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
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Priv.-Doz. Dr. med. Wolf Drescher, Oberarzt
Klinik für Orthopädie und Unfallchirurgie
Schwerpunkt Orthopädie
Universitätsklinikum Aachen
Pauwelsstraße 30
52074 Aachen
Email: wdrescher@ukaachen.de