Aseptic necrosis of the hip joint: symptoms, diagnosis, treatment and consequences

Necrosis of the femoral head is the process of destruction of the bone mass of the femoral head as part of a circulatory disorder.

The reasons for this may be different - some of them are still unknown. Necrosis of the femoral head is death of the bone without any infection. If treatment appropriate to the stage of the disease is not carried out in time, irreversible destruction of the hip joint occurs, which leads to the accelerated development of arthrosis, even if there is no circulatory disturbance in the cartilage. Destruction occurs mainly due to a decrease in the strength of the femoral head dying under the cartilage, and the cartilage breaks, which can lead to arthrosis. If left untreated, 85% of patients experience failure of the femoral head and arthrosis of the hip (Coxarthrose).

What happens in the bone?

As a result of circulatory disorders, bone cells die, because the blood vessels supplying the head remain blocked.

As a result, the supply of oxygen, minerals and nutrients to the bone of the hip joint is very limited.

The main function of bone cells is to maintain a balance between the decrease and increase of bone during the process of its adaptation to changing loads. The dead bone tissue of the hip joint can no longer support this natural process.

As a result, the bone beams lying inside the bones, which are responsible for the stability and shape of the femoral head, are no longer renewed: the bones affected by necrosis break due to insufficient strength. A hole forms in the bone under the cartilage! The underlying cartilage can be severely damaged and there is a risk of arthrosis of the hip joint! The result is irreversible damage to the joint and bone mass.

Comparing with the frozen surface of a lake, where the ice breaks where its layer is not thick enough, the bone also breaks in the thinnest place.

The biggest problem with femoral head necrosis is that the disease affects the regions adjacent to the joint and therefore leads to joint destruction. Bone infarcts, for example, which are often diagnosed incidentally on x-rays, lie within the bone away from the joint and therefore do not play a major role.

ANGKB stages according to ARCO

However, in Russia the classification into five stages is more common:

1. There are no radiological signs. The histological specimen shows signs of necrosis of the spongy substance of the head and bone marrow structures. Clinically expressed by aching pain and stiffness in the joint, increasing muscle weakness.
2. multiple impression fractures. Against the background of necrosis, many microscopic fractures occur. The radiograph shows a homogeneous darkening of the femur, its height is reduced, the surfaces of the head in places are in the form of compacted facets, the joint space is widened. MRI data indicate a necrotic defect in the head.
3. sequestration. The articular head is flattened and looks like structureless isolated fragments with different shapes and sizes. The neck of the bone shortens and thickens, and the joint space widens even more.
4. reparative. The spongy substance of the femoral head is restored. On X-ray, sequestration-like zones are not noticeable; the shadow of the head is outlined, but with rounded cyst-like clearings.
5. secondary deforming arthrosis. The bone structure of the femur begins to be traced, significantly changed, the congruence of the articular surfaces is disrupted.

Disease in dynamics.

Important: collapse of the femoral head occurs in an incredibly short period of time - 5 months.

What leads to necrosis of the femoral head?

The most common causes of necrosis of the femoral head in adults:

• Injuries with damage to the vessels of the femoral head, for example after a femoral neck fracture (post-traumatic necrosis of the femoral head)
• destruction of the femoral head due to alcohol consumption (ethyltoxic necrosis of the femoral head)
• destruction of the femoral head due to radiation (postradial necrosis of the femoral head)
• destruction of the femoral head due to the use of cortisone (glucocorticoid necrosis of the femoral head)
• use of anti-cancer drugs with bone-damaging effects
• damage to scuba divers when ascending too quickly (caisson or decompression sickness)
• Occupational diseases of divers and mountain builders
• circulatory disorders of the femoral head due to impaired metabolism (increased bile acid, increased blood sugar in Diabetes mellitus, impaired fat metabolism)
• hip diseases as a consequence of kidney disease (renal necrosis of the femoral head)
• necrosis due to bleeding disorders blood cell cancer

Despite modern diagnostic methods and a good research base, not all causes of necrosis of the femoral head are already known. Patients regularly come to our clinic with circulatory disorders of the femoral head and all signs of necrosis of the femoral head, but for whom none of the above-mentioned causes can be traced.

Disability

ANGKB affects all areas of life: health, performance, socialization. With a long duration of the disease at different stages of conservative treatment, patients were forced to change activities with increased physical activity. They choose professions that do not require long periods of being on their feet, moving, or close to their place of residence.

The disability group of such people is determined during a medical and social examination in accordance with the Appendix to the Order of the Ministry of Health of the Russian Federation dated January 27, 1977 No. 33 to the Resolution of the Ministry of Labor and Social Development of the Russian Federation dated January 27, 1977 No. 1: “Classifications and temporary criteria used in the implementation of medical social expertise".

Disability is assigned based on the severity of the disease and decreased quality of life. Changes in the level of disability were carried out only in the case of surgical intervention.

In other words, surgical intervention is most effective in treating aseptic necrosis. Despite the impressiveness of conservative treatment methods, proven effectiveness is questionable.

What are the early symptoms?

Necrosis of the femoral head at an early stage manifests itself in gradually occurring nagging pain in the groin or sudden shooting pain in the groin. Initial complaints usually do not indicate a cause. The hip joint can no longer cope with everyday stress. In addition, limited mobility during inward movements is often observed.

Severe pain in the hip or groin usually occurs when the femoral head prolapses.

Therefore, diagnosis and initiation of treatment are often delayed.

Pharmacological drugs

Most medications used in the treatment of coxarthrosis are prescribed to patients to eliminate symptoms. For pathology of 1st degree of severity, medications are used in the form of tablets and (or) ointments. And to reduce the severity of severe pain in coxarthrosis at stages 2 or 3, solutions for intramuscular injections, periarticular, periarticular, and intraarticular blockades are used.

Elimination of pain

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first choice drugs for eliminating the pain that occurs when the hip joint is destroyed. These are Piroxicam, Indomethacin, Diclofenac, Ketoprofen, Ibuprofen. NSAIDs are not intended for long-term use, since their active ingredients negatively affect the liver, kidneys, gastrointestinal tract, and also suppress the ability of cartilage tissue to regenerate.

Often, NSAID ointments or gels are prescribed along with tablets:

• Nurofen;
• Fastum;
• Ketonal;
• Finalgel;
• Nise.

This method of treatment allows to reduce the pharmacological load and minimize the likelihood of damage to internal organs. An analgesic effect also occurs when using warming ointments - Finalgon, Capsicam, Apizartron, Nayatox. Their components have a pronounced local irritating and distracting effect, stimulating the acceleration of blood circulation.

And Menovazin solution and Espol cream relax skeletal muscles, eliminating painful muscle spasms.

Improving blood supply to the joint with nutrients

The use of drugs that accelerate blood circulation in it helps to stop further destruction of the hip joint. These are Stugeron, Cinnarizine, Trental, Pentoxifylline, Xanthinol nicotinate. A course of medications helps eliminate the deficiency of nutrients and bioactive substances and prevents spasms of small blood vessels.

If necessary, the therapeutic regimen includes muscle relaxants (Mydocalm, Sirdalud, Tizanidine) - drugs that relax striated muscles and reduce the severity of pain.

In the treatment of pathologies accompanied by destruction of the hip joints, chondroprotectors are necessarily used: Artra, Structum, Teraflex, Alflutop, Dona. Their active ingredients are glucosamine and (or) chondroitin - substances that stimulate the restoration of damaged hyaline cartilage. But taking chondroprotectors is effective only for coxarthrosis of 1st degree of severity. Experienced orthopedists prescribe them to patients either in tablets or in solutions for intramuscular administration. The ability of chondroitin and glucosamine to penetrate into the hip joints from ointments has not yet been clinically confirmed.

How is necrosis of the femoral head recognized?

During the appointment, we review the patient’s complaints about the hip and analyze possible risk factors for necrosis of the femoral head.

An accurate history of hip pain and a thorough clinical examination are then performed.

The examination criteria are:

• hip mobility
• sensation of hip mobility
• pain areas in the hip
• positions that can cause pain
• Muscle mass and strength of the gluteal hip muscles
• gait

Thanks to our many years of experience, we can correctly assess the symptoms and begin treatment.

In orthopedics, a number of different hardware diagnostic methods are used. X-rays and magnetic resonance imaging (MRT) confirm the diagnosis of the hip.

What is the diagnosis using x-rays?

Digital X-rays are a modern low-emission examination method, but they are not very suitable for diagnosis in the early stages of the disease, because X-rays show only changes in bone structure.

Bone beams begin to break down only weeks after necrosis (death of bone cells due to lack of blood circulation) has occurred. Therefore, necrosis of the femoral head cannot be detected using x-rays in the early stages of the disease.

What are the benefits of using MRI?

MRI can make a diagnosis in the early stages. Making a diagnosis in the early stages is also the only way to restore or at least preserve the hip joint.

Computed tomography, like X-rays, only determines changes in bone structure and is therefore effective only in the later stages of the disease.

All three methods have been successfully used to determine the nature and extent of femoral head necrosis and to establish an accurate analysis and treatment plan.

Study of the blood circulation of the femoral head

Laser Doppler flowmetry and microsensory intraosseous pressure transducers are used. Histological examination makes it possible to diagnose the disease, differentiate it from other pathologies and determine the pathogenetic paths of development of the process.

As the disease progresses, the bone structure undergoes changes. In the subchondrial zone and the zone of necrosis, the activity of osteoclasts increases, and in the zone of sclerosis, on the contrary, the activity of osteoblasts increases.

With ANFH, laboratory parameters such as prothrombin time, aPTT (activated partial thromboplastin time) are normal. However, in a comparison of patients with non-traumatic necrosis and healthy volunteers, significant deviations in the concentration of coagulation factors in the blood plasma were revealed.

In people with ANFH, the level of ghrelin is reduced, the level of von Willebrand factor, plasminogen activator inhibitor-1 (PAI-1), and C-reactive protein is increased, which indicates the involvement of these factors in the mechanism of pathogenesis.

The use of certain laboratory parameters as markers for the diagnosis of ANFH is a promising method.

What treatment methods are used for necrosis of the femoral head?

When choosing a treatment method, the disease must be classified according to the so-called international ARCO classification:

• ARCO 0 necrosis of the femoral head: All images are negative in all examinations
• ARCO I necrosis of the femoral head: MRI and bone scintigraphy shows necrosis
• ARCO II necrosis of the femoral head: X-rays and CT scans show minor decalcification, MRI examination shows a typical area of ​​necrosis.
• ARCO III necrosis of the femoral head: X-rays and CT scans show a break under the cartilage, later deformation of the femoral head occurs.
• ARCO IV necrosis of the femoral head: signs of joint wear (secondary arthrosis of the hip joint)

What treatment can help with necrosis of the femoral head?

To make a treatment decision, classification in ARCO is mandatory. In this case, the age of the patient, the degree and localization of necrosis are very important. In adults, unlike children diagnosed with necrosis of the femoral head (M. Perthes), self-healing is impossible. The condition of the hip joint, the general condition of the patient, additional diseases, and life expectancy are also taken into account in the decision-making process about treatment.

The earlier the stage of the disease with necrosis of the femoral head, the higher the chances of mitigating symptoms and even a complete recovery.

What therapeutic methods are used?

Reducing the load on the hip joint with physical therapy, careful attitude when abstaining from sports, immobilization of the hip joint (for example, orthopedic prosthesis) Hyperbaric oxygen therapy (hyperbaric oxygen therapy) in the earliest stage of necrosis of the femoral head.

Surgeries on the hip with drilling holes in the hip bones (for example, pri-foramen), Surgeries on the hip with transplantation of bone cartilage Surgeries on the hip such as osteotomy (for example, varisation osteotomy according to M. Perthes) Artificial hip joint using endoprosthetics for a fractured femoral head .

Treatment

For each stage according to ARCO, the duration of each of them is determined. For stage I and stage II - up to 6 months, stage III - 3-6 months and an immediate transition to stage IV.

Early initiation of treatment, while symptoms reveal only minor discomfort in the periarticular area with irradiation to the groin area and knee joint, is extremely important.

Tasks during the treatment period:

1. For patients with a history of trauma, intoxication, and those at risk (taking glucocorticoids, cytostatics), use the diagnostic algorithm for ANFH in the early stages. It includes early clinical manifestations, information analysis of cardiac signals using the Screenfax system, MRI/CT, ​​radiography, laboratory tests of markers of bone metabolism, scintigraphy, X-ray/ultrasound densitometry.
2. Using a non-surgical treatment method, improve metabolic processes in the lesion, regenerate the elements of the femur and restore the function of the joint itself.

Taking into account the fact that ANFH is a multifactorial pathology, it is necessary to use an integrated approach in diagnosis, treatment and rehabilitation aimed at restoring:

• optimal functioning of all systems and organs;
• microvasculature and hemocoagulation parameters;
• neuroregulatory factors;
• immune reactions;
• myodiscoordinate processes and biomechanics of joints.

Treatment of stages 1-2

Seems most effective for a favorable prognosis. The most important condition for successful treatment is strict adherence to the regimen. You should give up bad habits (alcohol and smoking), avoid overloading and hypothermia of the affected joint.

Therapy is directed in several areas: medication, physiotherapy and exercise therapy.

Drugs . For aseptic necrosis, the following groups of drugs are prescribed:

1. Bone resorption inhibitors (bisphosphonates). They slow down the destruction of bone tissue and prevent compression and deformation of the femoral head.
2. Calcium and vitamin D preparations. In the form of active forms, they facilitate the formation of bone structures and their mineralization. The dose is selected individually.
3. Additional sources of minerals and phosphates (ossein-hydroxyapatite).
4. Since blood coagulation factors change in ANFH, antiplatelet drugs (chimes, dipyridamole, xanthinol) are necessarily prescribed.
5. Non-steroidal anti-inflammatory drugs (NSAIDs). They have an analgesic and anti-inflammatory effect. The most commonly prescribed drugs are ibuprofen, ketoprofen, diclofenac and their analogues.
6. Muscle relaxants to relieve muscle tension around the joint.
7. Multivitamin complexes, chondroprotectors.

Physiotherapy. The main task is to stimulate blood flow in tissues and start/accelerate regenerative processes.

• a) hyperbaric oxygenation. The patient is placed in a pressure chamber, where he is exposed to air enriched with oxygen under conditions of high pressure. This procedure improves oxygen supply to the damaged area.
• b) shock wave therapy (SWT). Represents the action of a sound wave. It is carried out pointwise, certainly at the site of damage. It effectively affects pathological tissues that interfere with the healing of diseased joints (calcium crystals or adhesions). UVT improves blood supply to the treated area and thereby enhances the reparative effect.
• c) myostimulation. Allows you to restore muscle tone during developing hypotrophy, which is often found in ANFH. Stimulation relieves spasm of the muscle fibers surrounding the joint and accelerates local blood flow.

Physiotherapy

The initial stage is unloading the affected joint. In this case, the patient is fitted with crutches, which can take up to a year to walk on.

If after therapy the pain has decreased and bone turnover markers have returned to normal, crutches should be discontinued after 2-3 months. But don't rush. Unloading the joint will relieve pain and prevent further destruction of the femoral head. The gentle regime accelerates healing, it is faster and easier.

On the other hand, the patient needs exercise therapy. A special set of exercises will reduce pain and swelling of the joint and increase its mobility. Physical exercise will develop not only the joint, but also the muscles surrounding it, preventing the development of malnutrition.

Obese patients are advised to combine exercise with a specially selected diet. This combination will allow you to achieve better results.

The importance of physical therapy at the rehabilitation stage should be especially emphasized. It will help not only to develop the operated/replaced joint, but also to prevent its instability.

What other diseases should be distinguished from necrosis of the femoral head?

It is necessary to distinguish between inflammation of the hip joint with necrosis of the femoral head caused by inflammation (septic necrosis of the femoral head). The cause in this case is usually bacteria. Osteomyelitis or suppuration of the bone of the femoral head, tumors and neoplasms in the femoral head (rare malignant tumors of the femoral head are Klarzellchondrosarkom, benign tumors of the femoral head Chondroplast), the occurrence of tumors in the femoral head with other tumors (metastases in the bone of the femoral head). Possible confusion with prostate cancer. Bone cysts of the femoral head as part of wear and tear of the hip (arthrosis of the hip joint)

Risk of developing avascular necrosis due to trauma

One of the main reasons for the development of ANFH is fractures of the head or neck of the femur. The greatest risk is a transepiphyseal fracture (impaired blood supply to the proximal fragment up to 97.6%), subepiphyseal fracture (impaired blood supply to the proximal parts of the head up to 97.4%), subcapital fracture (impaired blood supply up to 92%).

There are several types of fractures:

Type 1: abduction, subcapital, incomplete fracture without displacement. It occurs due to the action of diverting tension. During a fracture, the neck and diaphysis of the femur are directed towards the head. The bone fragments are firmly wedged, and the fracture surface line is close to horizontal. The disturbance of blood supply is minimal (up to 10.2%). The prognosis for recovery is good.

From left to right: subcapital, transcervical, basicervical fractures.

Type 2: adduction, subcapital, complete fracture without displacement. The fracture is located in a vertical plane, passing through the femoral neck. Trabeculae and lower cortex are torn, without displacement. Microcirculation is impaired by 23.6%. The prognosis is favorable.

Type 3: adduction fracture with incomplete displacement of bone structures. It is characterized by varus deformity of the femoral neck, but the fragments remain connected due to the posteroinferior block. The distal bone fragment is in a position of external rotation and abduction with an angle open anteriorly. There is a comminuted fracture of the posterior surface of the neck. The trabeculae and lower cortex are torn. Vascularization disorders reach 42.8%. Risk of developing avascular necrosis.

Type 4: adduction fracture with complete displacement. The head is deprived of all connections with the synovial membrane of the capsule, as a result of which the fragment becomes free. The disturbance of blood supply is maximum (54.4%). The risk of aseptic necrosis is increased.

To summarize: in the event of a potential injury to the hip joint, you must go to the nearest emergency room and have an x-ray taken. Early diagnosis can save the joint from destruction and maintain a high quality of life!

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Generalization

Necrosis of the femoral head is a serious disease of the bones of the hip joint. In this case, local destruction of the bone of the femoral head occurs, as bone tissue dies in certain areas. Necrosis of the femoral head in adults is a typical disease of civilization. As with a heart attack, the main risk factors are smoking, high blood fat levels and alcohol abuse. Every year, many thousands of people suffer from necrosis of the femoral head in Germany alone!

By age, these patients are usually from 35 to 45 years old.
Men are more often affected than women. The disease necrosis of the femoral head significantly reduces the quality of life of people. In 30-70% of cases, bilateral necrosis of the femoral head is observed. Arrival arrangements

1.6. Toolkit of the new method

The patented technology used by the authors - a new method of treating ANFH - combines modern high technologies and principles of Chinese medicine.

● Image diagnostics

– a computer graphic display system of ANFH, developed within the framework of a new method, uses quantitative changes in the microstructure and conducts a morphological analysis of the structure of the femoral head.

● Treatment with electrical impulses –

A device for the treatment of ANFH supplies electrical signals to biologically active points, thereby regulating the electrochemical environment in the bone and optimizing the growth of new bone tissue.

● Phytotherapy

– preparations from the “Chengzai” series not only increase the body’s resistance, restoring its normal functions, but also improve the mechanical properties of trabeculae, restore the structure of the trabeculae and microcirculation. They also remove fat droplets from cartilage and bone tissue.

● Theory about the displacement of muscles and bones

- “a method of regulating the balance of the pelvis”, used in Chinese traditional medicine, eliminates pelvic distortion, straightens the spine, restores the parallelism of the lines of the sciatic angle and the size of the obturator foramina.

● Rehabilitation theory

– electromechanical effect of “a method of modeling the hip joint, elasticity of the joint, and strengthening bones and muscles” used in Chinese medicine.

● Exercise therapy according to an individual plan

– involves creating restoration tension throughout the course of treatment to accelerate the growth and development of new bone.

It should be noted that during treatment, the patient has the opportunity to gradually adapt and socialize while maintaining a familiar communicative environment. Improved well-being, disappearance of pain, increased range of motor functions create confidence in the patient’s abilities. These circumstances create a positive attitude and confidence in both the patient and his relatives in the successful outcome of the disease.