What are the management options for osteonecrosis of the humeral head?

Management of Osteonecrosis of the Humeral Head

Management of humeral head osteonecrosis should be stage-based: core decompression for early-stage disease (Ficat stages I-III) and arthroplasty (hemiarthroplasty or total shoulder arthroplasty) for late-stage disease with articular collapse (stage IV). 1, 2

Initial Diagnostic Approach

• Begin with plain radiographs (anteroposterior, lateral, and oblique views) to exclude other causes of shoulder pain such as fracture, primary arthritis, or tumor, though radiographs are less sensitive for early osteonecrosis 1
• MRI is the gold standard for early detection and staging, as it can identify disease before radiographic changes appear and quantify the size of the necrotic lesion 1
• CT imaging is essential for surgical planning when intervention is considered, showing precise location and extent of the necrotic lesion 3

Risk Stratification and Prognosis

• Lesion size is the most critical prognostic factor: lesions involving <30% of the humeral head have <5% progression to collapse, while lesions >30% have 46-83% risk of progression 4
• Risk factors that worsen prognosis include corticosteroid therapy, alcohol use, HIV, blood dyscrasias, chemotherapy, radiation, age >40 years, BMI >24 kg/m², joint effusion, and increased bone marrow edema 1, 4
• Screen for bilateral disease: 70-80% of nontraumatic cases are bilateral, requiring evaluation of both shoulders 4
• Assess for multifocal involvement: osteonecrosis can affect multiple sites including knee, ankle, and hip 4

Stage-Based Treatment Algorithm

Early-Stage Disease (Ficat Stages I-II, Pre-Collapse)

Noninvasive therapy should be attempted first, though supporting data remains limited 1:

• Pharmacological options: statins, bisphosphonates, anticoagulants 1, 4
• Alternative modalities: extracorporeal shock wave therapy, hyperbaric oxygen 1, 4

Core decompression is the surgical intervention of choice for early-stage disease when conservative measures fail 1, 2:

• Success rates are excellent: 94% for Stage I and 88% for Stage II disease 5
• Can be supplemented with autologous bone marrow cell injection, vascular fibular grafting, or electric stimulation 1
• Postoperative protocol requires protected weight-bearing to prevent fracture 3
• Can be performed on an outpatient basis with few complications 5
• Arthroscopic debridement is an alternative minimally invasive option 6, 7

Intermediate-Stage Disease (Ficat Stage III, Early Collapse)

Core decompression remains a viable option with 70% success rate for Stage III disease, providing early pain relief and increased function 5:

• This represents subchondral fracture with early collapse 8
• Monitor closely with regular radiographic follow-up for disease progression or further collapse 3

Late-Stage Disease (Ficat Stage IV, Advanced Collapse with Secondary Osteoarthritis)

Arthroplasty is the definitive treatment for advanced disease 1, 2:

• Hemiarthroplasty for late-stage osteonecrosis with articular collapse but preserved glenoid 1, 6, 2
• Total shoulder arthroplasty for severe secondary osteoarthritis involving both humeral head and glenoid 1, 6, 2
• Core decompression has only 14% success rate at Stage IV and should not be performed 5

Critical Pitfalls to Avoid

• Do not delay diagnosis: early detection allows for joint-preserving interventions before articular collapse occurs 1, 4
• Do not perform core decompression on Stage IV disease: success rates are poor (14%) and arthroplasty is indicated 5
• Do not forget to evaluate the contralateral shoulder: bilateral involvement occurs in 70-80% of nontraumatic cases 4
• Do not rely solely on radiographs for early disease: MRI is necessary for detection before radiographic changes appear 1
• The efficacy of core decompression at preventing eventual articular collapse remains controversial despite reported success rates, so patient counseling about potential progression is essential 1