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Abstract：
BACKGROUND: 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.
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.
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.
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.
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.
摘要：
背景：在德国，成人非创伤性股骨头缺血性坏死（AVN;N-ANFH）的治疗每年估计发病率为5000-7000例仍然是一个挑战。危险因素包括类固醇,酗酒,化疗和免疫抑制药物，但是有人提出了遗传倾向。这种通常是双侧疾病过程的早期诊断对于成功的保守或保留关节的手术治疗至关重要。在这次审查中,我们将最新的德国共识S3指南“N-ANFH的诊断和管理”作为简明摘要。
方法：本系统综述基于1970年1月1日至2013年4月31日的已发表文献（德语和英语）。纳入标准是系统评价，荟萃分析和相关同行评审出版物。我们确定了总共3715种相关出版物，其中422个符合SIGN标准，但只有159个符合我们的入选标准。
结论：临床怀疑N-ANFH需要进行影像学评估。如果X光片是正常的，建议进行MRI扫描，应根据ARCO分类进行评估。鉴别诊断包括短暂性骨质疏松症，骨头瘀伤,功能不全骨折和破坏性关节病。未治疗,软骨下骨折通常发生在2年内，在此期间，对侧受累的风险很高，此后不太可能。可以尝试使用Ilomedin和Alendronat进行保守管理，但是其他药物或物理治疗是不合适的。没有特定的关节保留程序可以推荐，但如果坏死<30%，应在早期阶段考虑核心减压。在ARCOIIIc或IV期应考虑全髋关节置换术（THA），与骨关节炎相比，它提供了相似的结果。年轻年龄是N-ANFHTHA后较高修订率的主要危险因素。
方法：本系统综述基于1970年1月1日至2013年4月31日的已发表文献（德语和英语）。纳入标准是系统评价，荟萃分析和相关同行评审出版物。我们确定了总共3715种相关出版物，其中422个符合SIGN标准，但只有159个符合我们的入选标准。
结论：临床怀疑N-ANFH需要进行影像学评估。如果X光片是正常的，建议进行MRI扫描，应根据ARCO分类进行评估。鉴别诊断包括短暂性骨质疏松症，骨头瘀伤,功能不全骨折和破坏性关节病。未治疗,软骨下骨折通常发生在2年内，在此期间，对侧受累的风险很高，此后不太可能。可以尝试使用Ilomedin和Alendronat进行保守管理，但是其他药物或物理治疗是不合适的。没有特定的关节保留程序可以推荐，但如果坏死<30%，应在早期阶段考虑核心减压。在ARCOIIIc或IV期应考虑全髋关节置换术（THA），与骨关节炎相比，它提供了相似的结果。年轻年龄是N-ANFHTHA后较高修订率的主要危险因素。
