Etiology of femoral head necrosis
The etiology of femoral head necrosis is diverse and complex, and it is difficult to classify comprehensively and systematically, which is related to the unclear pathogenesis. In our long-term theoretical research and clinical treatment, we have summarized more than ten common pathogenic factors as follows.
① Trauma causes femoral head necrosis. For example, external impact causes femoral neck fracture, hip dislocation, hip joint sprain and contusion, etc. Trauma is the main factor causing femoral head necrosis. However, the occurrence and extent of traumatic ischemic necrosis of the femoral head mainly depend on the degree of vascular destruction and the compensatory ability of the collateral circulation.
②Drugs cause femoral head necrosis. For example, long-term use of hormonal drugs due to bronchitis, asthma, rheumatism, rheumatoid, neck, shoulder, back and leg pain, diabetes, skin disorders, etc. It is an early statement that the accumulation of hormones in the organism due to the large amount or long-term use of hormones has led to the development of the disease. Recently, it is believed that the occurrence of femoral head necrosis is directly related to the type, dosage form and route of administration of hormones, and is not proportional to the total amount and time of hormone application. However, the long-term use of large amounts of hormones or excessive daily doses, and sudden changes in dose increases and decreases are also one of the reasons for the occurrence of femoral head necrosis.
③Alcohol stimulation causes femoral head necrosis. The accumulation of alcohol in the body due to long-term heavy drinking leads to the increase of blood lipids and damage of liver function. The elevation of blood lipids causes the increase of blood viscosity, slows down the blood flow, and changes the coagulation of blood, thus blocking the blood vessels, bleeding or fat embolism, and causing osteonecrosis. Clinical manifestations are aggravation after drinking, walking duck walk, heart failure, weakness, abdominal pain, nausea and vomiting, etc.
④ Wind, cold and dampness lead to femoral head necrosis. The clinical manifestations are hip pain, cold and dampness, and difficulty in squatting.
⑤ Liver and kidney deficiency causes osteonecrosis of the femoral head. The symptoms are generalized emaciation, yellow face, impotence, premature ejaculation, excessive dreaming, seminal emission, weakness, etc.
(6) Osteonecrosis due to osteoporosis. Clinical manifestations are weakness and weakness of lower limbs, pain, inability to bear weight, and easy to fracture.
(7) Osteonecrosis due to flat hip. Clinical manifestations are walking duck step, short lower limbs, muscle atrophy, pain gradually worsens around 50 meters, and limited function.
(8) Abnormal bone marrow hyperplasia leads to osteonecrosis. The symptoms are cold, soreness, inability to bear weight, easy fracture, and obvious bone atrophy.
⑨ Bone tuberculosis combined with osteonecrosis. The manifestation is positive nodule test, low fever in the afternoon, pain with a fixed location, wasting, night sweats, weakness, etc.
⑩Osteonecrosis after surgery. In the clinic bone necrosis occurs after three years of bone grafting, vascular transplantation, and insufficient blood supply to the bone.
In addition, there are pneumatic, radioactive, hematological, vascular diseases? (11) endure the simmering resentment of the cliff deng Lai take?
Among the above many factors, osteonecrosis of the femoral head caused by local trauma, hormonal drug abuse, and excessive alcohol consumption is common. The common core problem is the impaired blood circulation of the femoral head caused by various reasons, which leads to ischemia, degeneration and necrosis of bone cells.
The main symptoms of femoral head necrosis
① Pain. Pain can be intermittent or continuous, aggravated after walking activities, sometimes rest pain. The pain is mostly pins and needles, dull pain or soreness and discomfort, often radiating to the groin area, inner thigh, posterior hip and medial knee, with numbness in the area.
②Joint stiffness and limitation of movement. The affected hip joint has unfavorable flexion and extension, difficulty in squatting, inability to stand for a long time, and duck walk. The early symptoms are limited abduction and external rotation activities.
(iii) Limp. Progressive shortening limp, due to hip pain and femoral head collapse, or late onset of hip subluxation. Intermittent claudication is often seen in the early stage, and it is more obvious in children.
④Signs. Local deep pressure pain, pressure pain at the stop point of the adductor muscle, positive 4-letter test, positive Gaja s sign, positive A11is sign, positive TKdele latuq test. There is limitation of abduction, external rotation or internal rotation, shortening of the affected limb, muscle atrophy, and even signs of subluxation. Sometimes the axial stroke pain is positive.
⑤ X-ray manifestations. The bone texture is thin or interrupted, and the femoral head is cystic, sclerotic, flattened or collapsed.
The manifestation of pain in early and late stages of femoral head necrosis
The first conscious symptom of femoral head necrosis is pain, which is around the hip joint, inner thigh, anterior side or knee. In the early stage, the pain is vague, dull or intermittent, and the pain is aggravated by more activities and can be relieved or reduced by rest. However, there are also cases of persistent pain, regardless of exertion or rest, even when lying in bed. Moreover, the pain gradually increases. In this case, although there is no obvious abnormal morphological change on the X-ray, the function of the hip joint is already limited to different degrees. For example, the patient’s hip joint on the affected side is limited in abduction and rotation, and cannot squat in place. In the advanced stage of Chinese medical health, the femoral head collapses, fractures and deforms, and some of them may cause hip dislocation, and the pain is directly related to the hip joint activities and weight bearing. The pain is directly related to the movement and weight-bearing of the hip joint. The pain is caused by bony friction in the joint when moving, but it is not obvious when there is no friction between the head and socket at rest. Therefore, the pain is aggravated by walking and activity, while the pain is relieved by movement.
Treatment of femoral head necrosis
1.Conservative treatment.
Conservative treatment is mainly adapted to early patients whose femoral head is not deformed. Conservative treatment can only be considered as always care and health care, and cannot be considered as a treatment method, so conservative treatment does not play the role of treating femoral head necrosis. Its methods include.
(1) Try to avoid the adverse stimulation of the external environment on the human body. A beautiful natural environment, a good social environment, and a happy family atmosphere are conducive to spiritual recuperation, thus it is important to actively create such an environment and atmosphere and try to avoid adverse stimuli from the natural environment, social environment, and family factors. Family members and patients should actively cooperate with doctors in the treatment of this disease to prevent adverse stimulation from exogenous mental stimulation and indirectly form endogenous factors on the organism. Mental burden can indirectly affect the body’s orderly physiological functions, but also due to abnormal emotional changes, aggravating the disease, affecting physical and mental health.
(2) Restriction of weight-bearing, bed rest with traction, hip herringbone cast fixation, etc.: to facilitate the healing and reconstruction of femoral head necrosis, but the effect of the treatment method of avoiding weight-bearing alone is not ideal, with a success rate of less than 15%, mainly suitable for femoral head necrosis whose lesions are located on the medial side of the femoral head.
(3) Prevention and treatment of osteoporosis: adequate calcium and vitamin D supplementation, use of some osteoporosis treatment drugs such as calcitonin or alendronate, etc;
(4) Lipid-lowering drugs and anticoagulants: Some studies have reported that the occurrence of osteonecrosis was significantly reduced when statins (lovastatin, fluvastatin, atorvastatin, etc.) were used in combination with hormones, suggesting that statins can prevent the occurrence of osteonecrosis.
(5) Physiotherapy: mainly through the thermal effect or mechanical stress on bone tissue or cells after the action, causing potential changes and cavitation effect, etc., activating cells and tissues, activating cell proliferation, promoting tissue growth, thereby improving local blood circulation. Physical therapy includes shock wave, ultrashort wave, fractional meter wave, electrical stimulation and other treatment methods.
(6) Interventional therapy: Interventional therapy is the direct injection of thrombolytic, anticoagulant, vasodilator and Chinese medicine into the blood supply arteries of the femoral head, such as the internal and external femoral artery and the closed artery, or cannula perfusion with the injection of bone growth promoter in the local necrotic area, in order to expand the blood vessels in the femoral head area, dissolve fat emboli, unblock the microcirculation of the femoral head, improve the local blood supply, promote new bone growth and repair the necrotic femoral head.
(7) Hyperbaric oxygen therapy: to promote femoral head repair by increasing the partial pressure of blood oxygen and improving bone cell hypoxia.
(8) Stem cell therapy: bone marrow mesenchymal stem cells are stem cells with multi-directional differentiation potential derived from the mesoderm, which mainly exist in connective tissue and organ mesenchyme throughout the body, with the most abundant in bone marrow tissue. After isolated and cultured in vitro, bone marrow MSCs have the ability to differentiate into osteoblasts, chondrocytes, neuronal cells, adipocytes, cardiomyocytes, etc. under certain induction conditions. It promotes early microcirculation reconstruction, thus enhancing blood supply and creating a microenvironment for vascular regeneration, which contributes to early repair of ischemic necrotic area of femoral head. At present, stem cell therapy is only applied to early stage of femoral head necrosis, and the long-term efficacy needs to be further observed. Stem cell therapy has important research and application prospects, but its induction differentiation process and related mechanisms need further research.
(9) Traditional Chinese medicine treatment: Su et al. used 20g each of Shu Di, Cornu Cervi Pantotrichum and Fructus Lycii, 15g each of Sheng Di, Cistanches and Bonesetters, 10g each of Ze Di, Yam, Epimedium, Paeoniae, Panax notoginseng, Dan Pi, Safflower, Eucommia, Radix et Rhizoma, 25g each of Astragali, Angelicae Sinensis and Chuan Xiong, 30g of Salviae Sinensis and 5g of Glycyrrhiza glabra. The treatment is divided into 6 types: Qi stagnation, blood stasis, wind-cold dampness, phlegm-dampness, qi-blood deficiency, liver-kidney yin deficiency and spleen-kidney yang deficiency.
2.Surgical treatment.
Surgery is the main method of treatment for ischemic necrosis of the femoral head in the middle and late stages, but surgery is not suitable for all the people, surgery for necrosis of the femoral head has a large risk, high cost and other disadvantages. Moreover, the femoral head has to be replaced every few years after surgery, so even if we don’t consider the cost, we have to consider whether the patient’s body can bear it.
(1) Medullary core decompression + simple bone grafting: At present, simple medullary core decompression of the femoral head (because it can accelerate the collapse of the femoral head) is used less often, and medullary core decompression + simple bone grafting is generally used, which once became popular for the treatment of ischemic necrosis of the femoral head because it not only removed the necrotic bone but also reduced the intraosseous pressure, while providing limited mechanical support.
(2) Marrow core decompression + vascular bundle implantation or bone grafting with blood transport: Although marrow core decompression plus simple bone grafting achieves better efficacy, the implanted bone has no blood transport and the vast majority of the bone may become necrotic. In order to solve the blood transport of the transplanted bone, vascular bundle implantation or iliac flap with vascular tip and vascular bundle implantation or large bone flap with vascular tip or with myotis plus vascular bundle implantation with dead bone removal is used to achieve good results.
(3) Osteotomy: The principle of osteotomy is to change the line of gravity of the femoral head by osteotomy, rotating the necrotic area from the weight-bearing area to the non-weight-bearing area to create conditions for its repair. The efficacy of osteotomy has been improved through continuous improvement.
(4) Periosteal transplantation: Some people have designed iliac periosteal transplantation with rotating deep iliac vessels to treat ischemic necrosis of the femoral head, and its blood supply implantation is indeed reliable, which can rebuild the blood circulation of the femoral head and fundamentally reduce the intraosseous pressure. The inner layer cells of the tipped periosteum can differentiate into osteoblasts, which has a positive effect on the repair of femoral head necrosis.
(5) Femoral head surface replacement and femoral head resurfacing: for patients with severe subchondral bone collapse in late stage, femoral head replacement, bipolar artificial femoral head replacement and artificial total hip replacement can be chosen, but these methods have high incidence of late joint loosening, prosthesis sinking and many complications. Therefore, some people use femoral head surface replacement treatment to achieve better results, and believe that femoral head resurfacing surgery can replace femoral head hemispheric replacement, bipolar femoral head replacement and total hip replacement, which is especially suitable for adolescents.
Prevention of femoral head necrosis
1. Be sure to strengthen the awareness of self-protection of the hip.
2. Pay attention to your feet when walking and be careful of falling, especially in winter when walking on snow and ice.
3. Before playing sports, prepare your hip well and feel your body is warm and your limbs are flexible.
4. When carrying and carrying heavy objects, avoid spraining the hip and try not to do heavy work.
5, hip injuries should be treated in a timely manner, do not walk too much before the injury is healed, so as not to repeatedly damage the hip joint.
6, in the treatment of certain diseases, especially some painful diseases, try not to use or use less hormonal drugs.
7, Try not to develop the problem of drinking a lot of alcohol for a long time.
8. Use strong internal fixation for femoral neck fracture, and also apply bone graft with vascular tip bone flap head to promote femoral neck healing, increase blood flow to the head and prevent osteonecrosis, regular follow-up should be done after surgery, and appropriate oral herbal medicine and calcium to promote blood flow and prevent the occurrence of ischemic femoral head.
9.When hormones must be applied because of related diseases, the principle of short-term and moderate amount should be mastered, together with vasodilators, vitamin D and calcium, etc. Do not abuse hormonal drugs without listening to medical advice.
10, should change the bad habits of long-term alcohol abuse or abstain from alcohol, get rid of the contact environment of the causative factors, remove the chemical toxicity of alcohol and prevent tissue absorption.
11, occupational factors such as deep-water divers, high-altitude pilots, high-pressure work environment should pay attention to labor protection and improve working conditions, and those who have fallen ill should change the type of work and seek timely medical treatment.
12, diet should be done: do not eat chili, do not drink alcohol in excess, do not eat hormonal drugs, pay attention to increase the intake of calcium, eat fresh vegetables and fruits, more sunshine, prevent weight bearing, regular activities, etc. have a preventive effect on femoral head necrosis