Monday, April 18, 2016

Avascular necrosis of the humeral head in sickle cell disease - to decompress or not to decompress?

Core decompression and arthroplasty outcomes for atraumatic osteonecrosis of the humeral head

These authors evaluated radiographic and functional outcomes after procedures for humeral head atraumatic avascular necrosis (HAAVN), decompression efficacy in sickle cell disease (SCD) populations, and report outcomes of advanced disease requiring arthroplasty. The condition was staged according to the system of Cruess:

• Stage I was defined by radiographs showing no abnormalities and only marrow signal changes on MRI.

• Stage II disease was marked by wedged or mottled sclerosis on plain films but overall maintained sphericity of the humeral head.

• Stage III was identified by subchondral fracturing with frequently associated crescent sign signifying this compromised chondral integrity.

• Stage IV showed further subchondral bone collapse and flattening, with marked loss of humeral head sphericity on plain films.

• Stage V, the final stage of AVN, showed humeral head collapse along with significant deformation and extension of erosion into the glenoid.

Stage I/II disease received core decompression and ultrasound bone stimulation. Stage III received surface replacement or hemiarthroplasty, and arthroplasty was performed for stage IV/V.

Seven of 8 shoulders (88%) progressed to stage III/IV after decompression. All SCD patients progressed to collapse.

19 shoulders had a surface replacement, hemiarthroplasty, or TSA.  13 of 16 arthroplasty patients (81%) had satisfactory to excellent results. One surface replacement was revised to reverse TSA.

The authors concluded that core decompression for AVN in SCD patients does not alter osteonecrosis progression and humeral head collapse. Resurfacing and hemiarthroplasty are viable treatment options for stage III, whereas shoulder replacement for stage IV/V disease appears to offer better functional results.

Comment: This article points to poor results from core decompression in sickle cell disease. The role of core decompression for early stage avascular necrosis from other etiologies remains unclear.


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