(C) Western medical treatment.
1.Western medicine treatment
(1) Vasoactive class (ergometrine, vincristine, cardiac pain).
(2) Promote fibrinolytic activity class (Warfarin, low molecular heparin, urokinase, etc.).
(3) Lipid-lowering and lipid scavengers (statins).
2.Non-surgical treatment
(1)Weight-bearing restriction: It is suitable for early stage patients and can reduce intra-articular pressure.
(2)Traction therapy: it can relieve the spasm of soft tissue, correct part of the deformity, reduce intra-articular pressure and increase the envelope capacity of the acetabulum to the femoral head.
(3) Electrical pulse stimulation and electromagnetic field stimulation.
3.Surgical treatment
(1) Interventional treatment (super-selective insertion of the medial and lateral spinofemoral arteries, injection of urokinase, compound salvia, low molecular dextrose, etc.).
(2) Medullary core decompression plus simple bone grafting.
(3) Medullary core decompression with vascular bundle implantation or bone grafting with blood transport.
(4) Osteotomy (Sugioka rotational osteotomy anterior to the rotor, Mont’s modified inter-rotor osteotomy).
(5) Femoral head lesion removal with bone grafting and tumescence.
(6) Artificial hip joint surface replacement.
(7) Artificial total hip replacement.
(8) Hip fusion.
Treatment strategy selection
(i) Treatment process.
The patient has a confirmed history of long-term or short-term intermittent use of large amounts of hormones, or long-term alternating use with non-steroidal anti-inflammatory analgesics, and the main symptom is hip pain, which is commonly hidden gradual dull pain, with only local pressure pain in the early stage, and positive “4” test and Thomas sign. In the late stage, there is limited movement in all directions of the hip joint, shortening of the limb, flexion contracture deformity, muscle atrophy, semi-dislocation of the affected hip, positive Trendelenburg’s sign, and hormonal femoral head necrosis is diagnosed by X-ray and/or CT and MRI. Chinese medicine treatment mainly includes activating blood circulation, relieving pain, nourishing the liver and kidney, nourishing blood and filling the marrow, strengthening the capital and nourishing the blood. Western medicine treatment is generally based on the ARCO stage selection treatment plan, divided into conservative treatment and surgical treatment.
(B) Identification points.
Femoral head necrosis belongs to the category of “bone erosion” in Chinese medicine. “The tendons and bones depend on the nourishment of liver and kidney essence and blood, as well as the warmth of kidney yang. The deficiency of liver and kidney essence, deficiency of kidney yang, poor flow of qi and blood, internal stagnation of toxins, inability to nourish and warm the tendons and bones, making the tendons contracted, bone withered and marrow reduced is the basic pathogenesis. In the early and middle stages, the disease may be characterized by paralysis and stagnation of qi and blood, with the main evidence being actual pain, purple tongue or petechiae, blue veins under the tongue, and astringent pulse; in the middle and late stages, the disease may be characterized by deficiency of liver and kidney, with the main evidence being deficiency, with the main evidence being fatigue, shortness of breath, weakness, pale tongue, fat and tender, with teeth marks on the side, thin white fur, and thin and weak pulse. The location of the disease lies in the tendons and bones.
(C) Characteristics of medication.
On the basis of the diagnosis and treatment, the basic formula should be added and subtracted. The pain of Qi stagnation and blood stasis is obvious with the addition of San Ling, Curcuma longa and other drugs that break Qi and remove stasis; the deficiency of liver and kidney with kidney Yang deficiency can be added with aphrodisiacs such as bone marrow, deer horn gum, Eucommia globulus, cinnamon, etc.; the deficiency of liver and kidney with Yin deficiency can be added with Yin nourishing drugs such as Fructus Lycii, Tortoise Plate, Salvia miltiorrhiza, Medlar, etc.; the deficiency of both Qi and Blood and the deficiency of both liver and kidney with weakness of spleen and stomach can be added with Astragalus, Chen Pi, rice kernel, sand kernel, etc. According to the coagulation condition western medicine can be given urokinase, supplemented with Chinese medicine such as Danshen preparation for intravenous drug treatment.
(IV) Treatment features.
At present, comprehensive treatment combining Chinese and Western medicine should be adopted, and its ideal treatment should be in the early stage. If early diagnosis can be confirmed and effective measures can be taken quickly, the femoral head can be prevented from collapsing and joint function can be preserved. There are many surgical methods for hip preservation, and the efficacy is relatively certain, which is the main method of early treatment. For patients in stages I and II, interventional treatment and/or marrow core decompression plus simple bone grafting can be used; for patients in stages II-III, age <45 years, with small to moderate lesions, osteotomy can be used; for patients in stages III or above, marrow core decompression plus hematoprosthesis or bone grafting with hematoprosthesis can be used.
When the hip preservation surgery fails and the femoral head is severely collapsed, artificial joint replacement should be chosen to solve the pain, improve the joint function and enhance the quality of life, and joint replacement is the most efficient treatment for this type of patients. For hormonal head necrosis collapse in young adults, artificial hip surface replacement can be used to delay the time to perform total hip replacement. For patients with failed arthroplasty and those who are not suitable for arthroplasty, hip fusion can be performed.
According to the latest research progress, at present, patients with stage I and II femoral head necrosis can be treated by femoral head marrow core decompression with BMP bone graft, marrow core decompression with bone marrow stromal cell infusion, rotary internal femoral artery cannulation vascularization with pluripotent stem cell transplantation, which can achieve good clinical results. And femoral head lesion removal plus bone graft tumescence and cartilage transplantation can be used to treat patients with stage III or above, and the efficacy is under further observation.
(E) Precautions.
Patients should avoid smoking and alcohol, control weight, avoid heavy physical labor, avoid trauma and maintain good mood.
When using drugs such as urokinase, warfarin and low molecular heparin, attention should be paid to monitoring coagulation function. Medullary core decompression alone is no longer used. The operation of medullary core decompression with bone grafting should be performed so that the proximal end of the grafted bone can not only be in anastomotic contact with the subchondral bone, but also its end needs to be in uniform contact with the subchondral bone; otherwise, the stress/strength ratio of the bone around the graft may be elevated to a harmful level; the bone must be drilled to the osteonecrotic area during the operation, but it should be avoided to pass through the subchondral bone to avoid damage to the femoral head.
For young and strong patients, emphasis should be placed on surgical methods that preserve the femoral head, on osteotomy, and on strictly grasping the surgical indications for artificial total hip replacement. For patients undergoing artificial total hip replacement, a thorough preoperative and intraoperative plan and postoperative rehabilitation plan should be made to reduce or avoid the incidence of various complications only possible. Contact with related departments should be strengthened.
Judgment of curative effect
Cured: no limp in walking, no pain in the hip joint, no shortening of the lower limb, complete or basic recovery of function, and basic disappearance of collapse of the dead bone area of the femoral head, osteonecrosis and sclerosis of osteophytes on X-ray.
Improved: symptoms were reduced, hip joint function improved, lower limb shortening was about 1cm, femoral head became larger or flattened on X-ray, but osteonecrosis and osteophyte sclerosis were improved.
Not healed: no improvement of symptoms, no change of X-ray signs.