Monday, October 31, 2016

Avascular necrosis: to decompress or not to decompress

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

These authors evaluated the radiographic and functional outcomes after procedures for two forms of humeral head atraumatic avascular necrosis (HAAVN):
(1) chronic steroid-induced(CSI) 12 cases  and 
2) sickle cell disease (SCD) 13 cases. 
Patients with post traumatic AVN were excluded.

11 shoulders (stage I/II disease) underwent core decompression. Seven of 8 shoulders (88%) progressed to stage III/IV after decompression. All SCD patients progressed to collapse. 

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

The improvement in the Simple Shoulder Test Scores for the arthroplasty patients were comparable to the improvement seen with other pathologies. On average, patients improved from an SST of 2 preoperatively to 10 at year one and year two.

They concluded that core decompression for AVN in SCD patients does not alter osteonecrosis progression or humeral head collapse; shoulder arthroplasty was their preferred treatment for stages III, IV and V. 

Comment: In our experience patients with AVN of the shoulder related to sickle cell disease have high levels of pain (in spite of seemingly mild radiographic changes) and often have multiple sites of involvement. For these reasons - in addition to the progression of disease after decompression - we often discuss with the patient the alternative of a total shoulder arthroplasty to maximize the changes of improving their comfort and function.