The latest version of the S3 guidelines.
Diagnosis and management of non-traumatic femoral osteonecrosis in adults; risk factors for non-traumatic femoral osteonecrosis include: glucocorticoids, alcohol abuse, chemotherapy and immunosuppression. Recently, it has also been suggested that the development of the disease may be genetically related. Early detection and diagnosis greatly affect the success or failure of treatment. Early detection has a good chance of preserving the hip joint.
The German S3 guidelines were established by the German Society for Orthopaedic Trauma, the German Society for Radiology, Physiotherapy and Rehabilitation and the German Orthopaedic Society. In an article in Arch Orthop Truma Surg, Roth et al. bring us the 2015 edition of the S3 guidelines, which review new findings in the diagnosis and treatment of non-traumatic femoral head necrosis in adults. A literature search resulted in 159 relevant publications for the review. Among them, 43 were on history and conservative treatment, 72 on diagnosis and imaging, and 64 on surgical treatment. The conclusions of the review are as follows.
1. imaging diagnosis of N-ANFH
1. Clinically, pelvic plain radiographs, lateral hip radiographs, and frog radiographs should be performed in patients with suspected N-ANFH (no other cause of groin pain and/or hip/thigh pain for more than 6 weeks with known risk factors, limping due to pain, and pain leading to limitation of motion). (Grade of recommendation: strong)
2. Recommend imaging classification using ARCO classification. (Recommended grade: moderate)
3. If the plain radiograph is normal but the patient continues to have clinical symptoms, bilateral MRI of the hip is recommended to exclude the underlying pathology. (Evidence level: 2++, recommendation level: strong)
4. If the plain film grading is ARCO grade 2 or 3 and the extent of necrosis can be clarified by MRI, the diagnosis of subtrochanteric fracture and femoral head collapse can also be confirmed or excluded. (Evidence level: 2~3, recommendation level: strong)
If the plain film is graded as ARCO grade 2, the subtrochanteric fracture that cannot be defined by MRI can be defined by CT. (Evidence level 2++, recommended level: strong)
2.Difficulties in diagnosis and differential diagnosis
Transient osteoporosis of the hip (TOH) is an important differential diagnosis. Both of them have diffuse edema on MRI. However, the edema in TOH is more heterogeneous and there are no focal defects or subxiphoid changes. (Grade of recommendation: medium)
Other differential diagnoses are stress/incomplete fractures, osteonecrosis and joint destruction.
3. Natural course/untreated N-ANFH and risk factors
N-ANFH is a progressive disease that usually results in subtrochanteric fracture or femoral head collapse within 2 years. Therefore, surgery is not possible to preserve the hip joint. This is particularly true in patients with bilateral onset and other uncontrollable factors. (Evidence level: 2+/2++, recommendation level: strong)
4. Conservative treatment
1. In N-ANFH, conservative treatment alone cannot control the symptoms in the long term, let alone prevent progression of the disease. (Evidence level 2+/2++, recommendation level: strong)
2. For patients with ARCO grade 1-2 and contraindications to surgery, iloprost can be used to reduce pain and bone marrow edema. When the patient already has a subtrochanteric fracture, continued use of over iloprost is contraindicated. (Level of Evidence: 2+, Grade of Recommendation: Strong)
3. diphosphonates (alendronate) can inhibit bone resorption and retard destruction of the femoral head, and therefore can be used to reduce pain. (Level of Evidence 2+, Grade of Recommendation: Strong)
4. There is insufficient evidence to support the use of anticoagulants (warfarin, etc.) in patients with N-ANFH, and therefore they are not recommended. (Level of Evidence 2+, Grade of Recommendation: Strong)
5. Narcotic analgesics do not reduce the risk for N-ANFH and are therefore not recommended. (Level of Evidence: 2+, Grade of Recommendation: Strong)
6. Hyperbaric oxygen therapy can promote tissue supply, reduce edema, relax blood vessels, and improve microcirculation to reduce the pressure of bone tissue reflux, but there is no evidence that hyperbaric oxygen slows the onset of femoral head collapse. At this time, hyperbaric oxygen therapy is not recommended. (Evidence level: 2+, Recommendation level: Strong)
7. There is no evidence to support that extracorporeal shock wave or ultrasound therapy slows femoral head collapse. Therefore, it is not recommended. (Level of evidence: 1, Grade of recommendation: strong)
8. Electrical stimulation and pulsed electromagnetic fields may exacerbate symptoms in early-stage patients, not to mention that there is no evidence that they can delay femoral head collapse. Therefore, they are not recommended for the treatment of N-ANFH. (Evidence level 2+, Recommendation level: Strong)
5. Hip preservation surgery: timing, rationale and indications for surgery
1. Evidence suggests that patients with ARCO grade 1 to 3 can be treated with or tried for hip preservation surgery. (Evidence level: 2+, recommendation level: strong)
2. There is no such thing as an optimal surgical approach. The type of surgery depends on the status of the femoral head lesion (necrosis). (Evidence level: 2++, recommendation level: strong)
3. central femoral decompression is required for N-ANFH patients with early lesions (potentially reversible, ARCO grade 1 or non-reversible early ARCO grade 2 with <30% medial or central femoral necrosis) (Level of Evidence: 2++, Grade of Recommendation: Strong)
4. Consider brief decompression for symptomatic relief in patients with ARCO grade 3 but with indications for femoral decompression (Level of Evidence: 2++, Grade of Recommendation: Strong)
5. Treatment with femoral decompression combined with alendronate may provide pain relief as well as delay progression compared to femoral decompression alone. (Level of Evidence 2+, Grade of Recommendation: Moderate)
6. The efficacy of central femoral decompression combined with bone grafting is not superior to central femoral decompression alone, although both approaches are better than conservative treatment. Centric femoral decompression is only indicated for less than 20% necrosis or Kerboul angle less than 200°. (Level of evidence: 2+, level of recommendation: strong)
7. Vascular fiber grafting is technically demanding and its efficacy is variable; it is not recommended as a routine treatment for N-ANFH. It may be indicated in young patients with necrosis limited to the center of the femoral head and ARCO grade 1-2. (Level of evidence: 2+, level of recommendation: strong)
8. Osteochondral grafting is not recommended for the treatment of N-ANFH because the efficacy is not clear (Level of Evidence: 2+, Grade of Recommendation: Strong)
9. autogenous cancellous bone grafting is not recommended for the treatment of N-ANFH because the efficacy is not clear.(Level of Evidence: 2+, Grade of Recommendation: Strong)
10. Appropriate femoral osteotomy is acceptable, although it is technically demanding and only indicated for patients in the early stages of life. (Evidence level: 2++, Recommendation level: Strong)
11. There is no scientific evidence that titanium grafts and ischemic necrotic rods are effective, and therefore they are not recommended. (Level of Evidence: 2+, Grade of Recommendation: Strong)
12. Central femoral decompression is not recommended in patients with ARCO grade 3c and 4, when total hip arthroplasty should be considered more often. (Evidence level 2++, recommendation level: strong)
6. Total hip replacement (THR): efficacy and indications
Postoperative outcomes and risk factors for revision after first total hip arthroplasty; the revision rate after total hip arthroplasty in N-ANFH patients has decreased significantly since 1990 and is now close to the global average revision rate for THR.
The postoperative outcome of patients with N-ANFH undergoing THR is similar to that of patients undergoing THR for osteoarthritis of the hip. THR may be more complicated when performed after other surgical operations (e.g., fiber graft, osteotomy, etc.) THR can be used to treat all stages of femoral head necrosis, but postoperative outcomes are poor in alcoholics and those using glucocorticoids. The age of the young patient is a major risk factor for premature prosthesis damage and revision.
7. Fixation of the prosthesis
Whether cemented or uncemented THR is used, both have similar outcomes and can be recommended as the gold standard. (Level of Evidence 2+-2++, Level of Recommendation: Strong) For young male patients under 55 years of age, special consideration needs to be given to whether the surface material of the prosthesis affects the fixation of the prosthesis and side effects due to metal ion coating must be considered. (Level of Evidence: 2+-2++, Level of Recommendation: Strong) There is no evidence to recommend the use of prostheses with shorter femoral ends.