title: S3-Guideline non-traumatic adult femoral head necrosis.
abstract: BACKGROUND
  The treatment of adult non-traumatic avascular necrosis of the femoral head (AVN; N-ANFH) within an estimated incidence of 5000-7000 cases per annum in Germany remains a challenge. Risk factors include steroids, alcohol abuse, chemotherapy and immunosuppressive medication, but a genetic predisposition has been suggested. Early diagnosis of this often bilateral disease process is essential for successful conservative or joint preserving surgical management. In this review, we present the update German consensus S3 guideline "diagnosis and management for N-ANFH" as a concise summary.
  
  
  METHODS
  This systematic review is based on the published literature from January 1, 1970 to April 31, 2013 (German and English language). Inclusion criteria were systematic reviews, meta-analyses and relevant peer review publications. We identified a total of 3715 related publications, of which 422 were suitable according to the SIGN criteria, but only 159 fulfilled our inclusion criteria.
  
  
  CONCLUSIONS
  Clinical suspicion of N-ANFH mandates radiographic evaluation. If radiographs are normal MRI scans are recommended, which should be evaluated according to the ARCO-classification. Differential diagnoses include transient osteoporosis, bone bruise, insufficiency fracture and destructive arthropathy. Untreated, subchondral fractures commonly occur within 2 years, during which the risk for contralateral involvement is high-thereafter unlikely. Conservative management with Ilomedin and Alendronat can be tried, but other pharmacological or physical treatments are inappropriate. No specific joint preserving procedure can be recommended, but core decompression should be considered in early stages if necrosis is <30 %. In ARCO stages IIIc or IV total hip arthroplasty (THA) should be contemplated, which offers similar outcome compared to osteoarthritis. Young age is the main risk factor for higher revision rates after THA for N-ANFH.
authors.affiliation: Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie; Bereich Endoprothetik/Orthopädie, Universitätsklinik Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Germany. andreas.roth@medizin.uni-leipzig.de.
authors.forename: A
authors.identifier: http://orcid.org/0000-0002-1145-955X
authors.initials: A
authors.lastname: Roth
authors.affiliation: Sektion Endoprothetik, Sportklinik Stuttgart, Stuttgart, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Beckmann
authors.affiliation: Universitätsklinik für Radiologie und Nuklearmedizin, Exzellenzzentrum für Hochfeld MR, Medizinische Universität Wien, Vienna, Austria.|Christian Doppler Laboratory for Molecular Imaging, Medizinische Universität Wien, Vienna, Austria.
authors.forename: K
authors.initials: K
authors.lastname: Bohndorf
authors.affiliation: Abteilung für Physikalische und Rehabilitative Medizin, Klinikum Burgenlandkreis GmbH, Naumburg, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Fischer
authors.affiliation: Klinik für Unfallchirurgie, Universitätsklinikum Gießen-Marburg, Marburg, Germany.
authors.forename: C
authors.initials: C
authors.lastname: Heiß
authors.affiliation: Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Würzburg, Würzburg, Germany.
authors.forename: W
authors.initials: W
authors.lastname: Kenn
authors.affiliation: Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Essen-Duisburg, Essen, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Jäger
authors.affiliation: Klinik für Orthopädie und orthopädische Chirurgie, Universitätsklinik für Orthopädie und Unfallchirurgie, Pius-Hospital, Oldenburg, Germany.
authors.forename: U
authors.initials: U
authors.lastname: Maus
authors.affiliation: Klinik für Orthopädie und Unfallchirurgie, Evangelisches Waldkrankenhaus Spandau, Berlin, Germany.
authors.forename: U
authors.initials: U
authors.lastname: Nöth
authors.affiliation: Orthopädie und Osteologie, Dr. Becker Rhein-Sieg-Klinik, Nümbrecht, Germany.
authors.forename: K M
authors.initials: KM
authors.lastname: Peters
authors.affiliation: Praxisklinik Orthopädie Aachen, Franziskushospital Aachen, Aachen, Germany.
authors.forename: C
authors.initials: C
authors.lastname: Rader
authors.affiliation: Orthopädische Klinik König-Ludwig-Haus, Julius-Maximilians-Universität Würzburg, Würzburg, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Reppenhagen
authors.affiliation: Institut für Physiotherapie, Friedrich-Schiller Universität Jena, Jena, Germany.
authors.forename: U
authors.initials: U
authors.lastname: Smolenski
authors.affiliation: Klinik für Orthopädie, Universitätsklinikum Aachen, Aachen, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Tingart
authors.affiliation: AWMF-Institut, Philipps-Universität Marburg, Marburg, Germany.
authors.forename: I
authors.initials: I
authors.lastname: Kopp
authors.affiliation: Pirogov-Universität Moskau, 64. Städtisches Krankenhaus, Moscow, Russia.
authors.forename: I
authors.initials: I
authors.lastname: Sirotin
authors.affiliation: FRCS Ed, Orthopaedic Department, Edinburgh Royal Infirmary, Edinburgh, UK.
authors.forename: S J
authors.initials: SJ
authors.lastname: Breusch
mesh_terms: D000328:Adult; D019386:Alendronate / Q000627:therapeutic use; D019644:Arthroplasty, Replacement, Hip; D050071:Bone Density Conservation Agents / Q000627:therapeutic use; D019299:Decompression, Surgical; D003937:Diagnosis, Differential; D005271:Femur Head Necrosis / Q000175:diagnosis* / Q000628:therapy*; D006622:Hip Prosthesis; D006801:Humans; D016285:Iloprost / Q000627:therapeutic use; D014665:Vasodilator Agents / Q000627:therapeutic use
chemical_list: D050071:Bone Density Conservation Agents; D014665:Vasodilator Agents; D016285:Iloprost; D019386:Alendronate
keywords: AVN; Atraumatic avascular necrosis; Bisphosphonate; Bone grafting; Bone transplant; Core decompression; Diagnosis; Ilomedin; Total hip arthroplasty; Total hip replacement