A. What is called femoral head necrosis?
Femoral head necrosis, known as aseptic necrosis of the femoral head or ischemic necrosis of the femoral head, is a lesion caused by poor local blood flow to the femoral head for a variety of reasons, resulting in further ischemia, necrosis of bone cells, fracture of bone trabeculae, and collapse of the femoral head. Since 1888, when the disease was first recognized by the world medical community, osteonecrosis of the femoral head has been transformed from an uncommon disease to a common and frequent disease. Especially since the introduction of hormones and their widespread use, the incidence of femoral head necrosis has gradually increased. In addition, the increase in the number of accidents after the change of transportation and the change of people’s life style have made the number of patients with this disease increase dramatically. According to incomplete statistics, there are currently 30 million people with osteonecrosis of the femoral head worldwide, and about 4 million in China. The latest survey shows that there is no significant gender difference in the occurrence of osteonecrosis of the femoral head, and the disease can occur at any age, while the incidence of the disease increases significantly in people with a history of hormone application, hip trauma, alcoholism, and related diseases.
Femoral head necrosis can occur at any age, but it is most common at the age of 31-60 years old, with no gender difference. It starts with hidden pain and dull pain in the hip joint or its surrounding joints, which is aggravated by activities.
Second, the stages and clinical manifestations of femoral head necrosis
The first conscious symptom of femoral head necrosis is pain, and the location of pain is around the hip joint, inner thigh, anterior side or knee. In the early stage, the pain starts as vague, dull or intermittent pain, which is aggravated by more activities and can be relieved or reduced by rest. However, there are also cases of persistent pain, whether it is from exertion or rest, or 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 femoral head necrosis, the femoral head collapses, fractures and deforms, and some of them may cause hip dislocation, and the pain is directly related to hip joint activities and weight bearing. The pain is caused by bony friction in the joint when moving, but the pain 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 stopped or reduced by movement. In short, the early stage is dominated by pain with functional limitation; the late stage is dominated by functional impairment with pain.
Femoral head necrosis stage I (ultrastructural variant stage).
X-rays show disorganized and fractured bone trabecular structures in the bearing system of the femoral head, with the appearance of hairy femoral head edges, with or without limited mild pain clinically.
Femoral head necrosis stage II (sensitized stage).
X-rays show small cystic lesion shadows inside the femoral head with uneven density in the ring area around the cystic lesion area. The bone trabecular structure is disturbed, sparse or blurred. Small collapses may also appear, and the area of collapse may be 10-30%. The clinical condition is accompanied by significant pain and slight restriction of movement.
Femoral head necrosis stage III (necrotic stage).
X-rays show morphological changes of the femoral head, including incomplete, worm-like or flattened edges, partial loss of bone trabeculae, uneven bone density, widening or narrowing of the acetabulum and femoral head gap, and formation of redundant bone.
Femoral head necrosis stage IV (disabling stage).
The morphology and structure of the femoral head are obviously changed, with large irregular collapse or flattening, and structural variation of bone trabeculae. The gap between the acetabulum and the femoral head disappears, etc. The clinical manifestations are pain, dysfunction, stiffness and inability to walk, dislocation or subluxation, and limitation of functional activities of the involved knee joint.
Since osteonecrosis often involves both sides, most patients end up with joint deformity and secondary osteoarthritic changes. Although there are numerous treatment methods available, none of them are sure of their efficacy, making treatment quite tricky. However, it has been proven that the earlier the treatment, the better the results. Because ischemic necrosis of the femoral head is common and difficult to deal with, treatment is used as an example.
Third, how to determine the early femoral head necrosis disease
Femoral head necrosis, the earliest symptom is hip joint soreness, sleepiness, and sometimes intermittent pain. This is the main symptom of the disease. There are many causes of hip joint pain, such as trauma, hip dislocation, degenerative disease, inflammation, tumor, lumbar spine disorders and medical and dermatological diseases, which can cause hip joint pain. Femoral head necrosis is only one of the many diseases that cause hip pain.
Self-examination to determine if you have osteonecrosis of the femur can be done from the following aspects.
(1) Hip pain radiating to the inguinal region or to the posterior, lateral or medial side of the hip or knee.
(2) Stiffness, weakness and limited movement of the hip joint, inflexibility in lifting the leg, early appearance of symptoms such as planking or outward skimming of the leg as well as difficulty in squatting.
(3) Limping: the affected limb does not dare to put weight on it when walking, like walking on tiptoe.
(4) After the fracture, dislocation or sprain of hip joint heals, intermittent or persistent pain in the hip appears gradually or suddenly. The pain is aggravated after walking activities, sometimes it is resting pain, and the pain is mostly pins and needles or soreness, and the above-mentioned reaction occurs.
(5) Hip pain occurs in people who use a lot of hormones for a long time or for a short time or who often drink alcohol, and it is mostly vague or dull pain, often located in the groin, obvious when moving and relieved after rest.
(6) Cold and damp: When the weather is cold, the hip joint becomes sore and painful, and the function is limited.
(7) Inflammation: When you have a cold and fever, the blood sedimentation is accelerated and the white blood cells are elevated, which increases the pain in the affected hip joint.
If the above-mentioned conditions occur, it is possible to suffer from osteonecrosis of the femoral head, which needs to be diagnosed in hospital.
Four, femoral head necrosis treatment methods
1.Conservative treatment
(1) Avoid weight-bearing: you can rely on cane, axillary cane and other supports to strictly limit weight-bearing, which can restore blood supply to ischemic tissues and protect them from pressure, so as to control the development of lesions, prevent collapse and promote the healing of ischemic necrosis of the femoral head by itself. However, it is generally believed that weight-bearing restriction cannot save the development of femoral head necrosis. This method is mainly applied to elderly patients who are not suitable for surgical treatment, poor general condition, progressive ischemic necrosis and patients with poor prognosis. The possibility of self-healing is related to the size of the lesion and the distance from the joint surface: if the lesion is small or far from the joint surface, it can mostly heal by itself; if the lesion is adjacent to the joint surface or if the lesion is large in scope, the possibility of self-healing is extremely small even without weight-bearing.
(2) Electrical stimulation: it has osteogenic effect and can promote fracture healing. Electrical stimulation can be used as an independent treatment for osteonecrosis or as an adjunct to surgery.
2.Surgical treatment
(1)Treatment of preserved femoral head, applicable to early osteonecrosis of femoral head.
(1) Borehole decompression: it can reduce intraosseous pressure, promote venous reflux, release trophoblastic vascular spasm, so that new blood vessels can grow down the bone hole to the ischemic area. It is mainly used for patients without joint surface collapse in early stage, and is the simplest surgical method to treat osteonecrosis.
②Osseous grafting: Because it is necessary to drill holes before bone grafting, it is also called drilling and decompression osteotomy. There is both drilling and decompression, bone graft to provide mechanical support, and bone graft with myotome to increase the blood supply to the femoral head.
(3) Osteotomy: By changing the corresponding position between the femoral head and the femoral stem, it can increase the weight-bearing area of the femoral head, reduce the pressure on the femoral head, move the necrotic lesion out of the weight-bearing area, and thus reduce the local stress, at the same time, the osteotomy opens the medullary cavity, which can reduce the intraosseous pressure and improve the blood circulation of the femoral head.
(2) Arthroplasty
It should be used for patients with collapsed femoral head necrosis, and metal cup arthroplasty, joint surface replacement, femoral head replacement, total hip replacement, etc. are feasible.
3.The medicine of femoral head necrosis
V. Diet of osteonecrosis of femoral head
You can choose some dairy products with a relatively moderate calcium to phosphorus ratio, which can make calcium and phosphorus and other substances fully absorbed food. Milk also contains protein, lactose and other substances. If you drink 2 cups of milk (about 480 ml) per day, it is enough to meet the calcium requirement of adults. Of course, since older people already lose a lot of calcium, they need even more calcium. Rational meal preparation from the diet can help in the treatment of osteonecrosis of the femur. In order to better absorb the calcium and phosphorus in dairy products, it is important to consume dairy products with regular “sunshine” for about one hour a day to get better results. In addition to dairy products, another food that contains more calcium is animal bone broth. However, bone soup has less calcium ions and a lower concentration of calcium, so when cooking soup, the bones are first cracked to increase the rate of dissolution of minerals and proteins.
Staple food: should be mainly rice, noodles, mixed grains, to achieve a variety of varieties, coarse and fine with. Side food: should eat more calcium-containing foods, such as milk, dairy products, lamb liver, pig liver, shrimp, beans, seaweed, eggs.