What are the treatment options for an old fracture dislocation of the shoulder with Avascular Necrosis (AVN)?

Treatment Options for Old Fracture Dislocation Shoulder with AVN

For old fracture dislocations of the shoulder with avascular necrosis (AVN), shoulder arthroplasty (either total shoulder arthroplasty or hemiarthroplasty) is the most effective treatment option to improve pain, function, and quality of life.

Understanding the Condition

• Old fracture dislocations of the shoulder with AVN represent a complex injury pattern where the humeral head has lost its blood supply, leading to bone death and eventual collapse 1
• Common causes include trauma (such as the fracture dislocation itself), chronic corticosteroid use, or systemic diseases like sickle cell disease, systemic lupus erythematosus, or alcohol abuse 1

Treatment Algorithm

Non-operative Management

• Non-operative treatment may be considered in early stages of AVN or in patients who are poor surgical candidates 1
• Options include:
  • Risk factor management (discontinuing steroids if possible, limiting alcohol intake) 1
  • Physical therapy and muscle strengthening exercises 2
  • Anti-inflammatory medications for pain control 1
  • Activity modification to limit overhead activities 1

Surgical Management

1. Shoulder Arthroplasty (Preferred Option)

   • Total Shoulder Arthroplasty (TSA):

     • Provides better outcomes with higher median scores in all functional measurements compared to hemiarthroplasty 3
     • Particularly beneficial for patients with concurrent glenoid arthritis 4
     • Shows significantly better internal rotation outcomes compared to hemiarthroplasty 4
     • Has 10-year survivorship of approximately 80% 4

   • Hemiarthroplasty:

     • Viable option when the glenoid is preserved 3
     • May be preferred in younger patients 5
     • Has 10-year survivorship of approximately 89% 4
     • Shorter operative time and potentially fewer complications 6

2. Other Surgical Options (Less Common for Advanced AVN with Fracture Dislocation)

   • Core decompression - typically only for early-stage AVN without collapse 1
   • Vascularized bone grafts - limited role in advanced cases 1
   • Arthroscopic debridement - limited role in advanced cases 1

Special Considerations

• Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with pre-existing rotator cuff dysfunction or after failure of first-line treatment 6
• Rehabilitation is crucial and should include:
  • Early range-of-motion exercises including shoulder, elbow, wrist, and hand motion within the first postoperative days 6
  • A sling for comfort that may be discarded as pain allows 6
  • Restriction of above chest level activities until healing is evident 6
  • Progressive muscle strengthening exercises 2
  • Long-term continuation of shoulder exercises 2

Outcomes and Prognosis

• Both TSA and HA demonstrate significant improvements in pain, range of motion, and shoulder function 3, 5, 4
• TSA generally provides better functional outcomes than hemiarthroplasty, particularly for internal rotation 4
• Long-term survivorship (>10 years) is good for both procedures (80% for TSA, 89% for HA) 4
• Forward elevation may not approach normal levels even after successful arthroplasty 5

Pitfalls and Caveats

• Overly aggressive physical therapy in the early postoperative period may increase the risk of fixation failure 6
• Patients should be monitored for complications including infection, implant loosening, and continued pain 2
• The etiology of AVN (traumatic vs. steroid-related) may affect preoperative status but does not significantly impact postoperative outcomes 5