- Email: [email protected]
A Novel Surgical Procedure for Osteonecrosis of the Humeral Head: Reposition of the Joint Surface and Bone Engraftment
Case Report
A Novel Surgical Procedure for Osteonecrosis of the Humeral Head: Reposition of the Joint Surface and Bone Engraftment Yasuaki Nakagawa, M.D., Toyoji Ueo, M.D., and Takashi Nakamura, M.D.
Summary: A novel surgical procedure was performed on a 33-year-old woman with idiopathic osteonecrosis of the head of the left humerus. The operation involved repositioning of the joint cartilage and bone engraftment through her humeral head from under the greater tuberosity with shoulder arthroscopy. The patient wore an abduction brace for 8 weeks after the operation to hold the joint surface in its new position. This surgical procedure resulted in considerable improvement of the functional status of the shoulder by relieving pain and increasing range-of-motion. A preoperative radiograph showed stage IV osteonecrosis of the humeral head. However, at follow-up, repositioning of the joint surface and improvement of the necrotic bone were observed by radiography and magnetic resonance imaging. Key Words: Shoulder—Osteonecrosis—Humeral head—Arthroscopic surgery.
A
lthough the head of the humerus is the second most common site of nontraumatic osteonecrosis, after the head of the femur,1 there have been few reports concerning the natural history and treatment of this condition.1-6 Most studies have implicated steroids as etiological factors, in association with a variety of conditions such as systemic lupus erythematosus, asthma, and chronic renal diseases.1,5 Treatment has usually consisted of a combination of exercises and the avoidance of strenuous use and overhead movements of the shoulder.1,2 In cases where these measures have failed to relieve disability, hemiarthroplasty or total shoulder replacement have been used.2 We treated a case of osteonecrosis of the humeral head by repositioning the joint cartilage and bone From the Department of Orthopaedic Surgery, Faculty of Medicine, Kyoto University; and the Department of Orthopaedic Surgery, Tamatsukuri Koseinenkin Hospital, Shimane (T.U.), Japan. Address correspondence and reprint requests to Yasuaki Nakagawa, M.D., Department of Orthopaedic Surgery, Faculty of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. r 1999 by the Arthroscopy Association of North America 0749-8063/99/1504-2131$3.00/0
engraftment through the greater tubercle of the head of the humerus, with arthroscopy of the shoulder. This technique has provided the patient with 24 months of symptom relief, and considerable improvement of her shoulder has been observed by radiography and magnetic resonance (MRI). This operative procedure for the treatment of osteonecrosis of the humeral head has not been reported previously.
CASE REPORT AND OPERATIVE TECHNIQUE A 33-year-old woman complained of pain in her left shoulder and inability to abduct or flex her shoulder above 90° after she had been employed carrying heavy bags for several months. Preoperative anteroposterior and axial radiographs of her left shoulder showed extensive subchondral bone collapse, with severe articular incongruity of the head of the humerus and normal articular congruity of the glenoid (Fig 1). Preoperative MRI scans showed decreased signal intensity of the humeral head and detachment of the articular cartilage on a T1-weighted image (Fig 2).
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 4 (May-June), 1999: pp 433–438
433
434
Y. NAKAGAWA ET AL.
FIGURE 1. Preoperative radiographs: (A) anteroposterior view, (B) axial view. These radiographs show extensive subchondral bone collapse with articular incongruity and a crescent sign. The glenoid appeared normal.
OSTEONECROSIS OF THE HUMERAL HEAD
435
Bone and gallium scintigraphy findings were compatible with a diagnosis of osteonecrosis of the humeral head. This was categorized further as radiographic stage IV, as proposed by Cruess.6 The patient had no history of steroid use, systemic lupus erythematosus, sickle cell disease, or trauma to her left shoulder. No other osteonecrosis was detected by scintigraphy. A final diagnosis was made of idiopathic osteonecrosis of the humeral head. On April 13, 1992, surgery was performed on the patient’s left shoulder. She was placed in the right lateral decubitus position, under general anesthesia, so that her left shoulder was directed upward. Intraarticular examination, viewed from the posterior portal, showed a partially detached articular cartilage of the humeral head and necrotic bone in the focus (Fig 3A). The articular cartilage was partially resected via the anterior portal to cover the focus of the humeral head. A 3-cm incision was then made in the skin of the left upper arm, and a bone tunnel approximately 9 mm in diameter was created with the aid of an image intensifier, from the area under the greater tubercle to the focus of the humeral head (Fig 4). Bone chips collected from the left iliac bone were used to fill up the focus of the humeral head through the tunnel (Fig 3B). Any bone chips falling into the joint space were removed through the anterior portal. After the bone chips had filled up the focus completely, the bone tunnel was covered with a bone plug, retained after opening the bone tunnel, and the preserved piece of articular cartilage was used to cover the focus of the humeral head. Arthroscopic examination showed that
FIGURE 3. (A) Intra-articular examination, viewed from the posterior portal, showing a partially detached articular cartilage of the humeral head and necrotic bone in the humeral head focus. (B) Bone chips (arrow) collected from the left iliac bone filled up the focus of the humeral head through the tunnel. (C) Arthroscopic examination showed that the joint surface of the humeral head was repositioned completely when the patient’s left shoulder was abducted 100°.
FIGURE 2. Preoperative MRI scan in a coronal oblique plane. A T1-weighted image showed decreased signal intensity of the humeral head and detachment of the articular cartilage.
the joint surface of the humeral head was repositioned perfectly when the left shoulder was abducted through 100° (Fig 3C). Immediately after the operation, the patient was fitted with an abduction brace with her left
436
Y. NAKAGAWA ET AL.
FIGURE 4. Schema of the operative procedure. A bone tunnel was made from the area under the greater tubercle to the focus of the humeral head with the aid of an image intensifier. The shoulder joint was examined by arthroscopy.
shoulder in the 100° abduction position, to maintain the new position of her shoulder joint surface. Eight weeks after surgery, the abduction brace was removed and rehabilitation of her left shoulder was started. The patient was discharged 10 weeks after the operation, and returned to work after 13 weeks. Her shoulder pain decreased gradually, and she was free of pain and could abduct and flex her shoulder through 160°, 2 years after the operation. At that time, anteroposterior and axial radiographs showed good preservation of joint congruity and no evidence of progression of the disease process (Fig 5). MRI scans showed continuity of the articular cartilage of the humeral head, and sclerosis and adherence of the engrafted bone to the focus (Fig 6). DISCUSSION The head of the humerus is the second most common site of osteonecrosis after the head of the femur.1 The etiological factors that cause osteonecrosis of the humeral head are known to include excessive use of corticosteroids,1,6-8 alcoholism,1 hyperuricemia,1 sickle-cell anemia,9,10 Gaucher’s disease,11 chronic dialysis,12 and decompression sickness.13 Posttraumatic osteonecrosis of the humeral head has also been described.14,15 In a small number of patients, osteonecrosis may develop without the presence of
any recognized etiological factor and this is classified as idiopathic osteonecrosis.16 Because our patient had no history of corticosteroid use, sickle-cell anemia, Gaucher’s disease, or any other recognized etiological factor, this case was diagnosed as idiopathic osteonecrosis of the head of the left humerus. Bilateral osteonecrosis of the heads of both humeri was reported as the source of pain in an active paraplegic who had no evidence of disease or medical treatment normally associated with the development of osteonecrosis.17 Our patient did strenuous work involving the use of her shoulders before she complained of shoulder pain and it is, therefore, possible that her humeral osteonecrosis may have been caused by excessive use of her shoulder. In osteonecrosis of the humeral head, subchondral osteolysis occurs in the superior portion. When resorption of subchondral bone is extensive, it appears that even ordinary forces transmitted across the joint will lead to subchondral fracture and a humeral head crescent sign. The collapse occurs in a characteristic location, the lesion is circular, and corresponds to the area of contact between the humeral head and the glenoid at 90° abduction. Biomechanical studies have shown that this position is responsible for the maximum amount of force being transmitted across the glenohumeral joint.18 Our case had a similar type of lesion and, therefore, we presumed that postoperative fixation at 100° abduction would give good repositioning of her humeral head, including the joint cartilage, after bone engraftment into the lesion. Conservative treatment, drilling into the humeral head, core decompression, muscle-pedicled bone graft, arthroscopic debridement, and prosthetic arthroplasty, have all been reported as possible treatments for osteonecrosis of the humeral head. Conservative treatment, such as range-of-motion exercises, restriction of activities, and nonsteroid anti-inflammatory medication, have been effective in some patients.1,2 Drilling of the humeral head was not effective in preventing clinical or radiographic progression of the disease when used for stage III disease.2 Core decompression was effective in the early stages of humeral head osteonecrosis.4 One case report suggested that musclepedicled bone engraftment could be useful for treating post-traumatic osteonecrosis of the humeral head.5 Prosthetic arthroplasty was effective in the later stages of this disease, but satisfactory long-term results with this technique have been difficult to obtain.2 In other cases of humeral head osteonecrosis, arthroscopic removal of the loose bodies, debridement of the joint, and removal of the large osteochondral fragment have
OSTEONECROSIS OF THE HUMERAL HEAD
FIGURE 5. Radiographs of the left shoulder 2 years after the operation: (A) anteroposterior view, (B) axial view. These radiographs showed preservation of joint congruity and no evidence of progression of the disease process. The joint surface of the humeral head (arrow) can be observed faintly in the axial view.
437
438
Y. NAKAGAWA ET AL. which allowed complete repositioning when the left shoulder was abducted through 100°. As osteonecrosis of the shoulder is a rare condition, no large series of cases have been reported and the natural history of this condition is unknown. The influence of the natural history of our patient’s condition on the success of our method of treatment is, therefore, unclear. We advocate this method for treating symptomatic stage III or IV osteonecrosis of the humeral head. REFERENCES
FIGURE 6. T1-weighted MRI scans, 2 years after the operation, showed continuity of the articular cartilage of the humeral head and adherence to the focus of the engrafted bone.
produced excellent symptomatic relief. However, following these surgical procedures, an irregular defect may remain in the humeral head that permanently disrupts the mechanics of the joint, thus necessitating future prosthetic replacement.3 In our case, conventional open procedures on the shoulder joint would have been severely invasive and may have given poor results, particularly with regard to range-of-motion. The method we used, therefore, involved minimal invasion of the shoulder joint, and resulted in improvement of the patient’s functional and radiographic status through relief of pain and improved range-of-motion. Two years after the operation, anteroposterior and axial radiographs showed good preservation of joint congruity and no evidence of progression of the disease process. MRI scans showed continuity of the articular cartilage of the humeral head, and sclerosis and adherence to the focus of the engrafted bone. However, it is unclear whether the articular cartilage of the humeral head observed 2 years after the operation was fibrocartilaginous tissue or hyaline cartilage. We believe that the techniques that had the most impact on the outcome of our patient were (1) the creation of a bone tunnel from the area under the greater tubercle to the focus of the humeral head, which involved minimal invasion of the shoulder joint; and (2) preservation of the piece of articular cartilage covering the focus of the humeral head,
1. Cruess RL. Experience with steroid-induced avascular necrosis of the shoulder and etiologic considerations regarding osteonecrosis of the hip. Clin Orthop 1978;130:86-93. 2. L’Insalata JC, Pagnani MJ, Warren RF, Dines DM. Humeral head osteonecrosis: Clinical course and radiographic predictors of outcome. J Shoulder Elbow Surg 1996;5:355-361. 3. Hayes JM. Arthroscopic treatment of steroid-induced osteonecrosis of the humeral head. Arthroscopy 1989;5:218-221. 4. Mont MA, Maar DC, Urquhart MW, Lennox D, Hungerford DS. Avascular necrosis of the humeral head treated by core decompression. J Bone Joint Surg Br 1993;75:785-788. 5. Rindell K. Muscle pedicled bone graft in revascularization of aseptic necrosis of the humeral head. Ann Chir Gynecol 1987;76:283-285. 6. Cruess RL. Osteonecrosis of bone. Current concepts as to etiology and pathogenesis. Clin Orthop 1986;208:30-39. 7. Cruess RL. Corticosteroid-induced osteonecrosis of the humeral head. Orthop Clin North Am 1985;16:789-796. 8. Usher Jr BW, Friedman RJ. Steroid-induced osteonecrosis of the humeral head. Orthopedics 1995;18:47-51. 9. David HG, Bridgman SA, Davies SC, Hine AL, Emery RJH. The shoulder in sickle-cell disease. J Bone Joint Surg Br 1993;75:538-545. 10. Wingate J, Schiff CF, Friedman RJ. Osteonecrosis of the humeral head in sickle-cell disease. J South Orthop Assoc 1996;5:101-107. 11. Tauber C, Tauber T. Gaucher disease-the orthopaedic aspect. Report of seven cases. Arch Orthop Trauma Surg 1995;114:179182. 12. Langevitz P, Buskila D, Stewart J, Sherrard DJ, Hercz G. Osteonecrosis in patients receiving dialysis: Report of two cases and review of the literature. J Rheumatol 1990;17:402406. 13. Blarcom STV, Czarnecki DJ, Fueredi GA, Wenzei MS. Does dysbaric osteonecrosis progress in the absence of further hyperbaric exposure? A 10-year radiologic follow-up of 15 patients. AJR Am J Roentgenol 1990;155:95-97. 14. Schai P, Imhoff A, Preiss S. Comminuted humeral head fractures: A multicenter analysis. J Shoulder Elbow Surg 1995;4:319-330. 15. Resch H, Beck E, Bayley I. Reconstruction of the valgusimpacted humeral head fracture. J Shoulder Elbow Surg 1995;4:73-80. 16. Cicak N, Pecina M, Dakovic M. Idiopathic osteonecrosis of the humeral head. Acta Med Croatica 1995;49:93-98. 17. Barber DB, Gall NG. Osteonecrosis: An overuse injury of the shoulder in paraplesia. Case report. Paraplesia 1991;29:423426. 18. Inman VT, Saunders JB, Abbott LC. Observations on the function of the shoulder joint. J Bone Joint Surg 1944;26:1-30.
A Novel Surgical Procedure for Osteonecrosis of the Humeral Head: Reposition of the Joint Surface and Bone Engraftment Yasuaki Nakagawa, M.D., Toyoji Ueo, M.D., and Takashi Nakamura, M.D.
Summary: A novel surgical procedure was performed on a 33-year-old woman with idiopathic osteonecrosis of the head of the left humerus. The operation involved repositioning of the joint cartilage and bone engraftment through her humeral head from under the greater tuberosity with shoulder arthroscopy. The patient wore an abduction brace for 8 weeks after the operation to hold the joint surface in its new position. This surgical procedure resulted in considerable improvement of the functional status of the shoulder by relieving pain and increasing range-of-motion. A preoperative radiograph showed stage IV osteonecrosis of the humeral head. However, at follow-up, repositioning of the joint surface and improvement of the necrotic bone were observed by radiography and magnetic resonance imaging. Key Words: Shoulder—Osteonecrosis—Humeral head—Arthroscopic surgery.
A
lthough the head of the humerus is the second most common site of nontraumatic osteonecrosis, after the head of the femur,1 there have been few reports concerning the natural history and treatment of this condition.1-6 Most studies have implicated steroids as etiological factors, in association with a variety of conditions such as systemic lupus erythematosus, asthma, and chronic renal diseases.1,5 Treatment has usually consisted of a combination of exercises and the avoidance of strenuous use and overhead movements of the shoulder.1,2 In cases where these measures have failed to relieve disability, hemiarthroplasty or total shoulder replacement have been used.2 We treated a case of osteonecrosis of the humeral head by repositioning the joint cartilage and bone From the Department of Orthopaedic Surgery, Faculty of Medicine, Kyoto University; and the Department of Orthopaedic Surgery, Tamatsukuri Koseinenkin Hospital, Shimane (T.U.), Japan. Address correspondence and reprint requests to Yasuaki Nakagawa, M.D., Department of Orthopaedic Surgery, Faculty of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. r 1999 by the Arthroscopy Association of North America 0749-8063/99/1504-2131$3.00/0
engraftment through the greater tubercle of the head of the humerus, with arthroscopy of the shoulder. This technique has provided the patient with 24 months of symptom relief, and considerable improvement of her shoulder has been observed by radiography and magnetic resonance (MRI). This operative procedure for the treatment of osteonecrosis of the humeral head has not been reported previously.
CASE REPORT AND OPERATIVE TECHNIQUE A 33-year-old woman complained of pain in her left shoulder and inability to abduct or flex her shoulder above 90° after she had been employed carrying heavy bags for several months. Preoperative anteroposterior and axial radiographs of her left shoulder showed extensive subchondral bone collapse, with severe articular incongruity of the head of the humerus and normal articular congruity of the glenoid (Fig 1). Preoperative MRI scans showed decreased signal intensity of the humeral head and detachment of the articular cartilage on a T1-weighted image (Fig 2).
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 4 (May-June), 1999: pp 433–438
433
434
Y. NAKAGAWA ET AL.
FIGURE 1. Preoperative radiographs: (A) anteroposterior view, (B) axial view. These radiographs show extensive subchondral bone collapse with articular incongruity and a crescent sign. The glenoid appeared normal.
OSTEONECROSIS OF THE HUMERAL HEAD
435
Bone and gallium scintigraphy findings were compatible with a diagnosis of osteonecrosis of the humeral head. This was categorized further as radiographic stage IV, as proposed by Cruess.6 The patient had no history of steroid use, systemic lupus erythematosus, sickle cell disease, or trauma to her left shoulder. No other osteonecrosis was detected by scintigraphy. A final diagnosis was made of idiopathic osteonecrosis of the humeral head. On April 13, 1992, surgery was performed on the patient’s left shoulder. She was placed in the right lateral decubitus position, under general anesthesia, so that her left shoulder was directed upward. Intraarticular examination, viewed from the posterior portal, showed a partially detached articular cartilage of the humeral head and necrotic bone in the focus (Fig 3A). The articular cartilage was partially resected via the anterior portal to cover the focus of the humeral head. A 3-cm incision was then made in the skin of the left upper arm, and a bone tunnel approximately 9 mm in diameter was created with the aid of an image intensifier, from the area under the greater tubercle to the focus of the humeral head (Fig 4). Bone chips collected from the left iliac bone were used to fill up the focus of the humeral head through the tunnel (Fig 3B). Any bone chips falling into the joint space were removed through the anterior portal. After the bone chips had filled up the focus completely, the bone tunnel was covered with a bone plug, retained after opening the bone tunnel, and the preserved piece of articular cartilage was used to cover the focus of the humeral head. Arthroscopic examination showed that
FIGURE 3. (A) Intra-articular examination, viewed from the posterior portal, showing a partially detached articular cartilage of the humeral head and necrotic bone in the humeral head focus. (B) Bone chips (arrow) collected from the left iliac bone filled up the focus of the humeral head through the tunnel. (C) Arthroscopic examination showed that the joint surface of the humeral head was repositioned completely when the patient’s left shoulder was abducted 100°.
FIGURE 2. Preoperative MRI scan in a coronal oblique plane. A T1-weighted image showed decreased signal intensity of the humeral head and detachment of the articular cartilage.
the joint surface of the humeral head was repositioned perfectly when the left shoulder was abducted through 100° (Fig 3C). Immediately after the operation, the patient was fitted with an abduction brace with her left
436
Y. NAKAGAWA ET AL.
FIGURE 4. Schema of the operative procedure. A bone tunnel was made from the area under the greater tubercle to the focus of the humeral head with the aid of an image intensifier. The shoulder joint was examined by arthroscopy.
shoulder in the 100° abduction position, to maintain the new position of her shoulder joint surface. Eight weeks after surgery, the abduction brace was removed and rehabilitation of her left shoulder was started. The patient was discharged 10 weeks after the operation, and returned to work after 13 weeks. Her shoulder pain decreased gradually, and she was free of pain and could abduct and flex her shoulder through 160°, 2 years after the operation. At that time, anteroposterior and axial radiographs showed good preservation of joint congruity and no evidence of progression of the disease process (Fig 5). MRI scans showed continuity of the articular cartilage of the humeral head, and sclerosis and adherence of the engrafted bone to the focus (Fig 6). DISCUSSION The head of the humerus is the second most common site of osteonecrosis after the head of the femur.1 The etiological factors that cause osteonecrosis of the humeral head are known to include excessive use of corticosteroids,1,6-8 alcoholism,1 hyperuricemia,1 sickle-cell anemia,9,10 Gaucher’s disease,11 chronic dialysis,12 and decompression sickness.13 Posttraumatic osteonecrosis of the humeral head has also been described.14,15 In a small number of patients, osteonecrosis may develop without the presence of
any recognized etiological factor and this is classified as idiopathic osteonecrosis.16 Because our patient had no history of corticosteroid use, sickle-cell anemia, Gaucher’s disease, or any other recognized etiological factor, this case was diagnosed as idiopathic osteonecrosis of the head of the left humerus. Bilateral osteonecrosis of the heads of both humeri was reported as the source of pain in an active paraplegic who had no evidence of disease or medical treatment normally associated with the development of osteonecrosis.17 Our patient did strenuous work involving the use of her shoulders before she complained of shoulder pain and it is, therefore, possible that her humeral osteonecrosis may have been caused by excessive use of her shoulder. In osteonecrosis of the humeral head, subchondral osteolysis occurs in the superior portion. When resorption of subchondral bone is extensive, it appears that even ordinary forces transmitted across the joint will lead to subchondral fracture and a humeral head crescent sign. The collapse occurs in a characteristic location, the lesion is circular, and corresponds to the area of contact between the humeral head and the glenoid at 90° abduction. Biomechanical studies have shown that this position is responsible for the maximum amount of force being transmitted across the glenohumeral joint.18 Our case had a similar type of lesion and, therefore, we presumed that postoperative fixation at 100° abduction would give good repositioning of her humeral head, including the joint cartilage, after bone engraftment into the lesion. Conservative treatment, drilling into the humeral head, core decompression, muscle-pedicled bone graft, arthroscopic debridement, and prosthetic arthroplasty, have all been reported as possible treatments for osteonecrosis of the humeral head. Conservative treatment, such as range-of-motion exercises, restriction of activities, and nonsteroid anti-inflammatory medication, have been effective in some patients.1,2 Drilling of the humeral head was not effective in preventing clinical or radiographic progression of the disease when used for stage III disease.2 Core decompression was effective in the early stages of humeral head osteonecrosis.4 One case report suggested that musclepedicled bone engraftment could be useful for treating post-traumatic osteonecrosis of the humeral head.5 Prosthetic arthroplasty was effective in the later stages of this disease, but satisfactory long-term results with this technique have been difficult to obtain.2 In other cases of humeral head osteonecrosis, arthroscopic removal of the loose bodies, debridement of the joint, and removal of the large osteochondral fragment have
OSTEONECROSIS OF THE HUMERAL HEAD
FIGURE 5. Radiographs of the left shoulder 2 years after the operation: (A) anteroposterior view, (B) axial view. These radiographs showed preservation of joint congruity and no evidence of progression of the disease process. The joint surface of the humeral head (arrow) can be observed faintly in the axial view.
437
438
Y. NAKAGAWA ET AL. which allowed complete repositioning when the left shoulder was abducted through 100°. As osteonecrosis of the shoulder is a rare condition, no large series of cases have been reported and the natural history of this condition is unknown. The influence of the natural history of our patient’s condition on the success of our method of treatment is, therefore, unclear. We advocate this method for treating symptomatic stage III or IV osteonecrosis of the humeral head. REFERENCES
FIGURE 6. T1-weighted MRI scans, 2 years after the operation, showed continuity of the articular cartilage of the humeral head and adherence to the focus of the engrafted bone.
produced excellent symptomatic relief. However, following these surgical procedures, an irregular defect may remain in the humeral head that permanently disrupts the mechanics of the joint, thus necessitating future prosthetic replacement.3 In our case, conventional open procedures on the shoulder joint would have been severely invasive and may have given poor results, particularly with regard to range-of-motion. The method we used, therefore, involved minimal invasion of the shoulder joint, and resulted in improvement of the patient’s functional and radiographic status through relief of pain and improved range-of-motion. Two years after the operation, anteroposterior and axial radiographs showed good preservation of joint congruity and no evidence of progression of the disease process. MRI scans showed continuity of the articular cartilage of the humeral head, and sclerosis and adherence to the focus of the engrafted bone. However, it is unclear whether the articular cartilage of the humeral head observed 2 years after the operation was fibrocartilaginous tissue or hyaline cartilage. We believe that the techniques that had the most impact on the outcome of our patient were (1) the creation of a bone tunnel from the area under the greater tubercle to the focus of the humeral head, which involved minimal invasion of the shoulder joint; and (2) preservation of the piece of articular cartilage covering the focus of the humeral head,
1. Cruess RL. Experience with steroid-induced avascular necrosis of the shoulder and etiologic considerations regarding osteonecrosis of the hip. Clin Orthop 1978;130:86-93. 2. L’Insalata JC, Pagnani MJ, Warren RF, Dines DM. Humeral head osteonecrosis: Clinical course and radiographic predictors of outcome. J Shoulder Elbow Surg 1996;5:355-361. 3. Hayes JM. Arthroscopic treatment of steroid-induced osteonecrosis of the humeral head. Arthroscopy 1989;5:218-221. 4. Mont MA, Maar DC, Urquhart MW, Lennox D, Hungerford DS. Avascular necrosis of the humeral head treated by core decompression. J Bone Joint Surg Br 1993;75:785-788. 5. Rindell K. Muscle pedicled bone graft in revascularization of aseptic necrosis of the humeral head. Ann Chir Gynecol 1987;76:283-285. 6. Cruess RL. Osteonecrosis of bone. Current concepts as to etiology and pathogenesis. Clin Orthop 1986;208:30-39. 7. Cruess RL. Corticosteroid-induced osteonecrosis of the humeral head. Orthop Clin North Am 1985;16:789-796. 8. Usher Jr BW, Friedman RJ. Steroid-induced osteonecrosis of the humeral head. Orthopedics 1995;18:47-51. 9. David HG, Bridgman SA, Davies SC, Hine AL, Emery RJH. The shoulder in sickle-cell disease. J Bone Joint Surg Br 1993;75:538-545. 10. Wingate J, Schiff CF, Friedman RJ. Osteonecrosis of the humeral head in sickle-cell disease. J South Orthop Assoc 1996;5:101-107. 11. Tauber C, Tauber T. Gaucher disease-the orthopaedic aspect. Report of seven cases. Arch Orthop Trauma Surg 1995;114:179182. 12. Langevitz P, Buskila D, Stewart J, Sherrard DJ, Hercz G. Osteonecrosis in patients receiving dialysis: Report of two cases and review of the literature. J Rheumatol 1990;17:402406. 13. Blarcom STV, Czarnecki DJ, Fueredi GA, Wenzei MS. Does dysbaric osteonecrosis progress in the absence of further hyperbaric exposure? A 10-year radiologic follow-up of 15 patients. AJR Am J Roentgenol 1990;155:95-97. 14. Schai P, Imhoff A, Preiss S. Comminuted humeral head fractures: A multicenter analysis. J Shoulder Elbow Surg 1995;4:319-330. 15. Resch H, Beck E, Bayley I. Reconstruction of the valgusimpacted humeral head fracture. J Shoulder Elbow Surg 1995;4:73-80. 16. Cicak N, Pecina M, Dakovic M. Idiopathic osteonecrosis of the humeral head. Acta Med Croatica 1995;49:93-98. 17. Barber DB, Gall NG. Osteonecrosis: An overuse injury of the shoulder in paraplesia. Case report. Paraplesia 1991;29:423426. 18. Inman VT, Saunders JB, Abbott LC. Observations on the function of the shoulder joint. J Bone Joint Surg 1944;26:1-30.