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.
①Drug therapy.
From the domestic and foreign literature, so far mankind has not really found a drug with reliable efficacy that can cure femoral head necrosis. Nevertheless, pharmacological treatment is still the preferred method of all non-surgical treatments. According to the current understanding of the pathogenesis of femoral head necrosis, i.e. the doctrine of vascular injury, pharmacological treatments are classified 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 of 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 is more effective in preventing femoral head collapse.
Other drugs: non-steroidal anti-inflammatory drugs – relieve joint pain and other symptoms, facilitate restoration of joint function and prevent joint deformity. Cartilage-protective drugs (Vibram) – have the effect of repairing joint cartilage, protecting and delaying the destruction of joint cartilage.
②High frequency magnetic field.
Magnetic therapy is a proven treatment for promoting 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 used in the treatment of femoral head necrosis can improve microcirculation and promote the growth of blood vessels into the necrotic foci, which has better efficacy in relieving pain symptoms and can be used as an adjunct to the treatment of early femoral head necrosis.
③Extracorporeal 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 its characteristic of causing 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 stage I ischemic necrosis of the femoral head was treated with hyperbaric oxygen therapy, in which patients inhaled 100% oxygen with a mask in a hyperbaric chamber at 2 to 2.4 atmospheres for 90 minutes/day, 6 times a week, for a total of 100 treatments. 81% of patients with stage I ischemic necrosis of the femoral head recovered normal MRI after hyperbaric oxygen therapy, while only 17% of patients without hyperbaric oxygen therapy recovered, thus 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% The modified method of Osteonecrosis and Joint Preservation and Reconstruction Center of China-Japan Friendship Hospital is to extract about 150 ml of bone marrow each time, separate the bone marrow cells by cell separator, compress them to 7-10 ml, and use X-ray fluoroscopy or navigation guidance to fine target multiple perforations in the osteonecrosis area, to The compressed bone marrow cells plus osteoinductive factor (BMP2) were pressurized and punched into the decompression zone. The preliminary results are good after more than 6 months of follow-up in several cases. The advantage of this method is that it is less invasive and allows early debridement. The disadvantage is that it is not effective if the osteonecrosis is well defined and has cystic changes.
(2) Open window through the femoral head neck, bulb decompression in the decompression zone, and compression bone grafting.
This method is suitable for middle-aged and young patients with stage II or early stage III with clear necrosis boundary, necrotic area close to the joint surface and necrosis area greater than 15% to 30%. 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 by compression. According to the osteonecrosis center of China-Japan Friendship Hospital, more than 100 cases were followed up for more than 4 years, and the excellent rate of stage II was 100%, and early stage III was 75%, which was better than foreign reports.
(3) Lesion removal and vascularized fibular bone graft.
It is suitable for early stage III and IV young patients (less than 40 years old). This procedure is slightly more invasive and requires two incisions, but the excised fibula implanted with blood flow (living bone) and good mechanical support is desirable for femoral heads that have begun to collapse. Domestic and foreign clinical reports show that the 10-year excellent rate is between 60% and 70%.
(4) Osteotomy.
In some young patients (less than 45 years old), where the necrotic focus is located in the weight-bearing zone and there is no osteonecrosis in the non-weight-bearing zone, the necrotic focus can be moved to the non-weight-bearing zone and the normal cartilage surface is transferred to the weight-bearing zone to protect the femoral head from collapse by trans-femoral trochanteric rotational osteotomy or internal and external osteotomy. The requirements of this type of surgery make the joint mobility better and the physician has experience to achieve better results.
(5) It should be understood that.
The surgery to preserve the femoral head makes to avoid or delay the artificial joint replacement surgery. Because no matter how hard one tries, there will always be some patients with femoral head necrosis who eventually need artificial joint surgery, therefore, surgical treatment to preserve the femoral head should try not to leave behind the difficulties to do artificial joint surgery, from the above several procedures, (1), (2) and (3) are more in line with this situation.
Currently some medical units are keen on vascular interventions, we believe that this therapy is harmful and unhelpful. Because according to the experience of cardiovascular and cerebrovascular embolism treatment, thrombolysis is effective only 6-12 hours after embolization. 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, which can aggravate the ischemia by damaging the undamaged vessels.