Chinese Orthopaedic Association Orthopaedic Branch Microprosthetics Group Chinese Committee of Restorative and Reconstructive Surgery Bone Defects and Osteonecrosis Group Chinese Journal of Orthopaedics Corresponding author: Zhao Dewei Osteonecroois 0f the femoral head (ONFH), also known as avascular necrosis of the femoral head (AVNFH), is a common orthopaedic disease. In 2006, the Joint Surgery Group of the Orthopaedic Branch of the Chinese Medical Association and the Editorial Department of the Chinese Journal of Orthopaedics organized domestic experts in osteonecrosis to formulate the “Expert Recommendations on the Diagnosis and Treatment of Osteonecrosis of the Femoral Head”, which to a certain extent standardized the diagnosis, treatment and assessment methods of ONFH. In March 2012, the Microprosthetics Group of the Orthopaedic Branch of the Chinese Medical Association and the Bone Defects and Osteonecrosis Group of the Chinese Committee of Prosthetic Xiajian Surgery organized relevant professional experts to discuss, modify and supplement the Expert Recommendations on the Diagnosis and Treatment of Femoral Head Necrosis, and formulated the Expert Consensus on the Diagnosis and Treatment Criteria of Adult Femoral Head Necrosis (2012 Edition). I. Overview The Assaciation Research Circulation Osseous (ARCO) and the American Academy of Orthopaedie Surgeons (AAOS) define ONFH as a disruption or impairment of the blood supply to the femoral head, causing the death of bone cells and The former is mainly caused by hip trauma such as femoral neck fracture and hip dislocation, while the latter is mainly caused by the application of corticosteroids, alcoholism, decompression sickness, sickle cell disorder, and other diseases in China. The latter is mainly caused by corticosteroid application, alcoholism, decompression sickness, sickle cell anemia and idiopathic etc. in China.
Second, the diagnostic criteria refer to the Japanese InvestigationCommittee (JIC) and the diagnostic criteria proposed by Etienne and Mon, to develop our ONFH diagnostic criteria.
(I) Clinical symptoms, signs and history: arthralgia mainly in the groin, hip and thigh area, occasionally accompanied by knee pain, limited hip flexion, internal rotation and external rotation, often with a history of hip trauma, history of corticosteroid application, history of alcohol abuse and occupational history such as diving.
(B) X-ray changes: in the early stage of the disease, the femoral head appears to have increased density (sclerosis) and translucent areas (cystic changes); further development of the disease, the typical crescent sign appears; in the late stage, the femoral head may collapse, the joint gap narrows and severe osteoarthritic changes may appear, and sclerosis and cystic changes of the skeletal socket are common.
(C) CT scan changes: sclerotic bands encircling necrotic bone, repaired bone or subchondral bone fracture are seen in the femoral head.
(iv) MRI signs: T of necrotic area; WI shows banded low signal or T2wI shows double line sign.
(E) Nuclear bone scan: early stage of necrosis shows perfusion defect (cold zone); further development of the disease, the phenomenon of cold zone in the hot zone, that is, “bagel-like” changes.
(f) Bone biopsy: 50% of osteocyte vacuoles in bone trabeculae, and involvement of adjacent trabeculae, bone marrow necrosis.
Expert advice: the diagnosis can be confirmed by meeting two or more of the above criteria. In addition to (i) and (v), one of (–), (iii), (iv) and (vi) can be diagnosed by meeting the criteria.
The differential diagnosis should be made for disorders with similar clinical symptoms and imaging signs (Table 1).
(a) Middle- and late-stage hip osteoarthritis: common in middle-aged and elderly people, caused by degeneration of hyaline cartilage, cartilage softening, erosion, etc., mostly involving bilateral hip joints, often causing hip joint tingling pain. It may be confused with ONFH when the joint space becomes narrow and subchondral cystic changes appear. Its CT manifestation is sclerosis with cystic changes, and MRI changes are mainly low signal, which can be differentiated accordingly. (–) Acetabular dysplasia secondary to osteoarthritis: This disease occurs in children and young people, and is common in women, mostly involving both sides. x-ray shows incomplete wrapping of the femoral head, narrowing and disappearance of the joint smelling gap, osteosclerosis and cystic changes. Similar changes appear in the corresponding area of the acetabulum, which is easy to distinguish.
(C) Ankylosing spondylitis involving the hip joint: common in adolescent males, mostly bilateral sacroiliac joint involvement, HLA-B27 mostly positive, femoral head remains round, but the joint gap narrows, disappears or even fuses, easy to distinguish. Some patients with long-term application of corticosteroids can be combined with ONFH and collapse of the Yin head, but it is often not serious.
(iv) Rheumatoid arthritis: mostly seen in middle-aged and elderly women, involving both sides, the x-ray shows that the femoral head remains round, but the joint space becomes narrower and disappears. Erosion of the articular surface of the femoral head and acetabular bone is common and easily distinguished.
(v) Chondroblastoma of the femoral head: usually develops in late childhood or adolescence, usually in males, with a male to female ratio of 2 to 3:1. It occurs in the epiphysis and prominence of the long bones and is unilateral.
(vi) Bone fibrous dysplasia involving the femoral head: This disease is more common in children and young adults and women, and is a self-limiting benign bone fibrous tissue disease of unknown etiology and slow progression. It occurs in the long bones of the extremities and often involves most of the bones of the unilateral limbs. The typical x-ray shows a “shepherd’s cane” deformity of the proximal femur.
(vii) Temporary osteoporosis: It can be seen in young and middle-aged people and often develops on one side. MRI shows uniform low signal in TWI and high signal in T2W1, which can reach the femoral neck and rotor, without banded low signal, which can be distinguished from ONFH.4J. The lesion can dissipate within 3-12 months.
(H) Subchondral insufficiency fracture: Mostly seen in elderly patients over 60 years of age, more common in women, often unilateral onset, no obvious history of trauma. MRI signs: T1wI and T2wI subchondral low signal lines, surrounding bone marrow edema, T2 lipid suppression image as lamellar high signal “j.
(ix) pigmented villous nodular synovitis: it occurs in young adults aged 20–40 years, mostly with single joint onset, with no significant difference between men and women. It is characterized by mild to moderate pain in the hip joint with claudication and mild limitation of joint movement in the early and middle stages, CT and radiographs show cortical bone erosion of the femoral head neck or acetabulum and mild to moderate narrowing of the joint space, and Mm signs of extensive synovial hypertrophy and uniform distribution of low or moderate signal.
(x) Bone infarction: the epidemiological features of the disease are unknown and it is often bilateral. The imaging manifestations of bone infarction occurring in different periods of the long bone stem are different, and the MRI manifestations are as follows: (1) acute stage: the lesion center shows equal or slightly high signal with normal bone marrow in T and WI, high signal in ‘I’2WI, and long TI and long T2 signal at the edges; (2) subacute stage: the lesion center shows similar or slightly low signal with normal bone marrow in T-WI, and low signal with normal bone marrow in LWI. LWI showed similar or slightly high signal to normal bone marrow, with long T1 and long T2 signal at the edges; (3) chronic stage: both T. WI and ‘BWI showed low signal.
Fourth, staging ONFIt once diagnosed, then should be immediately staged to guide the development of treatment plans. Accurately determine the prognosis. It is recommended to use ARCO staging “J, refer to Steinberg staging and Ficat staging), clinical ONFH can be divided into: early, ARCO stage 0 a stage I; intermediate, ARC0 stage II a lllb stage; late, ARCO stage IIIc ~ IV.
V, the treatment of ONFH 0NFH treatment methods are more, the development of a reasonable treatment plan should take into account the stage, necrosis volume, joint function, as well as the patient’s age, occupation and compliance with the preservation of joint treatment and other factors.
(a) Non-surgical treatment is mainly applied to patients in the early stages of ONFH.
1, protective weight-bearing: the use of double crutches can effectively reduce pain, but do not advocate the use of wheelchairs’ 2, drug therapy: non-steroidal anti-inflammatory drugs, low-molecular heparin, aminodiphosphonates, etc. have certain efficacy, vasodilator drugs also have certain efficacy” 3, Chinese medicine treatment: the holistic view of Chinese medicine as a guide, follow ” The basic principles of “combination of movement and static, tendon and bone, internal and external treatment, cooperation between doctors and patients”, emphasize early diagnosis, combination of disease and evidence, early standardized treatment. For high-risk groups and patients without pain in the early stage, the main treatment is to brace blood and resolve blood stasis. For early onset of pain and other symptoms of ONFH, on the basis of protective weight-bearing, the application of blood circulation and dampness herbs can relieve pain and improve joint function; for middle and late stage 0NFH, it can be combined with surgical repair surgery to improve the surgical effect.
4.Physical therapy: including extracorporeal shock wave, high frequency electric field, hyperbaric oxygen, magnetic therapy, etc., which is beneficial to relieve pain and promote bone repair.
5, braking and appropriate traction: applicable to early and middle cases of ONFHI.
(B) Surgical treatment of ONFH Due to the rapid progress of 0NFH and the poor results of phenotypic surgical treatment, most patients need surgical treatment. The surgical modalities include repair and reconstruction surgery mainly to preserve the patient’s own femoral head and artificial hip joint replacement surgery. Femoral head preservation surgery includes medullary core decompression, bone grafting, osteotomy, bone grafting with or without hemorrhage, etc. (iv), which is suitable for patients with early and mid-stage ONFH and patients with ONFH with necrosis volume of 15% or more. If the method is appropriate, artificial arthroplasty can be avoided or postponed.
1, femoral head medullary core decompression medullary core decompression surgery has a long history. The efficacy is certain. At present, it can be divided into fine needle drilling decompression and coarse channel medullary core decompression. The main difference is that the diameter of the decompression channel is different”, the diameter of the orifice for fine needle drilling decompression is 3 nlnl, 3, 5ml or 4ml; the diameter of the orifice for coarse channel medullary decompression is 6mm. It can be combined with implant material. The core decompression combined with stem cell transplantation (or concentrated autologous bone marrow single nucleus cell transplantation) is currently a Class III medical technology under the control of the Ministry of Health and is not widely performed in China. Based on the current better results of clinical application in some domestic medical institutions I”
1, experts recommend that it should be applied with caution after the establishment of a multicenter long-term follow-up reporting system with large samples.
2.Bone grafting without hemorrhage is more commonly used in trans-femoral rotor decompression bone grafting and trans-femoral head neck bulb decompression bone grafting. Bone grafting methods include compression bone grafting and support bone grafting. The applied bone grafting materials include autologous cortical bone and cancellous bone, allogeneic bone and bone replacement materials.
3.Osteotomy to move the necrotic area out of the weight-bearing area of the femoral head. The osteotomy used in clinical practice includes internal or external osteotomy and rotational osteotomy via the femoral rotor. The choice of osteotomy is based on the principle of not altering the femoral marrow cavity.
4.Autologous bone graft with blood transportAutologous bone graft can be divided into periprosthetic bone flap graft and fibula graft. There are various choices of periprosthetic bone flaps with vascularized tips: (1) iliac (membrane) flap transfer with ascending branch of the lateral femoral vessel ∞3; (2) greater trochanteric flap transfer with ascending branch of the lateral femoral vessel gluteus medius branch nursing 1; (3) greater trochanteric flap transfer with transverse branch of the lateral femoral vessel; (4) iliac (membrane) flap transfer with deep vascularized tip of the rotating ilium; (5) the whole femoral head or even part of the femoral neck is involved. The femoral head (neck) can be reconstructed by combining the transverse branch greater trochanteric bone flap with the ascending branch iliac (membrane) flap; (6) posterior hip maneuvering rotary femoral medial vascular deep branch greater trochanteric bone flap, superior hip vascular deep superior branch iliac bone flap, etc.; (7) bone flap (column) C2s-3″ with femorotibial tilts. The periprosthetic bone flap with vascular tip is less invasive, more effective, and easy to master, so it is recommended. In order to increase the strong support in the femoral head, tantalum rods can be implanted in conjunction with the periprosthetic femoral flap, which can effectively prevent the femoral head from collapsing after surgery. The short-term efficacy of this method is good, but the long-term efficacy is yet to be determined. The surgical effect of anastomotic vascularized fibular bone graft was also confirmed a few days ago, and the application of blood-transported autologous bone graft is recommended. The choice of different vascularized bone flaps can be based on their advantages and disadvantages, the operator’s proficiency and other factors.
5, human ding arthroplasty femoral head collapse more serious (ARCO stage IIIc, stage IV), there is a serious loss of joint function or pain is more serious, should choose artificial joint replacement. It is generally believed that non-cemented or hybrid prostheses have better medium- and long-term outcomes than cemented prostheses. 0NFH arthroplasty is different from arthroplasty for other diseases, and some related issues should be noted: (1) patients with long-term application of corticosteroids or underlying disease requiring continued treatment, which increases the rate of infection; (2) long-term non-weight bearing and osteoporosis, which lead to easy penetration of the prosthesis into the acetabulum; (3) Previous surgery to preserve the femoral head. Can bring a variety of technical difficulties; (4) hormonal ONFH, alcoholic ONFH is not only femoral head lesions, its surrounding that is, the whole body bone has also been damaged, so its long-term effect may not be as good as osteoarthritis or traumatic ONFH.
Six, the principles of treatment plan selection selection treatment plan should be based on the stage of necrosis, patient age, patient compliance with joint preservation treatment and other comprehensive consideration.
(a) Treatment options for different stages of ONFH For non-planar injury ONFH cases, if one side is diagnosed, the contralateral side should be highly suspected and bilateral MR examination should be performed, and follow-up every 3-6 months is recommended. Asymptomatic ONFH: Those with large necrosis volume (>30%) and necrosis located in the weight-bearing area should be treated aggressively and should not wait for symptoms to appear. Combined application of medullary core decompression and non-surgical treatment is recommended.ARCOI stage: for asymptomatic, non-weight-bearing area and necrosis volume <15%, close observation and regular follow-up can be performed; those with symptoms or necrosis volume >15%. ARCO stage II: For cases where the femoral head has not yet collapsed, marrow core decompression (stem cell transplantation or concentrated autologous bone marrow single nucleus cell transplantation), autologous bone grafting with hematopoiesis, and bone grafting without hematopoiesis are recommended. ARCOIlla, Petri b stage: various kinds of autologous bone grafting with blood transport are recommended.ARC0111 c, IV stage: for cases with mild symptoms and young age, joint preservation surgery can be chosen and bone grafting with vascular autologous bone is recommended (e.g. greater trochanteric bone flap with vascular tip combined with bone graft); for severe femoral head collapse, artificial Total hip replacement is recommended for those with severe femoral head collapse. The femoral head can be preserved by one or more of these procedures. Combined application, such as medullary core decompression with bone flap grafting, is recommended. Non-surgical treatment should also be within the scope of comprehensive treatment.
(B) Age factors and treatment options for young adults with ONFH cases, due to the high activity, should choose a treatment option that preserves the femoral head and does not adversely affect the possible future artificial joint replacement. The recommended treatment options are marrow core decompression (stem cell transplantation), autologous bone grafting with hematopoiesis and bone grafting without hematopoiesis (15% < necrosis volume < 30%). Middle-aged ONFH cases. If in the early stages of ONFH (no collapse), the femoral head should be preserved as much as possible, such as medullary core decompression, bone grafting with or without hematopoiesis. If in the middle or late stage of ONFH, the patient's subjective wishes and technical conditions should be combined to choose preservation of the femoral head for treatment or artificial joint replacement. When deciding to use artificial arthroplasty, the preoperative prosthesis selection should fully consider the secondary revision of the ding energy. In elderly (over 55 years old) ONFH cases, total hip arthroplasty is recommended. For elderly ONFH cases, the decision should depend on the patient's daily activity status, the bone quality of the hip, and the expectation of the longevity of life. Bipolar (tri-polar) artificial femoral head replacement or artificial total hip arthroplasty is recommended.
VII. Efficacy evaluation and rehabilitation exercise (a) Efficacy evaluation of ONFH is divided into clinical evaluation and imaging evaluation. Clinical evaluation uses hip function score (such as Harris hip score snap], WOMAC osteoarthritis score [“? , Chinese Medical Association Orthopedic Branch Percentage Method III1, etc.), which should be evaluated on a case-by-case basis according to the same necrosis stage, similar necrosis area and the same treatment method. Gait analysis is also recommended. Imaging evaluation can be applied to X-ray films with concentric circle templates to observe femoral head shape, joint space and acetabular changes. MR examination information should be available for lesion evaluation within ARCO stage II. For patients with hemorrhagic bone graft, DSA examination should be performed and used to evaluate hemorrhagic recovery.m1 Experts suggest establishing case files for ONFH patients to accumulate more valuable information, which can help evaluate the efficacy of different etiologies, different periods of necrosis, different ages, and different treatment methods. It is conducive to reach a more standardized consensus on the treatment of ONFH.
(B) rehabilitation exercise rehabilitation exercise can be used to stop wasting muscle atrophy in ONFH patients. It is an effective means to promote their early return to function. Functional exercise should be mainly active, passive as a supplement. From small to large, from less to more, gradually increase, and according to the stage of ONFH, treatment mode, hip function score and gait analysis data to choose the appropriate exercise method.
1, prone leg lift method: lie on your back, lift the affected leg, flex the hip and knee 900, and repeat the action. Each Et 200 times, divided into 3 “4 times. Apply to ONFH conservative treatment and surgical treatment of postoperative bed rest period.
2. Sitting partition: sit on a chair, hands on knees, feet shoulder-width apart, left leg to the left, right leg to the right while fully abducted. Inward retraction. 300 times daily in 3^4 times. Apply to ONFH conservative treatment and surgical treatment after surgery can be part of the weight-bearing period.
3.Standing leg lift method: hold the fixed object, keep the body upright, lift the affected leg, make the body at right angles to the thigh, bend the hip and knee 900, the action is repeated. 300 times a day, divided into 3,4 times. Apply to ONFH conservative treatment and surgical treatment can be part of the weight-bearing period.
4, hold the object squat method: hand hold the fixed object, the body upright, feet and shoulder width, squat and then stand up, the action repeated. 300 times a day, divided into 3 – 4 times. Apply to 0NFH conservative treatment and surgical treatment can be fully weight-bearing period.
5, internal rotation and abduction method: hand holding the fixed object, legs respectively do full internal rotation, abduction, circle movement. 300 times a day, divided into 3 – 4 for. Apply to ONFH conservative treatment and surgical treatment can be fully weight-bearing period.
6, walking training or cycling exercise: applied to ONFH conservative treatment and surgical treatment can be fully weight-bearing period.