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Published on: September 7, 2022
[Avascular necrosis of the hip - diagnosis and treatment]
1Klinik für Orthopädie und Unfallchirurgie - Schwerpunkt Orthopädie, RWTH Universitätsklinikum Aachen. wdrescher@ukaachen.de
Insights
Femoral head necrosis, a condition causing hip joint destruction, affects young patients and is a leading cause for hip replacements. Early diagnosis and tailored treatments are crucial for preserving the hip joint.
Area of Science:
- Orthopedics
- Bone Diseases
- Vascular Surgery
Context:
- Femoral head necrosis (osteonecrosis) is a significant cause of hip joint destruction, particularly in young individuals.
- It accounts for 10% of total hip replacements, highlighting its clinical impact.
- Nontraumatic etiologies include alcoholism, steroid use, sickle cell anemia, and Gaucher's disease, with other risk factors like chemotherapy and autoimmune conditions.
Purpose:
- To review the pathogenesis, diagnosis, and treatment of femoral head necrosis.
- To emphasize the importance of the ARCO classification for staging and guiding treatment.
- To discuss current and emerging therapeutic strategies for different stages of the disease.
Summary:
- Femoral head necrosis involves ischemic bone death leading to hip destruction.
- Diagnosis utilizes the ARCO classification, progressing from MR signal changes to X-ray findings, subchondral fracture, and arthritis.
- Treatment options range from core decompression and bisphosphonates in early stages to osteotomies, bone grafting, and hip arthroplasty in advanced stages, with a focus on joint preservation in young patients.
Impact:
- Highlights the challenges of treating femoral head necrosis in young patients, often requiring joint preservation strategies.
- Discusses the evolving therapeutic landscape, including stem cell therapy, for managing this debilitating condition.
- Underscores the need for timely diagnosis and appropriate management to prevent long-term hip joint destruction and the need for total hip arthroplasty.
Abstract:
Femoral head necrosis is an ischaemic bone necrosis of traumatic or nontraumatic pathogenesis which can lead to hip joint destruction in young age. It is today the indication for 10 % of all the total hip joint replacements. Known aetiologies of nontraumatic femoral head necrosis are alcoholism, steroids, sickle cell anaemia, caisson, and Gaucher's disease. Further risk factors are chemotherapy, chronic inflammatory bowel disease, systemic lupus erythematosus, and multiple sclerosis, in which also steroids are involved. Gravidity is another risk factor, but still idiopathic pathogenesis is found. In diagnosis, the ARCO-classification of the Association for the Research of Osseous Circulation is essential. While stage 0 can only be found histologically, the reversible early stage 1 shows MR signal changes. In the irreversible early stage 2, first native x-ray changes are seen as lower radiolucency reflects new bone apposition on dead trabeculae. In stage 3, subchondral fracture follows, and in stage 4 secondary arthritis of the hip. Established therapy in stage 1 is core decompression, physiotherapy, and more and more also bisphosphonates. Sufficient data to support extracorporeal shock wave therapy are still lacking. Stem cell therapy seems to be a promising new therapy method in stage 2. In stage 2 and 3 mainly proximal femoral osteotomies and (non)vascularised bone transplantation are performed. In stage 4, depending on size and location of the necrotic zone and pathology of the adjacent bone, resurfacing or short stem hip arthroplasty can be performed. However, conventional THA is still golden standard. The problem and challenge, however, is the often young patient age in femoral head necrosis. Especially chemotherapy-associated osteonecrosis in leukaemia is found in patients in their second decade of life. Therefore, the hip should be preserved as long as possible.