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Arthroscopic Treatment of Bilateral Humeral Head Osteonecrosis
Case Report
Arthroscopic Treatment of Bilateral Humeral Head Osteonecrosis Philippe Hardy, M.D., Edouard Decrette, M.D., Ce´cile Jeanrot, M.D., Arnaud Colom, M.D., Alain Lortat-Jacob, M.D., and Je´rome Benoit, M.D.
Summary: A 37-year-old woman with a renal transplant was treated by arthroscopic debridement for bilateral steroid-induced humeral head osteonecrosis. Radiologically, the right shoulder had been categorized as stage III and the left as stage IV according to Arlet and Ficat. Relief of pain and improved range of motion were obtained especially on the right shoulder. Arthroscopy is an efficient procedure for treatment of humeral head osteonecrosis in the renal transplant recipient including radiological stages III with episodes of locking. Key Words: Humeral head—Osteonecrosis— Shoulder arthroscopy—Renal transplant—Steroid.
O
steonecrosis is a well-known complication of corticotherapy.1 Most cases involve the femoral head, although the humeral head can also be affected.2 Prevention is the best treatment but corticotherapy often remains essential. Treatment requires either a medical procedure of combined nonsteroidal antiinflammatory therapy and rehabilitation or a surgical approach consisted of core decompression and in last resort prosthetic arthroplasty.3,4 Arthroscopy is an interesting therapeutic modality for shoulder pathologies. Its use in humeral head osteonecrosis has already been described.5 We report an unusual case of arthroscopic treatment of bilateral steroid-induced humeral head osteonecrosis in a renal transplant recipient. CASE REPORT A 37-year-old woman, a housewife, with chronic renal failure received for the first time in 1976 a From the Orthopaedic Department, Hoˆpital Ambroise Pare´, Boulogne, France. Address correspondence and reprint requests to Philippe Hardy, M.D., Orthopaedic Department, Hoˆpital Ambroise Pare´, 9 Ave Charles de Gaulle, 92100 Boulogne, France. E-mail: philippe. [email protected] r 2000 by the Arthroscopy Association of North America 0749-8063/00/1603-2078$3.00/0 doi:10.1053/ay.2000.5665
332
cadaveric kidney after 2 years of hemodialysis. The post-transplantation course was complicated by 3 acute cellular rejections requiring hemodialysis from 1978 to 1987. She received a second transplant in 1987 followed by a chronic rejection which was treated by high doses of corticosteroids and hemodialysis since 1995. After the second transplantation, tests for antibodies to the human immunodeficiency virus and hepatitis B virus were positive. The patient is asymptomatic with a concentration of helper (CD4) lymphocytes of 500/mL. She first complained of a bilateral femoral head osteonecrosis that was treated successively by a bilateral core decompression in 1988 and 2 bipolar arthroplasties, 1 in 1989 (left hip) and 1 in 1990 (right hip). In 1992, this right-handed patient started to suffer from bilateral daily and nightly shoulder pain increasing on motion with audible click and getting worse. The patient was treated by the association of 2 to 3 oral analgesic medications. Physical examination of the 2 shoulders showed painful active and passive movements with severe weakness during active abduction. Radiographs showed osteonecrosis affecting both the humeral heads (Fig 1). In March 1993, we decided to perform an arthroscopy on the most affected right shoulder with removal of loose bodies and joint debridement (Fig 2). Abduction of the right shoulder was limited to 90E, forward flexion to 100E, external
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 3 (April), 2000: pp 332–335
BILATERAL HUMERAL HEAD OSTEONECROSIS
333
FIGURE 1. Preoperative anteroposterior radiographs showing typical aspect of bilateral humeral head osteonecrosis. (A) Right shoulder, (B) left shoulder.
rotation to 45E, and internal rotation to the L4 level. In 1995, the left shoulder became more and more stiff and painful with abduction limited to 90E, forward flexion to 10E, external rotation to 60E, and internal rotation to the L5 level. A new arthroscopy was carried out on the left shoulder in March 1995 after several episodes
of locking. Under general anesthesia and interscalene block, the patient was placed in the lateral decubitus position such that the upper limb was directed upward. The intra-articular examination as viewed from the posterior portal showed involvement of the entire humeral head cartilage, which was separated from
334
P. HARDY ET AL. rotation to the D7 level. Five months after arthroscopy, examination of the left shoulder showed that abduction had increased to 90E, forward flexion to 20E, external rotation to 90E, and internal rotation to the D10 level. Radiography revealed regular humeral head contours without foreign bodies (Fig 3). The left shoulder remained painful but the patient had stopped oral analgesic treatment. DISCUSSION
FIGURE 2. (A) Removed osteochondral fragments. (B) Humeral head and the glenoid after fragment removal.
subchondral bone as a free cap. We first performed debridement of the humeral head using a motorized shaver, then articular cleaning, synovectomy, and removal of all the loose osteocartilaginous bodies via a second posteroinferior portal. The cartilage of the right glenoid surface was normal whereas on the left it was irregular with a degenerative labrum. Three months after the first arthroscopy, the functional status of the right shoulder improved through relief of pain and increased range of motion, with 90E of abduction, 120E of forward flexion, 45E of external rotation, and internal rotation to the D7 level. Two years later, the right shoulder remained completely asymptomatic with 110E of abduction, 160E of forward flexion, 70E of external rotation, and internal
Osteonecrosis includes traumatic and atraumatic etiologies. Among the atraumatic etiologies, corticotherapy is most frequently encountered, especially in organ transplant recipients receiving immunosuppressive drugs.6 After renal transplantation, the femoral head is most often affected by osteonecrosis,2 followed by humeral head, calcaneum, metatarsus, femoral condyles, and proximal tibia. Osteonecrosis is made of multiepiphyseal involvement of subchondral bone resembling osteochondral fracture. The diagnosis of osteonecrosis is often late, but fortunately the shoulder is not a weight-bearing joint. Pain is not correlated with the severity of osteonecrosis. The scapulothoracic joint yields some mobility although the glenohumeral joint is already involved. According to Cruess,1 range of motion of the shoulder is diminished mainly because of pain. Four radiographic stages of avascular necrosis of the shoulder were proposed by Ficat and Arlet.7 Stages I and II can be treated effectively by core decompression3,8 or rehabilitation consistent with pendulum exercises and avoidance of abduction, particularly against resistance.2 Stages III and IV require an hemiarthroplasty or a total arthroplasty whether the glenoid surface is intact or involved.9 The use of arthroscopy as a diagnostic and therapeutic modality in humeral head osteonecrosis has already been described5 but remains still uncommon.8 It is justified by the cosmetic and analgesic benefits, the muscular and capsular preservation, the short and relatively easy recovery, and the least risk of infection, especially in renal transplant recipients. In our patient, the first arthroscopy was performed on the right shoulder with stage III radiological changes according to Ficat and Arlet. Complete relief of pain associated with improved range of motion were obtained 10 days postoperatively. Three years after arthroscopy, the patient’s functional status remains unchanged. The left shoulder was treated with an initial stage IV. The patient is completely asymptomatic 5 months later, but abduction, forward flexion, and external rotation remain
BILATERAL HUMERAL HEAD OSTEONECROSIS
335
FIGURE 3. Postoperative anteroposterior radiographs of both shoulders.
limited. A total replacement arthroplasty will be carried out on the left shoulder. Arthroscopy is an efficient modality for treatment of humeral head osteonecrosis in the renal transplant recipient including those with radiological stage III with episodes of locking. It is an interesting and nonaggressive procedure for young and still active patients that avoids or at least delays arthroplasty.
3. 4. 5. 6. 7.
REFERENCES 8. 1. Cruess RL. Steroid-induced avascular necrosis of the humeral head: Natural history and management. J Bone Joint Surg Br 1976;58:313-317. 2. Davidson JK, Tsakiris D, Briggs JD, Junor BJ. Osteonecrosis
9.
and fractures following renal transplantation. Clin Radiol 1985;36:27-35. 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. Fischer DE, Bickel NH. Corticosteroid-induced avascular necrosis. J Bone Joint Surg Am 1971;53:859-873. Hayes JM. Arthroscopic treatment of steroid-induced osteonecrosis of the humeral head. Arthroscopy 1989;5:218-221. Frostick SP, Wallace WA. Osteonecrosis of the femoral head. Baillieres Clin Rheumatol 1989;3:651-667. Ficat RP, Arlet J. Necrosis of the femoral head. In: Ischemia and necrosis of bone. Baltimore: Williams & Wilkins, 1980;171182. Usher BW, Friedman RJ. Steroid-induced osteonecrosis of the humeral head. Orthopedics 1985;18:47-51. Neer CS, Watson KD, Stanton FJ. Recent experiences in total shoulder replacement. J Bone Joint Surg Am 1982;64:319337.
Arthroscopic Treatment of Bilateral Humeral Head Osteonecrosis Philippe Hardy, M.D., Edouard Decrette, M.D., Ce´cile Jeanrot, M.D., Arnaud Colom, M.D., Alain Lortat-Jacob, M.D., and Je´rome Benoit, M.D.
Summary: A 37-year-old woman with a renal transplant was treated by arthroscopic debridement for bilateral steroid-induced humeral head osteonecrosis. Radiologically, the right shoulder had been categorized as stage III and the left as stage IV according to Arlet and Ficat. Relief of pain and improved range of motion were obtained especially on the right shoulder. Arthroscopy is an efficient procedure for treatment of humeral head osteonecrosis in the renal transplant recipient including radiological stages III with episodes of locking. Key Words: Humeral head—Osteonecrosis— Shoulder arthroscopy—Renal transplant—Steroid.
O
steonecrosis is a well-known complication of corticotherapy.1 Most cases involve the femoral head, although the humeral head can also be affected.2 Prevention is the best treatment but corticotherapy often remains essential. Treatment requires either a medical procedure of combined nonsteroidal antiinflammatory therapy and rehabilitation or a surgical approach consisted of core decompression and in last resort prosthetic arthroplasty.3,4 Arthroscopy is an interesting therapeutic modality for shoulder pathologies. Its use in humeral head osteonecrosis has already been described.5 We report an unusual case of arthroscopic treatment of bilateral steroid-induced humeral head osteonecrosis in a renal transplant recipient. CASE REPORT A 37-year-old woman, a housewife, with chronic renal failure received for the first time in 1976 a From the Orthopaedic Department, Hoˆpital Ambroise Pare´, Boulogne, France. Address correspondence and reprint requests to Philippe Hardy, M.D., Orthopaedic Department, Hoˆpital Ambroise Pare´, 9 Ave Charles de Gaulle, 92100 Boulogne, France. E-mail: philippe. [email protected] r 2000 by the Arthroscopy Association of North America 0749-8063/00/1603-2078$3.00/0 doi:10.1053/ay.2000.5665
332
cadaveric kidney after 2 years of hemodialysis. The post-transplantation course was complicated by 3 acute cellular rejections requiring hemodialysis from 1978 to 1987. She received a second transplant in 1987 followed by a chronic rejection which was treated by high doses of corticosteroids and hemodialysis since 1995. After the second transplantation, tests for antibodies to the human immunodeficiency virus and hepatitis B virus were positive. The patient is asymptomatic with a concentration of helper (CD4) lymphocytes of 500/mL. She first complained of a bilateral femoral head osteonecrosis that was treated successively by a bilateral core decompression in 1988 and 2 bipolar arthroplasties, 1 in 1989 (left hip) and 1 in 1990 (right hip). In 1992, this right-handed patient started to suffer from bilateral daily and nightly shoulder pain increasing on motion with audible click and getting worse. The patient was treated by the association of 2 to 3 oral analgesic medications. Physical examination of the 2 shoulders showed painful active and passive movements with severe weakness during active abduction. Radiographs showed osteonecrosis affecting both the humeral heads (Fig 1). In March 1993, we decided to perform an arthroscopy on the most affected right shoulder with removal of loose bodies and joint debridement (Fig 2). Abduction of the right shoulder was limited to 90E, forward flexion to 100E, external
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 3 (April), 2000: pp 332–335
BILATERAL HUMERAL HEAD OSTEONECROSIS
333
FIGURE 1. Preoperative anteroposterior radiographs showing typical aspect of bilateral humeral head osteonecrosis. (A) Right shoulder, (B) left shoulder.
rotation to 45E, and internal rotation to the L4 level. In 1995, the left shoulder became more and more stiff and painful with abduction limited to 90E, forward flexion to 10E, external rotation to 60E, and internal rotation to the L5 level. A new arthroscopy was carried out on the left shoulder in March 1995 after several episodes
of locking. Under general anesthesia and interscalene block, the patient was placed in the lateral decubitus position such that the upper limb was directed upward. The intra-articular examination as viewed from the posterior portal showed involvement of the entire humeral head cartilage, which was separated from
334
P. HARDY ET AL. rotation to the D7 level. Five months after arthroscopy, examination of the left shoulder showed that abduction had increased to 90E, forward flexion to 20E, external rotation to 90E, and internal rotation to the D10 level. Radiography revealed regular humeral head contours without foreign bodies (Fig 3). The left shoulder remained painful but the patient had stopped oral analgesic treatment. DISCUSSION
FIGURE 2. (A) Removed osteochondral fragments. (B) Humeral head and the glenoid after fragment removal.
subchondral bone as a free cap. We first performed debridement of the humeral head using a motorized shaver, then articular cleaning, synovectomy, and removal of all the loose osteocartilaginous bodies via a second posteroinferior portal. The cartilage of the right glenoid surface was normal whereas on the left it was irregular with a degenerative labrum. Three months after the first arthroscopy, the functional status of the right shoulder improved through relief of pain and increased range of motion, with 90E of abduction, 120E of forward flexion, 45E of external rotation, and internal rotation to the D7 level. Two years later, the right shoulder remained completely asymptomatic with 110E of abduction, 160E of forward flexion, 70E of external rotation, and internal
Osteonecrosis includes traumatic and atraumatic etiologies. Among the atraumatic etiologies, corticotherapy is most frequently encountered, especially in organ transplant recipients receiving immunosuppressive drugs.6 After renal transplantation, the femoral head is most often affected by osteonecrosis,2 followed by humeral head, calcaneum, metatarsus, femoral condyles, and proximal tibia. Osteonecrosis is made of multiepiphyseal involvement of subchondral bone resembling osteochondral fracture. The diagnosis of osteonecrosis is often late, but fortunately the shoulder is not a weight-bearing joint. Pain is not correlated with the severity of osteonecrosis. The scapulothoracic joint yields some mobility although the glenohumeral joint is already involved. According to Cruess,1 range of motion of the shoulder is diminished mainly because of pain. Four radiographic stages of avascular necrosis of the shoulder were proposed by Ficat and Arlet.7 Stages I and II can be treated effectively by core decompression3,8 or rehabilitation consistent with pendulum exercises and avoidance of abduction, particularly against resistance.2 Stages III and IV require an hemiarthroplasty or a total arthroplasty whether the glenoid surface is intact or involved.9 The use of arthroscopy as a diagnostic and therapeutic modality in humeral head osteonecrosis has already been described5 but remains still uncommon.8 It is justified by the cosmetic and analgesic benefits, the muscular and capsular preservation, the short and relatively easy recovery, and the least risk of infection, especially in renal transplant recipients. In our patient, the first arthroscopy was performed on the right shoulder with stage III radiological changes according to Ficat and Arlet. Complete relief of pain associated with improved range of motion were obtained 10 days postoperatively. Three years after arthroscopy, the patient’s functional status remains unchanged. The left shoulder was treated with an initial stage IV. The patient is completely asymptomatic 5 months later, but abduction, forward flexion, and external rotation remain
BILATERAL HUMERAL HEAD OSTEONECROSIS
335
FIGURE 3. Postoperative anteroposterior radiographs of both shoulders.
limited. A total replacement arthroplasty will be carried out on the left shoulder. Arthroscopy is an efficient modality for treatment of humeral head osteonecrosis in the renal transplant recipient including those with radiological stage III with episodes of locking. It is an interesting and nonaggressive procedure for young and still active patients that avoids or at least delays arthroplasty.
3. 4. 5. 6. 7.
REFERENCES 8. 1. Cruess RL. Steroid-induced avascular necrosis of the humeral head: Natural history and management. J Bone Joint Surg Br 1976;58:313-317. 2. Davidson JK, Tsakiris D, Briggs JD, Junor BJ. Osteonecrosis
9.
and fractures following renal transplantation. Clin Radiol 1985;36:27-35. 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. Fischer DE, Bickel NH. Corticosteroid-induced avascular necrosis. J Bone Joint Surg Am 1971;53:859-873. Hayes JM. Arthroscopic treatment of steroid-induced osteonecrosis of the humeral head. Arthroscopy 1989;5:218-221. Frostick SP, Wallace WA. Osteonecrosis of the femoral head. Baillieres Clin Rheumatol 1989;3:651-667. Ficat RP, Arlet J. Necrosis of the femoral head. In: Ischemia and necrosis of bone. Baltimore: Williams & Wilkins, 1980;171182. Usher BW, Friedman RJ. Steroid-induced osteonecrosis of the humeral head. Orthopedics 1985;18:47-51. Neer CS, Watson KD, Stanton FJ. Recent experiences in total shoulder replacement. J Bone Joint Surg Am 1982;64:319337.