Arthroscopic-Assisted Intraosseous Bioplasty of the Humeral Head for Osteonecrosis

Abstract

Osteonecrosis of the humeral head is an uncommon condition, and treatment options are controversial. The shoulder is the second most common location for osteonecrosis, typically presenting between the second and fifth decades of life. Early diagnosis and treatment are essential because osteonecrosis may progress and lead to significant pain and loss of function. Nonoperative options are limited and are based on addressing the cause of the osteonecrosis. Multiple surgical treatments have been described, and these techniques continue to evolve. Open core decompression of the humeral head has been found to be an effective surgical option to restore blood supply and stimulate new bone formation. The evolution of arthroscopic techniques combined with biological adjuncts allows a minimally invasive approach with potential to accelerate revascularization and bone growth. We describe our technique for arthroscopic-assisted intraosseous bioplasty of the humeral head for the treatment of osteonecrosis.

Fig 1

Harvest of bone marrow aspirate from right iliac crest (white arrow) using fenestrated aspiration trocar with patient in lateral decubitus position in preparation for arthroscopic-assisted intraosseous bioplasty of humeral head for osteonecrosis.

Fig 2

In a right shoulder with the patient in the lateral decubitus position, viewing through the posterior portal, the surgeon palpates the humeral head cartilage with a probe (black arrow) through the anterior portal during arthroscopic-assisted intraosseous bioplasty of the humeral head for osteonecrosis.

Fig 3

In a right shoulder with the patient in the lateral decubitus position, viewing through the lateral portal, the surgeon uses an arthroscopic burr to harvest autologous bone graft from the undersurface of the acromion (black arrow) through the posterior portal during arthroscopic-assisted intraosseous bioplasty of the humeral head for osteonecrosis. As shown in the inset, the bone graft is collected in the GraftNet (white arrow) attached to the shaver suction tubing.

Fig 4

Mixing of morselized bone graft, radiopaque dye, platelet-rich plasma concentrate from bone marrow aspirate, and demineralized bone matrix in mixing and delivery syringe (white arrow) during arthroscopic-assisted intraosseous bioplasty of humeral head for osteonecrosis.

Fig 5

In a right shoulder with the patient in the lateral decubitus position, an anterior cruciate ligament (ACL) guide (white arrow) is used under fluoroscopy to localize the area of osteonecrosis in the humeral head through the anterior portal during arthroscopic-assisted intraosseous bioplasty of the humeral head for osteonecrosis. The inset shows the tip of the ACL guide localizing the area of osteonecrosis on the humeral head (black arrow) on arthroscopy, viewed through the posterior portal.

Fig 6

In a right shoulder with the patient in the lateral decubitus position, a FlipCutter drill is used to decompress the area of osteonecrosis in the humeral head (white arrow) under fluoroscopy during arthroscopic-assisted intraosseous bioplasty of the humeral head for osteonecrosis.

Fig 7

Injection of mixture of morselized bone graft, radiopaque dye, platelet-rich plasma concentrate from bone marrow aspirate, and demineralized bone matrix into decompressed osteonecrotic area of humeral head using mixing syringe and delivery cannula (white arrow) in right shoulder with patient in lateral decubitus position during arthroscopic-assisted intraosseous bioplasty of humeral head for osteonecrosis.

Fig 8

Right shoulder with patient in lateral decubitus position after injection of mixture of morselized bone graft, radiopaque dye, platelet-rich plasma concentrate from bone marrow aspirate, and demineralized bone matrix into area of osteonecrosis in humeral head (white arrow) on fluoroscopy during arthroscopic-assisted intraosseous bioplasty of humeral head for osteonecrosis.