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.
Schlüsselwörter
Hüftkopfnekrose - aktuelle Behandlung - Diagnostik
Key words
avascular necrosis of the hip - current treatment - diagnosis
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
