S3-Leitlinie. Teil 3: Atraumatische Femurkopfnekrose des Erwachsenen – Operative Therapie der atraumatischen Femurkopfnekrose des Erwachsenen

 

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Zusammenfassung

Der Artikel beschreibt die Leitlinien der operativen Therapie der atraumatischen Femurkopfnekrose (aFKN). Diese umfassen gelenkerhaltende und gelenkersetzende Verfahren. Im Rahmen der gezielten Literaturrecherche konnten 43 Publikationen zur Bewertung der operativen Therapie eingeschlossen und ausgewertet werden. Entsprechend der GRADE- und SIGN-Kriterien werden Level of Evidence (LoE), Empfehlungsgrad (EG) und Expertenkonsens (EK) zu jeder Aussage und Fragestellung aufgeführt. Die ausgewerteten Studien konnten zeigen, dass bis zu einem ARCO-Stadium III einschließlich gelenkerhaltend operiert werden kann. Ein bestimmter gelenkerhaltender Eingriff kann derzeit nicht bevorzugt empfohlen werden. Die Auswahl des Verfahrens ist abhängig von der Ausdehnung der Nekrose. Die Core-Dekompression soll in den Stadien ARCO I (reversibles Frühstadium) oder Stadium ARCO II (irreversibles Frühstadium) mit medialer oder zentraler Nekrose mit einer Ausdehnung von weniger als 30 % des Hüftkopfs durchgeführt werden und zeigt hier bessere Ergebnisse als die konservative Therapie. In Stadium ARCO III mit Infraktion des Hüftkopfs kann die Core-Dekompression zur kurzfristigen Schmerzreduktion eingesetzt werden. Ab einem ARCO-Stadium IIIC oder in Stadium IV sollte keine Core-Dekompression mehr erfolgen. In diesen Fällen sollte die Indikation zur Implantation einer Hüft-TEP überprüft werden. Weitere Therapieverfahren (z. B. Osteotomien) sowie innovative Behandlungsoptionen (advanced core decompression, autologes Knochenmark, Spongiosaplastik u. a.) können im Einzelfall diskutiert werden. Beim elektiven Hüftgelenksersatz sind die Komplikations- und damit Revisionsraten seit Jahrzehnten deutlich rückläufig. Im Fall einer zugrunde liegenden aFKN können jedoch vorangegangene gelenkerhaltende Voroperationen (insbesondere Umstellungen und Grafts) die Implantation einer HTEP deutlich erschweren. Die Implantatstandzeit scheint jedoch auch von der Ätiologie abhängig zu sein. Höhere Revisionsraten für Femurkopfnekrose sind insbesondere zu erwarten bei Sichelzellanämie, Morbus Gaucher oder nach Nierentransplantation. Ferner ist das relativ junge Alter von Patienten mit Femurkopfnekrose als Hauptrisikofaktor der höheren Revisionsrate zu werten. Die Ergebnisse nach Oberflächenersatz (mit heute bekannter zurückhaltender Indikationsstellung) und zementierter wie zementfreier HTEP bei aFKN sind bei korrekter Indikationsstellung vergleichbar mit denen bei Koxarthrose oder anderen Diagnosen. Unabhängig von der zugrunde liegenden Erkrankung führt die endoprothetische Versorgung bei aFKN endoprothetisch zu guten Ergebnissen. Hierbei können sowohl zementierte als auch zementfreie Verankerungstechniken empfohlen werden.

Abstract

The present article describes the guidelines for the surgical treatment of atraumatic avascular necrosis (aFKN). These include joint preserving and joint replacement procedures. As part of the targeted literature, 43 publications were included and evaluated to assess the surgical treatment. According to the GRADE and SIGN criteria level of evidence (LoE), grade of recommendation (EC) and expert consensus (EK) were listed for each statement and question. The analysed studies have shown that up to ARCO stage III, joint-preserving surgery can be performed. A particular joint-preserving surgery currently cannot be recommended as preferred method. The selection of the method depends on the extent of necrosis. Core decompression performed in stage ARCO I (reversible early stage) or stage ARCO II (irreversible early stage) with medial or central necrosis with an area of less than 30 % of the femoral head shows better results than conservative therapy. In ARCO stage III with infraction of the femoral head, the core decompression can be used for a short-term pain relief. For ARCO stage IIIC or stage IV core decompression should not be performed. In these cases, the indication for implantation of a total hip replacement should be checked. Additional therapeutic procedures (e.g., osteotomies) and innovative treatment options (advanced core decompression, autologous bone marrow, bone grafting, etc.) can be discussed in the individual case. In elective hip replacement complications and revision rates have been clearly declining for decades. In the case of an underlying aFKN, however, previous joint-preserving surgery (osteotomies and grafts in particular) can complicate the implantation of a THA significantly. However, the implant life seems to be dependent on the aetiology. Higher revision rates for avascular necrosis are particularly expected in sickle cell disease, Gaucher disease, or kidney transplantation patients. Furthermore, the relatively young age of the patient with avascular necrosis should be seen as the main risk factor for higher revision rate. The results after resurfacing (today with known restricted indications) and cemented as well as cementless THA in aFKN are comparable for the appropriate indication to those in coxarthrosis or other diagnoses. Regardless of the underlying disease endoprosthetic treatment in aFKN leads to good results. Both cemented and cementless fixation techniques can be recommended.

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