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[Conservative treatment of atraumatic femoral head necrosis]. DER ORTHOPADE 2018; 47:735-744. [PMID: 30097686 DOI: 10.1007/s00132-018-3616-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Femoral head necrosis is a progressive disease that can progress within a relatively short time. Therefore, an early and clear diagnosis including stage classification and treatment is necessary to prevent or delay the onset of the femoral head and joint destruction. TREATMENT In addition to the identification of possible risk factors and treatment, the question of the available treatment options arises. The present article deals with conservative treatment options and presents the published results in the sense of the currently available evidence and against the background of the S3 guideline on atraumatic femoral head necrosis. The results of physical therapy, drug therapy (iloprost and bisphosphonates ), electrotherapy, shockwave therapy, etc. are presented. In the early stages of femoral head necrosis with low expansion, alendronate gives positive results. Iloprost is also a successful conservative treatment option in the early stages of atraumatic femoral head necrosis (ARCO I and II). In stages ARCO III and IV, Ilomedin is no longer indicated. Anticoagulants, such as enoxaparin, have demonstrated an arthroprotective effect.
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Beckmann J, Roth A, Niethard C, Mauch F, Best R, Maus U. [Bone marrow edema and atraumatic necrosis of the femoral head : Therapy]. DER ORTHOPADE 2016; 44:662-671. [PMID: 26245631 DOI: 10.1007/s00132-015-3146-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND An increase in interstitial bony fluid occurs in bone-marrow edema (BME). The exact pathogenetic processes still remain unknown. BME is an unspecific finding that can occur on its own or accompany multiple diseases and pathologies. GOAL Literature review and presentation of new guidelines. MATERIAL AND METHODS This is a narrative literature review followed by current advice for the therapy of atraumatic osteonecrosis of the hip, based on the recently published S3-guidelines for this disease. RESULTS AND DISCUSSION The differentiation of at least 3 different etiologies is proposed (mechanic, reactive and ischemic). Difficult, but important, is the distinction between the mostly painful, but benign entities (BME syndrome, bone bruise) and the progressive pathologies (osteonecrosis, arthritis, CRPS, tumour). Treatment options are dependent on etiology and clinic and can often be symptomatic. Core decompression is the surgical gold standard, leading to immediate pressure relief and therefore reduction in pain. Recently, it was shown that intravenous administration of Iloprost and bisphosphonates are also effective in achieving a reduction of BME and pain, with considerable improvement in the accompanying symptoms. The combination of core decompression and infusion seems to be another possible optimization ofthe therapy, in particular in the treatment of osteonecrosis.
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Affiliation(s)
- J Beckmann
- Sportklinik Stuttgart, Taubenheimstr. 8, 70372, Stuttgart, Deutschland.
| | - A Roth
- Bereich Endoprothetik/Orthopädie, Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universität Leipzig AöR, Leipzig, Deutschland
| | - C Niethard
- Orthopädische Gemeinschaftspraxis, Heinsberg, Deutschland
| | - F Mauch
- Sportklinik Stuttgart, Taubenheimstr. 8, 70372, Stuttgart, Deutschland
| | - R Best
- Sportklinik Stuttgart, Taubenheimstr. 8, 70372, Stuttgart, Deutschland
| | - U Maus
- Universitätsklinik für Orthopädie und Unfallchirurgie, Klinik für Orthopädie und spezielle orthopädische Chirurgie, Pius-Hospital Oldenburg, Oldenburg, Deutschland
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Roth A, Beckmann J, Bohndorf K, Fischer A, Heiß C, Kenn W, Jäger M, Maus U, Nöth U, Peters KM, Rader C, Reppenhagen S, Smolenski U, Tingart M, Kopp I, Sirotin I, Breusch SJ. S3-Guideline non-traumatic adult femoral head necrosis. Arch Orthop Trauma Surg 2016; 136:165-74. [PMID: 26667621 DOI: 10.1007/s00402-015-2375-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The treatment of adult non-traumatic avascular necrosis of the femoral head (AVN; N-ANFH) within an estimated incidence of 5000-7000 cases per annum in Germany remains a challenge. Risk factors include steroids, alcohol abuse, chemotherapy and immunosuppressive medication, but a genetic predisposition has been suggested. Early diagnosis of this often bilateral disease process is essential for successful conservative or joint preserving surgical management. In this review, we present the update German consensus S3 guideline "diagnosis and management for N-ANFH" as a concise summary. MATERIALS AND METHODS This systematic review is based on the published literature from January 1, 1970 to April 31, 2013 (German and English language). Inclusion criteria were systematic reviews, meta-analyses and relevant peer review publications. We identified a total of 3715 related publications, of which 422 were suitable according to the SIGN criteria, but only 159 fulfilled our inclusion criteria. RESULTS AND CONCLUSIONS Clinical suspicion of N-ANFH mandates radiographic evaluation. If radiographs are normal MRI scans are recommended, which should be evaluated according to the ARCO-classification. Differential diagnoses include transient osteoporosis, bone bruise, insufficiency fracture and destructive arthropathy. Untreated, subchondral fractures commonly occur within 2 years, during which the risk for contralateral involvement is high-thereafter unlikely. Conservative management with Ilomedin and Alendronat can be tried, but other pharmacological or physical treatments are inappropriate. No specific joint preserving procedure can be recommended, but core decompression should be considered in early stages if necrosis is <30 %. In ARCO stages IIIc or IV total hip arthroplasty (THA) should be contemplated, which offers similar outcome compared to osteoarthritis. Young age is the main risk factor for higher revision rates after THA for N-ANFH.
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Affiliation(s)
- A Roth
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie; Bereich Endoprothetik/Orthopädie, Universitätsklinik Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Germany.
| | - J Beckmann
- Sektion Endoprothetik, Sportklinik Stuttgart, Stuttgart, Germany
| | - K Bohndorf
- Universitätsklinik für Radiologie und Nuklearmedizin, Exzellenzzentrum für Hochfeld MR, Medizinische Universität Wien, Vienna, Austria.,Christian Doppler Laboratory for Molecular Imaging, Medizinische Universität Wien, Vienna, Austria
| | - A Fischer
- Abteilung für Physikalische und Rehabilitative Medizin, Klinikum Burgenlandkreis GmbH, Naumburg, Germany
| | - C Heiß
- Klinik für Unfallchirurgie, Universitätsklinikum Gießen-Marburg, Marburg, Germany
| | - W Kenn
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Würzburg, Würzburg, Germany
| | - M Jäger
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Essen-Duisburg, Essen, Germany
| | - U Maus
- Klinik für Orthopädie und orthopädische Chirurgie, Universitätsklinik für Orthopädie und Unfallchirurgie, Pius-Hospital, Oldenburg, Germany
| | - U Nöth
- Klinik für Orthopädie und Unfallchirurgie, Evangelisches Waldkrankenhaus Spandau, Berlin, Germany
| | - K M Peters
- Orthopädie und Osteologie, Dr. Becker Rhein-Sieg-Klinik, Nümbrecht, Germany
| | - C Rader
- Praxisklinik Orthopädie Aachen, Franziskushospital Aachen, Aachen, Germany
| | - S Reppenhagen
- Orthopädische Klinik König-Ludwig-Haus, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
| | - U Smolenski
- Institut für Physiotherapie, Friedrich-Schiller Universität Jena, Jena, Germany
| | - M Tingart
- Klinik für Orthopädie, Universitätsklinikum Aachen, Aachen, Germany
| | - I Kopp
- AWMF-Institut, Philipps-Universität Marburg, Marburg, Germany
| | - I Sirotin
- Pirogov-Universität Moskau, 64. Städtisches Krankenhaus, Moscow, Russia
| | - S J Breusch
- FRCS Ed, Orthopaedic Department, Edinburgh Royal Infirmary, Edinburgh, UK
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