Update S3-Leitlinie Atraumatische Femurkopfnekrose des Erwachsenen

Abstract

The update of the German S3 guideline on atraumatic femoral head necrosis in adults aims to provide an overview of diagnosis and treatment. All clinical studies, systematic reviews, and meta-analyses published in German or English between 01.05.2013 and 30.04.2017 were included. Of 427 studies, 28 were suitable for analysis. Risk factors are corticosteroids, chemotherapy, kidney transplants, hemoglobinopathies, and alcoholism. Differential diagnoses are for example bone marrow edema, insufficiency fracture, and destructive arthropathy. Radiography should be performed upon clinical suspicion. In patients with normal radiography findings but persistent complaints, magnetic resonance imaging (ARCO classification) is the method of choice. Computed tomography (CT) can be used to confirm/exclude articular surface collapse. A subchondral sclerosis zone >30% in CT indicates a better prognosis. Left untreated, a subchondral fracture will develop within 2 years. The risk of disease development in the opposite side is high during the first 2 years, but unlikely thereafter. In conservative therapy, iloprost and alendronate can be used in a curative approach, the latter for small, primarily medial necrosis. Conservative therapy alone as well as other drug-based and physical approaches are not suitable for treatment. No particular joint-preserving surgery can currently be recommended. Core decompression should be performed in early stages with <30% necrosis. From ARCO stage IIIc or in stage IV, the indication for total hip arthroplasty should be checked. Results after total hip arthroplasty are comparable with those after coxarthrosis, although the revision rate is higher due to the relatively young age of patients. Statements on the effectiveness of cell-based therapies such as expanded stem cells or bone marrow aspirates cannot currently be made.

Efficacy and safety of stem cell therapy for the early-stage osteonecrosis of femoral head: a systematic review and meta-analysis of randomized controlled trials

“…Several researchers investigated that older patients usually have complicated microenvironment changes characterized with dysregulation of metabolism and immune system influenced by various epigenetic factors and signaling networks [ 45 – 48 ]. In addition, different from our results, a previously [ 6 ] published guideline on ONFH suggested that effectiveness of stem cells are limited on preserving joint and the revision was relative high due to young patients. We believed that this difference may due to the heterogeneity arising from limited studies and procedures but basing on our analysis of strict RCTs there was a better effect on preventing progression events for patients under 40.…”

“…Current operation procedures include core decompression (CD), vascularized bone graft, osteotomy, transplanting tissue engineer materials, and total hip replacement (THR) [ 2 – 5 ]. Unfortunately, there is still no effective therapy that could delay the progression of ONFH [ 6 ]. Besides, early intervention before the subchondral fracture would achieve better outcomes.…”

Operative Interventionen beim Knochenmarködem und bei Osteonekrose

“…Die mACD zeigte im Vergleich zur klassischen CD im Stadium ARCO II nach 30 Monaten eine Überlebensrate von 75,9 % vs. 65,0 %, wobei kleine Nekrosen (< 15 %) in beiden Gruppen deutlich bessere Ergebnisse zeigten als mittlere (15-30 %) und große (> 30 %) Nekrosen [34]. Im Rahmen einer prospektiven Studie konnten Serong et al [36] [37,39,40]. Modifikationen wie die mACD oder die Kombination mit einer Arthroskopie zeigen vielversprechende Resultate, welche in gegenwärtigen und zukünftigen Forschungsprojekten noch weiter etabliert werden müssen.…”

“…Es handelt sich um eine hoch anspruchsvolle Operation, die daher nicht als Routineverfahren eingesetzt werden sollte. Die Operation sollte in spezialisierten Zentren durchgeführt werden und kann bei jüngeren Patientinnen und Patienten in frühen Stadien der Nekrose eine Therapieoption darstellen [37,39].…”

“…Für den Einsatz von mesenchymalen Stammzellen und Wachstumsfaktoren ist laut Leitlinien eine abschließende Bewertung anhand der vorliegenden Literatur aktuell noch nicht möglich. Hierzu sind weitere Studien erforderlich [37].…”