Atraumatic osteonecrosis of the humeral head: pathophysiology and current concepts of evaluation and treatment

The humeral head is considered the second most common site for osteonecrosis to occur after the femoral head. As seen in the femoral head, the circulatory implications characteristic of this condition are attributable to the interaction between a genetic predisposition and the exposure to certain risk factors. There is no consensus regarding the pathogenesis of osteonecrosis, yet the final common pathway results in disrupted blood supply, increased intraosseous pressure, and bone death. Disease staging using radiography and magnetic resonance imaging is predictive of disease progression and can help the orthopedic surgeon to guide treatment. Although there is a myriad of treatment modalities, there is a lack of high-quality evidence to conclude what is the most appropriate treatment option for each stage of humeral head osteonecrosis. Nonoperative treatment is the preferred option in early-stage disease, and it may prevent disease progression. Nonetheless, in some cases, disease progression occurs despite nonoperative measures, and surgical treatment is required. The purpose of this article is to provide an updated review of the available evidence on risk factors, diagnosis, and treatment of atraumatic humeral head osteonecrosis.