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Avascular Necrosis in the Shoulder: Progression and Treatment Options

| | Shoulders
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Hello, Dr. Markle at Centeno-Schultz Clinic.

Today, we’re talking about Avascular Necrosis in the shoulder. Now a recap: Avascular Necrosis is essentially a lack of blood flow, eventually resulting in necrosis, or dying of the bone. This happens in multiple joints. And today we’re talking specifically about the shoulder. So talking about AVN in the shoulder, patients typically come up with two main questions.

Number one, can this heal on its own? And if not, how long or how fast will this progress?

avascular necrosis in the shoulder - progression

Now we classify AVN in multiple different stages:

  1. Number one: we have stage one, where it’s very normal X-ray  — usually, typically, someone just has pain with activity.
  2. Two: is the bone itself continues to deteriorate, then we start getting some changes on your X-ray.
  3. Number three: as that lack of blood flow to the bone progresses, we’re getting what we call a crescent-shaped lesion in the bone. And we start changing some of the architecture of the joint.
  4. Stage four and stage five is when we start losing full architecture, where we have collapse or flattening of the joint’s surface. That flattening of the joint’s surface essentially leads to severe degeneration or secondary arthritis of the joint.


How Fast Is this Progress?

For each individual it can be extremely different. It could progress over a number of months — could progress over a number of years. Typically, at the time of diagnosis, if someone is symptomatic, the chances of progressing over a three year period is probably in the 85/90 percent range. If someone is asymptomatic, meaning this was found just by chance, or for a different reason, someone has a chance progression of probably 65 percent.

And that progression looks like this. Where, initially, you have some mild changes on the X-ray. Typically, the symptoms are very mild. As we progress, here is that crescent shape lesion. And, on the bottom right, total destruction of the joint.

Is AVN of the Shoulder Serious?

In one word: yes. It’s extremely serious from the perspective of joint preservation. Now, the earlier we are able to identify this, the quicker we’re able to identify some of the causes of the AVN, remove those causes, and, hopefully, stop the progression. And if we treat this early enough, the goal is joint preservation, so we can avoid the need for a total of joint replacement.

What Is the Best Treatment for Avascular Necrosis of the Shoulder?

If we look at the last 15 to 20 years from a research standpoint, there have been two main treatments that become the standard of care.

One is the removal of whatever is causing Avascular Necrosis, such as if it is high-dose cortical steroids; stop the steroid use. Or, if someone’s consuming high amounts of alcohol. Ideally, abstaining from alcohol use itself will, ideally, help stop the progression. From a treatment standpoint, trying to get the Avascular Necrosis to reverse or cure. That’s why identifying early-on and getting in that early stage one to stage three is extremely important.

For an orthopedic surgeon, they typically do what’s called a core decompression, where they take a large drill bit, go into the bone itself and ideally try to stimulate the bone, to regenerate it. Aside from that, a less invasive option would be a bone marrow concentrate, utilizing the repair cells in your bone marrow — concentrating them, and, with a small needle, injecting them directly into the lesion to stimulate your body to regenerate the blood flow, as well as try to heal the bone itself.

Here’s a nice progression from someone that was diagnosed from a stage three (see above). All this area is Avascular Necrotic lesions. We can see the crescent-shape lesion here (where it says “Pre-treatment,” to the left). But the good news is they still had preservation of the joint structure. After treatment, we can see five months (middle). We have a resolution of the majority of the bone swelling. We still have a small lesion, but it hasn’t progressed, and, if we fast forward several years, the patient themselves is 95 percent improved from pain and function after two years. And there’s been no progression of the Avascular Necrosis lesion, as well as the joint preservation aspects are maintained (the right-most image).

So, if you or any loved one have been dealing with any issues with Avascular Necrosis in the shoulder, feel free to give us a call. If you have any questions, you can always reach out to us on social media, such as Instagram, Facebook, and we’re always more than welcome to do Telemedicine evaluations. You can send in your imaging and set up a review of your imaging to see if you are a candidate for these advanced regenerative techniques. Have a good day.

Related: Avascular Necrosis Staging 

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