S3-Leitlinie. Teil 2: Atraumatische Femurkopfnekrose des Erwachsenen – unbehandelter Verlauf und konservative Behandlung

 

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Zusammenfassung

Hintergrund: Die atraumatische Femurkopfnekrose des Erwachsenen (aFKN) hat eine Inzidenz von 5000 bis 7000 pro Jahr in Deutschland. Sie tritt meist im mittleren Alter auf, es ist eine zunehmende Häufung idiopathischer Fälle zu beobachten. Chemotherapie, Kortikoide und Nierentransplantationen gehen gehäuft mit der Erkrankung einher. Meist tritt die Erkrankung beidseits auf. Die frühzeitige Diagnose ist von besonderer Bedeutung, da sich hier am ehesten Spätschäden mit Gelenkdestruktion vermeiden lassen. Während bisher der zeitlich begrenzte operative Gelenkerhalt und folgende Gelenkersatz häufig einzige Option waren, spielen konservative und gelenkerhaltende Maßnahmen zunehmend eine Rolle. Material und Methoden: Nach den AWMF-Vorgaben für eine S3-Leitlinie wurden klinische Fragestellungen formuliert. Über den Zeitraum vom 01.01.1970 bis einschließlich 31.05.2013 wurde eine gezielte Literaturrecherche durchgeführt. Bewertet wurden systematische Reviews, Metaanalysen, Originalarbeiten und klinische Studien jeglichen Designs. Es fanden sich insgesamt 3715 Literaturstellen, von denen 422 für die Bewertung nach SIGN (Scottish Intercollegiate Guidelines Network) geeignet waren und 180 den definierten Ein- bzw. Ausschlusskriterien entsprachen. Für den unbehandelten Verlauf und die Beurteilung der konservativen Maßnahmen waren insgesamt 42 Literaturstellen geeignet. Bei der Formulierung der Empfehlungen wurde nach GRADE (Grading of Recommendations, Assessment, Development and Evaluation) zwischen den Empfehlungsgraden (EG) A: „soll“, B: „sollte“ und 0: „kann“ unterschieden, ferner je der Level of Evidence (LoE) und ggf. eine Einschätzung des Expertenkonsenses (EK) angegeben. Ergebnisse und Schlussfolgerung: Unbehandelt führt die aFKN innerhalb von 2 Jahren zur subchondralen Fraktur mit anschließendem Kollaps. Nach der Diagnose einer Hüftkopfnekrose ist das Risiko für einen Befall der Gegenseite in den folgenden 2 Jahren hoch, danach unwahrscheinlich. Die alleinige konservative Behandlung bringt keinen Benefit zur Therapie der atraumatischen Femurkopfnekrose des Erwachsenen. Hiermit werden lediglich eine verbesserte Funktion und eine geringere Schmerzhaftigkeit erreicht. Die chirurgische Intervention kann verzögert werden. Die Progression wird damit jedoch nicht aufgehalten. Konservative Behandlung muss daher immer Teil des Gesamtbehandlungskonzepts sein, auch als Ergänzung zur operativen Therapie. Im ARCO-Stadium I–II kann Iloprost als pharmakologischer Ansatz zur Reduktion der Schmerzen und des Knochenmarködems erwogen werden. Dies gilt auch für Alendronat. Da es sich in beiden Fällen um einen Off-Label Use und damit einen Heilversuch handelt, muss eine entsprechende Aufklärung der Patienten erfolgen. Für den Einsatz von Antikoagulanzien und Statinen existiert keine Empfehlung. Auch für die hyperbare Sauerstofftherapie, Stoßwellen sowie pulsierende elektromagnetische Felder oder Elektrostimulation lässt sich keine ausreichende Evidenz nachweisen.

Abstract

Background: In Germany there are 5000 to 7000 new cases of atraumatic avascular necrosis of the femoral head in adults per year. It occurs mostly in middle age. An increased frequency of idiopathic cases can be observed. Chemotherapy, corticoids and kidney transplants are frequently associated with the disease. In most cases the disease occurs on both sides. Early diagnosis is of particular importance, since in early stages it is most likely to avoid late damage with joint destruction. Whereas previously the temporary operational joint preservation and subsequent joint replacement were often the only option of treatment, conservative and joint-preserving measures today play an increasing role. Material and Methods: After the AWMF guidelines for S3 guideline clinical questions were formulated. Over the period from 01/01/1970 to 31/05/2013 a literature search was conducted. Systematic reviews, metaanalyses, original papers and clinical trials of all designs were evaluated. There were a total of 3715 references, of which 422 for the assessment regarding SIGN were eligible and finally 180 were in accord with the defined inclusion and exclusion criteria. For the untreated course and the assessment of conservative measures, a total of 42 references was suitable. In formulating the recommendations the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system was used, which distinguishes A “shall”, B “should” and 0 “can”. Results and Conclusion: If left untreated, the aFKN within 2 years leads to a subchondral fracture and subsequent collapse. After the diagnosis of femoral head necrosis, the risk of a disease of the opposite side is high within the next 2 years, then unlikely. The sole conservative treatment brings no benefit for the treatment of atraumatic avascular necrosis in the adult. Although it improves function, less pain can be obtained, and surgical intervention can be delayed, the progression is not stopped. Conservative treatment must therefore always be part of the overall treatment. In ARCO stage I to II Iloprost may be considered as a pharmacological approach to reduce the pain and the bone marrow oedema. This also applies to alendronate. Since this is an off-label use, and thus a therapeutic trial, an appropriate patient education must take place. For the use of anticoagulants and statins, there is no recommendation. Also the hyperbaric oxygen therapy, shock waves and pulsating electromagnetic fields or electrical stimulation cannot be recommended.

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