Cleveland Clinic, Department of Orthopaedic Surgery, Cleveland, OH, USA.
Lenox Hill Hospital, New York City, NY, USA.
Int Orthop. 2019 May;43(5):1089-1095. doi: 10.1007/s00264-018-4018-4. Epub 2018 Jun 18.
Osteonecrosis of the femoral head (ONFH) typically impacts middle-aged patients who are typically more active and in whom many surgeons would try to delay performing a total hip arthroplasty (THA). This poses a clinical decision-making challenge. Therefore, several options for joint preservation have been advocated, but varying indications and success rates have led to debate on when to use the various procedures. This is due in part to the lack of a generalized system for assessing ONFH, as well as the absence of a standardized method of data collection for patient stratification. Due to the paucity of studies, in this review, we aimed to provide an up-to-date review of the most widely utilized classification systems and discuss the characteristics of each system.
A comprehensive literature review was conducted. Studies published between January 1st, 1975 and March 1st, 2018 were reviewed. The following key words were used in combination with Boolean operators AND or OR for the literature search: "osteonecrosis," "avascular necrosis," "hip," "femoral head," "classification," "reliability," and "validity." We defined the inclusion criteria for qualifying studies for this review as follows: (1) studies that reported on the classification systems for hip osteonecrosis, (2) studies that reported on the inter-observer reliability of the classification systems, and (3) studies that reported on the intra-observer reliability of any ONFH classification systems. In addition, we employed the following exclusion criteria: (1) studies that assessed classification systems for traumatic osteonecrosis, (2) Legg-Calvé-Perthes disease, or (3) Developmental Dysplasia of the Hip. Additionally, we excluded case reports and duplicate studies among searched databases.
The following classification systems were the most commonly utilized: The Ficat and Arlet, Steinberg, the Association Research Circulation Osseous (ARCO), and the Japanese Investigation Committee (JIC) classification systems. The details of each system have been discussed and their inter- and intra-observer reliability has been compared.
To this date, there is a lack of consensus on a universal and comprehensive system, and the use of any of the previous classification systems is a matter of dealer's choice. The Ficat and Arlet system was the earliest yet remains the most widely utilized system. Newer classification systems have been developed and some such as the JIC shows promising prognostic value while maintaining simplicity. However, larger validating studies are needed. While all of these systems have their strengths, the lack of a unified classification and staging system is still a problem in the diagnosis and prognosis ONFH. Further multi-center collaborative efforts among osteonecrosis experts are needed to adopt a universal classification system that may positively reflect on patient's outcomes.
股骨头坏死（ONFH）通常影响中年患者，这些患者通常更活跃，许多外科医生会试图延迟进行全髋关节置换术（THA）。这带来了临床决策的挑战。因此，已经提倡了几种关节保留选择，但不同的适应证和成功率导致了关于何时使用各种手术的争论。部分原因是缺乏用于评估 ONFH 的通用系统，以及缺乏用于患者分层的标准化数据收集方法。由于研究数量有限，在本综述中，我们旨在提供最广泛使用的分类系统的最新综述，并讨论每个系统的特点。
进行了全面的文献回顾。回顾了 1975 年 1 月 1 日至 2018 年 3 月 1 日期间发表的研究。使用布尔运算符 AND 或 OR 组合以下关键词进行文献检索：“osteonecrosis”、“avascular necrosis”、“hip”、“femoral head”、“classification”、“reliability”和“validity”。我们将符合以下标准的研究定义为符合本综述要求的研究：（1）报告髋关节骨坏死分类系统的研究；（2）报告分类系统观察者间可靠性的研究；（3）报告任何 ONFH 分类系统观察者内可靠性的研究。此外，我们还采用了以下排除标准：（1）评估创伤性骨坏死分类系统的研究；（2）Legg-Calvé-Perthes 病；（3）发育性髋关节发育不良。此外，我们排除了搜索数据库中的病例报告和重复研究。
最常用的分类系统如下：Ficat 和 Arlet、Steinberg、Association Research Circulation Osseous (ARCO) 和 Japanese Investigation Committee (JIC) 分类系统。已经讨论了每个系统的详细信息，并比较了它们的观察者间和观察者内可靠性。
迄今为止，还没有一个通用的全面系统达成共识，使用任何以前的分类系统都是经销商的选择。Ficat 和 Arlet 系统是最早的，也是最广泛使用的系统。已经开发了一些新的分类系统，例如 JIC，它在保持简单性的同时显示出有希望的预后价值。然而，需要更大的验证研究。虽然所有这些系统都有其优点，但缺乏统一的分类和分期系统仍然是诊断和预测 ONFH 的一个问题。需要进一步的骨坏死专家之间的多中心合作，以采用可能对患者预后产生积极影响的通用分类系统。
