Treatment of avascular necrosis of the humeral head – Postoperative results and a proposed modification of the classification

Abstract

Background Avascular necrosis of the humeral head after proximal humeral fracture i.e. type 1 fracture sequelae (FS) according to the Boileau classification is a rare, often painful condition and treatment still remains a challenge. This study evaluates the treatment of FS type 1 with anatomic and reverse shoulder arthroplasty and a new subclassification is proposed. Methods This single-center, retrospective, comparative study, included all consecutive patients with a proximal humeral FS type 1 treated surgically in a four-year period. All patients were classified according to the proposed 3 different subtypes. Constant score (CS), Quick DASH score, subjective shoulder value (SSV) as well as revision and complication rate were analyzed. In the preoperative radiographs the acromio-humeral interval (AHI) and greater tuberosity resorption were examined. Results Of 27 with a FS type 1, 17 patients (63%) with a mean age of 64 ± 11 years were available for follow-up at 24 ± 10 months. 7 patients were treated with anatomic and 10 with reverse shoulder arthroplasty. CS improved significantly from 16 ± 7 points to 61 ± 19 points (p < 0.0001). At final follow-up the mean Quick DASH Score was 21 ± 21 and the mean SSV was 73 ± 21 points. The mean preoperative AHI was 9 ± 3 mm, however, 8 cases presented an AHI < 7 mm. 4 cases had complete greater tuberosity resorption. The complication and revision rate was 19%; implant survival was 88%. Conclusion By using the adequate surgical technique good clinical short-term results with a relatively low complication rate can be achieved in FS type 1. The Boileau classification should be extended for fracture sequelae type 1 and the general recommendation for treatment with hemiarthroplasty or total shoulder arthroplasty has to be relativized. Special attention should be paid to a decreased AHI and/or resorption of the greater tuberosity as indirect signs for dysfunction of the rotator cuff. To facilitate the choice of the adequate prosthetic treatment method the suggested subclassification system should be applied.

Surgical treatment of fracture sequelae of the proximal humerus according to a pathology-based modification of the Boileau classification results in improved clinical outcome after shoulder arthroplasty

“…However, since the RSA has shown good clinical results in the treatment of fracture sequelae in other studies, it should definitely be considered. In addition, after analyzing our patients, we found several morphological differences within the types and proposed a subclassification [ 22 – 24 ]. Comparing our postoperative results according to the subclassification and analyzing the available literature, we were able to identify an advantageous surgical procedure for each type.…”

Osteonecrosis of the Humeral Head 3 Years Following Fracture Fixation of a 4-Part Proximal Humerus Fracture: A Case Report

“…Osteonecrosis of the humeral head is a rare, but well-known complication of proximal humerus fractures [ 6 ]. In this case report, we present a unique case of a healthy 70-year-old woman who developed ON 3 years following open reduction and internal fixation of her proximal humerus.…”