S3-Leitline. Teil 1: Diagnostik und Differenzialdiagnostik der atraumatischen Femurkopfnekrose (aFKN) des Erwachsenen

Zusammenfassung

Die atraumatische Femurkopfnekrose (aFKN) ist primär eine Erkrankung des Erwachsenen im mittleren Lebensalter. Die frühzeitige Diagnose zu einem Zeitpunkt mit fehlender oder nur minimaler klinischer Symptomatik ist entscheidend, um konservativen und gelenkerhaltenden Maßnahmen eine therapeutische Chance zu geben. Die neue S3-Leitlinie zur Diagnostik und Therapie der aFKN ist eine Gemeinschaftsleistung von 5 Fachgesellschaften unter Federführung der Deutschen Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC). In dieser Übersichtsarbeit (Teil 1/3) werden die konsentierten Aussagen der S3-Leitlinie hinsichtlich des Einsatzes der bildgebenden Diagnostik bei der aFKN zitiert und begründet. Ein diagnostischer Algorithmus wird definiert. Bei klinischem Verdacht auf Hüftkopfnekrose (unklare Schmerzen im Bereich der Hüfte länger als 6 Wochen, eventuell bestehende Risikofaktoren, klinischer Befund mit Leistenschmerz, ggf. Hinken und Bewegungsschmerz bzw. Bewegungseinschränkungen, kein Hinweis auf Differenzialdiagnosen) soll zunächst eine Röntgenuntersuchung (Beckenübersicht und betroffene Hüfte in Lauenstein-Projektion) durchgeführt werden. Bei unauffälligem Röntgenbild und anhaltenden Beschwerden ist die MRT des Hüftgelenks Methode der Wahl. Neben der Diagnosestellung erlaubt die MRT die Beurteilung von Lokalisation und Größe der Nekrosezone sowie die Klärung der Frage nach Gelenkflächeneinbruch und subchondraler Fraktur. Ist bei Patienten im ARCO-Stadium II (ARCO: Association Research Circulation Osseous) die Frage nach einem Gelenkflächeneinbruch mittels MRT nicht zweifelsfrei beantwortbar, sollte eine CT erfolgen. Die Begründung der S3-Leitlinie für die Empfehlung zur Anwendung der ARCO-Klassifikation wird vorgestellt. Eine pragmatische, „erweiterte“ Anwendung der 1993 veröffentlichten, noch weitgehend auf die Röntgenaufnahme fixierten Klassifikation erscheint sinnvoll. Klassische „Röntgenkriterien“ wie Einbruch der Gelenkfläche und subchondrale Fraktur („crescent sign“) werden heute wesentlich sensitiver mittels MRT, in weniger ausgeprägten Fällen noch besser mit CT erfasst. Angaben über den betroffenen Femurkopfanteil und das Ausmaß der Beteiligung der Femurzirkumferenz sind die Domäne der MRT. Auch wird das Stadium „0“ der Originalklassifikation nicht mehr verwendet, da es allein auf der Röntgenaufnahme beruht. Auch für die Praxis wichtige Überlegungen zur Differenzialdiagnostik MR-tomografischer Befunde finden in der S3-Leitlinie ihren Niederschlag. Der Nachweis von sog. Knochenmarködemen („bone bruises“) in der MRT des Hüftkopfs ist regelmäßig Anlass zu Fehlinterpretationen. Die Abgrenzung der aFKN zum transitorischen Knochenmarködem (transitorische Osteoporose), zur Insuffizienzfraktur und zur destruierenden Arthropathie wird erläutert.

Abstract

Non-traumatic femoral head necrosis (FHN) is primarily a disease of the middle-aged adult. Early diagnosis, at a time with lacking or minimal clinical symptoms, is mandatory to consider conservative therapy or joint preserving operations as a therapeutic option. The new German S3 guideline about diagnosis and therapy of FHN is a cooperative effort of five professional medical societies, overall headed by the Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC). This review (part I/III) cites and explains the statements of the S3 guideline as agreed on the use of imaging methods for diagnosis of FHN. A diagnostic algorithm is presented. FHN clinically has to be considered in case of equivocal pain of a hip joint with a minimum of 6 weeks duration, when risk factors can be revealed, groin pain at clinical investigation, limping, pain or limitation of movement in case of load, and no obvious differential diagnoses. Is an FHN clinically suspected, primarily radiographs of the pelvis ap and a Lauenstein projection of the hip involved should be carried out. When the radiographs are normal, an MRI of the hips should follow routinely. MRI allows the diagnosis of FNH with high accuracy. Furthermore, MRI reveals the site and the size of the necrotic area involved and evaluates the integrity of the joint surface and subchondral fractures. When ARCO stage II (ARCO: Association Research Circulation Osseous) is diagnosed and MRI does not allow one to determine the joint surface with certainty, a CT of the hip joints should be performed. The S3 guideline explains and recommends the use of the ARCO classification. Although, this classification of 1993 is still largely based on radiographs, the pragmatic use of an “extended” version seems reasonable. Today, classical radiographic criteria like impression of the joint surface and subchondral fractures (“crescent sign”) are better to be evaluated by MRI, in cases of subtle findings MRI is even surpassed by CT. The extent of the necrosis in the femoral head as well as the size of the surface area involved is best revealed with MRI. Additionally, in the era of cross sectional imaging a stage “0” seems obsolete. The guideline also addresses practically important considerations about the differential diagnosis of misleading MRI findings. This especially holds true for bone marrow oedema in the femoral head which may be misinterpreted. The differentiating features between FHN, transient bone marrow oedema and destructive arthropathy are discussed.

Schlüsselwörter

Femurkopfnekrose - Osteonekrose - ARCO-Klassifikation - MRT - Knochenmarködem

Key words

femoral head necrosis - osteonecrosis - ARCO classification - MRI - bone marrow oedema

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