My Orthopaedic Surgeon

We describe a patient with avascular necrosis in both shoulders. Confirmatory testing in making the diagnosis included plain radiography, bone scan, and magnetic resonance imaging. The pathogenesis and staging of the disease by radiography are presented in the article. Treatment options include a conservative regimen of shoulder range of motion exercises and nonsteroidal anti-inflammatory agents or surgery (arthroplasty or core decompression). The patient’s risk factors include long-term corticosteroid use, smoking, and alcohol consumption. Other known risk factors include sickle cell disease, Gaucher disease, chemotherapy, lymphoma, dysbaric conditions, and trauma. This literature search shows that prevention and early diagnosis lend the best outcomes for the diagnosis of avascular necrosis.
Curtis J. Wolfe, MD; Kenneth L. Taylor-Butler, MD Arch Fam Med. 2000;9:291-294

Search String allintitle: (osteonecrosis OR "avascular necrosis" OR AVN) (shoulder OR "humerus" OR "humeral head") Yilded 36 results in July 2007

Search String "Osteonecrosis"[Majr:noexp] AND ("shoulder"[MeSH Terms] OR shoulder[Text Word]) Yielded 106 articles (not all on subject) July 2007

Co-authors: Milford H. Marchant Jr., M.D., Allston Stubbs, M.D., Carl J. Basamania, M.D. March 15, 2005
Background:
- Definition: In situ death of bone within the humeral head due to disruption of blood supply
- Other Names: Avascular Necrosis or Aseptic Necrosis
- Initially described in the Humeral Head in 1960 by Heimann and Freiberger (NEJM)
- 2nd Most common site of Osteonecrosis (Femoral Head = 1st)
- Knowledge based largely on extrapolated data from the Femoral Head
- Similar Etiology - Different Disease
- Non-Weight Bearing Joint
- Greater Vascular Watershed
- Functional capacity of shoulder is more forgiving
- Glenohumeral Joint is Less Constrained
- Progressive Osteoarthritis of Glenohumeral Joint (5%)

A case of osteonecrosis of the head of the humerus is described in which the only likely precipitant was pregnancy. The association of pregnancy and osteonecrosis is reviewed. This is the first reported case of osteonecrosis of the humerus alone associated with pregnancy.
L McGuigan and A Fleming Ann Rheum Dis. 1983 October; 42(5): 597–599.

Osteonecrosis of the humeral head is a disorder that involves osteocytes and marrow and is characterized by bone death. Osteonecrosis of the humeral head consists of 2 forms: traumatic and atraumatic. Osteonecrosis of the hip has been researched more thoroughly and is therefore better understood than osteonecrosis of the shoulder. Most of the information regarding osteonecrosis of the humeral head is extrapolated from the research findings of the disorder of the hip. The major difference between osteonecrosis of the hip and osteonecrosis of the humeral head is that the shoulder bears less weight than the hip.
Synonyms and related keywords: aseptic necrosis, avascular necrosis, osteonecrosis of the humeral head
Levine, Rajadhyaksha & Mont 2006

Steroid-induced avascular necrosis of the head of the humerus. Natural history and management RL Creuss Journal of Bone and Joint Surgery - British Volume, Vol 58-B, Issue 3, 313-317 Copyright © 1976
Ninety-five patients with steroid-induced avascular necrosis of bone have been personally treated by the author. Of these, eighteen had a lesion of the head of the humerus, on one or both sides. The conditions for which the steroids were given included post-transplantation, lupus erythematosus, glomerulonephritis and asthma. The characteristic lesion began as a subchondral osteolytic area which frequently progressed to collapse. The articular cartilage divided from the subchondral bone, either becoming detached as a free cap or at a later stage reattaching. In some cases the lesion was minimal and the symptoms were slight. Conservative treatment has consisted of pendulum exercises and avoidance of abduction, particularly against resistance. In fourteen patients this led to satisfactory function with only intermittent symptoms. Four patients required replacement of five humeral heads with Neer's prostheses. After one to seven years the results of all five were classified as excellent in terms of absence of symptoms and a free range of movement.