Late-presenting chronic humeral head collapse, Cruess stage V, managed with modular uncemented hemiarthroplasty

Abstract

Introduction

Chronic shoulder pain is common and is often initially attributed to periarticular disorders; however, in some patients it reflects humeral head osteonecrosis, a progressive ischemic process that may remain clinically silent until structural collapse has occurred [1–4]. The humeral head is the second most common site of nontraumatic osteonecrosis after the femoral head, and disease progression is commonly classified using the Cruess system, in which stage V denotes humeral head collapse with secondary glenoid involvement [1–4]. Once loss of sphericity, articular surface irregularity, and secondary arthropathy are present, joint-preserving procedures become unreliable and arthroplasty is usually required [2–4].

The optimal arthroplasty for advanced humeral head osteonecrosis remains controversial. Both hemiarthroplasty and total shoulder arthroplasty (TSA) can provide pain relief and functional improvement, but glenoid-related failure and future revision are major concerns in younger patients [5–13]. Therefore, hemiarthroplasty remains relevant when disease is predominantly humeral-sided, glenoid bone loss is limited, and rotator cuff continuity is preserved [5–13]. Modular uncemented humeral implants may further support this strategy by preserving bone stock, allowing intraoperative adjustment of head size and offset, and facilitating future revision if required [10, 14, 15]. We report a late-presenting Cruess stage V humeral head osteonecrosis managed with modular uncemented hemiarthroplasty, emphasizing the selection logic for hemiarthroplasty despite secondary glenoid change.

Case report

A 44-year-old man presented with progressive right shoulder pain and restricted motion for approximately 1 year. His medical history was notable for diabetes mellitus. No corticosteroid exposure, alcohol misuse, sickle cell disease, dysbarism, or other classic secondary risk factor was reported, and there was no documented history of directly shoulder trauma. Two years earlier, he had sustained a road-traffic accident with fractures of the anterior arches of the right second through sixth ribs; however, no shoulder injury or proximal humeral osseous lesion had been identified at that time.

Plain radiographs demonstrated marked flattening, deformity, and collapse of the right humeral head with complete loss of normal sphericity. Computed tomography (CT) showed articular surface irregularity, fragmentation, subchondral sclerosis, and secondary glenohumeral degenerative change, with glenoid involvement but without major glenoid bone loss (Fig. 1). These findings supported advanced osteonecrosis of the right humeral head with collapse and secondary glenohumeral arthropathy, most consistent with Cruess stage V disease. Preoperative ultrasound showed a narrowed subacromial space and reduced dynamic excursion of the supraspinatus tendon, but the long head of the biceps tendon, subscapularis, supraspinatus, infraspinatus, and teres minor remained continuous. There was no significant peritendinous or subacromial-subdeltoid fluid collection, and the findings did not support cuff-tear arthropathy as the primary pathology.

Figure 1

Preoperative imaging and postoperative radiograph of late-presenting chronic right humeral head collapse. (A) Preoperative anteroposterior radiograph showing marked deformity, flattening, and collapse of the right humeral head with loss of normal sphericity. (B, C) Three-dimensional CT reconstructions demonstrating advanced humeral head collapse and articular destruction. (D–F) Axial, coronal, and sagittal CT images showing fragmentation, subchondral sclerosis, articular surface irregularity, and secondary glenohumeral arthropathy without major glenoid bone loss. (G) Immediate postoperative anteroposterior radiograph after modular uncemented shoulder hemiarthroplasty showing satisfactory implant position.

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Because the humeral-sided destruction was end-stage and joint-preserving procedures were not feasible, surgical reconstruction was indicated. The patient underwent modular uncemented shoulder hemiarthroplasty in the beach-chair position under general anesthesia. Through a lateral deltoid-splitting approach with partial subscapularis release, the humeral head was exposed and the canal was sequentially prepared. Trial reductions with 40- and 42-mm humeral heads and + 0 or +4 adaptors were performed. A 42-mm head with a +4 adaptor provided satisfactory congruity, unrestricted passive motion, and stable posterior translation; therefore, the definitive modular uncemented press-fit implant was inserted. The subscapularis and remaining cuff tissues were repaired, and immediate postoperative radiographs confirmed satisfactory implant position. At the 3-month follow-up, the patient reported markerd pain relief and substantial improvement in shoulder range of motion.

Discussion

The central message of this case is that Cruess stage V disease does not necessarily mandate TSA or reverse shoulder arthroplasty. Instead, the reconstruction should be matched to the dominant pathology. In this patient, imaging showed chronic humeral head collapse rather than acute traumatic collapse: there was complete loss of sphericity, fragmentation, subchondral sclerosis, and secondary glenoid change, while no proximal humeral injury had been documented after the remote traffic accident [1–4]. The presentation was therefore interpreted as late-presenting chronic humeral head osteonecrosis of nontraumatic appearance.

In stage V disease, the glenoid is no longer entirely normal, and anatomic TSA is a valid option when the cuff is intact. However, available evidence does not establish one universally superior arthroplasty for humeral head osteonecrosis. Both hemiarthroplasty and TSA can provide durable improvement, whereas younger age makes glenoid implantation, glenoid loosening, and revision strategy particularly important [5–13]. Recent data suggest that 10-year implant survivorship may be comparable between TSA and hemiarthroplasty for humeral head avascular necrosis [13].

Several features favored hemiarthroplasty in this patient: destruction was predominantly humeral-sided, CT showed no major glenoid bone loss, and ultrasound demonstrated preserved rotator cuff continuity. Reverse arthroplasty was therefore not compelling, and implantation of a glenoid component would expose this 44-year-old patient to glenoid-component-related failure modes and potential future revision. Hemiarthroplasty replaced the collapsed humeral head and reconstructed the humeral side of the joint, avoided glenoid component implantation, and preserved future conversion options if progressive glenoid wear, pain, or dysfunction develops [10–13].

The modular uncemented construct was consistent with this bone-preserving strategy. Modularity allowed intraoperative adjustment of head size and offset to restore congruity and soft-tissue balance, although increased modularity alone has not been shown to guarantee superior clinical outcomes [15]. Uncemented humeral fixation has demonstrated acceptable long-term performance and may simplify later revision by avoiding cement removal [14]. The limitation of this report is the absence of long-term clinical follow-up; pain, range of motion, glenoid wear, and possible conversion remain important endpoints. Nevertheless, this case provides a practical decision-making message: in selected young patients with stage V humeral head osteonecrosis, preserved cuff continuity, limited glenoid bone loss, and predominantly humeral destruction, modular uncemented hemiarthroplasty remains a defensible reconstructive option [10–15].

Acknowledgements

We acknowledge the support of the Rotary Yoneyama Memorial Foundation.

Conflicts of interest

The authors declare no conflicts of interest.

Funding

This work was supported in part by Rotary Yoneyama Memorial Foundation (RY053565) to D.A.V.

References