The 2021 Association Research Circulation Osseous Classification for Early-Stage Osteonecrosis of the Femoral Head to Computed Tomography-Based Study

Kyung-Hoi Koo; Michael A Mont; Quanjun Cui; Jeremy T Hines; Byung-Ho Yoon; Wendy M Novicoff; Yun Jong Lee; Edward Y Cheng; Wolf Drescher; Philippe Hernigou; Shin-Yoon Kim; Nobuhiko Sugano; De-Wei Zhao; Yong-Chan Ha; Stuart B Goodman; Takashi Sakai; Lynne C Jones; Mel S Lee; Takuaki Yamamoto; Young-Kyun Lee; Yusuhn Kang; James Burgess; Dennis Chen; Nicole Quinlan; Jian Zhong Xu; Jung-Wee Park; Hong-Seok Kim

doi:10.1016/j.arth.2022.02.009

The 2021 Association Research Circulation Osseous Classification for Early-Stage Osteonecrosis of the Femoral Head to Computed Tomography-Based Study

J Arthroplasty. 2022 Jun;37(6):1074-1082. doi: 10.1016/j.arth.2022.02.009. Epub 2022 Feb 11.

Authors

Kyung-Hoi Koo¹, Michael A Mont², Quanjun Cui³, Jeremy T Hines³, Byung-Ho Yoon⁴, Wendy M Novicoff³, Yun Jong Lee⁵, Edward Y Cheng⁶, Wolf Drescher⁷, Philippe Hernigou⁸, Shin-Yoon Kim⁹, Nobuhiko Sugano¹⁰, De-Wei Zhao¹¹, Yong-Chan Ha¹², Stuart B Goodman¹³, Takashi Sakai¹⁴, Lynne C Jones¹⁵, Mel S Lee¹⁶, Takuaki Yamamoto¹⁷, Young-Kyun Lee¹, Yusuhn Kang¹⁸, James Burgess³, Dennis Chen³, Nicole Quinlan³, Jian Zhong Xu¹⁹, Jung-Wee Park¹, Hong-Seok Kim¹

Affiliations

¹ Department of Orthopaedic surgery, Seoul National University Bundang Hospital and Seoul National University College of Medicine, Seongnam, South Korea.
² Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY.
³ Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA.
⁴ Department of Orthopaedic Surgery, Ewha Womans University College of Medicine, Seoul, South Korea.
⁵ Department of Internal Medicine, Seoul National University Bundang Hospital and Seoul National University College of Medicine, Seongnam, South Korea.
⁶ Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN.
⁷ Department of Orthopaedic and Trauma Surgery, RWTH Aachen University, Aachen, Germany.
⁸ Hôpital Henri Mondor, Creteil, University of Paris, France.
⁹ Department of Orthopaedic Surgery, Graduate School of Medicine, Kyungpook National University, Daegu, South Korea.
¹⁰ Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita, Japan.
¹¹ Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, China.
¹² Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, South Korea.
¹³ Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA.
¹⁴ Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan.
¹⁵ Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
¹⁶ Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
¹⁷ Department of Orthopaedic Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.
¹⁸ Department of Diagnostic Radiology, Seoul National University Bundang Hospital and Seoul National University College of Medicine, Seongnam, South Korea.
¹⁹ Department of Orthopaedic Surgery, the First Affiliated Hospital, Zhengzhou University, Zhengzhou, China.

PMID: 35151809
DOI: 10.1016/j.arth.2022.02.009

Abstract

Background: The Association Research Circulation Osseous developed a novel classification for early-stage (precollapse) osteonecrosis of the femoral head (ONFH). We hypothesized that the novel classification is more reliable and valid when compared to previous 3 classifications: Steinberg, modified Kerboul, and Japanese Investigation Committee classifications.

Methods: In the novel classification, necrotic lesions were classified into 3 types: type 1 is a small lesion, where the lateral necrotic margin is medial to the femoral head apex; type 2 is a medium-sized lesion, with the lateral necrotic margin being between the femoral head apex and the lateral acetabular edge; and type 3 is a large lesion, which extends outside the lateral acetabular edge. In a derivation cohort of 40 early-stage osteonecrotic hips based on computed tomography imaging, reliabilities were evaluated using kappa coefficients, and validities to predict future femoral head collapse by chi-squared tests and receiver operating characteristic curve analyses. The predictability for future collapse was also evaluated in a validation cohort of 104 early-stage ONFH.

Results: In the derivation cohort, interobserver reliability (k = 0.545) and intraobserver agreement (63%-100%) of the novel method were higher than the other 3 classifications. The novel classification system was best able to predict future collapse (P < .05) and had the best discrimination between non-progressors and progressors in both the derivation cohort (area under the curve = 0.692 [0.522-0.863], P < .05) and the validation cohort (area under the curve = 0.742 [0.644-0.841], P = 2.46 × 10^-5).

Conclusion: This novel classification is a highly reliable and valid method of those examined. Association Research Circulation Osseous recommends using this method as a unified classification for early-stage ONFH.

Level of evidence: Level III, diagnostic study.

Keywords: avascular necrosis; classification; femoral head; location; osteonecrosis; size.

MeSH terms

Acetabulum / pathology
Femur Head Necrosis* / diagnostic imaging
Femur Head* / diagnostic imaging
Femur Head* / pathology
Humans
Reproducibility of Results
Tomography, X-Ray Computed