The treatment of femoral head necrosis is still a major clinical problem in orthopedics. It has a high incidence and disability rate, and early diagnosis is difficult in primary care hospitals, and by the time patients have obvious symptoms, they have already developed to the middle or late stage. Currently, there are three main types of treatment for adult ischemic necrosis of the femoral head, namely non-surgical treatment, femoral head preservation surgery and artificial hip replacement surgery.
Femoral head preservation surgery is a remedial measure to slow down or stop the progression of the femoral head lesion and prevent collapse. In addition, some stage III patients with less collapse also have indications for femoral head preservation surgery.
The basic procedures of femoral head preservation surgery are.
1, femoral head decompression + dead bone removal + necrotic area implant.
2.rotational osteotomy.
I. Femoral decompression + dead bone removal + necrotic area implant.
1.Femoral decompression is currently common internationally in three ways.
(1) Bone tunnel decompression technique (the Phemister technique): the bone tunnel formed through the neck of the femoral head through the lateral drilling of the greater trochanter to reach the necrotic area for decompression purposes. It includes: small diameter multi-pin drilling and ring drilling (8~10mm diameter) decompression + vegetation.
(2) Light-bulb technique (light-bulb technique): a technique in which a window is opened under the base of the femoral head, anterior to the femoral neck, to reach the necrotic area, remove the necrotic bone, and cancellous or cortical bone is implanted into the lesion.
(3) Trapdoor technique: the technique of opening a “trapdoor” directly in the collapsed part of the necrotic bone and articular cartilage of the femoral head, revealing the lesion, cleaning it, and implanting cancellous bone and cortical bone.
2. Dead bone removal: The necrotic bone is completely removed, and the live bone at the edge of necrosis should have blood leakage. The dead bone removal technique is demanding and is the most difficult part for the surgeon to grasp.
3.Necrotic area implant: fill the necrotic area and support the joint surface that will collapse or has collapsed
(1) Autologous or allogeneic free cancellous bone, cortical bone, such as iliac bone, fibula, etc;
(2) Tantalum rods, bone cement, elastic cage implants, etc;
(3) Autologous bone graft with vascularized tip, such as vascularized fibula, greater trochanteric bone flap, iliac bone flap graft, etc;
(4) Autologous stem cell transplantation: a bioaugmentation technique, which is an accessory to all femoral head preservation surgeries. Bone morphogenetic protein, autologous stem cell culture transplantation (MSCs) is the most commonly used at present, which promotes bone healing and increases the success rate of hip preservation surgery. However, the most appropriate vectors containing various growth factors and MSCs for implantation into the femoral head have not been standardized to date. That is, we already have the seeds and fertilizers, the most suitable fertile soil within the femoral head remains to be investigated.
Many combinations of surgical approaches have emerged through different decompression pathways, using different methods of necrotic zone clearance and implantation of viable or non-viable supports. These surgical combination modalities and outcomes vary widely and are related to many factors. There are limitations to the application of various surgical approaches to preserve the femoral head, with a wide variation in surgical ease and difficulty, as well as varying surgical outcomes and complications. Therefore, the selection of the appropriate surgical technique for preserving the femoral head is critical for the patient. Cases with moderate to severe collapse of the femoral head are not suitable for femoral head preservation surgery.
II. Rotational osteotomy.
After osteotomy, the necrotic area of the femoral head is transferred from the weight-bearing area on the outer upper edge of the acetabulum by rotation. There are usually two types of osteotomy: intertrochanteric wedge osteotomy (flexion, internal rotation, external rotation) and transtrochanteric rotational osteotomy (anterior or posterior rotation).
Rotational osteotomy is elective, with difficult surgery and high potential complications, including failure of internal fixation, bone discontinuity, and difficulty in re-executing total hip replacement after osteotomy failure. It is rarely performed in China at present.