I. Definition.
Hormonal osteonecrosis of the femoral head is a pathological process caused by hyperadrenocorticism or increased exogenous cortisol, with the death of the active components of bone (osteocytes, bone marrow hematopoietic cells and adipocytes) as the main pathological change, which is generally considered irreversible and eventually leads to femoral head collapse, hip pain, dysfunction and high disability rate, and is a difficult to treat disease in orthopedic surgery.
Diagnostic criteria
(A) Medical history
There is a conclusive history of long-term or short-term intermittent high-dose hormone use, or long-term alternating use with non-steroidal anti-inflammatory and analgesic drugs. The time of onset varies and is related to the total dose of hormones. In some patients, there is minor trauma as a trigger for the onset of symptoms.
(II) Symptoms
The main symptom is hip pain, which is vague and gradual and dull, or it can be acute and severe. The vague and gradual dull pain is often located in the groin area, with mild limp, obvious from standing or walking activities and relieved after rest, some downward pain to the front of the femur, hip or medial knee, some low back pain, rest pain and intermittent limp at a later stage, etc. In those with mild symptoms, there is often a feeling of stiffness in the affected hip. The painful hip may be limited by muscle spasm, but sometimes there are two intervals between painful episodes, at which time the function of the affected hip returns to normal. Most of the time, the pain develops on one side first and then involves the opposite side. In the later stage, the symptoms worsen and limping, squatting and cross-legged movements become obvious, and some people need to walk with crutches. If the disease is bilateral, the gait is staggering and walking is difficult.
(C) Physical signs
In the early stage, there is only localized pressure pain (the starting point of the internal femoral retractor muscle, the midpoint of the groin, the starting point of the suture muscle, the lateral ramus of the hip joint and the gluteus medius are common pressure points). In the late stage, the hip joint is limited in all directions, the limb is shortened, flexion and internal contracture deformity, muscle atrophy, and the affected hip may show signs of subluxation, and the Trendelenburg sign is positive.
(IV) X-ray performance
The posterior anterior, lateral or tomographic films of the hip should be taken, and it is necessary to take both hips to compare the densities. Important signs of early lesions are often found on lateral and tomographic films. Clinically, the x-ray presentation can be divided into 4 stages.
Stage I: subchondral lysis stage. The head shape is normal, and only in some areas (such as the weight-bearing area) subchondral cystic changes or “crescentic signs” appear.
Stage II: head necrosis stage. The shape of the head is still normal, but there are areas of increased density in the outer or upper part of the head and in the middle of the head, and sometimes there are sclerotic bands around the head.
Stage III: head collapse stage. The head appeared stepwise collapse or bimodal sign, subchondral subtle fracture line, flattening of weight-bearing area, and surrounding osteoporosis.
Stage IV: Head dislocation stage. The necrotic area continues to develop inward and downward, the head is flattened, hyperplastic and hypertrophied, and may dislocate outward and upward, the joint space is narrowed, and the acetabular rim is hyperplastic and sclerotic.
(E) ARCO staging combining X-ray, CT, MRI, bone scan and bone biopsy
Stage 0: bone biopsy results are consistent with ischemic necrosis, but all other tests are normal.
Stage I: positive bone scan or positive MRI or both, depending on the location of femoral head involvement, the lesion is subdivided into medial, central and lateral.
ⅠA: femoral head involvement <15%.
ⅠB: femoral head involvement 15%-30%.
ⅠC: femoral head involvement >30%.
Stage II: abnormal radiographs (femoral head speckled presentation, osteosclerosis, cyst formation and osteoporosis), no femoral head collapse on radiographs and CT films, positive bone scan and MRI, no acetabular changes, depending on the location of femoral head involvement, lesions subdivided into medial, central and lateral.
IIA: femoral head involvement <15%.
IIB: femoral head involvement 15% to 30%.
IIC: femoral head involvement >30%.
Stage III: crescentic sign, depending on the location of femoral head involvement, the lesion can be subdivided into medial, central and lateral.
IIIA: crescentic sign <15% or femoral head collapse >2mm
IIIB: crescentic sign 15% to 3%0 or femoral head collapse 2 to 4 mm.
ⅢC: crescentic sign >30% or femoral head collapse >4mm.
Stage IV: X-ray shows flattening of the articular surface of the femoral head, narrowing of the joint space, sclerosis of the acetabulum, cystic changes and marginal bone redundancy.
The extent of involvement within the femoral head is determined by MRI, and the femoral head collapse depends on the frontal and lateral X-rays. The percentage of crescent sign refers to the length ratio of the crescent sign to the joint surface of the femoral head.
Identification and typing
(A) Qi stagnation and blood stasis evidence
The main symptoms are hip pain and mild claudication, with a purple tongue or petechiae, and astringent pulse.
(B) Liver and kidney deficiency evidence
The main symptoms are hip joint dysfunction and periprosthetic pain, accompanied by weakness and soreness of the lower limbs, with a pale tongue and thin coating and a sunken and stringent pulse.
(C) Qi and blood deficiency and deficiency of both liver and kidney
Intermittent pain in the hip, weakness of the lower limbs, unfavorable joint flexion and extension, accompanied by fatigue and shortness of breath, with thin white tongue coating and slippery pulse.
IV. Treatment plan
(I) Treatment principles
1. Internal treatment: to activate blood stagnation and relieve pain; to nourish the liver and kidney, to nourish the blood and fill the marrow; to consolidate the essence and cultivate the yuan, to nourish both the qi and blood.
2. External treatment: external application of ointment, external washing or ionization of Chinese medicine, manipulation, traction, electrical pulse stimulation and electromagnetic field stimulation, and surgery can be used.
3. Regardless of internal and external treatment, smoking and alcohol should be avoided, weight control, avoid heavy physical labor, avoid trauma and maintain a good mood.
(B) Identification and treatment
1.Cognitive treatment
(1)Qi stagnation and blood stasis
①Treatment: activating blood circulation and resolving blood stasis, promoting circulation and relieving pain.
(2) Prescription: Body Pain and Stasis Removal Soup or Peach and Red Four Objects Soup.
Body Pain and Blood Stasis Soup: Peach kernel 9g, safflower 9g, Chuanxiong 6g, myrrh 6g, wulin 6g, gentiana 3g, aromatic herb 3g, qiangwu 3g, dilong 6g, angelica 9g, niu knee 9g, licorice 6g.
Tao Hong Si Wu Tang: Peach kernel 9g Safflower 6g Chuanxiong 6g Angelica sinensis 9g Radix Rehmanniae 12g Paeonia lactiflora 9g
③ Chinese patent medicines.
ⅠYunnan Baiyao capsule orally, 2 capsules each time, 3 times daily.
Ⅱ Qi Li capsule orally, 3 capsules each time, 3 times a day.
(2) Liver and kidney deficiency
①Treatment: Tonify the liver and kidney, nourish the blood and enrich the marrow.
②Pharmaceuticals: Liu Wei Di Huang Wan.
Six Flavors Dihuang Pill: Shu Di Huang 24g Huai Shan Yao 12g Ze Di 9g Dan Pi 9g Fu Ling 9g Shan Yu Flesh 12g
③Chinese patent medicines.
Ⅰ Liu Wei Di Huang Wan Oral, 6g each time, 2 times daily.
Ⅱ Jin Kui Kidney Qi Pill orally, 6g each time, twice a day.
(3) Qi and blood deficiency, liver and kidney deficiency
①Treatment: Strengthening the root and nourishing both qi and blood.
②Pharmaceutical formula: Right Return Pill + Eight Precious Soup.
Right Return Pill + Eight Precious Soup: Ginseng 9g Atractylodes Macrocephala 9g Poria 9g Radix Angelicae Sinensis 9g Chuanxiong 6g Radix Rehmanniae 9g Radix Paeoniae Alba 9g Radix et Rhizoma Glycyrrhiza Glabra 5g Semen 12g Cornus Officinalis 9g Fructus Lycii 9g Semen Cuscutae 12g Deerstalker 12g Eucommia 12g Cinnamon 6g Radix et Rhizoma Prepared 6g
③Chinese patent medicines.
Ⅰ Angelicae Blood Tonic Cream Oral, 6g per dose, 3 times daily.
ⅡTurtle and Deer Erxian Gum orally, 6g each time, twice a day.
2.Other treatment methods
(1) Topical medicine: Peach kernel, safflower, samphire, frankincense, myrrh, rhubarb, etc. are mainly used to activate blood circulation and resolve blood stasis, supplemented by Sichuan pepper, pseudostellaria, nanxing, etc. to warm the meridians and relieve pain. Ointment, decoction or ionization can be applied externally.
(2) Traditional techniques: Start with light techniques such as pointing, pressing and kneading, mainly acting on the painful points around the hip and the corresponding acupuncture points; after relaxation, use heavier techniques to act on the muscles around the hip and the lower limbs; finally move the hip joint slowly to increase the mobility and end the treatment with pulling and tapping techniques.