There are many treatments for femoral head necrosis, which are summarized in two main categories, namely non-surgical treatment and surgical treatment. In general, patients suffering from osteonecrosis of the femoral head prefer to undergo non-surgical treatment because they are afraid of surgery. In fact, the choice of that treatment does not depend on one’s subjective desire, but depends on the stage of femoral head necrosis. Early stage (stage I and some stage II) patients can receive non-surgical treatment, while patients with intermediate and late stage (stage II and above) should receive surgical treatment, and some patients still need to receive other adjuvant treatment after surgery to obtain satisfactory results. Therefore, patients suffering from femoral head necrosis must get out of the misunderstanding in treatment, believe in science, and receive different treatments depending on the severity of their conditions, otherwise they will miss the time of treatment and cause irreversible and serious results.
Although scientists and medical workers at home and abroad have conducted more than half a century of painstaking research on the etiology of femoral head necrosis and its pathogenesis, there are still many areas that are not very clear and need to be further explored. There are many current treatment methods, but each of them has its limitations. Because of this, the medical market and the streets are flooded with many fancy “cure-all” and “cure-all” methods of treating femoral head necrosis, which is in fact unscientific. After the treatment, the result is a lot of suffering, know that the deceived when it is too late.
How to treat osteonecrosis of the femoral head? This is the most important concern of all patients with femoral head necrosis. The choice of treatment plan should be based on the patient’s age, necrosis site, necrosis area size and stage, and individualized treatment plan developed by experienced specialists in order to achieve satisfactory results and maximize the savings in medical costs.
Non-surgical treatment
Not all necrosis of the femoral head requires surgical treatment, and those with necrosis of less than 15% or less than 25% of the non-weight-bearing area and no symptoms can be treated without surgery and only need to be closely observed. Commonly used methods are: drug therapy, high frequency magnetic therapy, extracorporeal shock wave, hyperbaric oxygen and protective weight-bearing, etc., which can be tried for stage I or even stage II. Necrosis area greater than 30% should be closely observed.
1, drug therapy: from the domestic and foreign literature reports, so far mankind has not really found a really reliable efficacy can cure the femoral head necrosis drugs. Nevertheless, drug therapy is still the preferred method of all non-surgical treatment. According to the current understanding of the pathogenesis of femoral head necrosis, i.e. the doctrine of vascular injury, pharmacological treatments are divided into the following categories.
Drugs to improve local blood circulation: targeted prostaglandin E (Kaiser)- has the effect of strongly dilating blood vessels, inhibiting platelet coagulation and improving the deformability of red blood cells. Chuanxiongzin-Chinese herbal medicine, this drug can inhibit platelet release, reduce vascular inflammatory response, release vascular smooth muscle spasm, reduce whole blood and plasma viscosity and red blood cell pressure volume, and reduce plasma fibrinogen production.
Anticoagulant drugs: low molecular heparin (fast avoidance forest) – has the effect of anti-coagulation, reduce blood viscosity, improve the ability of fibrinolysis, is widely used in the prevention and treatment of thromboembolic diseases. Some foreign scholars have applied it in the treatment of early femoral head necrosis and achieved good results.
Lipid-lowering drugs: Statin lipid-lowering drugs can improve lipid metabolism, lower blood lipids, and reduce or avoid fat embolism of blood vessels in bone. Animal experiments have confirmed that the combination of these drugs with glucocorticoids in the treatment of disease can reduce the incidence of osteonecrosis of the femoral head. However, the drug is toxic to the liver and should be used with caution for long-term use.
Anti-osteoporosis drugs: sodium allantoin phosphate (Fosamax) – by inhibiting the activity of osteoclasts, it has a good effect on preventing the collapse of the femoral head.
Other drugs: Non-steroidal anti-inflammatory drugs – relieve joint pain and other symptoms, facilitate the restoration of joint function, and prevent the development of joint deformities. Joint cartilage protection drugs (bone strength) – have the effect of repairing joint cartilage, protecting and delaying the destruction of joint cartilage.
2. High frequency magnetic field: Magnetic therapy is a proven treatment method to promote fracture healing. The mechanism may be to improve local blood microcirculation, accumulate bone growth factor through humoral immunity, increase the activity of osteoblasts and promote fracture healing. High-frequency spiral magnetism is used for the treatment of femoral head necrosis, which can improve microcirculation and promote blood vessels to grow into the necrosis foci, and has better efficacy in relieving pain symptoms, and can be used as an auxiliary means for the treatment of early femoral head necrosis.
3.Extracorporeal shock wave: At present, it is mainly used in clinical practice for extracorporeal lithotripsy of urinary system and hepatobiliary system stones. In recent years, it has been applied to the treatment of early femoral head necrosis, using the feature that it can cause microfracture to the sclerotic zone at the edge of the femoral head necrosis foci, eliminating the blocking effect of the sclerotic zone on the growth of the repair vessels into the necrosis foci, thus promoting the repair.
4, hyperbaric oxygen: Israeli scholars reported that the treatment of stage I ischemic necrosis of the femoral head with hyperbaric oxygen therapy, patients in the hyperbaric chamber with a mask to inhale 100% oxygen at 2 to 2.4 atmospheres for 90 minutes / day, 6 times a week, a total of 100 times. 81% of patients with stage I ischemic necrosis of the femoral head recovered normal MRI after hyperbaric oxygen therapy, only 17% of patients without hyperbaric oxygen therapy recovered. Therefore, it is believed that hyperbaric oxygen can effectively treat stage I ischemic necrosis of the femoral head.
5.Protective weight-bearing: Whether walking with crutches can effectively avoid collapse of early necrotic femoral head is still controversial, but most scholars believe that walking with crutches has a certain protective effect on the femoral head, so they mostly advocate patients to walk with double crutches, but not with wheelchairs, because disuse osteoporosis can occur.
Surgical treatment to preserve the femoral head.
For osteonecrosis has entered stage II necrosis area greater than 30%, the efficacy of non-surgical treatment is not good, at this time should be taken to preserve the femoral head surgery, can be expected to achieve good results.
1, autologous bone marrow stem cell transplantation: This method was pioneered by a French scholar, who followed up more than 600 cases of stage I and II osteonecrosis treatment for more than 6 years, with an excellent rate of more than 80% Sino-Japanese Friendship Hospital Osteonecrosis and Joint Preservation and Reconstruction Center improved method, each time about 150 ml of bone marrow is extracted, the bone marrow cells are separated by a cell separator, compressed to 7-10 ml, using X-ray fluoroscopy or navigation guided by fine The compressed bone marrow cells plus osteoinductive factor (BMP2) were pressurized and punched into the decompression zone for multiple perforations in the osteonecrosis area. After several cases with more than 6 months of follow-up, the initial results were good. The advantage of this method is that it is less invasive and allows early debridement. The disadvantage is that if the osteonecrosis is clearly defined and has been cystic change, the efficacy is not good.
2, through the femoral head neck window, decompression area bulb decompression, playing pressure implantation: this method is suitable for necrosis boundary clear, necrosis area near the joint surface, necrosis area greater than 15% to 30% of the early stage II or III young and middle-aged patients. Under X-ray guidance, the necrotic bone is scraped out through a small incision (about 5 cm) in front of the hip, and autologous bone, artificial bone, BMP2, etc. are implanted under pressure. According to the osteonecrosis center of China-Japan Friendship Hospital, more than 100 cases have been followed up for more than 4 years, and the excellent rate of stage II is 100%, and early stage III is 75%, which is better than foreign reports.
3, lesion removal, with vascularized fibula bone graft: for early stage III and IV young patients (less than 40 years old) patients. This procedure is slightly more invasive and requires two incisions, but the cut fibula implanted with blood flow (living bone) and better mechanical support is desirable for femoral head that has started to collapse. Domestic and foreign clinical reports, the 10-year excellent rate is between 60% and 70%.
4.Osteotomy: For some young patients (less than 45 years old), the necrotic foci are located in the weight-bearing area, while there is no osteonecrosis in the non-weight-bearing area, the necrotic foci can be moved to the non-weight-bearing area by rotational osteotomy through the femoral ridge or inversion and exostosis osteotomy, while the normal cartilage surface is transferred to the weight-bearing area to protect the femoral head from collapse. The requirements of this kind of surgery make the joint mobility better and the physician has experience in order to achieve better results.
5. It should be understood that surgery to preserve the femoral head is done to avoid or delay the artificial joint replacement surgery. Because no matter how hard you try, there are always some patients with femoral head necrosis who eventually need artificial joint surgery, therefore, the surgical treatment of preserving the femoral head should try not to leave behind the difficulties to do artificial joint surgery, from the above several surgeries, (1), (2) and (3) are more in line with this situation.
Currently some medical units are keen on vascular intervention, we believe that this therapy is harmful and unhelpful. According to the experience of cardiovascular and cerebrovascular embolism treatment, thrombolysis is effective only 6-12 hours after embolism. Once the diagnosis of femoral head necrosis is established, vascular embolism is usually more than 3 months or even longer, so it is impossible to dissolve the embolism. Intravascular cannulation inevitably damages the vascular endothelium and can aggravate the ischemia by damaging the undamaged vessels.
Artificial joint replacement
1. Types of artificial joints and materials.
Femoral head necrosis such as early diagnosis and treatment can make more than 70% of patients avoid or delay artificial joint replacement. But because in our country, delayed diagnosis, non-standard treatment is more common, so that many patients with femoral head when the diagnosis has been late (III, IV) other methods have been very difficult to work, had to perform artificial joint replacement. However, with the improvement of artificial joint materials, prosthesis design and skill of physicians, the efficacy of artificial joint replacement is rapidly improving and excessive concerns are unnecessary.
The types of artificial hip joints include.
①Femoral head surface replacement;
②Artificial femoral head replacement;
③Total hip artificial joint replacement.
The commonly used artificial joint implant materials are.
①Metallic alloys;
②Polymer materials;
③Ceramic materials. The commonly used metals can be divided into three categories: titanium-based (titanium and titanium alloys), cobalt-based (cobalt-chromium, cobalt-nickel alloy, cobalt-chromium-molybdenum, etc.) and iron-based (stainless steel). Polymer materials refer to ultra-high polymer polyethylene, which is mainly used to make acetabular cup prosthesis and acetabular cup prosthesis lining. Alumina and zirconia ceramics have good inert stability and can be used in artificial joints for the cephalic portion of the artificial total hip joint. In both in vivo and in vitro experiments, the abrasion and wear rates of the artificial joint surfaces of alumina and zirconia were significantly reduced.
Depending on the different materials of the artificial total hip joint cephalic socket, the components of the joint bearing surface are.
①Metal-polyethylene;
②Ceramic-polyethylene;
③Metal-metal;
④ceramic-ceramic. The first two of these combinations are commonly used today.
According to the different fixation methods of artificial total hip prosthesis, they are divided into.
① Non-cemented biological fixation ;
②Bone cement fixation.
2.What is the service life of the artificial joint?
For patients who are about to undergo artificial total hip arthroplasty, the most important concern is the service life of the artificial joint. Although artificial total hip replacement has been widely carried out in China in the past decade, and orthopedic surgeons are becoming more and more mature, there is a lack of more frequent follow-up results. According to the results of foreign multicenter, large sample and long time studies, the survival rate of artificial joint reaches 80% in 20 years and 64% in 30 years, that is, about 80% of patients’ artificial joints can still be used 20 years after artificial joint replacement, and 64% of patients after 30 years, and the prosthesis they use is designed in 1970s or 1980s. In the 21st century, the material selection and design of artificial total hip prosthesis are now more reasonable, and the surgical techniques are widely improved, so the service life of the prosthesis is expected to be longer and the efficacy is more optimistic.
There are many factors affecting the service life of artificial joint prosthesis, the choice of prosthesis material and the location of the prosthesis (i.e., the orthopedic surgeon’s surgical technique) and the quality of the patient’s bone are the three main factors. 60% of the service life of the prosthesis depends on the surgical technique, 20% on the prosthesis material, and 20% on the quality of the bone. Among these factors, such as osteonecrosis of the femoral head, the occurrence of disuse osteoporosis due to long-term non-weight bearing of the affected limb, and the replacement of the artificial joint will definitely affect the service life. The Osteonecrosis and Joint Preservation and Reconstruction Center of China-Japan Friendship Hospital has accumulated more than 700 cases of artificial joint surgery experience, and since March 2003 was the first in China to carry out minimally invasive artificial hip and knee joint replacement under navigation guidance, achieving excellent results and accumulating a wealth of experience.
3.Bone cement artificial joint and its application.
In 1961, Carnley first introduced the technology of using bone cemented total hip joint, and this technology has been continuously improved and has developed to the fourth generation of bone cement technology, which has significantly extended the service life of joint prosthesis. The cemented total hip joint is mainly used for patients with osteoporosis or patients with straight barrel-like proximal femur and elderly patients (>65 years old).
4. Non-cemented artificial joints and their applications.
Its theoretical basis is that the porous metal surface of the prosthesis can occur bone growth into the prosthesis indicating that the bone is tightly compressed with the posterior bone union, thus achieving the purpose of biological fixation of the prosthesis, mainly for young and middle-aged people and good bone quality.
5, the application of minimally invasive surgery in artificial joint replacement.
With the continuous development of artificial total hip replacement surgery technology, it is possible to make small incision minimally invasive total hip replacement. Its surgical incision length is within 10cm, and the operation time is not prolonged or can even be shortened. This technique means more than simply a small incision; its technical focus is to reduce damage to ligaments, muscles and bone tissue, and to be safe, effective, repeatable and time-tested. The advantages are.
①Small incisions are aesthetically pleasing (intracutaneous sutures can be used);
②Less trauma to the soft tissues around the joint during surgery, less bleeding, less postoperative wound pain and fewer complications;
③ Early resumption of both daily life and function. Patients can walk on the ground with the help of crutches on the second to third day after surgery, which greatly reduces the complications in the perioperative period.
6, the application of navigation technology in artificial joint replacement.
Image-guided surgical navigation system is a new technology developed in the past 10 years and has been widely used in clinical practice. Since the angle of placement of the acetabular cup prosthesis is essential to prolong the life of the prosthesis, it is not very reliable when using mechanical guides for placement.
7.Femoral head surface replacement.
Since there is no fundamental solution to the osteolysis and prosthesis loosening caused by polyethylene abrasive debris of the cup after total hip arthroplasty, a kind of femoral head surface replacement, which preserves the amount of hip bone as much as possible and replaces only the surface of the femoral head, has come into being. This procedure is technically demanding and requires the training and clinical experience of an orthopaedic surgeon. It is considered as a transitional surgery and some people call it a “money for time surgery”, which can delay the time of total hip replacement. Common surgical complications include.
① Fracture of the femoral neck;
②Poor placement of the prosthesis;
(3) Loosening and dislocation of the prosthesis, etc.
Joint fusion
Hip fusion begins with the treatment of severe joint destruction caused by tuberculous arthritis, as well as significant joint instability and painful fibromuscular ankylosis. The advantages of a fused hip were that it was painless, absolutely stable and long-lasting, but over time it tended to cause low back pain and symptoms in the ipsilateral knee and contralateral hip. Until the late 1970s, this procedure was seen as an alternative to osteotomy and arthroplasty, especially in young patients with unilateral hip disease and heavy workload. In recent years hip fusion has been decreasing year by year.