New principles and methods of hip joint reconstruction.

1.1. New understanding of the etiology of ANFH

A new understanding of the etiology of aseptic necrosis of the femoral head is a breakthrough in the established ideas of academic medicine. When conducting research, it was established that the causes of ANFH are associated with the concentration of stress in its head, destruction of its structure, fragmentation of the mesh structure of trabeculae, their twisting, overlap, degeneration and change in the shape of the femoral head. The concentrated stress causes destruction of both the bone structure and the internal structure of the femoral head. A change in bone structure inevitably leads to compression and destruction of the capillary network, interferes with blood circulation, provokes the occurrence of ischemia and pathological processes, perversion of metabolic processes and malnutrition of the bone.

Thus, the pathogenesis of ANFH is associated with ischemia and other factors leading to concentration of stress in the femoral head, destruction of trabeculae, creation of obstacles to blood circulation and perversion of metabolic processes.

Internal risk factors

Internal factors for the occurrence of arthrosis include:

• hereditary predisposition - if one of your parents suffers or previously suffered from arthrosis, then your risk of developing the disease increases significantly. Also, hereditary factors for the occurrence of arthrosis include congenital pathologies of connective tissues (collagenosis);
• Excess body weight (obesity) is one of the most important factors that increases the chance of developing the disease, since excess weight significantly increases the load on the body as a whole, in particular on the hip and knee joints. Also, excess weight can cause the development of deforming osteoarthritis of the foot;
• metabolic disorders - the main factor in the occurrence of the disease can be diseases that lead to changes in metabolism. These may be metabolic diseases such as secondary and primary gout, hemochromatosis, Wilson-Konovalov disease and ochronosis;
• endocrine diseases - the main factor in the occurrence of arthrosis is diabetes. Very often, with insufficiently cured diabetes, the blood vessels of the legs suffer. This leads to a deterioration in the nutrition of the joints and an increased likelihood of developing diseases of cartilage tissue;
• age factor - the patient’s age greatly influences the development of the disease. The older the patient is, the higher the likelihood of arthrosis. According to statistics, 2-3% of people under 45 years of age suffer from arthrosis. In the age range of 45-65 years, the incidence of the disease increases to 30%. Among patients over 65 years of age, the probability of developing arthrosis is 75-85%, that is, almost everyone suffers from arthrosis. The age factor in women is superimposed on hormonal changes that are associated with menopause. This is one of the factors why women most often suffer from arthrosis, even though they have a longer life expectancy than men.

1.2. The essence of a new method of treating ANFH

With non-surgical treatment, without causing injury and while maintaining the integrity of the structure of the hip joint, the body's resistance increases, new bone tissue grows and normal functions of the hip joint are restored.

During the process of physiological recovery, products of necrotic bone tissue are eliminated, conditions are created not only for the growth of new bone tissue, but also for the reconstruction of the bone structure, improving microcirculation and the flow of Qi and blood. As a result, the strength, density and rigidity of the trabeculae are increased, the mechanical properties of the femoral head are improved, bones are strengthened and muscles are softened, and the function of the hip joint is restored, which improves the patient’s quality of life.

A new non-surgical, non-traumatic method of treating ANFH, being safe and effective, makes it possible to change the existing belief in the inevitability of endoprosthetics, presenting it as extreme and forced.

1.3. Basic rules for hip joint restoration with a new method of treating ANFH.

Over the past 20 years, in search of objective patterns of restorative treatment of ANFH, the authors, based on the provisions of biomechanics and relying on clinical practice through follow-up and retrospective assessment, as well as analyzing the advantages and disadvantages of other treatment methods, have formulated three basic rules that must be followed when treating this pathologies, namely:

1. During treatment, the load on the hip joint should be relatively stable; 2. A power load is required that is suitable in time and degree; 3. The restoration tension necessary to recreate the joint should be created.

The listed rules for the restoration of the hip joint are not only objective criteria by which one can judge whether the treatment method for ANFH corresponds to the laws of restoration, but also theoretically substantiate the new treatment method, which is of great importance for a clear and clear understanding of its clinical application. The first rule is the relative stability of the load on the hip joint

The force load on the hip joint is significantly higher than that in other joints. When standing on one leg, the load on the head of the femur is almost 2.5 times greater than the body weight, and if you run, jump from a height, etc., the forces perceived by the head of the femur increase several times. This is all the more important for patients with necrosis of the femoral head, because the structure inside the head is destroyed, there is local loosening of the bone or its ossification, and when stress is concentrated, the load becomes greater than normal. At the same time, the pressure along the periphery of the dead part of the femoral head far exceeds the normal physiological load on it, which causes its further destruction.

Because the function of the femoral head is support and movement, treatment of femoral head necrosis should focus on improving and restoring its normal physiological function. During the treatment process, it is necessary to find ways to preserve and improve not only the metabolism in bone tissue, but also the strength of the bone, i.e., attention should be paid to maintaining bone density, especially at the edges of its damaged part. In this regard, the goal of improving the quality and activity of bone tissue around the damaged area is to prevent the expansion of the affected area and to accelerate the growth of new bone tissue in it.

Based on the principles of functional adaptation of the bone, it is necessary to perform a certain functional load during the treatment of necrosis of the femoral head. The patient should perform functional training to keep the acetabulum and femoral head in relative motion, but the pace of training should not be significantly accelerated. By maintaining such relative stability of the load on the hip joint, not only is the goal of the movement achieved, but also the permissible stress on the damaged bone tissue is not exceeded. The second rule is power load, appropriate in time and degree.

Bone in the body is constantly in the process of growth, strengthening and absorption. This entire process is called bone reconstruction. The goal of bone remodeling in vivo is to ensure that the overall structure is adapted to changes in load.

Tension has been found to regulate bone growth and absorption. With reduced stress, the bone becomes weakened, with excess stress, it becomes brittle or susceptible to destruction. Optimal tension is required for bone reconstruction. The results of experiments and clinical observations indicate that there is a certain physiological balance between tension and bone tissue. Within physiological stress, the strengthening and subsequent absorption of bone are mutually balanced. Increasing tension causes bone tissue to strengthen, and as tension decreases, bone absorption occurs. X-ray studies of the acetabular arch confirm this point of view. The femoral head as a biological material corresponds to a state of stress both in terms of geometric shape and spatial structure, as well as the distribution of strength and density. Functional adaptation of the femoral head is manifested not only in its geometric and mechanical features, but also in the component composition of bone tissue. In the process of restoring a necrotic femoral head, it is necessary to take into account the characteristics of bone tissue in order to fully satisfy the needs of the physiological functioning of the femoral head after its restoration.

It is necessary to understand what the tension should be to control the restoration of the damaged femoral head and develop a rational plan for its restoration. This is extremely important, since during the treatment of ANFH the bone tissue will be in a newly created environment according to the stress distribution. If treated incorrectly, the femoral head bone may be weak and brittle after repair and may not be able to meet normal functional needs, preventing the treatment goals from being achieved.

Summarizing the above, it should be noted that the treatment process for ANFH is mainly the process of “removing the dead and growing the new” described in Chinese medicine, i.e., the process of bone restoration and shaping, which occurs in an open feedback system, carrying out adaptive restoration according to functional needs. The mechanical environment of the hip joint and the selected force load will act as an information feedback system, thereby regulating the repair of the entire bone so that the new bone structure in the dead femoral head and acetabulum approaches a normal functional state. In this regard, in the process of restoring the damaged femoral head, it is necessary to create for it a mechanical environment and conditions conducive to its normal functioning.

The third rule is to create recovery tension

As noted above, bone growth, development and absorption are directly related to the amount of stress perceived by the bone, which is confirmed by a large amount of experimental data and clinical practice. The relationship between the rate and quality of restoration of the damaged femoral head and stress is a problem that attracts close attention from scientists.

If a living bone, as a biological material, is subject to destruction, then it, as a biological body, is capable of self-healing. In the process of bone repair, there is a relationship between the rate and quality of improvement in hip function and the load taken by the joint. Tension that can accelerate the process of restoration of the necrotic head of the femur and improve the quality of this restoration is called restoration stress

, which is different for different patients.

The recovery voltage differs from the physiological one, since it is only variable (intermittent). At the same time, restoration tension can effectively stimulate local blood circulation and exchange of joint fluid, soften the effect of abnormal muscle efforts, prevent joint adhesions, improve the quality of molding, and activate the growth of new bone cells.

For research and clinical purposes, the authors distinguish two types of recovery stress:

• active recovery tension, meaning functional training;
• passive tension recovery, which involves the use of a device for the treatment of ANFH and massage of the periarticular soft tissues of the hip joint.

Usually, when they talk about recovery stress, they mean both of the above types. But for the purposes of treating ANFH, active tension restoration is especially important, which is very useful for accelerating the recovery of the femoral head affected by necrosis and improving the quality of the restored bone structure.

Thus, in order to restore the normal physiological function of the femoral head affected by necrosis, it is necessary that it perceive a certain tension during the treatment process. However, it is required that such effort be stable and limited within certain limits favorable for recovery.

What is the role of glycosamines

Synovial fluid contains glycosamines, which are produced by cartilage tissue. It is this component that is recommended to be taken for recovery, since it binds cells, making tissues more resistant to stretching and stronger. If the concentration of glycosamines in the joint decreases, the cartilage tissue loses its resistance to stress and becomes more sensitive to damage.

Taking glucosamines is one of the important steps in the treatment of arthrosis

1.4. Recovery criteria for a new treatment method for ANFH

Recovery and complete cure of femoral head necrosis cannot be measured by any single criterion. The concept of recovery with a non-surgical method of treating ANFH involves improving or increasing the physiological functions of the hip joint, approaching those of a healthy person. However, this does not at all mean the repair of the femoral head affected by necrosis to the level of the clone and a copy of the geometric dimensions of the normal femoral head in the sense of its anatomy, histology and morphology.

In practice, the degree of destruction of the hip joint in patients with ANFH is very diverse, the impact of destruction on the physiological function is different, so the best way to restore and renew the function of the hip joint is selected based on the specific case.

Requirements for the general condition of the patient and the functions of his hip joint, as well as for the restoration of the dynamics of muscle strength, constitute the content of the recovery criteria in the treatment of ANFH.

Restorative treatment of femoral head necrosis involves achieving the following results:

1. Improving the general condition of the patient:

• improvement of general somatic condition;
• improvement of psychological state;
• adaptation to performing functional duties;
• patient social activation;

2. Restoring the functions of the hip joint:

• dissolution and elimination of necrotic bone, replacing it with new bone, improving and restoring the structure of trabeculae;
• improvement and restoration of muscle strength and coordination;
• restoration and functional adaptation of the hip joint;
• restoration and improvement of motor function and ability to withstand stress;
• improvement or approaching normal gait and the patient’s condition in motion and at rest.

Restoration of the femoral head according to the following parameters:

• Muscle strength
  - improvement or normalization of the contractile and extensor strength of the muscles themselves;
• Stability
  - a stable state or improvement in the relative position and centering of the femoral head and acetabulum within physiologically acceptable limits;
• Mobility
  - normalization of the contractility of the muscles that provide mobility of the hip joint;
• Coordination
  - the ability of each muscle of the hip joint to quickly respond to the movement of the gluteal muscle group and lower extremities while maintaining a certain position - performing this physiological function or improving it;
• Balance
  - creating a balanced system of flexor and extensor muscles in the hip joint;
• Durability -
  the formation of strength, rigidity, surface hardness and cartilage lubrication in the bone tissue of the hip joint to adapt to the performance of functional loads;
• Absence of pain
  - absence of pathological reaction or its decrease under conditions of functional load of the hip joint;
• Shape
  - improvement or normalization of the physiological function of the hip joint during its restoration under power load conditions. (It must be noted that restoring the shape of the femoral head is in no way cloning or copying the shape of the normal femoral head).

In practice, the restoration criteria take into account: the type of necrosis of the femoral head, the degree of destruction of the structure of the femoral head, the degree of destruction of the hip joint, the degree of loss of physiological functions, the patient's age, his profession, his general state of health and his requirements for hip joint restoration. Based on developed, scientifically based recovery criteria, a treatment plan is developed.

The content of both general and intended recovery criteria should be explained to the patient. It is necessary to reasonably describe their difference from each other and the reasons that caused this difference (the degree of destruction of the hip joint, the individual characteristics of the patient, the possibility of receiving full treatment, etc.), so that the patient is confident in the results of treatment, and full mutual understanding is achieved between the doctor and patient.

It must be emphasized once again that for recovery according to the developed criteria, genuine cooperation between the patient and the doctor is necessary, since the goal can only be achieved as a result of their joint efforts. Otherwise, despite the maximum costs, the result will be minimal.

Is it possible to independently restore damaged cartilage?

Chondrocytes are cells within cartilage that produce the necessary substances for its restoration. They have a high metabolic rate and regenerate quickly, but there is one problem. The composition of cartilage contains only 2-3% chondrocytes, so cartilage tissue does not completely recover on its own.

Damaged cartilage rubs against each other if there is not enough synovial fluid, causing pain to the person. For the treatment of arthrosis or osteoarthritis, taking chondroprotectors is not enough, since the destruction process occurs faster than recovery. Experienced orthopedists recommend intra-articular injections of the synovial fluid substitute Noltrex. The drug separates rubbing surfaces and acts as a shock absorber.

Noltrex does not restore cartilage, but it does stop its breakdown and relieve pain.

1.5. Principles and features of treatment of ANFH using a new method

A new treatment method for ANFH, based on the fundamental theory of traditional Chinese medicine in combination with Western medicine, includes the latest scientific technologies, the achievements of modern scientific research in the field of traumatology, microstructure of bone joints and bone biomechanics, as well as other branches of science at the intersection of scientific disciplines. It reconsiders not only the causes of hip disease, its pathology and treatment, but also the stereotype of traditional judgments in traumatology. The new method forms a new approach to treatment, combining simultaneous effects on the body from the outside and from the inside.

The goal is to improve not only the microcirculation in the bone, the formation of the femoral head and acetabulum, but also to recreate the force relations in the hip joint, adjust the position of the pelvis and create a functionally adapted environment, so that in the process of restoring the biomechanical environment during the treatment of ANFH, integrity is maintained structures of the hip joint.

The principles of treatment of ANFH using the new method are as follows:

• absence of surgical intervention and mechanical damage to bone tissue;
• maintaining the integrity of the structure of the hip joint;
• replacement of dead bone tissue with new bone tissue;
• restoration of bone tissue structure;
• improvement of microcirculation;
• increasing the mechanical properties of the femoral head: strengthening bones, muscles and tendons;
• recreating the function of the hip joint.

As part of a comprehensive modeling of the interconnected physiological, pathological, regenerative and restorative process in necrotic bone tissue of the femur, the new method focuses on the balancing system of the human body itself, the redistribution and regulation of tension in the femoral head. During the treatment, the ability of the femoral head to recover is activated, bones, muscles and tendons are strengthened, and Qi

and blood.

Thus, this is a completely new treatment method in which the main way to update the function of the hip joint is a set of non-surgical, non-traumatic measures.

External risk factors

The most significant external factor that leads to the occurrence of arthrosis will be high physical activity, for example, playing sports, or a specific type of activity in which you need to do hard work and walk a lot. In such situations, the load on the joints increases significantly, which leads to inadequate nutrition of the cartilage tissue, which simply does not have time to recover from such excessive loads.

Another important trigger point will be exposure to unfavorable environmental conditions: environmental conditions, exposure to harmful substances (nicotine, alcohol, chemical toxins). The impact of all factors or one of them can become the main impetus for the development of arthrosis.

Since it is not always possible to determine the cause of the disease, there is a way to prevent the occurrence of arthrosis. This method is a systematic medical examination.

If you or your relatives are at risk of developing arthrosis, do not be lazy to periodically visit the doctor’s office. If you discover one of the signs characteristic of arthrosis, you should definitely consult a specialist. The sooner arthrosis is diagnosed and appropriate treatment is started, the more smoothly the disease will go and it can be controlled.

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.

1.7. Early diagnosis

Necrosis of the femoral head does not occur instantly; the disease is protracted, and the patient does not attach importance to the initial manifestations of the disease for a long time. The most common clinical symptoms are discomfort or pain in the hip joint during overload or after a long walk, but its intensity decreases after rest.

During the development of ANFH, pain often occurs in the lumbosacral region or knee joints, which can be mistakenly taken for prolapse of the lumbar intervertebral disc and narrowing of the spinal canal, sciatic neuralgia, rheumatoid arthritis, synovitis, etc. A feature of this disease is that the strength the experience of subjective symptoms does not depend on the degree of development of ANFH.

In no case should the patient be careless and remember that as the pain and lameness intensify, the functions of the hip joint are gradually limited. If time is lost to restore the mechanics of the femoral head, then the disease becomes irreversible, i.e., bone collapse or fibrous fusion of the articular surfaces occurs, which in the late stage leads to rigidity of the hip joint and disability.

In this regard, great attention should be paid to the problem of early diagnosis of the disease. Using data from regular clinical examinations and examinations by therapists and traumatologists, the authors formulated an algorithm for identifying the patient’s ANFH disease at an earlier stage.

Among the clinical manifestations, the following are alarming and require a comprehensive and dynamic assessment: pain in the hip joint, pain in the groin area with radiation to the knee joint, limitation of movements in the hip joint, signs of muscle atrophy, unmotivated pain in the knee joint. Particular attention is paid to patients at risk.

The presence of these clinical signs is the basis for special research methods:

• plain radiography of both hip joints using Launstein placement;
• magnetic resonance imaging, which makes it possible to diagnose ANFH in 90-100% of cases already at the initial stage of the disease;
• static and dynamic scintigraphy of the femoral head and skeleton for diagnosis and exclusion of specific processes;
• laboratory assessment of the endocrine status of indicators of mineral, carbohydrate and fat metabolism;
• X-ray dual-energy densitometry of the femoral head;
• processing of X-ray images in a computer program to determine the structure of the femoral head, assess the condition of trabeculae, identify necrotic zones, etc.