, CORR 1978;130:86)
    -Stage 1: preradiographic
    -Stage 2: mottled sclerosis
    -Stage 3: subchondral fracturing / cresent sign
    -Stage 4: collapse of subchondral bone and loss of sphericity
    -Stage 5: degenerative changes of the glenoid
  • ARCO Staging (Association for Research on Osseous Circulation) ARCO News 1992;4:41

  • Stage 0-Bone biopsy demonstrates AVN. All other tests normal. Generally treated non-operatively
  • Stage I-Bone scan or MRI positive. Lesions subdivided based on location (medial, central and lateral) and percentage of head involvement. Ia=<15% involvement; Ib=15-30%; Ic=>30%.  Treatment: consider core decompression in young patients or Alendronate 70mg weekly (Lai KA, JBJS 2005;87A:2155).
  • Stage II-Xray=osteoclerosis, cystic , osteopenia or mottled femoral head without collapse or acetabular involvement. Bone Scan/MF+RI=lesions subdivived based on location (medial, central and lateral) and percentage of head involvement. IIa=<15% involvement; IIb=15-30%; IIc=>30%.  Treatment: core decompression for IIa sclerotic disease in young patients.
  • Stage III-Xray=crescent sign; lesions subdivided based on location (medial, central and lateral) and percentage of head involvement. IIIa=<15% involvement or <2mm depression of head; IIIb=15-30% or 2-4mm depression; IIIc=>30% or >4mm depression.  Treatment:  Osteotomy vs vascularized fibula vs resurfacing vs THA.
  • Stage IV-Xray=flattened particular surface, joint space narrowing, acetabular changes, osteophytes.  Treatment: arthrodesis vs THA
  • Ficat based on plain radiographs. Stage I=symptomatic hip,no xray change. Stage II, xray= patchy areas that are radiolucent and radiodense. Stage III=“crescent sign”=subchondral collapse. Stage IV=articular surface collapse.
  • U of Pennslvania system (Steinberg). 0-normal MRI, XRAY, bone scan.1-abnormal MRI\bone scan .2-sclerotic\cystic changes on xray. 3-crescent sign. 4-flattened femoral head. 5-joint narrowing. 6-advanced DJD
  • Avoid chronic steriod use, correct lipid and coagulation abnormalities.
  • conservative tx/ resticted activity usually ineffective. 
  • Electrical stimulation -some studies have shown benefit from pulsing electromagnetic fields applied externally for hip AVN.  further study needed
  • Alendronate 70mg weekly (hip AVN) (Lai KA, JBJS 2005;87A:2155).
  • Core Decompression: (Chapman C, Arthroscopy 2004;20:1003), (Mont MA, JBJS 1993;75Br:785), (Dines JS, Arthroscopy 2007;23:103e1), (Laporte DM, CORR 1998:254:60)
  • Hemiarthroplasty
  • Total Shoulder Arthroplasty: (Hattrup SJ, JSES 2000;9:177),
  • Hemiarthroplasty vs TSA: no difference in outcome or ROM between hemiarthroplasty and TSA. Complication rate is significantly higher with TSA (22%) than with hemiarthroplasty (8%). TSA should be reserved for stage V osteonecrosis. (Feeley BT, JSES 2008;17:689).
  • Resurfacing arthroplasty: can be with bone loss up to 31% of humeral head (Raiss P. JBJBS 2009;91A:340), (Copeland S, JBJS 2006;88:900).

Osteonecrosis of the Humeral Head Associated Injuries / Differential Diagnosis

  • Shoulder osteoarthritis
  • Tumor
  • Infection

TSA Complications

  • Overall 12% incidence (Chin PY, JSES, 2006;15:19) (14%=Cofield RH, ICL 1990;39:449)
  • Instability / soft tissue imbalance:
  • Rotator cuff tear (Hattrup SJ, JSES, 2006;15:78)
  • ectopic ossification
  • glenoid loosening
  • Peri-Prosthetic fracture (0.5%-3%)
  • nerve injury (Lynch NM, JSES 1996;5:53)
  • infection: <1% with peri-operative antibiotics
  • humeral loosening
  • Long-head of biceps rupture

Osteonecrosis of the Humeral Head Follow-up Care

  • Dependent on stage and treatment.

Osteonecrosis of the Humeral Head Review References 

 

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