AVN Shoulder

Shoulder AVN




Much less common than hip OA

- usually presents late




Similar causes as hip (AS IT GRIPS 3C)


Alcohol / Steroid / Trauma / Idiopathic




RA / RTx


Sickle Cell 

- commonest cause worldwide

- bilateral


Caisons / Chemotherapy


Blood Supply


Gerber JBJSA 1990


1.  Anterior Circumflex Humeral Artery

- primary blood supply

- becomes arcuate artery

- runs lateral aspect bicipital groove


2.  Posterior Circumflex Humeral Artery

- collateral circulation

- supplies head when GT / LT fracture


3.  Via Rotator Cuff




Wide range of AVN after 4 part fractures

- about 1/3


Recent studies to explain this


1.   Suggest 2nd anastomotic system 

- via posteromedial branches of PCHA along inferomedial capsule

- blood supply may be further compromised by large exposure in ORIF


2.  Creeping substitution

- occurs more extensively in humeral head


3.  Rich vascular tissue surrounding humeral head


Natural History



- Difficult to predict

- Somewhat related to aetiology

- Sickle cell disease tend not to progress to arthroplasty

- Steroid induced far more likely


Less severe than femoral

- non weight bearing

- less conforming joint

- scapulothoracic motion




Superior head collapse at 90° mark 

- area of peak contact stress in abduction

- ROM Maintained until late

- Glenoid rarely affected

- Soft tissue and SSC rarely contracted


Classification / Cruess modification of Ficat-Arlet 


Stage 1

- prexray change

- only seen with MRI


Stage 2

- sclerotic changes in superior central head

- sphericity maintained


Humeral AVN Stage 2Humeral AVN Stage 2 MRI


Stage 3 

- "Crescent" Sign

- mild flattening articular surface


Shoulder AVN Stage 3


Stage 4

- significant humeral collapse with loss integrity joint surface

- loose bodies


Shoulder AVN Stage 4Shoulder AVN Stage 4


Stage 5

- degeneration extends to involve glenoid


AVN Shoulder Xray




Pain is major problem

- pain before significant loss ROM

- difficulty sleeping




Shoulder AVN MRIShoulder AVN MRI Sagittal




Remove insult

- corticosteroids, alcohol


Non Operative


Maintain current shoulder ROM / Halt Progression


A.  Prevent disuse related stiffness

- passive physio


B.  Limit overhead activities

- Joint Reaction Force greatest > 90o


C.  Bisphosphonates




Core Decompression


Decrease intraosseous pressure & increase blood flow

- moderate success mainly in stage 1 or 2




Usually works well

- glenoid not usually affected

- Soft tissue and subscapularis rarely contracted 


Smith et al J Should Elbow Surg 2008

- steroid induced AVN

- survival 92% 10 year

- 2 patients needed revision for painful glenoid arthrosis

- good option




Indicated in stage V only

- beware in young patient < 65