Osteonecrosis Of Humeral Head Research Articles

Management of osteonecrosis of the humeral head in the pediatric population: A systematic review.

Humeral head osteonecrosis in the pediatric patients most often occurs in patients with underlying hemoglobinopathies, exposure to chronic corticosteroids, or after trauma. The purpose of this study was to perform a systematic review evaluating the prevalence, clinical characteristics, and management of humeral head osteonecrosis in the pediatric population. PubMed, Ovid MEDLINE, and Scopus were screened with the terms "osteonecrosis," "avascular necrosis," "pediatric," and "proximal humerus" on January 10, 2024. A total of 218 studies were screened, and 74 studies were evaluated for eligibility. Studies that reported on the prevalence and/or management of pediatric humeral head osteonecrosis were included. The systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Twelve studies met inclusion criteria: four retrospective case series, three prospective case series, one retrospective cohort study, one retrospective case-control study, and three case reports. A majority of the studies (67%) discussed chemotherapy-induced osteonecrosis of the humeral head. A total of 77 patients (106 shoulders) with humeral head osteonecrosis were identified. The overall prevalence of osteonecrosis of the humeral head across eight studies examining at-risk populations (underlying hemoglobinopathies or undergoing chemotherapy) was 2%. Intra-articular steroid injections, physical therapy, and activity modification are effective conservative management strategies. Additionally, core decompression and hemiarthroplasty are surgical treatment options. The prevalence of osteonecrosis of the humeral head is low even among at-risk populations with associated medical conditions. A variety of conservative and surgical treatment options have been described, but no comparative evaluations of these modalities has been conducted. IV.

Arthroscopic-Assisted Core Decompression of Humeral Head Osteonecrosis With Bone Marrow Aspirate Concentrate Augmentation

Background: The proximal humerus is the second-most common anatomic site for osteonecrosis, a condition of disrupted blood supply leading to death of bone tissue, with resultant shoulder pain and dysfunction. Core decompression is a viable joint-preserving surgical intervention that aims to improve local blood supply and restore bone health prior to bony collapse. Indications: Humeral head osteonecrosis has numerous underlying causes, most commonly the sequelae of prior trauma, chronic use of systemic corticosteroids, sickle cell disease, and alcohol abuse. Core decompression may be indicated in the early, pre-collapse stages of osteonecrosis, whereas more advanced stages of disease are commonly indicated for joint reconstruction procedures, such as bone grafting or arthroplasty. Technique Description: With the patient in the beach chair position, bone marrow aspirate concentrate (BMAC) is harvested through a percutaneous incision along the anterolateral proximal humerus. While viewing through a standard posterior portal, a transtibial anterior cruciate ligament (ACL) guide is placed through an anterior portal at a site on the humeral head surface, centered at the area of greatest humeral head bone edema as identified on preoperative magnetic resonance imaging. A guide pin is placed through a lateral portal within the ACL guide, to the subchondral bone. A 7.0-mm reamer is applied over the guidewire, followed by administration of demineralized bone matrix soaked in BMAC into the reamed channel within the proximal humerus. Results: In patients with early stages of humeral head osteonecrosis, core decompression confers superior clinical outcomes with reduced rates of subsequent surgical procedures compared with nonoperative treatment. Core decompression has shown to reduce the radiographic progression of osteonecrosis. Further research is necessary to determine the additional clinical benefits of augmentation with orthobiologic agents, such as BMAC. Conclusion: Arthroscopic-assisted core decompression is a valuable, minimally invasive surgical treatment for early-stage proximal humerus osteonecrosis. Adjunctive treatment with BMAC and demineralized bone matrix may enhance clinical outcomes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Osteonecrosis of Humeral Head after Arthroscopic Capsular Release for Postoperative Shoulder Joint Stiffness: A Case Report

An arthroscopic capsular release (ACR) is used for persistent shoulder stiffness after an index surgery. No cases of post-ACR humeral head osteonecrosis have been reported to date. A 56-year-old male patient underwent open reduction and internal fixation using a hook plate for acromioclavicular joint dislocation. Despite hardware removal, the patient presented with unresolved shoulder pain and range-of-motion (ROM) limitations. He had a history of hypertension, chronic hepatitis B infection, and alcohol consumption. His preoperative ROM was 90° for active forward flexion, 90° for abduction, 40° for external rotation, and at a sacral level for internal rotation. His preoperative functional status was a visual analog scale (VAS) score of 4, an American Shoulder and Elbow Surgeons (ASES) score of 51, and a Constant–Murley (CMS) score of 48 through normal radiography and magnetic resonance imaging. A standard ACR was performed with a 360° release of the joint capsule via electrocautery ablation. Six months post-ACR, his ROM (forward flexion: 135°; abduction: 135°; external rotation: 70°; internal rotation: T10 vertebra) and functional outcomes (VAS 2; ASES 79; CMS 75) were significantly improved, without an interval change in radiographic assessment. However, 15 months post-operation, the patient experienced a recurrence of shoulder pain and subsequently underwent triamcinolone injections in both the 15th and 21st postoperative months. Radiography revealed humeral head osteonecrosis. Patients with intrinsic or extrinsic risk factors related to humeral head circulation disturbance should be monitored for humeral head osteonecrosis post-ACR.

The Hertel classification can't predict the risk of humeral head osteonecrosis after osteosynthesis using an anterolateral approach

BackgroundProximal humeral fractures can progress to osteonecrosis of the humeral head. Hertel developed a binary classification system (12 subtypes) and demonstrated that some patterns have more risk to develop osteonecrosis. Hertel described the prevalence and the risk factors for Humeral head osteonecrosis after osteosynthesis using a Deltopectoral approach. Few studies have evaluated the prevalence and the capacity of Hertel's classification to predict Humeral Head osteonecrosis following osteosynthesis of proximal Humeral fractures through the anterolateral approach. The objectives of this study were to correlate osteonecrosis predictors established by the Hertel classification with the risk of developing osteonecrosis and its prevalence after osteosynthesis using the anterolateral approach. MethodsThis was a retrospective study of patients who underwent osteosynthesis of proximal humerus fractures using an anterolateral approach. Patients were divided into two groups: high risk for necrosis (group 1) and low risk for necrosis (group 2) according to Hertel's criteria. The overall prevalence of osteonecrosis and the prevalence in each group were calculated. A radiological examination was performed in the true anteroposterior (Grashey), scapular, and axillary views, before and after the operation (minimum 1 year after surgery). A Kaplan-Meier curve was used to assess the pattern of the temporal evolution of osteonecrosis. The groups were compared using the Chi-square test or Fisher's exact test. The unpaired t-test (parametric variables – age) and the Mann-Whitney test (non-parametric time between trauma and surgery) were used. ResultsIn total, 39 patients were evaluated. The postoperative follow-up time was 14.5 ± 3.3 months. The time to onset of necrosis was 14.1 ± 3.9 months. Sex, age, and time between trauma and surgery did not influence the risk of necrosis. Type 2, 9, 10, 11, and 12, or fractures with posteromedial head extension less than or equal to 8 mm, or diaphysis deviation greater than 2 mm, as well as grouping did not influence the risk for osteonecrosis. ConclusionsHertel's criteria were not able to predict the development of osteonecrosis after osteosynthesis of proximal humerus fractures performed through the anterolateral approach. The total prevalence of osteonecrosis was 17.9% with a tendency toward an increased incidence after 1 year of surgical treatment.

Orthopaedic Diagnoses in the Black Pediatric Population.

The Black pediatric population is one that has been historically underserved and continues to have unmet needs. Factors including lack of diversity in orthopaedic studies and in historical standards, such as bone age, may inadvertently lead to inferior care. There are certain conditions in this population for which the practicing orthopaedic surgeon should have a higher degree of suspicion, including slipped capital femoral epiphysis, Blount disease, and postaxial polydactyly. Systemic diseases with higher rates in this population have orthopaedic manifestations, including sickle cell disease, vitamin D deficiency, and obesity. Racial discrepancies in access to prenatal care can have orthopaedic consequences for babies, especially cerebral palsy and myelodysplasia. Racial discrepancy exists in evaluation for nonaccidental trauma. Increased awareness of these issues better prepares practitioners to provide equitable care.

Incidental Findings of Acute Myeloid Leukemia in Sjögren's Syndrome Detected by Nuclear Medicine Techniques.

A 46-year-old female with Sjögren's syndrome previously treated with corticosteroids was referred to our department for suspicious humeral head osteonecrosis. Dual-phase bone scan showed an increased radiotracer distribution in the head of the left humerus. Nevertheless, whole-body scan revealed multiple sites of heterogeneous skeletal uptake. As lymphoproliferative disorder was hypothesized, also based on laboratory examination, F-18 fluorodeoxyglucose positron-emission tomography/computed tomography was performed and showed increased uptake in several osseous structures and in the subcutaneous nodules. Finally, bone marrow biopsy confirmed the diagnosis of acute myeloid leukemia as well as skin nodule biopsy revealed infiltration by malignant cells.

Specific Radiologic Risk Factors for Implant Failure and Osteonecrosis of the Humeral Head after Interlocking Nailing with the Targon PH+ of Proximal Humeral Fractures in a Middle to Old Population.

Background: Operative management of proximal humeral fractures is still challenging. While antegrade nailing has become a valid option in fracture fixation, risk factors for adverse events, and failure have not been sufficiently clarified. Methods: All patients of a single trauma center undergoing surgery for proximal humeral fractures with the Targon PH+ nail between 2014 and 2021 were evaluated retrospectively. This included complications, revisions, and failures. Pre- and postoperative radiographic imaging were assessed regarding fracture’s complexity, anatomic reduction, reconstruction of the medial hinge, metaphyseal head extension, and fixation of the implant in the calcar region. Follow-up was at a minimum of 12 months. Results: A total number of 130 patients with a mean age of 74.5 years (range 63–94, SD ± 8.2) are included in this study. Two- and three-part fractures were found in 58 patients, while 14 patients showed four-part fractures. Overall, a complication rate of 34.2% and an implant failure rate of 15.4% was found. Four-part fractures showed a significantly higher complication rate than two- and three-part fractures. Four-part fractures also showed significantly higher revisions (p = 0.005) and implant failures (p = 0.008). The nonsufficient anatomical reduction was found to be a risk factor for complications (p < 0.0001), implant failures (p < 0.0001), and later humeral head osteonecrosis (p < 0.0001). Insufficiently reconstructed medial hinges (p = 0.002) and a metaphyseal head extension of over 8 mm (p = 0.005) were also demonstrated as risk factors for osteonecrosis of the humeral head. Conclusions: Four-part fractures in an elderly population show high complication, revision, and implant-failure rates. Therefore, demonstrated radiologic risk factors should be evaluated for improvements. Anatomical reduction and fixation near the calcar proved to be vital for successful antegrade nailing of complex fractures. To prevent osteonecrosis of the humeral head, reconstruction of the medial hinge and metaphyseal head extension should be evaluated.

Outcomes and complications after arthroplasty in patients with osteonecrosis of humeral head- systematic review

BackgroundThe purpose of this study was to investigate the outcomes and complications of hemiarthroplasty (HA) and total shoulder arthroplasty (TSA) in patients of osteonecrosis of humeral head (ONHH) through systematic review. MethodsPRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines were followed by utilizing the PubMed, EMBASE, Scopus, Ovid, and Cochrane Library databases. Keywords included ONHH, avascular necrosis, head replacement, hemiarthroplasty, or total shoulder arthroplasty. Methodological Index for Nonrandomized Studies (MINORS) was used for quality assessment. ResultsTen studies (416 shoulders) were finally eligible and mean MINORS score was 11.9 (ranges, 8–16). HA was performed in 255 shoulders (61.3%) and TSA in 161 (38.7%). Mean age of the patients at the time of surgery was 50.6 years and mean follow-up period was 73.1 months. All clinical scores with range of motion were significantly improved after surgery. Overall complication rate was 20.0% with 10.1% in HA and 17.5% in TSA (p = 0.077). Overall reoperation rate was 11.2% with 7.0% in HA and 15.0% in TSA (p = 0.046). Overall revision rate was 6.4% with 5.7% in HA and 9.2% in TSA (p = 0.349). ConclusionsBoth HA and TSA in patients with ONHH yielded functional improvement with pain relief, but TSA had higher reoperation rate compared to HA.

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Open reduction and internal fixation (ORIF) for proximal humeral fractures is said to increase the incidence of osteonecrosis of humeral head. Fact or fiction? Therefore a systematic review was performed, searching multiple databases, online registers of randomized controlled trials (RCTs), and the proceedings of major meetings.

Osteonecrosis of the humeral head in a human immunodeficiency virus-infected patient under tenofovir disoproxil fumarate\u2013emtricitabine\u2013lopinavir/ritonavir for 10 years: a case report

BackgroundHuman immunodeficiency virus-infected patients are 100 times more likely to develop aseptic osteonecrosis compared with the general population. While 90% of cases concern the femoral head, the involvement of humeral bone remains rare.Case presentationWe report a case of aseptic osteonecrosis of the left humeral head complicating antiretroviral therapy in a female, 46-year-old, Bissau-Guinean human immunodeficiency virus-infected patient received in a context of progressive pain in the left shoulder followed by limitation of articular movements. Standard x-ray of the shoulder allowed us to make the diagnosis by showing a typical image of osteonecrosis. The treatment was medical combined with physiotherapy.ConclusionsAseptic osteonecrosis should be systematically looked for in human immunodeficiency virus patients on antiretroviral treatment. In addition to femoral head aseptic necrosis, the involvement of the humeral bone should also be considered.

RISK FACTORS FOR HUMERAL HEAD OSTEONECROSIS IN PATIENTS WITH PROXIMAL HUMERAL FRACTURES TREATED OPERATIVELY

Proximal humerus presents the second most frequent site of posttraumatic osteonecrosis. This complication is usually related to poor functional outcomes. The aim of this study is to identify and analyze the risk factors for posttraumatic humeral head osteonecrosis in surgically treated patients. Ninety-one patients with 92 acute proximal humeral fractures were operated on for a period of 39 months. Operative methods include open reduction and internal fixation and closed reduction and percutaneous fixation. Fractures were classified according to Neer, AO and LEGO classifications. The mean age of patients was 60.9 years. From 91 operated patients for follow-up were available 82. The mean follow-up period was 15 months. Patient data was collected prospectively. Functional results are present using age and gender adjusted Constant score. In 41 patients, the result is excellent, in 28-good, in 11-fair and in 3 poor. Bone union was evident in all cases. No deep wound infections, nerve injuries, vascular injuries and implant failure were observed. Osteonecrosis was seen in 5 (6.1%) patients. Patients with posttraumatic osteonecrosis had significant lower Constant results. Analyzing the pre- and intraoperative factors in patients with osteonecrosis, we find that the most significant factors for this complication are increasing fracture severity and а combination of short medial metaphyseal extension and disrupted medial hinge.

Clinical case of preiser disease, bilateral femoral head and humeral head osteonecrosis associated with chronic corticosteroid therapy

Osteonecrosis is a pathologic process that is associated with numerous conditions and therapeutic interventions. Most commonly the hip is involved but almost any bone can develop osteonecrosis. It can occur in the femoral head, but also affect the femoral condyles, humeral heads, proximal tibia, vertebrae, and small bones of the hand and foot. The most frequent etiological factors are trauma, alcoholism, and chronic corticosteroid therapy; the latter causing the most devastating form of osteonecrosis. Glucocorticoid-induced osteonecrosis is a known toxicity in pediatric and young adult patients treated for Acute Lymphoblastic Leukemia (ALL) and Non-Hodgkin Lymphoma (NHL). Osteonecrosis of the shoulders and weight-bearing joints of the lower extremities has emerged as a major adverse effect of modern ALL therapy. Pain in the absence of activity (ie, rest pain) occurs in approximately two-thirds of patients, and nocturnal pain occurs in one-third. MRI continues to be the gold standard for diagnosis in symptomatic and asymptomatic patients, especially in early-stage disease. Respectively to Preiser disease, this condition is a rare disease of unknown etiology characterized by Avascular Necrosis (AVN), also known as osteonecrosis, of the scaphoid bone and the clinical manifestations include insidious and progressive pain lasting from months to years, edema, loss of strength and reduced range of motion in the wrist. The treatment of non-traumatic osteonecrosis remains one of the most controversial subjects in the orthopedic literature. The purpose of this case report is to bring to attention osteonecrosis as a potential side effect of corticosteroid use in the pediatric population, as a delayed or missed diagnosis can lead to several joints destruction.

Surgical treatment of proximal humeral fractures with the transosseous suture fixation

BackgroundThe surgical treatment of displaced proximal humeral fractures is commonly affected by implant-related complications. We evaluated the functional and radiographic results of transosseous suture fixation in a series of displaced proximal humeral fractures (PHF).MethodsSixty-four patients were retrospectively classified by age, sex, and the Neer fracture classification. Two-part greater tuberosity (2pGT) displaced fractures and 3-part (varus and valgus) and 4-part valgus impacted fractures were managed with fragment reduction and transosseous suture fixation. Patients with minimum follow-up of 24 months and assessed with the Constant-Murley score (CMS) were included. Radiological and medical complications, as well as reinterventions were also recorded.ResultsForty-six patients with a mean follow-up of 58 (24–132) and a mean age of 58 years old were analyzed. Patients with 2pGT (n = 10) fractures had a CMS of 76 points (59–89); patients with 3-part fractures (n = 22) had a score of 67 points (13–91); and those with 4-part fractures (n = 14) had a score of 64 (24–76) points. The overall complication rate was 6 out of 46, and 4 patients required reintervention for different reasons. Patients presenting with 3-part varus fractures had significantly lower functional outcomes scores (p = 0.007). Humeral head osteonecrosis was present in 9 patients and significantly affected the functional outcomes (p < 0.05). However, only three out of nine patients with osteonecrosis required subsequent surgery at the indicated follow-up.ConclusionsThe fracture reduction and transosseous fixation technique represents a safe technique with low complication and reintervention rates. The presence of humeral head necrosis did not lead to subsequent surgical intervention because no hardware had protruded.Level of evidenceLevel IV, retrospective study

The humeral head: A review of the blood supply and possible link to osteonecrosis following rotator cuff repair.

Trauma, corticosteroid therapy and metabolic diseases are well established aetiologies of humeral head osteonecrosis; however, there is increasing evidence that arthroscopic rotator cuff surgery may be another possible cause. One of the reasons is that there may be inadvertent damage to the arterial blood supply to the humeral head during surgical intervention. The blood supply to the humeral head displays large amounts of variation with regard to origin, course and distribution. Therefore, to shed light on the pathogenesis, the blood supply of the humeral head is reviewed together with a summary of all reported cases of osteonecrosis of the humeral head that occurred following rotator cuff repair. Inconsistencies with regard to terminologies used and contradictions concerning arterial contributions from the anterior circumflex humeral artery and the posterior circumflex humeral artery towards humeral head supply are addressed. Moreover, variations in the course of the anterior circumflex humeral artery and its branches are summarized. The vascular anatomy of the humeral head is clinically relevant due to the close relationship of these blood vessels with the surgical repair sites for rotator cuff surgery and biceps tenotomies or tenodesis procedures. Potential sites of disruption of blood supply following arthroscopic rotator cuff surgery are discussed. Detailed knowledge of the course of the arteries supplying the humeral head may help to minimize the risk of vascular injury and subsequent osteonecrosis. Given the great interindividual variations of vascular anatomy, imaging procedures preceding arthroscopic rotator cuff surgery may be advisable.

Core decompression with autologous bone marrow aspirate injection in humeral head osteonecrosis in adults with sickle cell disease.

Sickle cell disease is often associated with osteonecrosis of the humeral head with a risk of progression to humeral head collapse. The aim of this study was to evaluate the clinical outcome and the effect on the necrosis evolution of humeral head core decompression with autologous bone marrow aspirate injection in these patients. Forty shoulders in 23 patients were treated with core decompression with autologous concentrated iliac crest bone marrow aspirate injection. Patients were followed for a minimum of two years (limits from 2 to 10 years). Functional outcomes metrics included the simple shoulder test (STT) and subjective shoulder value (SSV) as well as assessment of radiographic progression of disease. Shoulder function improved significantly at final follow-up. The STT improved by 2.9 points (p = 0.001) and the SVV improved by 15 % (p = 0.001). However, based on radiologic features, the intervention did not halt the radiographic progression of disease nor did it result in healing of the lesion. The benefits were mainly clinical with diminished pain and functional improvement. Improvement in shoulder function was observed following core decompression and bone marrow aspirate injection in patients with sickle cell disease and early humeral head necrosis stages. The procedure should not be considered for grade 3 or greater disease and for asymptomatic cases whatever the grade. Given the lack of radiographic improvement observed in this study, further study in the context of prospective controlled trials should be undertaken before this intervention can be widely recommended.

Aseptic osteonecrosis of the shoulder: Etiologies, diagnosis and medical management

Aseptic osteonecrosis of the humeral head is a multifactorial entity in which the final common pathway results in disrupted blood supply, increased intraosseous pressure, and bone death. It follows a pathologic and radiographic pattern of progression similar to that seen at the hip. Much of the information regarding the disease has been extrapolated from findings in the femoral head. In addition, many treatment modalities have been adapted from techniques used in the hip. The causative underlying factors seem to be multifactorial and can be traumatic or non-traumatic. Although clinical symptoms and the underlying cause of the disease influence the treatment of each patient, staging is the most objective criterion in determining the most appropriate treatment. Earlier identification of osteonecrosis should facilitate the management. MRI is important for asymptomatic humeral head osteonecrosis in patients with poor clinical symptom and risk factor. Conservative treatment can be effective in stages I and II, When symptoms persist and there are signs of collapse despite conservative treatment, surgical intervention is advocated.

Inlay hemiarthroplasty of the humeral head for nontraumatic osteonecrosis

BackgroundOsteonecrosis of the humeral head often occurs in younger individuals and presents a difficult clinical situation. The purpose of this study was to evaluate the patient reported outcomes in patients undergoing inlay hemiarthroplasty for nontraumatic osteonecrosis of the humeral head. We hypothesized that patients would achieve a meaningful clinical improvement. MethodsA retrospective review of prospectively collected data on 9 patients undergoing inlay hemiarthroplasty for humeral head osteonecrosis was conducted. The American Shoulder and Elbow Surgeons Shoulder score (ASES), Simple Shoulder Test (SST), visual analog scale for pain (VAS), and range of motion measurements were collected preoperatively and at final follow-up. Radiographs were evaluated for any evidence of component loosening or glenoid wear. The primary outcome was achievement of substantial clinical benefit (SCB) for ASES. ResultsPostoperatively at a mean of 7.2 years the ASES improved from 35 to 73 (p = 0.011), the SST improved from 2 to 6 (p = 0.038), and the VAS for pain decreased from 7 to 3 (p = 0.009). Forward elevation increased from 96° to 138° (p = 0.012) and external rotation increased from 13° to 63° (p = 0.007). SCB for ASES was seen in 7 out of the 9 patients (78%). Asymptomatic mild or moderate glenoid wear was seen in 4/9 (44%) of patients. One patient (11%) developed symptomatic glenoid wear necessitating conversion to total shoulder arthroplasty. ConclusionInlay hemiarthroplasty offers a viable solution to osteonecrosis of the humeral head.Level of Evidence: Level IV; Treatment Study

Humeral Head Osteonecrosis: Outcomes of Hemiarthroplasty After Minimum 10-Year Follow-Up.

Objective To analyze long-term functional and radiographic results of partial shoulder replacement for humeral head osteonecrosis. Methods Retrospective review of thirteen cases, with a mean postoperative follow-up of 17 years (range 10 to 26 years). The findings from the last follow-up were compared to those in which the patients had one year of postoperative follow-up. Functional assessment consisted of shoulder movement measurements and application of the University of California, Los Angeles (UCLA) shoulder score. All patients underwent radiographic examination to measure glenoid erosion, proximal humeral migration and lateral glenohumeral dislocation. Results Glenoid erosion increased over time significantly ( p < 0.05). Paradoxically, all active shoulder movements also improved ( p < 0.05), while UCLA scores remained the same. Radiographic deterioration was not correlated with clinical function. We had an 84.7% survival rate for arthroplasties after a mean time of 16 years. Conclusions Early functional outcomes were maintained in the long run and do not correlate with radiographic deterioration (increased erosion of the glenoid).

Humeral head necrosis associated to shaft non-union with massive bone loss: a case report.

Humeral non-union is a rare complication in shaft fractures, as well as humeral head necrosis is a possible complication in fracture involving the proximal third especially in four-part fractures. The presence of head osteonecrosis and diaphyseal non-union in the same arm represents a formidable challenge for an orthopaedic surgeon. We could not find any similar report in the literature dealing with this issue thus far. We present a case of a 65 years old woman referred to our hospital being affected by an atrophic humeral diaphyseal non-union with a massive bone loss (>10cm) associated to a humeral head osteonecrosis following a previous surgical procedures with a clear loosening of the hardware. At our institution, she was treated with hardware removal and insertion of a diaphyseal antibiotic spacer with Gentamycin for 2 months suspecting an active septic process at the union site despite negative cultural exams. Finally, she was treated with a cemented modular humeral megaprosthesis. At 20 months follow up, the patient, despite a reduced shoulder range of motion, referred to a pain-free recovery to an almost normal lifestyle, including car driving with no major disturbances. This case suggests that, in extreme selected cases following several failed treatments, megaprosthesis can represent a viable solution, especially in huge bone loss associated to joint degeneration, to ensure an acceptable return to a normal lifestyle. (www.actabiomedica.it)

Clinical and Radiographic Outcomes After Surgical Treatment of Proximal Humeral Fractures with Head-Split Component.

Head-split fractures are a subgroup of proximal humeral fractures in which the fracture line affects the articular surface. Limited data are available regarding outcomes and risk factors for failure following surgical treatment of this rare fracture type. Of 45 patients with head-split fractures identified, a total of 30 (67%) were included in this retrospective study, with a mean follow-up of 49 ± 18 months (range, 12 to 83 months). Of those 30, 24 were treated with open reduction and internal fixation (ORIF), 4 with reverse total shoulder arthroplasty (RTSA), and 2 with hemiarthroplasty. Subjective Shoulder Value, Simple Shoulder Test, Constant score, and biplanar radiographs were assessed. Fracture pattern, quality of reduction, eventual complications, revision procedures, and clinical failure (adjusted Constant score < 40) were analyzed, and risk factors for failure were calculated. The overall complication rate was 83% (ORIF: 21 of 24 [88%]; RTSA: 3 of 4 [75%]; and hemiarthroplasty: 1 of 2 [50%]). The most common complications following ORIF were humeral head osteonecrosis (42%), malunion of the lesser tuberosity (33%), and screw protrusion (29%), whereas all complications following RTSA were related to tuberosity problems. Revision was performed in 7 of 24 (29%) of initial ORIF patients, and no revisions were performed in RTSA or hemiarthroplasty patients. Four patients (17%) who underwent primary ORIF underwent conversion to RTSA, and 3 patients (12.5%) had screw removal due to penetration. The overall clinical failure rate was 50% (ORIF: 12 of 24 [50%]; RTSA: 1 of 4 [25%]; and hemiarthroplasty: 2 of 2 [100%]). No significant association was found between preoperative factors and clinical failure. ORIF and primary RTSA showed higher average clinical outcome scores than primary hemiarthroplasty and secondary RTSA. In general, patients who required revision had worse Subjective Shoulder Value (p = 0.014), Simple Shoulder Test (p = 0.028), and adjusted Constant scores (p = 0.069). Head-split fractures of the humerus treated with ORIF showed high complication and revision rates. RTSA resulted in comparable clinical outcomes and complication rates; however, the complications associated with RTSA were mostly related to tuberosity problems, which in this small series did not require revision. Therefore, RTSA may be the most predictable treatment option for head-split fractures in elderly patients. Therapeutic Level IV. See Instructions for Authors for a complete list of levels of evidence.