The Journal of arthroplasty · 2026
Integrating the Association Research Circulation Osseous Clinical Practice Guideline into the Diagnosis and Management of Osteonecrosis of the Femoral Head: Four Illustrative Case Scenarios.
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Thomas George, Mirzaei Alireza, Mont Michael A, Cheng Edward Y
Аннотация
BACKGROUND: Treatment choices for osteonecrosis of the femoral head (ONFH) are based on the patient's age, risk of collapse, lesion size, symptoms, and disease stage. To our knowledge, this represents the first international, evidence-based clinical practice guideline (CPG) developed specifically for the diagnosis and treatment of nontraumatic ONFH, which was recently released by the Association Research Circulation Osseous (ARCO). The CPG offers recommendations that are supported by evidence, but their practical implementation in day-to-day clinical practice may be less intuitive. These case scenarios illustrate the application of the CPG only and do not discuss treatment outcomes, which are discussed in the CPG itself.
METHODS: To illustrate how ARCO CPG recommendations can be applied to a range of ONFH presentations, four relevant clinical cases were chosen. The selection of imaging, evaluation of symptoms, estimation of collapse risk, grounds for observation, use of joint-preserving techniques, and consideration of total hip arthroplasty (THA) are all important diagnostic and therapy choices that are highlighted in each case.
RESULTS: For small, asymptomatic lesions with little chance of collapse, Case 1 illustrates the value of magnetic resonance imaging in the diagnosis and the suitability of observation. Case 2 shows how core decompression and bone marrow concentrate augmentation can be used to treat symptomatic pre-collapse disease. Case 3 illustrates the decision-making process for a young patient who has bilateral ONFH and needs joint-preserving therapy for the contralateral pre-collapse lesion and THA for one hip with collapse. Case 4 illustrates how patient age, lesion size, and symptom status affect the decision to choose observation over intervention for asymptomatic illness.
CONCLUSION: The ARCO CPG provides a practical framework for diagnosis, risk stratification, and treatment selection in patients who have ONFH. Application of the guideline recommendations can facilitate evidence-based and patient-centered decision-making across a broad spectrum of clinical scenarios.
METHODS: To illustrate how ARCO CPG recommendations can be applied to a range of ONFH presentations, four relevant clinical cases were chosen. The selection of imaging, evaluation of symptoms, estimation of collapse risk, grounds for observation, use of joint-preserving techniques, and consideration of total hip arthroplasty (THA) are all important diagnostic and therapy choices that are highlighted in each case.
RESULTS: For small, asymptomatic lesions with little chance of collapse, Case 1 illustrates the value of magnetic resonance imaging in the diagnosis and the suitability of observation. Case 2 shows how core decompression and bone marrow concentrate augmentation can be used to treat symptomatic pre-collapse disease. Case 3 illustrates the decision-making process for a young patient who has bilateral ONFH and needs joint-preserving therapy for the contralateral pre-collapse lesion and THA for one hip with collapse. Case 4 illustrates how patient age, lesion size, and symptom status affect the decision to choose observation over intervention for asymptomatic illness.
CONCLUSION: The ARCO CPG provides a practical framework for diagnosis, risk stratification, and treatment selection in patients who have ONFH. Application of the guideline recommendations can facilitate evidence-based and patient-centered decision-making across a broad spectrum of clinical scenarios.