Review Question - QID 219927

This patient has Stage II avascular necrosis of the humeral head from chronic alcohol dependence. Core compression for Stage I and II disease has been shown to have good to excellent outcomes in 88-100% of patients at 5-10 years follow-up.

Avascular necrosis of the humeral head can occur from several etiologies, including high-dose steroids, chronic alcoholism, and trauma. The condition progresses through 5 stages. Stage I has normal radiographs but findings on MRI. Stage II has the addition of sclerosis on radiographs. Stage III has a subchondral fracture. Stage IV has a flattening of the humeral head. Stage V has degenerative changes of the glenoid. The treatment of humeral head osteonecrosis varies by the stage of disease. Stages I and II can be treated with core decompression. Stage III and IV can be treated with hemiarthroplasty or humeral head resurfacing. Stage V disease is treated with total shoulder arthroplasty. The procedure selected for each patient must be selected on an individual basis based on their age, activity level, and stage of disease. Core decompression reduces subchondral bone marrow pressure and promotes neovascularization in hopes of slowing disease progression. It has produced good to excellent results in 88-100% of cases with Stage I and II disease. However, core decompression for Stage III disease had a good to excellent in 70% of patients and 14% of patients with Stage IV disease.

Mont and colleagues conducted a retrospective study of patients with osteonecrosis of the humeral head who underwent core decompression with an average follow-up of 5.6 years. All patients with Stage I or II disease had good or excellent results. Patients who had more advanced disease required additional arthroplasty. They concluded that core decompression is an effective treatment for early disease.

LaPorte and colleagues performed a retrospective study assessing the outcomes of core decompression for osteonecrosis of the humeral head at a mean 10-year follow-up. Successful outcomes were reported in 94% in Stage I disease, 88% in Stage II disease, 70% in Stage III disease, and 14% in Stage IV disease. They concluded that core decompression is an effective procedure for patients with Stage I-III disease.

Harreld and colleagues described the outcomes of a small-diameter percutaneous decompression technique. For patients with early disease, arthroplasty was avoided in all shoulders at 32 months after surgery. Ninety-five percent of patients had improved clinical outcomes and did not have disease progression. They concluded that percutaneous core decompression is an effective technique for osteonecrosis of the humeral head.

Figure A shows sclerosis of the humeral head without subchondral collapse. On MRI, there is subchondral edema of the humeral head. Illustration A shows the Cruess classification of avascular necrosis of the humeral head.

Incorrect answers:
Answer 1: Core decompression is an effective and reliable treatment for this stage of the disease.
Answers 2 and 4: About 90% of patients have a satisfactory outcome after core decompression.
Answer 3: Most patients do not need arthroplasty within 10 years after a core decompression.