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

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

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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, Belt 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 Water Timer 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.