744 THE JOURNAL OF BONE AND JOINT SURGERY
H. B. Durst, MD, Registrar
G. Blatter, MD, Consultant Orthopaedic Surgeon
M. S. Kuster, MD, PD, PhD, Consultant Orthopaedic Surgeon
Department of Orthopaedic Surgery, Kantonsspital St Gallen, 9007 St
Correspondence should be sent to Dr M. S. Kuster.
©2002 British Editorial Society of Bone and Joint Surgery
OSTEONECROSIS OF THE HUMERAL HEAD AFTER
EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY
H. B. Durst, G. Blatter, M. S. Kuster
From Kantonsspital, St Gallen, Switzerland
59-year-old woman with calciﬁc tendinitis in her right
shoulder underwent extracorporeal shock-wave
lithotripsy. Three years and four months later she presented
with osteonecrosis of the head of the right humerus. It is
known that shock waves in patients with urological
disorders can damage blood vessels. A possible reason for
the development of osteonecrosis in this patient may have
been damage to the blood supply of the head of the
J Bone Joint Surg [Br] 2002;84-B:744-6.
Received 21 March 2001; Accepted after revision 24 July 2001
Extracorporeal shock-wave lithotripsy has become a common
treatment for calciﬁc tendinitis of the shoulder. No severe compli-
cations have been reported,
and it is considered to be a safe
procedure. We present a case of osteonecrosis of the head of the
humerus after extracorporeal shock-wave lithotripsy. Possible
pathomechanisms are discussed.
In June 1996, a 59-year-old woman presented with chronic pain in
her right shoulder. Radiographs showed a deposit of calcium of 28
⫻ 10 mm in the tendon of supraspinatus (Fig. 1). Since three
subacromial injections of cortisone had not given symptomatic
relief she underwent three sessions of extracorporeal shock-wave
lithotripsy with 1600 to 1700 impulses at each session at a level of
12 to 13 kV over a period of one month. After treatment there was
less pain and a full range of movement. Radiographs revealed a
reduction in the size of the deposit of calcium by 79% to 12 ⫻
5 mm, without any evidence of osteonecrosis of the humeral head
(Fig. 2). Three years and four months later she presented again
with chronic pain in the shoulder. Radiographs showed partial
necrosis of the humeral head which was stage IV according to the
classiﬁcation of Neer
(Fig. 3). MRI conﬁrmed the radiological
diagnosis of partial necrosis. There were no signs of osteonecrosis
in the contralateral shoulder. Investigations for known predispos-
ing factors for osteonecrosis were negative.
To our knowledge no severe complications of extracorporeal
shock-wave lithotripsy have been published in the orthopaedic
literature. Minor problems such as pain in the shoulder, local soft-
tissue swelling, cutaneous erosions, erythema, petechial haemor-
rhage and local subcutaneous haematomas have been described.
Apart from a single report of changes in the MRI signal in the
subcortical area of the greater tuberosity 12 weeks after treat-
no bony or cartilaginous changes have been demonstrated
by radiography, MRI, sonography or arthroscopy.
radiological follow-up after shock-wave treatment to the shoulder
is, however, only two years.
Gerber, Schneeberger and Vinh
identiﬁed the ascending
branch of the anterior humeral circumﬂex artery and its continua-
tion, the arcuate artery, as being the main supply to the proximal
humeral epiphysis. It was further shown that the closer this artery
is injured to its point of entry into the bone the greater is the risk
to the vascularity of the humeral head, because of a lack of distal
anastomoses. The vessel enters the bone in the area of the lateral
and superior aspects of the intertubercular groove. In our patient
this point was only 10 mm from the deposit of calcium.
It is known that shock waves in patients with urological
disorders have caused damage to blood vessels ranging from
benign lesions of the endothelium to arterial occlusion with
capillary extravasation, and even ruptures of the vessel wall.
Destruction of the ascending branch of the anterior humeral
circumﬂex artery could thus be responsible for the osteonecrosis
in our patient. Also, the time interval between injury and the
radiological appearance of osteonecrosis is comparable to that
which may occur with fractures of the proximal humerus. Darder
showed that it may take up to four years for radiological
signs of osteonecrosis to develop in patients with four-part frac-
tures of the proximal humerus. In our patient MRI showed that the
osteonecrosis occurred in the area of perfusion of the anterior
circumﬂex artery. The bone in the area of perfusion of the
posterior circumﬂex artery was not affected (Fig. 4).
A possible alternative aetiology, although unlikely, may be the
repeated subacromial inﬁltrations of cortisone. We were unable to
ﬁnd any evidence in the literature of osteonecrosis after sub-
acromial inﬁltration of steroid, although there are some case
reports of osteonecrosis after intra-articular injection.
We found no other predisposing factors for osteonecrosis in our
patient. The development of idiopathic osteonecrosis may have
been simply coincidence and the reason for the development of
osteonecrosis of the humeral head in this patient remains uncer-
tain. With the increasing popularity of this form of treatment,
experimental and long-term clinical follow-up studies are neces-
sary to establish whether avascular osteonecrosis of the humeral
head is in fact a rare, but severe, complication of extracorporeal
shock-wave treatment. If shock waves are found to be harmful to
the blood supply of the humeral epiphysis, care must be taken to
avoid the intertubercular groove when targeting the shock wave
on deposits of calcium.
No beneﬁts in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
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VOL. 84-B, N
. 5, JULY 2002
AP radiograph of the right shoulder before
extracorporeal shock-wave lithotripsy showing
the deposit of calcium.
AP radiograph of the right shoulder after extra-
corporeal shock-wave lithotripsy showing the
reduction in size of the deposit of calcium.
AP radiograph of the right shoulder showing
osteonecrosis of the right humeral head three
years and four months after treatment.
Fig. 4a Fig. 4b
Figure 4a – Axial MRI of the right shoulder showing osteonecrosis of the right humeral head in the area of
perfusion of the anterior humeral circumﬂex artery. Figure 4b – According to Gerber et al
area is supplied by the anterior humeral circumﬂex artery (a, greater tuberosity; b, lesser tuberosity); reproduced
with permission of Journal of Bone and Joint Surgery [Am] ).
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746 CASE REPORT
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