Orthopaedic Oncology cases 1
A 45-year-old, left-hand-dominant male with a history of Crohn’s disease presents to your clinic complaining of left shoulder pain for the past 2 months. He is unable to localize the pain but says it is worse with overhead motion and radiates to his elbow. He was diagnosed with Crohn’s at age 20 and his symptoms are currently under fairly good control with etanercept, but he has had multiple flares in the past treated with courses of IV and PO steroids. He notes a history of traumatic left shoulder dislocation while playing high-school football but denies any subsequent dislocations or shoulder pain prior to 2 months ago. Physical examination is significant for pain with active abduction and forward flexion of the left shoulder. Imaging is shown in Figure 2–53.
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Figure 2–53
What is the most appropriate next step?
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MRI of the left shoulder
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CT of the left shoulder
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PET scan
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Diagnostic and therapeutic corticosteroid injection of the glenohumeral joint
Discussion
The correct answer is (A). In a patient with IBD and a history of steroid use, avascular necrosis (AVN) should be at the top of the differential diagnosis. Other risk factors for AVN of the humeral head include a history of trauma, chemo/radiation, Caisson disease, sickle cell disease, alcohol abuse, SLE, pregnancy, and tobacco use. The patient has x-rays with sclerotic changes suspicious for AVN, therefore MRI is the best next step for this patient. CT of the left shoulder (Answer B) would not show any of the bony edema that characterizes early AVN. PET scans (Answer C) can also be used to identify early AVN but have been shown to be less accurate than MRI. D is incorrect because AVN is a higher likelihood for this patient than glenohumeral arthritis or a labral tear and therefore should be investigated first with MRI.
MRI of the right shoulder is shown in Figure 2–54. What is the diagnosis?
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Stage I AVN of the humeral head
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Stage II AVN of the humeral head
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Stage III AVN of the humeral head
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Stage IV AVN of the humeral head
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Figure 2–54
Discussion
The correct answer is (B). The MRI shows bony edema consistent with avascular necrosis of the humeral head, which combined with the sclerotic radiographic changes shown in Figure 2–54, classify him as stage II in the Ficat classification. Although the Ficat classification was designed for AVN of the femoral head, it is also commonly used to classify AVN of the humeral head. Table 2–7 shows the Ficat classification stages I to IV. Different modifications of the Ficat classification exist as well, including the Steinberg and Cruess. Choices C and D are incorrect because they all are characterized by radiographic changes of varying degrees (such as osteolytic lesions, subchondral collapse, and osteoarthritis), which this patient does not have.
Table 2–7 FICAT CLASSIFICATION OF OSTEONECROSIS
Stage I
X-ray: no change
MRI: bone marrow edema
Bone scan: increased uptake
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Stage II X-ray: mixed sclerosis/osteopenia MRI: bone marrow edema Bone scan: increased uptake Stage III X-ray: crescent sign, no head collapse MRI: bone marrow edema |
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Stage IV |
X-ray: Collapse of head with joint space narrowing MRI: bone marrow edema, collapse |
Data from Harreld K, et al. Osteonecrosis of the Humeral Head. JAAOS 2009;17(6):345–355 (specifically in figure 2) and Lavernia C, Sierra R and Grieco F. Osteonecrosis of the Femoral Head. JAAOS 1999;7:250–261.
The patient returns to clinic to go over his MRI results. You tell him that he likely has avascular necrosis of his left humeral head. After you explain to him what AVN is and the nature of the disease process, you start to discuss treatment options.
What are you going to recommend for the patient at this point?
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Refer him back to his gastroenterologist for improved control over his Crohn’s disease
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Naproxen 500 mg BID taken with food
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A short taper of PO steroids
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Prescription for a 6-week course of physical therapy
Discussion
The correct answer is (D). As discussed in the second question, the patient is Ficat stage II and therefore conservative management must be the initial approach. In this case, the most appropriate conservative management consists of physical therapy to preserve shoulder strength and ROM and to maintain his ability to perform ADLs. Choice A is incorrect because AVN is not directly linked to the severity of Crohn’s disease or any other disease process. Choice B is incorrect as the patient is unable to take NSAIDs due to his inflammatory bowel disease and the increased risk of GI bleed. Choice C is incorrect because, as with Choice A, controlling a Crohn’s flare will not directly lead to improvement in the symptoms of AVN, and also it has been hypothesized that corticosteroid use over time may contribute to the risk for developing AVN.
The patient returns to you 3 months later. He participated in physical therapy and says that while he initially noticed moderate improvement in his pain, after approximately 1 month the pain has returned and he also notices decreased range of motion. Physical examination is significant for decreased range of motion compared with your examination of 3 months ago.
What is the most appropriate treatment for this patient?
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Left shoulder hemiarthroplasty
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Left total shoulder arthroplasty
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Core decompression of the left humeral head
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Left reverse total shoulder arthroplasty
Discussion
The correct answer is (C). Core decompression via insertion of pins into the area affected by AVN is thought to improve symptoms in patients with Ficat stage I or II by reducing bone marrow pressure and encouraging new vasculature to form. Patients are managed postoperatively in a sling for a few days and can perform shoulder range of motion as tolerated. Choice A would be more appropriate in a more advanced stage of AVN and/or if conservative treatment and core decompression have failed to relieve pain. Choices B and D are incorrect as they would be reserved for the elderly patient with advanced AVN characterized by concurrent osteoarthritic changes, with or without rotator cuff function.
Objectives: Did you learn...?
Understand the etiology of osteonecrosis of the humeral head? Recognize the clinical presentation of osteonecrosis of the humeral head? Manage a patient with osteonecrosis of the humeral head?