Z Orthop Unfall 2011; 149(2): 231-242
DOI: 10.1055/s-0030-1270984
Refresher Orthopädie und Unfallchirurgie
Rubrikherausgeber: R. Hoffmann, Frankfurt, R. Windhager, Graz
© Georg Thieme Verlag KG Stuttgart · New York

Hüftkopfnekrose – Diagnostik und Differenzialtherapie

Avascular Necrosis of the Hip – Diagnosis and TreatmentW. Drescher1 , T. Pufe2 , R. Smeets3 , R. v. Eisenhart-Rothe4 , M. Jäger5 , M. Tingart1
  • 1Klinik für Orthopädie und Unfallchirurgie – Schwerpunkt Orthopädie, RWTH Universitätsklinikum Aachen
  • 2Institut für Anatomie und Zellbiologie, RWTH Universitätsklinikum Aachen
  • 3Klinik und Poliklinik für Mund-, Kiefer- und Gesichtschirurgie, Universitätsklinikum Eppendorf, Hamburg
  • 4Klinik für Orthopädie und Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München
  • 5Orthopädische Klinik, Universitätsklinikum Essen
Further Information

Publication History

Publication Date:
05 April 2011 (online)

Zusammenfassung

Die Hüftkopfnekrose ist eine ischämische Knochennekrose posttraumatischer oder nicht traumatischer Genese, die im jungen Alter zur sekundären Koxarthrose führen kann. Sie ist heute Indikation für etwa 10 % der Hüftendoprothesenimplantationen. Für die nicht traumatische Hüftkopfnekrose sind neben den führenden Ätiologien Alkohol und Glukokortikoide mittlerweile auch Sichelzellanämie, Taucherkrankheit und Morbus Gaucher identifiziert. Weitere Risikofaktoren sind Chemotherapie bei Tumorerkrankungen, chronisch entzündliche Darmerkrankungen, systemischer Lupus erythematodes und Multiple Sklerose, wobei bei diesen die hochdosierte Kortisongabe von Bedeutung ist. Schwangerschaft stellt einen weiteren Risikofaktor dar, und es verbleibt noch ein Anteil an idiopathischen Hüftkopfnekrosen. Diagnostisch wichtig ist die ARCO-Stadieneinteilung nach der internationalen Association of the Research of Osseous Circulation. Während im Stadium 0 lediglich ein histologischer Nachweis erfolgen kann, zeigen sich im reversiblen Frühstadium 1 bereits kernspintomografische Signaländerungen. Erst im irreversiblen Frühstadium 2 zeigt das Nativröntgenbild gering verminderte Transparenz aufgrund von neuer Knochenauflagerung auf tote Trabekel. Im Stadium 3 erfolgt die subchondrale Fraktur und im Endstadium 4 liegt die sekundäre Koxarthrose vor. Therapeutisch bieten sich im Stadium 1 die Kernanbohrung, Physiotherapie und zunehmend gesichert auch die Bisphosphonattherapie an. Zur extrakorporalen Stoßwellentherapie liegen für die Hüftkopfnekrose nur wenige Daten vor. Noch als experimentelle, aber hoffnungsvolle Therapie im Stadium 1 und 2 ist die autologe Stammzelltransplantation zu werten. Im Stadium 2 und 3 kommen nicht vaskularisierte und gefäßgestielte Knochentransplantate zum Einsatz. Selten ist eine Umstellungsosteotomie des proximalen Femurs indiziert. Noch seltener werden ein Tantalumimplantat aus trabekulärem Metall nach Kernanbohrung implantiert oder Knorpel-Knochen-Zylinder transplantiert. Im Stadium 4 ist die Standardversorgung noch immer die herkömmliche Hüfttotalendoprothese. Die ersten kurz- bis mittelfristigen Erfahrungen mit Oberflächenersatz liegen nun vor. Die in den letzten Jahren entwickelten Kurzschaftendoprothesen könnten eine Hoffnung für diese junge Patientengruppe darstellen.

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.

Literatur

  • 1 Stulberg B N, Singer R, Goldner J et al. Uncemented total hip arthroplasty in osteonecrosis: a 2- to 10-year evaluation.  Clin Orthop Relat Res. 1997;  334 116-123
  • 2 Kim Y H, Oh S H, Kim J S et al. Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head.  J Bone Joint Surg Am. 2003;  85 675-681
  • 3 Mankin H J. Nontraumatic necrosis of bone (osteonecrosis).  N Engl J Med. 1992;  326 1473-1479
  • 4 Mont M A, Hungerford D S. Non-traumatic avascular necrosis of the femoral head.  J Bone Joint Surg Am. 1995;  77 459-474
  • 5 Arico M, Boccalatte M F, Silvestri D et al. Osteonecrosis: An emerging complication of intensive chemotherapy for childhood acute lymphoblastic leukemia.  Haematologica. 2003;  88 747-753
  • 6 Castro Jr. F P, Harris M B. Differences in age, laterality, and Steinberg stage at initial presentation in patients with steroid-induced, alcohol-induced, and idiopathic femoral head osteonecrosis.  J Arthroplasty. 1999;  14 672-676
  • 7 Mont M A, Payman R K, Laporte D M et al. Atraumatic osteonecrosis of the humeral head.  J Rheumatol. 2000;  27 1766-1773
  • 8 Mont M A, Baumgarten K M, Rifai A et al. Atraumatic osteonecrosis of the knee.  J Bone Joint Surg Am. 2000;  82 1279-1290
  • 9 Baumgarten K M, Mont M A, Rifai A et al. Atraumatic osteonecrosis of the patella.  Clin Orthop. 2001;  383 191-196
  • 10 Le T B, Mont M A, Jones L C et al. Atraumatic osteonecrosis of the adult elbow.  Clin Orthop. 2000;  373 141-145
  • 11 Marston S B, Gillingham K, Bailey R F et al. Osteonecrosis of the femoral head after solid organ transplantation: a prospective study.  J Bone Joint Surg Am. 2002;  84 2145-2151
  • 12 Fryer J P, Granger D K, Leventhal J R et al. Steroid-related complications in the cyclosporine era.  Clin Transplant. 1994;  8 224-229
  • 13 Fryer J P, Benedetti E, Gillingham K et al. Steroid-related complications in pediatric kidney transplant recipients in the cyclosporine era.  Transplant Proc. 1994;  26 91-92
  • 14 Abu-Shakra M, Buskila D, Shoenfeld Y. Osteonecrosis in patients with SLE.  Clin Rev Allergy Immunol. 2003;  25 13-24
  • 15 Klingenstein G, Levy R N, Kornbluth A et al. Inflammatory bowel disease related osteonecrosis: report of a large series with a review of the literature.  Aliment Pharmacol Ther. 2005;  21 243-249
  • 16 Ce P, Gedizlioglu M, Gelal F et al. Avascular necrosis of the bones: an overlooked complication of pulse steroid treatment of multiple sclerosis.  Eur J Neurol. 2006;  13 857-861
  • 17 Hauzeur J P, Malaise M, Gangji V. Osteonecrosis in inflammatory bowel diseases: a review of the literature.  Acta Gastroenterol Belg. 2009;  72 327-334
  • 18 Jones Jr. J P. Fat embolism, intravascular coagulation, and osteonecrosis.  Clin Orthop. 1993;  292 294-308
  • 19 Mukisi-Mukaza M, Elbaz A, Samuel-Leborgne Y et al. Prevalence, clinical features, and risk factors of osteonecrosis of the femoral head among adults with sickle cell disease.  Orthopedics. 2000;  23 357-363
  • 20 Katz K, Horev G, Grunebaum M et al. The natural history of osteonecrosis of the femoral head in children and adolescents who have Gaucher disease.  J Bone Joint Surg Am. 1996;  78 14-19
  • 21 Aigner N, Meizer R, Meraner D et al. Bone marrow edema syndrome in postpartal women: treatment with iloprost.  Orthop Clin North Am. 2009;  40 241-247
  • 22 Ugwonali O F, Sarkissian H, Nercessian O A. Bilateral osteonecrosis of the femoral head associated with pregnancy: four new cases and a review of the literature.  Orthopedics. 2008;  31 183
  • 23 Chang J D, Hur M, Lee S S et al. Genetic background of nontraumatic osteonecrosis of the femoral head in the Korean population.  Clin Orthop Relat Res. 2008;  466 1041-1046
  • 24 Drescher W, Schneider T, Becker C et al. Selective reduction of bone blood flow by short-term treatment with high-dose methylprednisolone. An experimental study in pigs.  J Bone Joint Surg Br. 2001;  83 274-277
  • 25 Drescher W, Weigert K P, Bunger M H et al. Femoral head blood flow reduction and hypercoagulability under 24 h megadose steroid treatment in pigs.  J Orthop Res. 2004;  22 501-508
  • 26 Jones Jr. J P. Intravascular coagulation and osteonecrosis.  Clin Orthop. 1992;  277 41-53
  • 27 Glueck C J, Freiberg R, Tracy T et al. Thrombophilia and hypofibrinolysis: pathophysiologies of osteonecrosis.  Clin Orthop. 1997;  334 43-56
  • 28 Oner A F, Gurgey A, Kirazli S et al. Changes of hemostatic factors in children with acute lymphoblastic leukemia receiving combined chemotherapy including high dose methylprednisolone and L-asparaginase.  Leuk Lymphoma. 1999;  33 361-364
  • 29 Cui Q, Wang G J, Balian G. Steroid-induced adipogenesis in a pluripotential cell line from bone marrow.  J Bone Joint Surg Am. 1997;  79 1054-1063
  • 30 Atsumi T, Yamano K, Muraki M et al. The blood supply of the lateral epiphyseal arteries in Perthes' disease.  J Bone Joint Surg Br. 2000;  82 392-398
  • 31 Ohzono K, Takaoka K, Saito S et al. Intraosseous arterial architecture in nontraumatic avascular necrosis of the femoral head. Microangiographic and histologic study.  Clin Orthop. 1992;  277 79-88
  • 32 Drescher W, Li H, Lundgaard A et al. Endothelin-1-induced femoral head epiphyseal artery constriction is enhanced by long-term corticosteroid treatment.  J Bone Joint Surg Am. 2006;  88 (Suppl. 3) 173-179
  • 33 Tingart M, Beckmann J, Opolka A et al. Influence of factors regulating bone formation and remodeling on bone quality in osteonecrosis of the femoral head.  Calcif Tissue Int. 2008;  82 300-308
  • 34 Saisu T, Sakamoto K, Yamada K et al. High incidence of osteonecrosis of femoral head in patients receiving more than 2 g of intravenous methylprednisolone after renal transplantation.  Transplant Proc. 1996;  28 1559-1560
  • 35 Ficat R P. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment.  J Bone Joint Surg Br. 1985;  67 3-9
  • 36 Delling G. Pathohistology of femoral head necrosis.  Orthopäde. 2007;  36 404 406-408 410-413
  • 37 Saini A, Saifuddin A. MRI of osteonecrosis.  Clin Radiol. 2004;  59 1079-1093
  • 38 Hofmann S, Engel A, Neuhold A et al. Bone-marrow oedema syndrome and transient osteoporosis of the hip. An MRI-controlled study of treatment by core decompression.  J Bone Joint Surg Br. 1993;  75 210-216
  • 39 Krämer J, Scheurecker G, Scheurecker A et al. Femoral head necrosis.  Radiologe. 2009;  49 410-418
  • 40 Wirtz C, Zilkens K W, Adam G et al. MRI-controlled outcome after core decompression of the femur head in aseptic osteonecrosis and transient bone marrow edema.  Z Orthop Ihre Grenzgeb. 1998;  136 138-146
  • 41 Mitchell D G, Rao V M, Dalinka M K et al. Femoral head avascular necrosis: correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical findings.  Radiology. 1987;  162 709-715
  • 42 Neumayr L D, Aguilar C, Earles A N et al. Physical therapy alone compared with core decompression and physical therapy for femoral head osteonecrosis in sickle cell disease. Results of a multicenter study at a mean of three years after treatment.  J Bone Joint Surg Am. 2006;  88 2573-2582
  • 43 Disch A C, Matziolis G, Perka C. The management of necrosis-associated and idiopathic bone-marrow oedema of the proximal femur by intravenous iloprost.  J Bone Joint Surg Br. 2005;  87 560-564
  • 44 Alves E M, Angrisani A T, Santiago M B. The use of extracorporeal shock waves in the treatment of osteonecrosis of the femoral head: a systematic review.  Clin Rheumatol. 2009;  28 1247-1251
  • 45 Wang C J, Wang F S, Huang C C et al. Treatment for osteonecrosis of the femoral head: comparison of extracorporeal shock waves with core decompression and bone-grafting.  J Bone Joint Surg Am. 2005;  87 2380-2387
  • 46 Heller K D, Niethard F U. Using extracorporeal shockwave therapy in orthopedics – a meta-analysis.  Z Orthop Ihre Grenzgeb. 1998;  136 390-401
  • 47 Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone marrow grafting.  Clin Orthop Relat Res. 2002;  405 14-23
  • 48 Hernigou P, Poignard A, Manicom O et al. The use of percutaneous autologous bone marrow transplantation in nonunion and avascular necrosis of bone.  J Bone Joint Surg Br. 2005;  87 896-902
  • 49 Jäger M, Hernigou P, Zilkens C et al. Cell therapy in bone-healing disorders.  Orthopäde. 2010;  39 449-462
  • 50 Gangji V, Hauzeur J P, Matos C et al. Treatment of osteonecrosis of the femoral head with implantation of autologous bone-marrow cells. A pilot study.  J Bone Joint Surg Am. 2004;  86 1153-1160
  • 51 Agarwala S, Shah S, Joshi V R. The use of alendronate in the treatment of avascular necrosis of the femoral head: follow-up to eight years.  J Bone Joint Surg Br. 2009;  91 1013-1018
  • 52 Wirth S M, Lawson A P, Sutphin S D et al. Osteonecrosis of the jaw associated with bisphosphonate therapy.  Orthopedics. 2009;  32 900-903
  • 53 Drescher W, Fürst M, Hahne H J et al. Survival analysis of hips treated with flexion osteotomy for femoral head necrosis.  J Bone Joint Surg Br. 2003;  85 969-974
  • 54 Schneider W, Aigner N, Pinggera O et al. Intertrochanteric osteotomy for avascular necrosis of the head of the femur. Survival probability of two different methods.  J Bone Joint Surg Br. 2002;  84 817-824
  • 55 Reck F, Thorey F, Lewinski G V et al. Analysis of 10-year survival after flexion osteotomy for femoral head necrosis.  Z Orthop Unfall. 2007;  145 448-451
  • 56 Schneider E, Ahrendt J, Niethard F U et al. Long-term results following intertrochanteric varus osteotomy in aseptic femur head necrosis in the adult.  Röfo. 1989;  150 402-406
  • 57 Seyler T M, Marker D R, Ulrich S D et al. Nonvascularized bone grafting defers joint arthroplasty in hip osteonecrosis.  Clin Orthop Relat Res. 2008;  466 1125-1132
  • 58 Mont M A, Etienne G, Ragland P S. Outcome of nonvascularized bone grafting for osteonecrosis of the femoral head.  Clin Orthop Relat Res. 2003;  417 84-92
  • 59 Yoo M C, Kim K I, Hahn C S et al. Long-term followup of vascularized fibular grafting for femoral head necrosis.  Clin Orthop Relat Res. 2008;  466 1133-1140
  • 60 Stronach B M, Duke J N, Rozensweig S D et al. Subtrochanteric femur fracture after core decompression and placement of a tantalum strut for osteonecrosis of the femoral head.  J Arthroplasty. 2010;  25 1168.e5-1168.e7
  • 61 Fung D A, Frey S, Menkowitz M et al. Subtrochanteric fracture in a patient with trabecular metal osteonecrosis intervention implant.  Orthopedics. 2008;  31 614
  • 62 Varitimidis S E, Dimitroulias A P, Karachalios T S et al. Outcome after tantalum rod implantation for treatment of femoral head osteonecrosis: 26 hips followed for an average of 3 years.  Acta Orthop. 2009;  80 20-25
  • 63 Floerkemeier T, Thorey F, Daentzer D et al. Clinical and radiological outcome of the treatment of osteonecrosis of the femoral head using the osteonecrosis intervention implant.  Int Orthop. 2010;  online publiziert
  • 64 Draenert F G, Huetzen D, Kammerer P et al. Bone augmentation in dental implantology using press-fit bone cylinders and twin-principle diamond hollow drills: a case series.  Clin Implant Dent Relat Res. 2009;  online publiziert
  • 65 Akbar M, Mont M A, Heisel C et al. Resurfacing for osteonecrosis of the femoral head.  Orthopäde. 2008;  37 672-678
  • 66 Sakagoshi D, Kabata T, Umemoto Y et al. A mechanical analysis of femoral resurfacing implantation for osteonecrosis of the femoral head.  J Arthroplasty. 2010;  25 1282-1289
  • 67 Revell M P, McBryde C W, Bhatnagar S et al. Metal-on-metal hip resurfacing in osteonecrosis of the femoral head.  J Bone Joint Surg Am. 2006;  88 (Suppl. 3) 98-103
  • 68 Mont M A, Seyler T M, Marker D R et al. Use of metal-on-metal total hip resurfacing for the treatment of osteonecrosis of the femoral head.  J Bone Joint Surg Am. 2006;  88 (Suppl. 3) 90-97
  • 69 Nöth U, Reichert J, Reppenhagen S et al. Cell based therapy for the treatment of femoral head necrosis.  Orthopäde. 2007;  36 466-471
  • 70 Gulow J, Scholz R, Freiherr von Salis-Soglio. Short-stemmed endoprostheses in total hip arthroplasty.  Orthopäde. 2007;  36 353-359
  • 71 Tingart M, Beckmann J, Opolka A et al. Analysis of bone matrix composition and trabecular microarchitecture of the femoral metaphysis in patients with osteonecrosis of the femoral head.  J Orthop Res. 2009;  27 1175-1181
  • 72 Fink B, Rüther W. Partial and total joint replacement in femur head necrosis.  Orthopade. 2000;  29 449-456
  • 73 Hungerford M W, Hungerford D S, Jones L C. Outcome of uncemented primary femoral stems for treatment of femoral head osteonecrosis.  Orthop Clin North Am. 2009;  40 283-289
  • 74 Chiu K H, Shen W Y, Ko C K et al. Osteonecrosis of the femoral head treated with cementless total hip arthroplasty. A comparison with other diagnoses.  J Arthroplasty. 1997;  12 683-688
  • 75 Aldridge 3rd J M, Berend K R, Gunneson E E et al. Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head. Surgical technique.  J Bone Joint Surg Am. 2004;  86 (Suppl. 1) 87-101
  • 76 Schneider W, Breitenseher M, Engel A et al. The value of core decompression in treatment of femur head necrosis.  Orthopäde. 2000;  29 420-429
  • 77 Plakseychuk A Y, Kim S Y, Park B C et al. Vascularized compared with nonvascularized fibular grafting for the treatment of osteonecrosis of the femoral head.  J Bone Joint Surg Am. 2003;  85 589-596
  • 78 Rijnen W H, Gardeniers J W, Buma P et al. Treatment of femoral head osteonecrosis using bone impaction grafting.  Clin Orthop Relat Res. 2003;  417 74-83
  • 79 Kim S Y, Kim Y G, Kim P T et al. Vascularized compared with nonvascularized fibular grafts for large osteonecrotic lesions of the femoral head.  J Bone Joint Surg Am. 2005;  87 2012-2018
  • 80 Keizer S B, Kock N B, Dijkstra P D et al. Treatment of avascular necrosis of the hip by a non-vascularised cortical graft.  J Bone Joint Surg Br. 2006;  88 460-466
  • 81 Berend K R, Gunneson E E, Urbaniak J R. Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head.  J Bone Joint Surg Am. 2003;  85 987-993
  • 82 Dean G S, Kime R C, Fitch R D et al. Treatment of osteonecrosis in the hip of pediatric patients by free vascularized fibular graft.  Clin Orthop Relat Res. 2001;  386 106-113
  • 83 Scully S P, Aaron R K, Urbaniak J R. Survival analysis of hips treated with core decompression or vascularized fibular grafting because of avascular necrosis.  J Bone Joint Surg Am. 1998;  80 1270-1275

Priv.-Doz. Dr. med. Wolf Drescher, Oberarzt

Klinik für Orthopädie und Unfallchirurgie
Schwerpunkt Orthopädie
Universitätsklinikum Aachen

Pauwelsstraße 30

52074 Aachen

Email: wdrescher@ukaachen.de