Cruess described how steroid‑induced osteonecrosis of the humeral head progresses and how it responds to treatment, drawing on his own patients.
Single‑surgeon series from the Royal Victoria Hospital and McGill University, Montreal, covering 18 humeral head cases among 95 patients with steroid‑induced necrosis.
Methods
Design
Patients personally treated by one surgeon
Patients
18 patients with humeral head necrosis in one or both shoulders
Drawn from 95 patients with steroid‑related osteonecrosis at any site
Steroid indications included transplantation, lupus, glomerulonephritis and asthma
Treatment
Pendulum exercises
Avoidance of abduction, especially against resistance
Neer humeral head replacement for severe persistent pain (4 patients, 5 shoulders)
Follow-up
Replaced shoulders followed up to 6 years
Outcomes
Symptoms
Range of movement
Lesion progression
Key Findings
Shoulder pain began gradually, never before 6 months and at most 18 months after steroid therapy started.
Pain came with movement rather than at rest or at night, and passive motion stayed nearly full until late in the disease.
The lesion was a localized subchondral collapse rather than necrosis of the whole head, and in every case it sat where the glenoid contacts the head at 80 to 90° of abduction.
The articular cartilage later separated from the dead bone, and when symptoms allowed conservative care it reattached over time.
Of the 14 patients managed without surgery, 8 with mild deformity returned to full activity including overhead use, while 6 with more severe deformity could not use the arm above the shoulder.
Humeral head replacement in 4 patients (5 shoulders) gave near‑normal final motion with no operative complications, though one shoulder kept occasional pain on strenuous activity.
Board pearl
Humeral head necrosis rarely occurred alone, since 16 of the 18 patients also had necrosis of both femoral heads.
Authors' conclusion
On the basis of this experience, it is felt that prosthetic replacement of the humeral head can be recommended for steroid-induced avascular necrosis. The excellence of the results is probably due to preservation of the glenoid articular cartilage, which appeared to be essentially normal in all instances.
Cruess described how steroid‑induced osteonecrosis of the humeral head progresses and how it responds to treatment, drawing on his own patients.
Single‑surgeon series from the Royal Victoria Hospital and McGill University, Montreal, covering 18 humeral head cases among 95 patients with steroid‑induced necrosis.
Methods
Design
Patients personally treated by one surgeon
Patients
18 patients with humeral head necrosis in one or both shoulders
Drawn from 95 patients with steroid‑related osteonecrosis at any site
Steroid indications included transplantation, lupus, glomerulonephritis and asthma
Treatment
Pendulum exercises
Avoidance of abduction, especially against resistance
Neer humeral head replacement for severe persistent pain (4 patients, 5 shoulders)
Follow-up
Replaced shoulders followed up to 6 years
Outcomes
Symptoms
Range of movement
Lesion progression
Key Findings
Shoulder pain began gradually, never before 6 months and at most 18 months after steroid therapy started.
Pain came with movement rather than at rest or at night, and passive motion stayed nearly full until late in the disease.
The lesion was a localized subchondral collapse rather than necrosis of the whole head, and in every case it sat where the glenoid contacts the head at 80 to 90° of abduction.
The articular cartilage later separated from the dead bone, and when symptoms allowed conservative care it reattached over time.
Of the 14 patients managed without surgery, 8 with mild deformity returned to full activity including overhead use, while 6 with more severe deformity could not use the arm above the shoulder.
Humeral head replacement in 4 patients (5 shoulders) gave near‑normal final motion with no operative complications, though one shoulder kept occasional pain on strenuous activity.
Board pearl
Humeral head necrosis rarely occurred alone, since 16 of the 18 patients also had necrosis of both femoral heads.
Authors' conclusion
On the basis of this experience, it is felt that prosthetic replacement of the humeral head can be recommended for steroid-induced avascular necrosis. The excellence of the results is probably due to preservation of the glenoid articular cartilage, which appeared to be essentially normal in all instances.