Etiologic Classification Criteria of ARCO on Femoral Head Osteonecrosis Part 1: Glucocorticoid-Associated Osteonecrosis

J Arthroplasty. 2019 Jan;34(1):163-168.e1. doi: 10.1016/j.arth.2018.09.005. Epub 2018 Sep 22.


Background: Glucocorticoid usage, a leading cause of osteonecrosis of the femoral head (ONFH), and its prevalence was reported in 25%-50% of non-traumatic ONFH patients. Nevertheless, there have been no unified criteria to classify glucocorticoid-associated ONFH (GA-ONFH). In 2015, the Association Research Circulation Osseous addressed the issue of developing a classification scheme.

Methods: In June 2017, a task force was set up to conduct a Delphi survey concerning ONFH. The task force invited 28 experts in osteonecrosis/bone circulation from 8 countries. Each round of the Delphi survey consists of questionnaires, analysis of replies, and feedback reports to the panel. After 3 rounds of the survey, the panel reached a consensus on the classification criteria. The response rates were 100% (Round 1), 96% (Round 2), and 100% (Round 3), respectively.

Results: The consensus on the classification criteria of GA-ONFH included the following: (1) patients should have a history of glucocorticoid use >2 g of prednisolone or its equivalent within a 3-month period; (2) osteonecrosis should be diagnosed within 2 years after glucocorticoid usage, and (3) patients should not have other risk factor(s) besides glucocorticoids.

Conclusion: Association Research Circulation Osseous established classification criteria to standardize clinical studies concerning GA-ONFH.

Keywords: Delphi; avascular necrosis; corticosteroid; femoral head; glucocorticoid; osteonecrosis.

MeSH terms

  • Advisory Committees
  • Consensus
  • Delphi Technique
  • Femur Head Necrosis / chemically induced*
  • Femur Head Necrosis / classification*
  • Femur Head Necrosis / etiology
  • Glucocorticoids / adverse effects*
  • Humans
  • Internationality
  • Prednisolone / adverse effects
  • Risk Factors


  • Glucocorticoids
  • Prednisolone