title: [S3 guideline. Part 2: Non-Traumatic Avascular Femoral Head Necrosis in Adults - Untreated Course and Conservative Treatment].
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.
  
  
  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".
  
  
  CONCLUSIONS
  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.
authors.affiliation: Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Bereich Endoprothetik/Orthopädie, Universitätsklinik Leipzig AöR.
authors.forename: A
authors.initials: A
authors.lastname: Roth
authors.affiliation: Sektion Endoprothetik, Sportklinik Stuttgart.
authors.forename: J
authors.initials: J
authors.lastname: Beckmann
authors.affiliation: Institut für Physiotherapie, Friedrich-Schiller Universität Jena.
authors.forename: U
authors.initials: U
authors.lastname: Smolenski
authors.affiliation: Abteilung für Physikalische und Rehabilitative Medizin, Klinikum Burgenlandkreis GmbH, Naumburg.
authors.forename: A
authors.initials: A
authors.lastname: Fischer
authors.affiliation: Klinik für Orthopädie und Unfallchirurgie, Universität Duisburg-Essen.
authors.forename: M
authors.initials: M
authors.lastname: Jäger
authors.affiliation: Orthopaedic Surgery, University of Aachen.
authors.forename: M
authors.initials: M
authors.lastname: Tingart
authors.affiliation: Praxisklinik Orthopädie Aachen, Franziskushospital Aachen.
authors.forename: C
authors.initials: C
authors.lastname: Rader
authors.affiliation: Orthopädie und Osteologie, Dr. Becker Rhein-Sieg-Klinik, Nümbrecht.
authors.forename: K M
authors.initials: KM
authors.lastname: Peters
authors.affiliation: Orthopädische Klinik König-Ludwig-Haus, Julius-Maximilians-Universität Würzburg.
authors.forename: S
authors.initials: S
authors.lastname: Reppenhagen
authors.affiliation: Klinik für Orthopädie und Unfallchirurgie, Evangelisches Waldkrankenhaus Spandau.
authors.forename: U
authors.initials: U
authors.lastname: Nöth
authors.affiliation: Klinik für Unfallchirurgie, Universitätsklinikum Gießen.
authors.forename: C
authors.initials: C
authors.lastname: Heiss
authors.affiliation: Klinik für Orthopädie und orthopädische Chirurgie, Universitätsklinik für Orthopädie und Unfallchirurgie, Pius-Hospital, Oldenburg.
authors.forename: U
authors.initials: U
authors.lastname: Maus
mesh_terms: D019386:Alendronate / Q000008:administration & dosage*; D050071:Bone Density Conservation Agents / Q000008:administration & dosage; D019317:Evidence-Based Medicine; D005260:Female; D005264:Femoral Fractures / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D005271:Femur Head Necrosis / Q000175:diagnosis* / Q000628:therapy*; D005858:Germany; D006801:Humans; D016285:Iloprost / Q000008:administration & dosage*; D008297:Male; D009985:Orthopedics / Q000592:standards*; D017410:Practice Guidelines as Topic; D016896:Treatment Outcome
chemical_list: D050071:Bone Density Conservation Agents; D016285:Iloprost; D019386:Alendronate