Background: Osteonecrosis is a debilitating condition characterized by bone tissue death and disrupted vascular circulation, most commonly affecting the femoral head. This study aimed to assess the epidemiology and surgical trends of hip osteonecrosis in the United States using a comprehensive national database, as well as to review the current literature on historical and contemporary surgical trends for patients who have osteonecrosis of the femoral head (ONFH).
Methods: Data from a research network (2015 to 2024) were used to identify patients diagnosed with ONFH using International Classification of Diseases, 10th revision, Clinical Modification codes. Patients who had osteonecrosis at other sites were excluded. Baseline demographics, comorbidities, and geographic distribution were characterized. Treatment trends were evaluated within 1 and 5 years of diagnosis. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review across three databases, resulting in a total of five articles. Articles met the inclusion criteria if they provided data regarding surgical trends of patients who have ONFH over at least a 10-year period.
Results: From the recent database, of 61,903 patients who have hip osteonecrosis, the majority were of idiopathic etiology (78.1%, n = 48,365). Men comprised 52.1% (n = 25,197) of the idiopathic cases, and the age at diagnosis ranged between 40 and 72 years. The Southern United States had the highest prevalence of hip osteonecrosis (42%), followed by the Northeast (30%). Corticosteroid use was the most common risk factor (75%, n = 36,274), followed by dyslipidemias (49%, n = 23,699) and nicotine use (27%, n = 13,058). Total hip arthroplasty (THA) was the predominant treatment modality within 1 year (22.6%, n = 10,931) and 5 years (25.2%, n = 12,187). In our systematic review, we found that THA was the most common procedure performed for patients who have ONFH, and joint-preserving procedures generally declined over the studies' time periods. However, joint-preserving procedures were more commonly performed in younger patients and appeared to increase in incidence over the studies' time periods. Studies using a database from Asian countries used more joint-preserving procedures than studies using a database based in the United States.
Conclusions: Hip osteonecrosis accounts for 40% of the osteonecrosis burden in the United States, and corticosteroid use was identified as the most common risk factor. Surgical interventions, particularly THA, are the primary modality of treatment, with limited use of other surgical and nonsurgical management. Our systematic review confirmed that the incidence of THA has increased over the years compared to joint-preserving procedures, although the latter has become more common in younger patients. There also appears to be considerable geographic variation in surgical trends, as patients in South Korea and Japan are more likely to undergo joint-preserving procedures. These findings underscore the need for consensus-driven treatment guidelines.
Level of evidence: III.
Keywords: avascular necrosis; epidemiology; hip joint; management; osteonecrosis; total hip arthroplasty.
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