Osteonecrosi asettica o vascolare

Definizione
Necrosi cellulare ossea causata da compromissione dell’apporto ematico che comporta perdita dell’integrità strutturale dell’osso.

Fattori di rischio
Traumi: frattura testa del femore, astragalo, scafoide radiale e carpale, navicolare, semilunare, lussazione dell’anca;

Sistemici: Terapie steroidee prolungate, dialisi e trapianto renale, abuso di alcool, malattie ematologiche e reumatologiche, radio e chemioterapia, osteoporosi, gravidanza.

Trattamento di prima linea dopo la diagnosi
Scarico ponderale.

Criteri diagnostici di ammissione
Osteonecrosi testa del femore Steimberg 1 – 3

Osteonecrosi altre sedi nei casi in cui è conservato il profilo corticale

Fratture e traumi a rischio

STAGE CRITERIA
  STEINBERG CLASSIFICATION
0 Normal or non-diagnostic X-Ray, MRI or Bone Scan
I Normal X-Ray – abnormal MRI or Bone Scan
  A – Mild         (< 15% of head)
  B – Moderate (15% – 30%)
  C – Severe       (> 30%)
II Sclerotic changes or cystic lesions
  A – Mild         (< 15%)
  B – Moderate (15% – 30%)
  C – Severe       (> 30%)
III Subchondral collapse without flattening
  A – Mild         (< 15% of articular surface)
  B – Moderate (15% – 30%)
  C – Severe       (> 30%)
IV Flattening of the femoral head
  A – Mild         (< 15% of surface and < 2 mm depression)
  B – Moderate (15% – 30% of surface or 2-4 mm depression)
  C – Severe       (> 30% of surface and > 4 mm depression)
V Joint narrowing and/or acetabular involvement
  A – Mild
  B – Moderate
  C – Severe
VI Advanced degenerative changes

Valutazione clinica, strumentale e anamnestica all’ingresso 

  • Valutazione del dolore mediante VAS
  • Radiografia
  • RMN – Scintigrafia Ossea (in casi dubbi)

Possibili terapie associate 

  • Alendronati, Bisfosfonati, Calcio,Vit. D3;
  • Terapia del dolore 

Trattamenti alternativi

  • Artroprotesi

Criteri di esclusione

  • Osteonecrosi Testa Femore stadio STEINBERG > 3
  • Osteonecrosi in sedi diverse dalla testa del femore con alterazione del profilo corticale osseo

Beneficio atteso

  • Riduzione del dolore
  • Miglioramento del quadro RM
  • Riduzione della % di protesizzazione.

Monitoraggio della terapia

  • Follow up clinico: VAS a riposo pre e post OTI
  • Follow up radiologico: RM pre e post OTI 

Schema di trattamento

DIAGNOSI N. max trattamenti 90 Osservazioni
Osteonecrosi asettica 1° ciclo 50 sedute2° ciclo 40 sedute ·       Valutazione clinica a tempo 0, 30, 50, 70, 90·       Valutazione radiologica a tempo 0, 50, 90
Fratture e traumi a rischio 30 sedute in fase sub acuta ·       Valutazione clinica e radiologica a tempo 0, 30.

Bibliografia utilizzabile ai fini dell’individuazione delle prove di efficacia 

  • No revisioni Cochrane o altre revisioni sistematiche
  • No Clinical evidence o UpToDate

HTA

Institut fuer Qualitat und Wirtschaftlichkeit im Gesundheitswesen. Hyperbaric oxygen therapy for idiopathic osteonecrosis of the femoral head in adults. Cologne: Institut fuer Qualitaet und Wirtschaftlichkeit im Gesundheitswesen (IQWiG). 2007 Worldwide, data on only about 100 to 200 patients have been published concerning the therapeutic effects of hyperbaric oxygen therapy for idiopathic osteonecrosis of the femoral head in adults. Due to the complete lack of relevant studies, a widespread use of this therapy outside the setting of clinical trials does not seem justified. There is no evidence of a benefit of this treatment.
  • The Journal of Arthroplasty Vol. 25 No. 6 Suppl. 1 2010 -

Hyperbaric Oxygen Therapy in Femoral Head Necrosis

Enrico M. Camporesi, MD,* Giuliano Vezzani, MD,y Gerardo Bosco, MD, PhD,z Devanand Mangar, MD,§ and Thomas L. Bernasek, MD∥

Abstract: We evaluated hyperbaric oxygen (HBO) therapy on a cohort of patients with femoral head necrosis (FHN). This double-blind, randomized, controlled, prospective study included 20 patients with unilateral FHN. All were Ficat stage II, treated with either compressed oxygen (HBO) or compressed air (HBA). Each patient received 30 treatments of HBO or HBA for 6 weeks.

Range of motion, stabilometry, and pain were assessed at the beginning of the study and after 10, 20, and 30 treatments by a blinded physician. After the initial 6-week treatment, the blind was broken; and all HBA patients were offered HBO treatment. At this point, the study becomes observational. Pretreatment, 12-month. and 7 year-follow-up magnetic resonance images were obtained. Statistical comparisons were obtained with nonparametric Mann-Whitney U test. Significant pain improvement for HBO was demonstrated after 20 treatments. Range of motion improved significantly during HBO for all parameters between 20 and 30 treatments. All patients remain substantially pain-free 7 years later: none required hip arthroplasty. Substantial radiographic healing of the osteonecrosis was observed in 7 of 9 hips. Hyperbaric oxygen therapy appears to be a viable treatment modality in patients with Ficat II FHN. Keywords: hyperbaric oxygen therapy, femoral head necrosis, hip arthroplasty.

© 2010 Published by Elsevier Inc.

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