Problems of diagnosis and treatment of aseptic necrosis of the femoral head in contemporary traumatology and orthopedics (literature review)

Introduction. Aseptic necrosis of the femoral head (ANFH) is a severe disease most commonly associated with previous trauma, alcohol intake, administration of corticosteroids or blood diseases. Early diagnosis is difficult, there is no conservative treatment protocol with proven effectiveness, and the organ-preserving surgical treatments which have been used may not always postpone hip arthroplasty. Arthroplasty provides good results in the short and long-term postoperative period, but the prevalence of this disease among young people requires developing new methods of conservative and operative treatment.

Objective. To determine the problems of diagnosis and treatment of aseptic necrosis of the femoral head; to study the experience of current approaches and concepts in the diagnosis and treatment of ANFH; determine the range of the most effective methods for treating this pathology; to establish the relevance of further research on this issue.

Materials and methods. Literature review was conducted of the sources from PubMed and Google Scholar databases. The material was selected that corresponded to the stated purpose of the research topic. For describing some aspects of the aetiology, pathogenesis and development of methods for diagnosing and treating ANFH, earlier publications (2009–2014) were also used.

Results. The main views on the aetiology and pathogenesis of ANFH have been studied. Classical and current diagnostic methods for ANFH were reviewed as well as current operative and conservative approaches to the treatment of this pathology. A review of the main classifications was conducted.

Discussion. Early detection and examination of at-risk patients plays an important role in the diagnosis of ANFH. The results of clinical trials on the use of bisphosphonates seem mixed, as the meta-analysis in five randomized clinical trials (RCTs) in 2016 showed no statistically significant improvement in patients with ANFH. Hyperbaric oxygenation reduces interstitial ischemia by increasing extracellular oxygen concentration and shows encouraging results. Core decompression is recognized as the standard care in the early stages of ANFH. At present, the use of combined treatment with bisphosphonates, core-decompression and mesenchymal stem cells has been investigated. Combined therapy may be effective in slowing the progression of collapse at an early stage of ANFH, but further research is needed to have long-term results.

Conclusion. Aseptic necrosis of the femoral head is a severe polyetiological disease that has not been sufficiently studied. For its diagnosis, it is necessary to take into account the possible risk factors and to ensure an early MRI study. At present, there is no data on a conservative method of treating the early stages of ANFH, which would have high evidence and effectiveness not only in the immediate, but also in the long-term follow-up. It is necessary to conduct additional prospective randomized clinical trials to determine the effectiveness of already known and developed methods of cell therapy in the treatment of ANFH.

1. Yu T., Xie L., Chu F. A sclerotic rim provides mechanical support for the femoral head in osteonecrosis. Orthopedics, 2015, vol. 38, no. 5, pp. e374-e379. DOI: 10.3928/01477447-20150504-53

2. Bilge O., Doral M.N., Yel M., Karalezli N., Miniaci A. Treatment of osteonecrosis of the femoral head with focal anatomic-resurfacing implantation (HemiCAP): preliminary results of an alternative option. J. Orthop. Surg. Res., 2015, vol. 10, pp. 56. DOI: 10.1186/S13018-015-0199-3

3. Atilla B., Bakırcıoğlu S., Shope A.J., Parvızı J. Joint-preserving procedures for osteonecrosis of the femoral head. EFORT Open Rev., 2020, vol. 4, no. 12, pp. 647-658. DOI: 10.1302/2058-5241.4.180073

4. Zuo W., Sun W., Gao F., Li Z., Wang B., Shi Z. [Effectiveness of bone grafting through windowing at femoral head-neck junction for treatment of osteonecrosis with segmental collapse of femoral head]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi, 2016, vol. 30, no. 4, pp. 397-401. (in Chinese)

5. Karasuyama K., Yamamoto T., Motomura G., Sonoda K., Kubo Y., Iwamoto Y. The role of sclerotic changes in the starting mechanisms of collapse: A histomorphometric and FEM study on the femoral head of osteonecrosis. Bone, 2015, vol. 81, pp. 644-648. DOI: 10.1016/J.BONE.2015.09.009

6. Pang Z., Wei Q., Zhou G., Chen P., He W., Bai B., Li Y. [Establishment and application of subject-specific three-dimensional finite element mesh model for osteonecrosis of femoral head]. Sheng Wu Yi Xue Gong Cheng Xue Za Zhi, 2012, vol. 29, no. 2, pp. 251-255. (in Chinese)

7. Chen Z., Xu Y., Qi Z., Zho J. The formation and function of the sclerosis rim in the femoral head: A biomechanical point of view. Med. Eng. Phys., 2015, vol. 37, no. 12, pp. 1125-1132. DOI: 10.1016/J.MEDENGPHY.2015.09.005

8. Turakhodzhaev F.A., Magomedov Kh.M., Kalashnikov S.A., Zagorodnii N.V. Endoprotezirovanie tazobedrennogo sustava primeneniem pary treniia keramika-poperechnosviazannyi polietilen srokom nabliudeniia 10 let [Arthroplasty of the hip using a ceramic-cross-linked polyethylene friction pair with an observation period of 10 years]. Vestnik Rossiiskogo Nauchnogo Tsentra Rentgenoradiologii, 2016, vol. 16, no. 3. (in Russian) Available at: https://elibrary.ru/item.asp?id=26931594 (accessed 14.12.2019).

9. Chen L., Hong G., Fang B., Zhou G., Han X., Guan T., He W. Predicting the collapse of the femoral head due to osteonecrosis: From basic methods to application prospects. J. Orthop. Translat., 2017, vol. 11, pp. 62-72. DOI: 10.1016/J.JOT.2016.11.002

10. Tikhilov R.M., Shubniakov I.I., eds. Rukovodstvo po khirurgii tazobedrennogo sustava [Hip Surgery Guide]. SPb., RNIITO im. R.R. Vredena, 2014, vol. 1, 368 p. (in Russian)

11. Ali S.A., Christy J.M., Griesser M.J., Awan H., Pan X., Ellis T.J. Treatment of avascular necrosis of the femoral head utilizing free vascularized fibular graft: A systematic review. Hip Int., 2014, vol. 24, no. 1, pp. 5-13. DOI: 10.5301/HIPINT.5000076

12. Guerado E., Caso E. The physiopathology of avascular necrosis of the femoral head: an update. Injury, 2016, vol. 47, no. Suppl. 6, pp. S16-S26. DOI: 10.1016/S0020-1383(16)30835-X

13. Aydin B.K., Sofu H., Konya M.N., Er T., Sahin V. Clinical and radiographic outcomes after femoral varus derotation osteotomy for LeggCalvé-Perthes disease at 25 years follow-up: what are the determinants of outcome in the long term? Hip Int., 2016, vol. 26, no. 3, pp. 301-306. DOI: 10.5301/HIPINT.5000329

14. Lamb J.N., Holton C., O'Connor P., Giannoudis P.V. Avascular necrosis of the hip. BMJ, 2019, vol. 365, pp. l2178. DOI: 10.1136/bmj.l2178

15. Lucey M.R., Mathurin P., Morgan T.R. Alcoholic hepatitis. N. Engl. J. Med., 2009, vol. 360, no. 26, pp. 2758-2769. DOI: 10.1056/NEJMra0805786

16. Goldblatt J., Sacks S., Beighton P. The orthopedic aspects of Gaucher disease. Clin. Orthop. Relat. Res., 1978, no. 137, pp. 208-214.

17. Woratanarat P., Thaveeratitharm C., Woratanarat T., Angsanuntsukh C., Attia J., Thakkinstian A. Meta-analysis of hypercoagulability genetic polymorphisms in Perthes disease. J. Orthop. Res., 2014, vol. 32, no. 1, pp. 1-7. DOI: 10.1002/JOR.22473

18. Mok M.Y., Farewell V.T., Isenberg D.A. Risk factors for avascular necrosis of bone in patients with systemic lupus erythematosus: is there a role for antiphospholipid antibodies? Ann. Rheum. Dis., 2000, vol. 59, no. 6, pp. 462-467. DOI: 10.1136/ARD.59.6.462

19. Perry D.C., Bruce C.E., Pope D., Dangerfield P., Platt M.J., Hall A.J. Legg-Calvé-Perthes disease in the UK: geographic and temporal trends in incidence reflecting differences in degree of deprivation in childhood. Arthritis Rheum., 2012, vol. 64, no. 5, pp. 1673-1679. DOI: 10.1002/ART.34316

20. Catto M. Pathology of aseptic bone necrosis. Davidson J.K., ed. Aseptic Necrosis of Bone. Amsterdam, Excerpta Medica, 1976, P. 3-100.

21. Wingstrand H., Egund N., Carlin N.O., Forsberg L., Gustafson T., Sundén G. Intracapsular pressure in transient synovitis of the hip. Acta Orthop. Scand., 1985, vol. 56, no. 3, pp. 204-210. DOI: 10.3109/17453678508992995

22. Choi H.R., Steinberg M.E., Cheng E. Osteonecrosis of the femoral head: diagnosis and classification systems. Curr. Rev. Musculoskelet. Med., 2015, vol. 8, no. 3, pp. 210-220. DOI: 10.1007/S12178-015-9278-7

23. Pierce T.P., Jauregui J.J., Cherian J.J., Elmallah R.K., Mont M.A. Imaging evaluation of patients with osteonecrosis of the femoral head. Curr. Rev. Musculoskelet. Med., 2015, vol. 8, no. 3, pp. 221-227. DOI: 10.1007/S12178-015-9279-6

24. Barskova V.G., Ilinykh E.V., Smirnov A.V., Vladimirov S.A., Mirovich O.V., Bozheva L.A., Nasonov E.L. Osteonekroz. Chast 2. Klinika i diagnostika avaskuliarnogo nekroza [Osteonecrosis. Part. 2. Clinical picture and diagnosis of avascular necrosis]. Sovremennaia Revmatologiia, 2013, vol. 7, no. 2, pp. 32-36. (in Russian)

25. Steinberg M.E., Hayken G.D., Steinberg D.R. A quantitative system for staging avascular necrosis. J. Bone Joint Surg. Br., 1995, vol. 77, no. 1, pp. 34-41. DOI: 10.1302/0301-620X.77B1.7822393

26. Mont M.A., Marulanda G.A., Jones L.C., Saleh K.J., Gordon N., Hungerford D.S., Steinberg M.E. Systematic analysis of classification systems for osteonecrosis of the femoral head. J. Bone Joint Surg. Am., 2006, vol. 88, no. Suppl. 3, pp. 16-26. DOI: 10.2106/JBJS.F.00457

27. Mont M.A., Zywiel M.G., Marker D.R., McGrath M.S., Delanois R.E. The natural history of untreated asymptomatic osteonecrosis of the femoral head: a systematic literature review. J. Bone Joint Surg. Am., 2010, vol. 92, no. 12, pp. 2165-2170. DOI: 10.2106/JBJS.I.00575

28. Banerjee S., Issa K., Pivec R., Kapadia B.H., Khanuja H.S., Mont M.A. Osteonecrosis of the hip: treatment options and outcomes. Orthop. Clin. North Am., 2013, vol. 44, no. 4, pp. 463-476. DOI: 10.1016/J.OCL.2013.07.004

29. Pritchett J.W. Statin therapy decreases the risk of osteonecrosis in patients receiving steroids. Clin. Orthop. Relat. Res., 2001, no. 386, pp. 173-178. DOI: 10.1097/00003086-200105000-00022

30. Yan S.G., Huang L.Y., Cai X.Z. Low-intensity pulsed ultrasound: a potential non-invasive therapy for femoral head osteonecrosis. Med. Hypotheses, 2011, vol. 76, no. 1, pp. 4-7. DOI: 10.1016/j.mehy.2010.08.016

31. Houdek M.T., Wyles C.C., Collins M.S., Howe B.M., Terzic A., Behfar A., Sierra R.J. Stem Cells Combined with Platelet-rich Plasma Effectively Treat Corticosteroid-induced Osteonecrosis of the Hip: A Prospective Study. Clin. Orthop. Relat. Res., 2018, vol. 476, no. 2, pp. 388-397. DOI: 10.1007/S11999.0000000000000033

32. Pierce T.P., Jauregui J.J., Elmallah R.K., Lavernia C.J., Mont M.A., Nace J. A current review of core decompression in the treatment of osteonecrosis of the femoral head. Curr. Rev. Musculoskelet. Med., 2015, vol. 8, no. 3, pp. 228-232. DOI: 10.1007/S12178-015-9280-0

33. Mont M.A., Cherian J.J., Sierra R.J., Jones L.C., Lieberman J.R. Nontraumatic osteonecrosis of the femoral head: where do we stand today? A tenyear update. J. Bone Joint Surg. Am., 2015, vol. 97, no. 19, pp. 1604-1627. DOI: 10.2106/JBJS.O.00071

34. Larson E., Jones L.C., Goodman S.B., Koo K.H., Cui Q. Early-stage osteonecrosis of the femoral head: where are we and where are we going in year 2018? Int. Orthop., 2018, vol. 42, no. 7, pp. 1723-1728. DOI: 10.1007/S00264-018-3917-8

35. Houdek M.T., Wyles C.C., Sierra R.J. Osteonecrosis of the femoral head: treatment with ancillary growth factors. Curr. Rev. Musculoskelet. Med., 2015, vol. 8, no. 3, pp. 233-239. DOI: 10.1007/s12178-015-9281-z

36. Pierce T.P., Elmallah R.K., Jauregui J.J., Poola S., Mont M.A., Delanois R.E. A current review of non-vascularized bone grafting in osteonecrosis of the femoral head. Curr. Rev. Musculoskelet. Med., 2015, vol. 8, no. 3, pp. 240-245. DOI: 10.1007/s12178-015-9282-y

37. Millikan P.D., Karas V., Wellman S.S. Treatment of osteonecrosis of the femoral head with vascularized bone grafting. Curr. Rev. Musculoskelet. Med., 2015, vol. 8, no. 3, pp. 252-259. DOI: 10.1007/s12178-015-9285-8

38. Aldridge J.M. 3rd, 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., 2004, vol. 86-A, no. Suppl. 1, pp. 87-101. DOI: 10.2106/00004623-200306000-00001

39. Li B., Hu R., Sun L., Luo R., Zhao J., Tian X. A CARE-compliant article: Biomechanics of treating early-stage femoral-head osteonecrosis by using a β-tricalcium phosphate bioceramic rod system: a 3-dimensional finite-element analysis. Medicine (Baltimore), 2018, vol. 97, no. 5, pp. e10808. DOI: 10.1097/MD.0000000000010808

40. Wang Y., Chai W., Wang Z.G., Zhou Y.G., Zhang G.Q., Chen J.Y. Superelastic cage implantation: a new technique for treating osteonecrosis of the femoral head with mid-term follow-ups. J. Arthroplasty, 2009, vol. 24, no. 7, pp. 1006-1014. DOI: 10.1016/j.arth.2008.07.010

41. Pierce T.P., Elmallah R.K., Jauregui J.J., Verna D.F., Mont M.A. Outcomes of total hip arthroplasty in patients with osteonecrosis of the femoral head – a current review. Curr. Rev. Musculoskelet. Med., 2015, vol. 8, no. 3, pp. 246-251. DOI: 10.1007/s12178-015-9283-x

42. Tripathy S.K., Goyal T., Sen R.K. Management of femoral head osteonecrosis: Current concepts. Indian J. Orthop., 2015, vol. 49, no. 1, pp. 28-45. DOI: 10.4103/0019-5413.143911

43. Lee Y.K., Ha Y.C., Cho Y.J., Suh K.T., Kim S.Y., Won Y.Y., Min B.W., Yoon T.R., Kim H.J., Koo K.H. Does zoledronate prevent femoral head collapse from osteonecrosis? A prospective, randomized, open-label, multicenter study. J. Bone Joint Surg. Am., 2015, vol. 97, no. 14, pp. 1142- 1148. DOI: 10.2106/JBJS.N.01157

44. Agarwala S., Shah S.B. Ten-year follow-up of avascular necrosis of the femoral head treated with alendronate for 3 years. J. Arthroplasty, 2011, vol. 26, no. 7, pp. 1128-1134. DOI: 10.1016/j.arth.2010.11.010

45. Li D., Yang Z., Wei Z., Kang P. Efficacy of bisphosphonates in the treatment of femoral head osteonecrosis: a PRISMA-compliant meta-analysis of animal studies and clinical trials. Sci. Rep., 2018, vol. 8, no. 1, pp. 1450. DOI: 10.1038/s41598-018-19884-z

46. Glueck C.J., Freiberg R.A., Wang P. Treatment of osteonecrosis of the hip and knee with enoxaparin. Koo K.-H., Mont M.A., Jones L.C., eds. Osteonecrosis. Berlin, Heidelberg, Springer-Verlag, 2014, pp. 241-247. DOI: 10.1007/978-3-642-35767-1_32

47. Cao F., Liu G., Wang W., Wang B., Wei X., Lu F., Yang F., Kang K., Wang Y., Yang J., Qin K., Zhao D. Combined treatment with an anticoagulant and a vasodilator prevents steroid-associated osteonecrosis of rabbit femoral heads by improving hypercoagulability. Biomed. Res. Int., 2017, vol. 2017, pp. 1624074. DOI: 10.1155/2017/1624074

48. Song Q., Ni J., Jiang H., Shi Z. Sildenafil improves blood perfusion in steroid-induced avascular necrosis of femoral head in rabbits via a protein kinase G-dependent mechanism. Acta Orthop. Traumatol. Turc., 2017, vol. 51, no. 5, pp. 398-403. DOI: 10.1016/j.aott.2017.07.002

49. Ajmal M., Matas A.J., Kuskowski M., Cheng E.Y. Does statin use reduce the risk of corticosteroid-related osteonecrosis in renal transplant population? Orthop. Clin. North Am., 2009, vol. 40, no. 2, pp. 235-239. DOI: 10.1016/j.ocl.2009.01.004

50. Al-Jabri T., Tan J.Y.Q., Tong G.Y., Shenoy R., Kayani B., Parratt T., Khan T. The role of electrical stimulation in the management of avascular necrosis of the femoral head in adults: a systematic review. BMC Musculoskelet. Disord., 2017, vol. 18, no. 1, pp. 319. DOI: 10.1186/s12891-017-1663-5

51. Li W., Ye Z., Wang W., Wang K., Li L., Zhao D. Clinical effect of hyperbaric oxygen therapy in the treatment of femoral head necrosis: a systematic review and meta-analysis. Orthopade, 2017, vol. 46, no. 5, pp. 440-446. DOI: 10.1007/s00132-016-3360-8

52. Xu S., Zhang L., Jin H., Shan L., Zhou L., Xiao L., Tong P. Autologous stem cells combined core decompression for treatment of avascular necrosis of the femoral head: a systematic meta-analysis. Biomed. Res. Int., 2017, vol. 2017, pp. 6136205. DOI: 10.1155/2017/6136205

53. Piuzzi N.S., Chahla J., Schrock J.B., LaPrade R.F., Pascual-Garrido C., Mont M.A., Muschler G.F. Evidence for the Use of Cell-Based Therapy for the Treatment of Osteonecrosis of the Femoral Head: A Systematic Review of the Literature. J. Arthroplasty, 2017, vol. 32, no. 5, pp. 1698-1708. DOI: 10.1016/j.arth.2016.12.049

54. Zou J., Yuan C., Wu C., Cao C., Yang H. The effects of platelet-rich plasma on the osteogenic induction of bone marrow mesenchymal stem cells. Connect. Tissue Res., 2014, vol. 55, no. 4, pp. 304-309. DOI: 10.3109/03008207.2014.930140

55. Son S.R., Sarkar S.K., Nguyen-Thuy B.L., Padalhin A.R., Kim B.R., Jung H.I., Lee B.T. Platelet-rich plasma encapsulation in hyaluronic acid/ gelatin-BCP hydrogel for growth factor delivery in BCP sponge scaffold for bone regeneration. J. Biomater. Appl., 2015, vol. 29, no. 7, pp. 988-1002. DOI: 10.1177/0885328214551373

56. Sallam A.A., Imam M.A., Salama K.S., Mohamed O.A. Inverted femoral head graft versus standard core decompression in nontraumatic hip osteonecrosis at minimum 3 years follow-up. Hip Int., 2017, vol. 27, no. 1, pp. 74-81. DOI:10.5301/hipint.5000426

57. Gao Y.S., Chen S.B., Jin D.X., Sheng J.G., Cheng X.G., Zhang C.Q. Modified surgical techniques of free vascularized fibular grafting for treatment of the osteonecrosis of femoral head: results from a series of 407 cases. Microsurgery, 2013, vol. 33, no. 8, pp. 646-651. DOI: 10.1002/micr.22149

58. Gianakos A.L., Moya-Angeler J., Duggal S., Zambrana L., Fields K.G., Mintz D.N., Cornell CN., Lane J.M. The efficacy of bisphosphonates with core decompression and mesenchymal stem cells compared with bisphosphonates alone in the treatment of osteonecrosis of the hip: a retrospective study. HSS J., 2016, vol. 12, no. 2, pp. 137-144. DOI: 10.1007/s11420-016-9487-7

59. Kim-Orden M., Kody B., Monti K. Algorithm for treatment of hip and knee osteonecrosis: review and presentation of three example cases. J. Rheum. Dis. Treat., 2017, vol. 3, pp. 053. DOI: 10.23937/2469-5726/1510053