I. What is femoral head necrosis?
The International Association for Research in Osseous Circulation (ARCO) and the American Academy of Orthopaedic Surgeons (AAOS) define ischemic necrosis of the femoral head as a disease in which the blood supply to the femoral head is interrupted or impaired, causing death of bone cells and bone marrow components and subsequent repair, followed by structural changes in the femoral head, femoral head collapse and joint dysfunction. Femoral head ischemic necrosis is still recognized as one of the most difficult to treat diseases in the world.
Femoral head ischemic necrosis is generally divided into two categories: the former is mainly caused by hip trauma (femoral neck fracture, hip dislocation, acetabular fracture, etc.); the latter has nearly 70 kinds of causative factors, and in China, the top two causes of non-traumatic femoral head necrosis are, application (including abuse) of corticosteroids (prednisone, cortisone, dexamethasone, etc.) and long-term heavy alcohol abuse. It is speculated that there are 100-150,000 new cases of ischemic necrosis of the femoral head in China every year, and the cumulative number of cases requiring treatment exceeds 5 million, and there are currently about 30 million patients worldwide.
According to Chinese medicine, femoral head necrosis belongs to the category of “bone erosion”. According to TCM, physical weakness, deficiency of liver and kidney essence and blood, phlegm and dampness, qi stagnation and blood stasis, and osteoporosis are the potential causes of ischemic necrosis of the femoral head. The lesions involve the liver, spleen and kidney.
Second, what are the main symptoms of femoral head necrosis?
Early symptoms.
The initial stage of the disease is dominated by pain in the hip, knee and inner thigh, followed by posterior hip and anterior thigh. With dull pain, soreness is common. The more specific manifestations: vague pain in the hip, soreness and weakness, soreness or pulling sensation in the inner thigh and groin. Pain when lying on the affected side makes it difficult to assume a comfortable position. These symptoms do not necessarily occur at the same time, and the pain is intermittent. The duration of pain is gradually increased as the disease progresses. In the early stage, internal rotation of the hip joint is limited. Patients may have intermittent claudication. If you have used hormones, you can go to the hospital to check the above symptoms so as not to miss the best time for treatment.
Mid-stage symptoms.
The pain in the affected limb increases, and sometimes the pain site cannot be clearly identified, and the pain is persistent and difficult to be relieved. When the disease progresses acutely, rest pain appears, and the pain is more intense at night. Walking pain with claudication. Hip extension, flexion, adduction and abduction. Internal and external rotation is limited. On X-ray, most of the bone trabeculae are lost, with cystic changes and sclerosis of the bone.
Late symptoms.
Pain is fixed in the lumbosacral region, hip, groin, and inner thigh. X-rays will show flattening of the femoral head, collapse, narrowing or loss of joint space.
Third, what causes femoral head necrosis?
Direct causes: trauma, radiation, sickle cell disease, caisson disease, Gaucho’s disease, chemotherapy (cytotoxic), bone marrow value-added disorder, etc.
Indirect causes: corticosteroids, alcohol, coagulation disorders, smoking, hyperlipidemia, connective tissue disease, systemic lupus erythematosus, nodular disease, Cushing’s disease, endocrine disorders, gout, pregnancy, oral contraceptives, pancreatitis, inflammatory bowel disease, AIDS, hemophilia, renal dysfunction, organ transplantation, thalassemia, etc.
Most common causes.
(1) Trauma: Fracture of the femoral neck in the elderly, hip dislocation in young and middle-aged people, etc. ;
(2) Heavy alcohol consumption: Chronic alcoholism caused by long-term heavy alcohol consumption;
(3) large amount or long-term use of adrenal glucocorticoids, etc.
Fourth, what tests should be done for femoral head necrosis?
1.X-ray examination: routine X-ray examination for the first consultation, including pelvic plain film and double hip frog position film. For experienced doctors, a clear X-ray film can provide a lot of information, such as limited osteoporosis, diffuse cystic degeneration or sclerosis, crescent or dead bone fragments, the size of the damage, the degree of depression or collapse of the femoral head, changes in the acetabulum, and changes in the joint space. The disadvantage is the poor sensitivity of the diagnosis of early (stage I) femoral head necrosis.
2, CT examination: poor sensitivity to the diagnosis of stage I femoral head necrosis, CT for stage II and III lesions, can clearly show the border of necrosis foci, area, sclerotic zone, foci repair and subchondral fracture, etc. CT shows the clarity and positive rate of subchondral fracture is better than MR and X-ray plain film, so CT is considered to be a “tool” to detect early collapse of the femoral head. “Therefore, CT is considered to be a good tool for detecting early femoral head collapse, and is particularly important for the choice of treatment.
3. Magnetic resonance imaging (MRI) is currently the only method to diagnose early femoral head necrosis, and the diagnostic accuracy of head necrosis can reach 96~99%, which is considered as the “gold standard” for diagnosis. In addition, MRI, because there is no X-ray radiation, can be considered a non-invasive examination of the human body.
4.Laboratory examination: blood routine, blood lipid, blood sugar, blood rheology, primary disease side related examination.
V. What should patients with femoral head necrosis pay attention to in the treatment process?
(1) The most prominent feature of femoral head necrosis is that the severity of self-conscious symptoms is not proportional to the degree of femoral head necrosis, so patients should pay special attention to the need to adhere to the course of treatment, not halfway, and not intermittent;
(2) No abuse of other drugs and means of treatment for osteonecrosis of the femoral head during the treatment process;
(3) Adrenocorticotropic hormones or other drugs that affect the efficacy of the treatment should not be used during the treatment;
(4) No alcohol and no smoking during treatment;
(5) Minimize weight bearing and use crutches if necessary;
(6) During the treatment process, carry out functional exercises according to the treatment stage;
Six, which are the patients at risk of ischemic necrosis of the femoral head
There are nearly 70 causes of non-traumatic ischemic necrosis of the femoral head, common causes of ischemic necrosis of the femoral head: mainly the application of glucocorticoids (dexamethasone, prednisone, methylprednisolone, etc.), alcoholism, decompression sickness, hemoglobin disease, Gaucher’s disease, radiation therapy, pancreatic disease, hyperuricemia, atherosclerosis, sickle cell disease, connective tissue disease, lipoprotein abnormalities, Cushing’s disease, iron toxicity diabetes mellitus, bronchial asthma, pregnancy, birth control pills, leukemia, hemophilia, etc.
Patients at high risk of femoral head necrosis.
① with obvious causative factors (long-term, large amounts of glucocorticoids, long-term heavy alcohol consumption);
②After hip trauma: after displaced femoral neck fracture, after acetabular fracture and hip dislocation in young and middle-aged people;
③there are the above-mentioned reasons, there is unknown hip pain, occasional claudication;
④The opposite side has been diagnosed as non-traumatic necrosis.
Seven, how to achieve early diagnosis of femoral head necrosis
The treatment effect of femoral head necrosis has a great relationship with the severity of the disease, the early and late detection, and the stage of the disease, the earlier the lesion is found, the lighter the disease, the better the treatment effect, so femoral head necrosis should be diagnosed and treated early. Early diagnosis of femoral head should follow the following principles.
(1) Any adult aged 20-50 years old with pain in the groin or hip and dispersion to the thigh (or hip pain after activity of knee pain on one side), slow progressive aggravation, obvious pain at night, ineffective by general drug treatment, and history of trauma or alcoholism or other causative factors and diseases causing femoral head necrosis should first consider this disease.
(2) All patients with low back pain should be routinely checked for hip function during physical examination. If abduction and internal rotation of the affected hip joint are found to be limited, the existence of this disease should be suspected.
(3) Patients with femoral neck fracture should be followed up until 3-5 years after the injury if diminishing height of the femoral neck, nail scar phenomenon and cystic changes are found. The disease should be considered if clinical symptoms are present.
(4) In suspected cases, orthogonal and frog radiographs of the hip must be taken first. If there is no abnormality, close observation or further CT, MRI, ECT, intraosseous pressure measurement, arteriography and other examinations should be performed.
Eight, which conditions belong to the early stage of ischemic necrosis of the femoral head
Early ischemic necrosis of the femoral head has two meanings: First, the pre-radiographic phase (phase 0 and phase I): high-risk patients have no clinical symptoms, no change in X-ray film, and the diagnosis is confirmed by MRI and femoral head biopsy, also known as “silent hip” or “occult femoral head necrosis”; Second, the former Collapse stage (stage II): clinical symptoms appear, X-ray film shows cystic change of femoral head, sclerosis, no hemimelia sign, no subchondral fracture and collapse on CT and MRI. Early diagnosis of these asymptomatic anterior radiographic stage (stage 0 and I) and symptomatic anterior collapsed stage (stage II) patients remains challenging.
Nine, which osteonecrosis patients can take conservative treatment?
Main indications.
①Stage 0, stage I, stage II, middle-aged and young people, necrosis area less than 30%, preferably less than 15%, necrosis area is located in the medial or central, these patients still have the ability to repair;
②Conservative treatment should be carefully chosen for small necrosis in the lateral area and closely observed for changes in the condition;
③ For elderly patients, 65 years old or older, due to poor physical condition, postoperative complications, in the affected limb pain is not very serious, moderate functional limitations. In addition to some patients with contraindications to surgery can also be used some Chinese medicine.
Ten, what are the conservative treatment methods for femoral head necrosis?
Conservative treatment methods.
① Observation therapy, restrictive weight-bearing;
②Medication: Western medicine: lipid-lowering drugs, anticoagulants, vasodilators, biphosphonates, Chinese medicine: Danshinone, Chuanxiongin, Gegenin, Danshin-Safflower injection, etc.; different prescriptions and pills for diagnosis and treatment, etc;
③Physical therapy: electrical stimulation, high-energy shock wave, hyperbaric oxygen, etc.; radiological intervention.