Guidelines for clinical diagnosis and treatment of osteonecrosis of the femoral head in adults (2019 version)

Abstract

Osteonecrosis of the femoral head (ONFH) is a common and refractory disease in orthopaedic clinics. The number of patients with ONFH is increasing worldwide every year. There are an estimated 8.12 million patients with nontraumatic osteonecrosis in China alone. Treatment of nontraumatic osteonecrosis has always been a clinical challenge for orthopaedic surgeons. To further standardize diagnosis and treatment of ONFH, these guidelines provide not only basic diagnosis, treatment, and evaluation systems for ONFH but also expert advice and standards in many aspects, including epidemiology, aetiology, diagnostic criteria, pathological staging, prevention and treatment options, and postoperative rehabilitation. The aetiological factors of ONFH can currently be divided into two major categories: traumatic and nontraumatic; however, the specific pathological mechanism of ONFH is not completely clear. Currently, the staging system of ONFH formulated by the Association Research Circulation Osseous is widely used in clinical practice. Based on the changes in the intraosseous blood supply at different stages, the corresponding nonsurgical and surgical treatments are recommended, and when there are risk factors for possible ONFH, certain preventive measures to avoid the occurrence of osteonecrosis are recommended. These guidelines provide brief classification criteria and treatment regimen for osteonecrosis. Specification of the aetiology, treatment plan based on comprehensive consideration of the different stages of osteonecrosis, hip function, age, and occupation of the patients are important steps in diagnosis and developing treatment strategies.

Translational potential of this article: New advances in the epidemiology, etiology, pathophysiology, imaging, diagnosis and treatment of ONFH have been renewed in this revision. This guideline can be used for reference by orthopedic professionals and researchers, and for standardized diagnosis and treatment management under the clinical guidance, which is conducive to the prevention, treatment and further research of ONFH, improving the diagnosis and treatment level, making patients' symptoms under good control, and improving their quality of life.

Keywords: ARCO, Association Research Circulation Osseous; BMES, Bone marrow oedema syndrome; CT, Computed tomography; DSA, Digital subtraction angiography; Diagnosis; Guideline; MRI, Magnetic resonance imaging; ONFH, Osteonecrosis of the femoral head; Osteonecrosis of the femoral head (ONFH); PET, Positron emission tomography; RHS, Reconstruction Hip Scores; SPECT, Single-photon emission computed tomography; T1WI, T1-weighted images; Treatment.

Figure 1

Representative DSA imaging and micro-CT scanning of intraosseous vessels in the early phase of venous stasis (permission obtained from Guoshuang et al [45] and Benjie [47]). CT = computed tomography; DSA = digital subtraction angiography.

Figure 2

Representative DSA imaging and micro-CT scanning of intraosseous vessels in the midphase of arterial ischaemic (permission obtained from Guoshuang et al [45] and Benjie [47]). CT = computed tomography; DSA = digital subtraction angiography.

Figure 3

Representative DSA imaging and micro-CT scanning of intraosseous vessels in the late phase of arterial occlusion (permission obtained from Guoshuang et al [45] and Benjie [47]). CT = computed tomography; DSA = digital subtraction angiography.

Figure 4

Clinical diagnosis flow chart of osteonecrosis of the femoral head (ONFH). ARCO = Association Research Circulation Osseous; CT = computed tomography; MRI = magnetic resonance imaging; AP = Anteroposterior.