The present article describes the guidelines for the surgical treatment of atraumatic avascular
necrosis (aFKN). These include joint preserving and
joint replacement procedures. As part of the targeted literature, 43 publications were included and evaluated to assess the surgical treatment. According to the GRADE and SIGN criteria level of evidence (LoE), grade of recommendation (EC) and expert consensus (EK) were listed for each statement and question. The analysed studies have shown that up to
ARCO stage III, joint-preserving surgery can be performed. A particular joint-preserving surgery currently cannot be recommended as preferred method. The selection of the method depends on the extent of
necrosis. Core
decompression performed in stage
ARCO I (reversible early stage) or stage
ARCO II (irreversible early stage) with medial or central
necrosis with an area of less than 30 % of the femoral head shows better results than
conservative therapy. In
ARCO stage III with infraction of the femoral head, the core
decompression can be used for a short-term
pain relief. For
ARCO stage IIIC or stage IV core
decompression should not be performed. In these cases, the indication for implantation of a
total hip replacement should be checked. Additional therapeutic procedures (e.g.,
osteotomies) and innovative treatment options (advanced core
decompression, autologous bone marrow,
bone grafting, etc.) can be discussed in the individual case. In elective hip replacement complications and revision rates have been clearly declining for decades. In the case of an underlying aFKN, however, previous joint-preserving surgery (
osteotomies and grafts in particular) can complicate the implantation of a THA significantly. However, the implant life seems to be dependent on the aetiology. Higher revision rates for avascular
necrosis are particularly expected in
sickle cell disease,
Gaucher disease, or
kidney transplantation patients. Furthermore, the relatively young age of the patient with avascular
necrosis should be seen as the main risk factor for higher revision rate. The results after resurfacing (today with known restricted indications) and cemented as well as cementless THA in aFKN are comparable for the appropriate indication to those in
coxarthrosis or other diagnoses. Regardless of the underlying disease endoprosthetic treatment in aFKN leads to good results. Both cemented and cementless fixation techniques can be recommended.