Aseptic necrosis of the femoral head. Causes and methods of treatment of aseptic necrosis of the femoral head

Content

With aseptic necrosis, the head is damaged femur due to disruption of its oxygen supply. Most serious complication This disease is gangrene, which will eventually lead to amputation of the limb. Doctors strongly recommend treating aseptic necrosis of the head hip joint at the first symptoms. Diagnosis in the early stages of the disease will help to avoid the risk of developing many serious ailments.

Causes and symptoms of aseptic necrosis

it vascular diseases when blood microcirculation changes, which leads to the development of foci of tissue necrosis. The cause of the disease can also be an excessive load on the hip joint. This is connected not only with the profession of a person (truck drivers, parquet workers, gas welders), but also with being overweight and with a shift in the center of gravity when walking.

The reasons for the development of necrosis of the hip joint may be associated with metabolic disorders in the human body or with a genetic predisposition. But none of the above factors alone cause this disease cannot, it develops only as a result of a combination of several conditions.

Depending on the severity of the lesion of the hip joint, the course of the disease has stages, each of which is characterized by the following symptoms:

1. At the first stage of the development of the disease, rare pain and small bone changes are observed. Slight pain radiates to the groin, but mobility in the hip joint remains.
2. At the second stage, cracks appear on the head of the hip bone, which can occupy up to 30% of its surface. Pain in the affected area increases.
3. At the third stage of the disease, the acetabulum is involved in the process, and up to 50% of the articular tissues are affected. The pain becomes constant and strong, the mobility of the joint decreases.
4. Completely reduced motor function severe pain never stop, the muscles of the buttocks and thighs atrophy.

Types and stages of development of the disease

The stages of development of aseptic necrosis of the head of the hip joint do not have a clear distinction between them. The first stage lasts about six months, when the pain occurs during exercise or during bad weather, after the disappearance of the provoking factor, it goes away. The second stage also lasts about six months. During this period, there is a thinning of the muscles of the buttocks and thighs.

The third stage takes longer - up to 2.5 years, during which the tissues surrounding the area of ​​necrosis resolve. Patients are already beginning to move exclusively with a cane. In the fourth stage, which takes about 6 months to develop, patients are unable to walk on their own. However, the duration of the development of the disease in each person is individual, depending on concomitant diseases, timely treatment and other factors.

Doctors distinguish four types of necrosis:

1. Segmental (observed in 48% of patients with this diagnosis). A small area of ​​necrosis appears as a cone on the top of the femoral head.
2. Complete necrosis (diagnosed in 42% of patients). The whole head is affected.
3. Peripheral (occurs in 8% of patients). Pathology affects the outer section of the head, located under the articular cartilage.
4. Central (observed in 2% of cases). A zone of necrosis is formed in the center of the head of the hip bone.

Diagnostic methods

For pain that occurs in the pelvic area, you should consult a doctor who, based on the symptoms, will prescribe a diagnostic examination. At early detection disease and adequate treatment, patients have a chance to avoid subsequent surgical intervention. The choice of research method depends on the stage of the disease.

hardware

Mandatory hardware diagnostics of the disease include control blood pressure(to exclude the presence of hypertension), an electrocardiogram (to exclude heart diseases) and ultrasound densitometry, when the condition of the patient's bone tissue is determined by the degree of absorption of ultrasonic waves and the speed of their passage through it. Hardware diagnostic methods are effective both in the early stages of the disease and in the later stages, when it is necessary to track changes in bone tissue during treatment.

Radiography

To check the condition of the hip bone, the doctor will definitely refer the patient for x-rays. When it is carried out, images are taken that are taken in two projections: from the side or directly. In the first case, the patient is placed on the table, lying on his back, the leg being examined is bent at the knee and taken to the side by 90 degrees. In the second, the patient lies on his back with straight legs, and the feet are fixed inside with the help of special rollers. If the joint is motionless, then the patient is placed on the stomach, and the opposite side of the pelvis is fixed with rollers.

CT scan

With the help of CT computed tomography) bones and soft tissues The patient is examined in layers. X-rays are absorbed by tissues of different densities while passing through the body, and then fall on a sensitive matrix, which transmits data to a computer. Computed tomography determines the structure of the articular cartilage and the damaged head of the hip bone. During the procedure, the patient is placed on the tomograph table, lying on his back, and the doctor moves the table using the remote control so that the desired area of ​​\u200b\u200binvestigations is in the device frame.

Magnetic resonance imaging

The principle of this study is to obtain images of the patient's bones and soft tissues using electromagnetic waves. Magnetic resonance imaging (MRI) helps to identify at an early stage the focus of changes in the femoral head and detect even a small intraosseous edema or inflammation. During the study, a person is placed in a tomograph flask, in which he must lie motionless for 10-20 minutes. At this time, a series of pictures is taken, and the doctor monitors the patient with a video camera.

Laboratory research

If aseptic necrosis of the femoral head is suspected, the patient is always referred for urine and blood tests. They are taken to determine the level of minerals in the body and identify markers of bone formation. When the disease occurs, natural collagen is destroyed, and, breaking down, forms markers that are excreted from the body along with urine. These studies are assigned, both for the diagnosis of the disease, and for the evaluation of the treatment.

Which doctor to contact

If mobility is impaired in the hip joint or pain occurs when walking, then you should immediately contact a surgeon or rheumatologist. For a more informative diagnosis, one specialist often refers the patient for a consultation to another. In multidisciplinary clinics, an arthrologist deals with joints, which determines all types of aseptic necrosis.

Treatment

After medical examination and diagnosis, the doctor prescribes treatment. The complex of therapeutic measures in the early stages of the disease includes: drug therapy, massage, mud baths in sanatoriums, vitamin therapy, hirudotherapy (treatment with leeches), swimming. However, conservative methods do not lead to a complete cure of the disease, but only slow down its development, keeping the joint functioning for many years.

No one can completely destroy the necrotic process. modern medicine. If it is not possible to slow down the development of the disease, then doctors use surgery. This is the only radical treatment for necrosis of the femoral head, which can significantly improve the living conditions of a person with this disease. Surgical operations are used in all four stages of the disease.

Medical

The choice of drug treatment depends on the development of symptoms, the age of the patient and the overall picture of the disease after careful diagnostic examination. Medicines prescribed by doctors for this disease:

1. Non-steroidal anti-inflammatory drugs. They are prescribed to relax the thigh muscles, restore normal blood circulation and relieve pain. The course of treatment is intramuscularly one ampoule daily for a week. Well-known drugs - "Naklofen", "Diclofenac", "Ksefokam", "Ibuprofen".
2. Vasodilators. They allow you to eliminate blood stasis, improve arterial blood flow. The regimen of admission depends on the severity of the course of necrosis of the hip joint, but is at least 8 weeks with repetitions of courses every six months. Popular vascular agents- "Kurantil", "Trental", "Dipyridamole", "Xanthinol nicotinate".
3. Calcium metabolism regulators that prevent excessive loss of calcium. They improve the process of bone regeneration, reduce the destruction of collagen. Use drugs for at least 8 months continuously or with interruptions of several weeks. The best drugs- "Calcium D3 Nycomed", "Ksidifon", "Bonviva", "Fosamax", "Vitrum", "Osteomag", "Osteogenon", "Alfacalcidol".
4. Chondroprotectors. These are the most effective drugs at stage 3 of necrosis of the hip joint, when the cartilage begins to exfoliate and break down in the head of the femur. They help restore cartilage tissue, stimulating the regeneration of ligaments. These drugs should be taken in long courses, at least 6 months, with an interval of six months. The most famous chondroprotectors are Structum, Chondroitin sulfate, Chondrolon.
5. Muscle relaxants. These drugs are able to relax the muscles, which inhibit the transmission of nerve impulses, improving blood circulation. The course of treatment is 15-20 days, one tablet 2 times daily. The best relaxing drugs are Mydocalm, Sirdalud.

Surgical methods

If a drug treatment does not produce results surgery. In the first stages of aseptic necrosis of the hip joint, it is used to decompress twisted vessels that do not provide adequate nutrition to the femoral head, or to transplant a transplant. Types of surgical treatment:

• tunneling, when additional holes are formed in the bone to reduce pain and intraosseous pressure;
• transplantation of a musculoskeletal graft to increase local blood flow and eliminate pain;
• intertrochanteric osteotomy to eliminate the worn part of the femoral head and redistribute the load on its other parts;
• arthrodesis (artificial fusion) to immobilize the joint to eliminate pain;
• arthroplasty to increase range of motion, eliminate lameness, improve blood supply to the hip joint.

At the 4th stage of the disease, arthroplasty is used, when the destroyed joint is replaced with an artificial one. The duration of the use of the prosthesis is about 15 years, after which it requires replacement. All surgical operations are performed under general or epidural (in the lumbar region) anesthesia. The timing, level and volume of rehabilitation depends on the method of surgery and the individual characteristics of the body.

Therapeutic gymnastics and massage

One of the main methods of treatment of aseptic necrosis - physiotherapy. Physical exercises do not require any financial investment. All that the patient needs to maintain health is a little free space on the floor and a rug. Instead of active dynamic exercises, you need to do static movements while lying on your back, for example, slowly raising your leg and keeping it on weight.

Therapeutic massage can also bring tangible benefits to a sick person, provided that it is done by a professional, and inept exposure will only worsen the condition. Proper massage for necrosis of the hip joint is done gently, smoothly, without sudden movements. It should give the patient a feeling of warmth and comfort without causing pain or injury.

Medical centers

Conservative and surgical treatment of hip necrosis is carried out both in Russia and abroad. But the prices for services in clinics in Germany, Israel and other countries are an order of magnitude higher than in medical centers Moscow or St. Petersburg. The quality level of Russian medicine is in no way inferior to foreign clinics. Here are the addresses of the leaders medical institutions Russia, where effective treatment aseptic necrosis, and prices for services:

Video

According to statistics, necrosis of the femoral head is more common in men than women. The disease affects, as a rule, people 20-50 years old and often leads to disability, so it is very important to diagnose it in the early stages.

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Aseptic necrosis of the femoral head is detected in young people of working age and, if left untreated, leads to disability of the patient within 3-4 years due to progressive destruction of the head of the hip joint. This disease is polyetiological, that is, it occurs under the influence of several factors. Diagnosis of necrosis is carried out by X-ray methods. Conservative (drug and physiotherapy) methods of treatment have a positive effect only in the early stages of the disease.

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  Description of the disease

  Aseptic necrosis of the femoral head (aseptic osteonecrosis, or Perthes' disease) is a disease of the hip joint associated with the necrosis of the bone tissue of its head as a result of impaired local blood circulation. Bilateral lesion of the legs is observed in 10-20% of cases, and with unilateral necrosis most often occurs in the right femoral head. The disease is more common in men (the ratio with the detection of the disease among women is 8:1), aged 30-50 years.

  There are 5 stages of the course of the disease:

  • Zero, early stage. cell necrosis bone marrow, no violation of tissue integrity. Local edema develops. There are no symptoms, and changes in the bone can only be detected during contrast magnetic resonance imaging.
  • The first initial stage, reversible. Total necrosis of the bone marrow in the head of the hip joint, the beginning of necrosis of the septa of the bone tissue. MRI reveals bone marrow edema, in the upper part of the head - a sickle-shaped dark strip. There are no other symptoms.
  • The second initial stage, irreversible. Separation of the necrotic area granulation tissue. Bone formation begins. Periodically there is pain in the groin. Pathological light areas are revealed on the x-ray. On MRI, a bone area delimited by two stripes is clearly visible.
  • Third stage (impression fracture). Depression of the affected area of ​​the head. There is a pronounced pain syndrome, aggravated by movement.
  • Fourth, late stage. Characterized by progressive deformity hip head and development of dystrophic process in the joint. The dead fragment is separated from the bone. There is its fragmentation, and in some cases - resorption and replacement with connective tissue. The femoral neck is shortened and deformed.

  Aseptic necrosis of the femoral head

  In children, this disease most often occurs between the ages of 5-12 years among boys. In girls, necrosis of the hip head is less common, but the disease is more severe. Since one of the determining factors in the prognosis of this pathology is early diagnosis, if even a slight pain in the legs of a child or a violation of his gait appears, it is necessary to consult an orthopedist.

  

  Complications

  If left untreated, aseptic osteonecrosis in a third of cases leads to coxarthrosis of the hip joint - damage to the articular cartilage, bone deformity and destruction of the hip joints. The symptoms of these two diseases are similar. The difference from coxarthrosis is that in this case, the destruction of cartilage tissue occurs.

  As a result of the destruction of the hip joint, patients have a violation of motor functions, limitation of movements, muscle atrophy in the thigh. A pronounced pain syndrome significantly impairs the quality of life and leads to the need for regular use of analgesics. Involvement in inflammatory process the inner layer of the articular bag and blood vessels, changes in bone tissue make the process of destruction of the joint irreversible.

  In 80% of patients, the destruction of the femoral head occurs within 3-4 years. One of the consequences of the disease is the need for complete replacement (arthroplasty) of the joint in half of the patients. This surgical operation is expensive and does not guarantee full recovery of physical activity. Re-surgical intervention is required for 40% of patients, earlier than 10 years after the first prosthesis. Often the rapid destruction of the hip head, limitation of joint mobility and lameness due to shortening of the limb lead to disability.

  

  The reasons

  The main factors of aseptic osteonecrosis are violations:

  • arterial blood supply to the hip head;
  • lipid metabolism (overlapping of vessels with fatty plaques, observed in alcoholism, hyperlipidemia and treatment with hormonal drugs);
  • blood clotting;
  • resorption of bone tissue.

  The development of the disease occurs for the following reasons:

  • joint injuries, especially with damage to blood vessels (fracture of the femoral neck, dislocation);
  • chronic alcoholism (drinking more than 0.4 liters of alcohol per week);
  • chemotherapy and radiation therapy;
  • reception hormonal drugs(one of the most common causes);
  • increased levels of lipids in the blood;
  • decompression sickness (blockage of small arteries with air bubbles);
  • systemic scleroderma;
  • hereditary predisposition;
  • rheumatoid arthritis;
  • systemic lupus erythematosus;
  • a decrease in the strength of the head as a result of a sharp increase in weight during pregnancy.

  When drinking alcohol, hormonal drugs Smoking inhibits bone marrow stem cells. Bone tissue becomes weaker and microfractures occur in its septa under load. Due to mechanical compression of the veins, there is an increase in bone marrow pressure and a decrease in blood flow.

  Risk factors for developing the disease include:

  • systemic osteoporosis;
  • diseases of the circulatory system;
  • pathology of the liver, adrenal glands;
  • acute or chronic pancreatitis;
  • sickle cell anemia;
  • operations on the hip joint;
  • immunopathological inflammation of blood vessels.

  In children, the decisive factor in the appearance of necrosis is congenital underdevelopment spinal cord in lumbar, which in itself can go unnoticed throughout life, and manifest itself in the form of orthopedic pathologies. Anatomically, this is expressed in the fact that in a child, instead of 10-12 large arteries, which should normally surround the femoral head, there are only 2-4 underdeveloped ones. The impetus for the development of necrosis in children are:

  • physical trauma (including minor), leading to squeezing of underdeveloped blood vessels;
  • infectious diseases.

  

  Diseases of the hip joints - clinical picture and treatment

  Signs of illness

  Symptoms of necrosis are different - from the absence of any manifestations to severe pain in the affected hip joint. Pain syndrome is characterized by the following features:

  • localization - in the inguinal region, given to the knees (70% of all cases), lower back, buttocks, shins, groin;
  • at the initial stage, periodic attacks appear;
  • at rest, the pain subsides, increases with exercise, walking, bad weather;
  • subsequently, the intensity of painful sensations increases and becomes constant;
  • no fever with pain;
  • despite treatment, the pain syndrome is persistent.

  Irradiation of pain to other areas leads to the need to differentiate the diagnosis from lumbosacral sciatica and other pathologies. In addition, the following symptoms are observed:

  • restriction of movements in the joint (including when there is no pain), especially rotational;
  • some patients have a sudden onset of the disease;
  • flattening of the gluteal muscles and their pronounced atrophy on the affected leg;
  • bilateral localization in 50-60% of cases. Involvement of the second leg often occurs within a year of the onset of necrosis on the first leg.

  Some patients during an exacerbation are unable to stand and walk, but with spontaneous onset of relief, they return to normal activity. Children most often periodically complain of pain in the thigh or knee. There may be a violation of gait (falling on one leg or dragging it).

  Diagnostics

  The traditional diagnostic method is an X-ray examination, which is carried out at the first stage of diagnosis. The x-ray image visualizes the area of ​​necrosis, its size and shape. The disadvantage of this method is that it is uninformative in the early stages of the disease, since during this period the head still retains its shape and the bone structure is not broken. Spongy bone necrosis can be detected using histological examination. A frequent medical mistake is to stop further search for the cause of pain, and patients begin to be treated for lumbar osteochondrosis, inflammation sciatic nerve or osteoarthritis of the knee.

  It is possible to identify the disease in the initial stage using more advanced and high-tech methods: spiral X-ray computed (CT) or magnetic resonance imaging (MRI). The absence of signs of the disease on x-rays does not mean that the pathological process is absent. On computed tomograms, the damaged area of ​​the bone is visualized in the form of a darkened border, and the swelling of the nearby tissues is in the form of a hyperintense (light) focus. MRI and CT also allow you to evaluate additional factors that are not available with conventional X-ray examination:

  • visualization of soft periarticular tissues;
  • assessment of cartilage structures;
  • detection of cystic inclusions;
  • detection of intra-articular fluid accumulation;
  • determination of the stage of the pathological process and the area of ​​joint damage.

  Aseptic necrosis of the femoral head on MRI

  MRI and CT allow to obtain images of the joint in different planes without changing the position of the patient's body. Early diagnosis helps to start treatment of the hip joint in time and avoid serious consequences. Using these methods, it is possible to monitor the condition of the prosthesis in postoperative period and structural integrity. The only drawback of computer research is their high cost, which hinders the use of these methods by doctors in practice.

  When confirming changes in the joint on a tomogram, an additional blood and urine test is performed to determine the level of calcium. Increased calcium in the urine, indicating an increased excretion of it from the human body, is another sign of the disease.

  Conservative treatment

  In the early stages of the disease, when there is no deformation of the hip head, treatment can be carried out by conservative methods, without surgery. Medical therapy includes the use of the following groups of drugs:

  • Non-steroidal anti-inflammatory drugs.
  • Antispasmodics.
  • Antioxidant drugs administered intramuscularly, intraosseously or in ointment form (Mexidol, Perftoran and others).
  • Bisphosphonates that slow down the process of bone tissue destruction (Xidifon, Etidronate, Pleostat, Clodronate, Phosphotech, Pamidronate, Risedronate and others).
  • Calcium metabolism regulators (Alfacalcidol, Oteogenon and others).
  • Vascular drugs to reduce ischemic events in the femoral head (Dipyridamole, Curantil, Xanthinol nicotinate).
  • Chondroprotectors that restore metabolic processes in articular cartilage.
  • Vitamin complexes (group B vitamins are used in combination with chondroprotectors, 1-2 times a year).
  • Anticoagulants, when the disease is combined with thrombophilia (a predisposition to thrombosis of blood vessels) or hypofibrinolysis.

  Professor Mirzoyeva's tire

  Since they play an important role in the appearance of necrosis bad habits, you must stop drinking alcohol and smoking. The hip joint should be protected from hypothermia, heavy loads, heavy lifting, jumping and long walking or running. Children with this disease are contraindicated in physical education in the general group and participation in competitions. in the best way maintaining physical form is swimming. Regular examination an orthopedic visit should be done at least 2 times a year.

  Surgery

  In the later stages of the disease, when irreversible deformation of the joint begins, surgery.There are several types of operations:

  • intertrochanteric osteotomy (excision of a bone wedge and connection of fragments with a fixator in order to change the biomechanics of the joint and remove the affected area of ​​the head from the load);
  • decompression (open or tunneling);
  • rotational osteotomy (removal of the segment of the femoral head from under the load by turning the neck);
  • plastic surgery - replacement of the focus of necrosis (biocomposite granular or cement materials, crushed bone grafts, implantation of vascular bundles);
  • endoprosthetics (complete joint replacement).

  Endoprosthetics of the hip joint

  The most radical and traumatic method is arthroplasty, the indications for which are:

  • advanced age of the patient;
  • large deformity of the head or acetabulum of the joint;
  • systemic diseases of the arterial vessels of the legs;
  • thrombophlebitis;
  • diabetes;
  • pyelonephritis and other severe comorbidities.

  This operation is undesirable at a young age. Full recovery of the joint most often does not occur. Surgery in children is performed at the age of at least 6 years in the presence of a large focus of necrosis, which can cause severe deformity or subluxation of the joint. AT childhood apply the least traumatic operations - corrective osteotomy of the femur or rotational transposition of the acetabulum. Fragments of bones are fixed with special metal devices, which are removed after a few months. Immediately after the operation, the child is put in a plaster cast.

  Alternative and traditional medicine

  Treatment of the disease in the initial stage can be carried out folk remedies. At the same time, it is very important to visit a doctor, follow all his recommendations and conduct periodic instrumental monitoring of the condition of the joint.

  Since ancient times, acupuncture has been used to treat various diseases, the principle of which is still not entirely clear from the point of view of medical science. Long-term exposure to the body through the introduction of needles or electrical stimulation of special points improves microcirculation in the hip joint and can contribute to the complete recovery of its head. Hirudin also contributes to the restoration of local blood flow - active substance leeches saliva. Good results are shown by manual therapy, sessions of which should be carried out at least 2-3 times a week.

  AT traditional medicine For the treatment of diseases of the hip joint, the following recipes are used:

  • Yolk of 1 egg, 1 tbsp. l. turpentine and apple cider vinegar are thoroughly beaten and rubbed into the joint area.
  • 2 tbsp. l. lingonberry leaves pour 1 tbsp. boiling water and keep on low heat for 30 minutes. Means drink during the day in small portions.
  • 1 st. l. a mixture of roots and flowers of dandelions pour 1 tbsp. boiling water and insist 1 hour, then filter. The infusion is consumed ¼ cup 4 times a day.
  • Spruce branches are poured with boiling water in a large saucepan and boiled for 15 minutes, filtered. The decoction is used for taking warm baths 2-3 times a week.
  • 20 g of black currant leaves pour 1 tbsp. boiling water and insist half an hour. Infusion is taken 2 times a day for half a cup.
  • Gauze or a piece of cotton fabric is impregnated with propolis, the area of ​​​​the hip joint is wrapped at night.
  • In a large radish, a core is cut out and flower honey is poured. After a few hours, when the juice begins to stand out, the product is rubbed into the affected area.

Description:

The bones of our skeleton are made up of bone tissue, which, like most other body tissues, is made up of living cells and contains blood vessels (arteries, capillaries, and veins). If the local blood supply is disturbed, necrosis (necrosis) of the tissue or organ may develop, which can lead to serious problems. Violation of the blood supply occurs when a blockage (thrombosis or) of the arteries that supply blood to this area. Especially often tissues arise in areas that are supplied with blood from the basin of a single artery. These "problem" areas include the head of the femur. When the blood supply to this area is disrupted, a disease called aseptic necrosis (AN) of the femoral head occurs.

Anatomical aspects:

The hip joint is the largest spherical joint in our body. It is formed from the deep articular cavity of the pelvic bone (acetabular cavity) and the head of the femur. The hip joint is surrounded by powerful muscles (gluteal and anterior thigh muscles). The acetabular cavity and the head of the femur are covered with articular (hyaline) cartilage. The articular cartilage has a very smooth slippery surface, and its thickness in the hip joint reaches 0.5-0.6 cm. The function of the articular cartilage is to reduce friction during movements in the joint and absorb shock loads. The head of the femur is supplied by a single artery that passes through the neck of the femur. Due to the absence of collateral circulation, when blood flow through this artery is interrupted, the blood supply to the femoral head is disrupted. As a result, necrosis (necrosis) of the femoral head develops. Necrosis leads to a deterioration in the mechanical properties of bone tissue. Bone is not a "frozen" structure. In bone tissue, bone beams are constantly being destroyed and regenerative processes are simultaneously taking place. The cessation of recovery processes due to a lack of oxygen and nutrients leads to a rapid deterioration in the mechanical properties of bone tissue. As a result, under the influence of mechanical loads, a collapse (collapse) of the necrotic bone area occurs. With the development of AN, the shape of the femoral head changes: it flattens in the area of ​​maximum gravity. As a result, the congruence (articulation) of the articular surfaces in the hip joint is disturbed, which leads to an increase in the internal load during the operation of the joint and rapid wear of the articular cartilage. The outcome of AN is the development of osteoarthritis, a degenerative disease of the joint, accompanied by pain and impaired function.

Causes of aseptic necrosis of the femoral head:

Many factors can lead to the development of AN of the femoral head. Almost any cause that contributes to impaired blood flow in the artery of the femoral head can be an impetus for the development of AN. So traumatic injuries of the hip joint can lead to disruption of the blood supply to the femoral head as a result of mechanical damage or artery. Hip dislocation is the most common injury leading to the development of AN. AN develops after several months, although the first clinical symptoms, as a rule, appear in patients much later (often 1.5-2 years after the injury).
Reception of some medicines may also contribute to the development of AN. Most often, AN develops against the background of long-term use of high doses of glucocorticoid hormones for severe, etc. It has been shown that treatment with short courses of hormonal drugs does not increase the risk of developing AN of the femoral head. It is also safe in this regard to single or double intraarticular or periarticular administration of hormonal drugs in the treatment of osteoarthritis, bursitis, tendonitis and other inflammatory diseases of the musculoskeletal system. A clear relationship has been traced between excessive alcohol intake and the incidence of AN. Alcohol contributes to damage to blood vessels, which can cause ischemia of the femoral head and the development of its necrosis. An increased incidence of AN is noted in individuals whose professional activity associated with exposure to high pressure (divers, miners). If the decompression mode is not correct, small air bubbles form in the blood, which can clog and damage blood vessels, including leading to impaired blood flow through the artery of the femoral head.

Symptoms of aseptic necrosis of the femoral head:

The first symptom of AN is pain in the hip joint, which occurs when the weight of the body is transferred to the “sore” leg. The pain can spread to the inguinal, gluteal region, radiate (give) along the front surface of the thigh. With the progression of the disease, lameness and impaired function (mobility) of the joint appear. In the later stages, pain may persist even at rest, contributing to sleep disturbance.

Diagnostics:

Diagnosis of AN begins with a study of the patient's complaints, medical history and physical examination. The doctor will ask you about the presence of chronic diseases, taking medications, and occupational hazards. You may be asked about alcohol abuse. Physical examination includes examination, palpation of the joint and the study of its function (angle of abduction, limb flexion, etc.). To clarify and confirm the diagnosis, it is necessary to conduct additional laboratory and instrumental methods of examination.

On radiographs, the AN zone of the femoral head is determined, as a rule, with a sufficient duration of the disease. In the early stages of the disease, X-ray examination pathological changes bones may not be determined, despite the fact that the patient may already be disturbed by severe pain in the joint. In the later stages of AN, osteoarthritis accompanies, and it can be difficult to determine which of these diseases causes the patient's symptoms to a greater extent.

Radioisotope scanning   (scintigraphy)
In the absence of pathological changes on radiographs, the doctor may prescribe a radioisotope scan to clarify the diagnosis. With this technique, a drug containing a radioactive element (radiopharmaceutical) is introduced into the patient's body. A few hours later, using a special gamma camera, the registration of radioactivity in the human body is carried out. Due to the lack of blood flow in the femoral head, this area on the scintigram (image obtained with scintigraphy) is presented as a “cold” spot, since there is no accumulation of the radiopharmaceutical in it. After appearing in clinical practice magnetic resonance imaging, the frequency of radioisotope scanning for the diagnosis of AN has decreased significantly.

Magnetic resonance imaging
Currently, magnetic resonance imaging is the most commonly used research method for the diagnosis of AN of the femoral head. The principle of magnetic resonance imaging is to obtain an image of the tissues and organs of the body in the form of a series of sections using electromagnetic waves. This is the most informative and completely safe method research. On magnetic resonance tomograms, even insignificant zones with a lack of blood flow can be detected, and in the very early stages of the development of the disease.

Treatment of aseptic necrosis of the femoral head:

The tactics of AN treatment is determined by the stage of the disease and the severity of clinical symptoms. Currently, the effectiveness of drugs aimed at restoring blood circulation in the artery of the femoral head has not been proven. As long as pain can be effectively controlled with analgesic and anti-inflammatory drugs, surgical treatment is usually not required. Although in some cases, if the femoral head has not occurred, the surgeon may suggest an operation aimed at increasing the blood supply to the femoral head. There are several options for such operations.

Decompression of the femoral head
The principle of this simple operation is to drill one or more channels through the neck into the head of the femur, directly into the area where there is no blood flow. This operation has two goals: 1) to increase the blood supply to the ischemic area due to the growth of new blood vessels inside the drilled channel 2) to reduce intraosseous pressure inside the femoral head and thereby help reduce pain in patients with AN.

This operation is performed through a very small incision on the side of the thigh under the control of an image intensifier tube (IOT). The image intensifier is a mobile digital x-ray machine that allows you to get images of the bones on the display screen directly during the operation. After decompression of the femoral head, the patient must use crutches for 6 weeks. This recommendation is due to the fact that reaming the channels leads to a temporary decrease in the mechanical strength of the femoral neck, which increases the risk of fracture.

Transplantation of an autograft from the fibula
It's over complex operation, which aims to increase blood flow in the ischemic femoral head. Its principle is to transplant a segment of the fibula on a vascular pedicle into the region of the head and neck of the femur. As a result, the ischemic femoral head receives additional blood supply from the vessels of the bone graft. In addition, the graft mechanically strengthens the femoral head, preventing its further collapse. This operation is rarely performed due to its high complexity. The positive effect of the operation is not observed in all patients due to thrombosis of the vessels supplying the bone graft.

Endoprosthetics of the hip joint
In the later stages of aseptic necrosis, patients develop a degenerative joint lesion - osteoarthritis. In these cases, to reduce and improve the function of the joint, hip arthroplasty is indicated.

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Aseptic necrosis (osteonecrosis, avascular necrosis) of the femoral head is a multifactorial disease consisting in impaired microcirculation and subsequent necrosis of the bone tissue located subchondral in the most loaded upper outer segment of the femoral head, leading to its collapse, disruption of the integrity of the hyaline cartilage covering this area and development of secondary deforming arthrosis.

Aseptic necrosis most often affects men aged 25 to 45 years. In 50% of patients, there is a bilateral lesion of the hip joints, and in 15% of them, aseptic necrosis of another localization develops (femoral condyles, head humerus). The disease is characterized by rapid progression and, without proper treatment, leads to a pronounced violation of the static-dynamic function of the joint and, as a result, to permanent disability.

A number of reasons can lead to a local disturbance of microcirculation and the development of a zone of bone necrosis, the most common of which are the first three:

1) damage to the vessels supplying the femoral head in case of fractures of the femoral neck or dislocations of the hip joint;

2) embolization of vessels with drops of fat, blood clots, nitrogen bubbles (caisson disease), sickle-shaped erythrocytes;

3) thrombosis in coagulopathy (thrombophilia, hypofibrinolysis) or vascular diseases;

4) vascular occlusion due to external compression due to dislocation, joint effusion, increased intraosseous pressure, hypertrophy of bone marrow cells;

5) damage vascular wall cytotoxic agents.

Distinguish between idiopathic aspetic necrosis, which develops spontaneously, without visible reasons, and a secondary one that is associated with the following pathological conditions: long systemic therapy glucocorticosteroids, excessive alcohol consumption, systemic lupus erythematosus and other connective tissue diseases, chronic kidney failure, organ transplantation, sickle cell anemia and other hemoglobinopathies, coagulopathy, decompression sickness, chronic diseases liver, inflammatory diseases intestines, pancreatitis, hyperlipidemia, gout, pregnancy, radiation sickness, atherosclerosis and other vascular diseases, smoking, Cushing's syndrome, allergic reactions and hypersensitivity, sarcoidosis, chemotherapy and intoxication chemicals, tumors. In 65% of patients with aseptic necrosis of the femoral head, there is a history of glucocorticosteroid therapy or chronic alcoholism, while idiopathic osteonecrosis is detected only in 15-20% of patients. An important predisposing factor is individual characteristics vascular anatomy, in particular, the lateral vessels of the epiphysis of the femur, which are poor in collaterals, supplying the upper outer segment of the head.

The starting factor of pathogenesis is a sharp decrease or cessation of microcirculation in the segmental area of ​​the epiphysis of the bone, leading to its infarction, i.e., the death of bone marrow cells, stroma and osteocytes. Around the area of ​​necrosis, a much superior zone of edema appears. Reparative processes begin in the bone tissue. However, due to discoordination of spasm and paresis of blood vessels, slowing down of blood flow, changes in its rheological properties and aggregation of formed elements, a pathological focus of blood circulation occurs, which is accompanied by a discharge of incoming arterial blood into the venous system of the diaphysis. These changes significantly inhibit reparation, making it ineffective, as a result of which new areas are subjected to necrosis and decompensation occurs. Under the action of a mechanical load, microfractures occur in the subchondral bone, leading to a decrease in its strength. Hyaline cartilage without underlying mechanical support rapidly undergoes progressive irreversible degeneration. Violation of the surface structure of the femoral head leads to a change in the mechanical load transmitted to the hyaline cartilage of the acetabulum, and the development of pathological changes in it. It should be noted that if the zone of osteonecrosis is limited in area and is located in the medial, less loaded part of the femoral head, then it can undergo spontaneous recovery. The timing of the development of the collapse of the femoral head ranges from several weeks to several years.

The first clinical manifestation is pain, most often localized in the inguinal region, less often in the thigh, knee joint, and lumbosacral spine.

At first, the pains are periodic, disappearing after rest, and then become constant, their intensity gradually increases, intensifying with slight physical activity. In the late stage of the disease, pain may occur at night. In some patients, the onset of the disease is sudden. Pain is not accompanied by fever, swelling of soft tissues in the joint area.

Often in the acute period, patients can neither stand nor walk for several days, then, as a rule, relief occurs with the return of the patient to normal motor activity. For several months, and sometimes even years, a normal range of motion in the joint can be maintained. First of all, there is a restriction of rotational movements and abduction, then there is a restriction of movements in the sagittal plane and, ultimately, persistent flexion-adductor contracture and functional shortening of the limb are formed. Characterized by progressive hypotrophy of the soft tissues of the thigh, flattening of the gluteal region on the side of the lesion. Rapidly progressive course of osteonecrosis with significant destruction of the head, early development deforming arthrosis, dysfunction of the joint and loss of professional ability to work most often occurs with bilateral lesions. With a unilateral process, the main symptoms, as a rule, develop more slowly.

Changes in laboratory parameters are nonspecific.

Be sure to perform x-ray of the hip joint in two projections. In the absence of pathological changes, MRI is indicated, which is the most sensitive method for diagnosing aseptic necrosis and makes it possible to detect pre-radiological changes in 90% of patients.

Early radiological sign is a change in bone density in certain areas of the femoral head: you can usually see a very gentle line of low density under the subchondral layer of the head, which duplicates the contour of the head and resembles an egg shell. Sometimes it is possible to identify focal areas of rarefaction and, along with them, islands or lines of compaction.

After the appearance of an impression fracture (in the subchondral zone, more often than the upper outer segment of the head), a triangular or disc-shaped area of ​​necrosis is indicated on the radiograph and changes in the contours of the head are detected, and its deformation most often begins on the lateral edge with a slight impression. The focus of necrosis is revealed as a dense shadow surrounded by a light osteolytic zone, followed by a denser zone corresponding to the sclerosis zone. Subsequently, secondary changes occur that are characteristic of deforming arthrosis: coracoid bone growths, saddle head deformity, cystic formations, narrowing of the joint space.

Differential diagnosis often has to be carried out with coxarthrosis, tuberculous coxitis, osteochondrosis of the lumbosacral spine.

Non-operative treatment is symptomatic and is indicated when it is impossible to perform surgical intervention. It includes a long-term (up to 6 months) restriction axial load on the affected limb, taking NSAIDs, physiotherapy (alternating electromagnetic field). In secondary aseptic necrosis, it is important to eliminate or correct the effect of the main damaging factor.

If the collapse of the femoral head has not yet occurred, then for its prevention, surgical decompression of the osteonecrosis zone is performed by removing 1-2 cylindrical columns of bone 8-10 mm in diameter, followed by replacement of this area with bone allo- or autografts, in the latter case, as free , and on the feeding vascular pedicle. To unload the affected area of ​​the head, corrective osteotomies of the proximal femur are also used. With the development of the collapse of the femoral head, total hip arthroplasty is indicated (Fig. 1).

Rice. one.

Traumatology and orthopedics. N. V. Kornilov

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A disease called aseptic necrosis of the femoral head is quite common. Women suffer from it several times less often than men. It is characteristic that 2/3 of the patients are young people 20-45 years old. This is a rapidly progressive disease.

With absence proper treatment threatens with dysfunction of the joint and, as a result, loss of ability to work.

That is why it is important not to miss the first symptoms of the disease.

The main causes of the disease

femoral head- this is a closed compartment, sensitive to circulatory disorders that change the architectonics of the bone.

The head is supplied with blood through three small arteries. When one of them stops (breaks) the blood supply, necrosis (ischemia, necrosis) occurs in that area of ​​the head that was supplied by the damaged artery.

The essence of asthenic necrosis is a violation of microcirculation and further necrosis of the bone tissue zone in the head of the femoral bone. As a result, the integrity of the cartilage covering this area is violated, and secondary deforming arthrosis develops.

Vascular causes

Common Causes cessation of blood supply to the head of the femoral bone by the artery:

• compression or twisting of the artery in case of injury,
• its blockage by a small thrombus,
• venous stasis,
• prolonged vasospasm,
• increased blood viscosity
• impaired venous return.

Vascular disorders increase intraosseous pressure, leading to mechanical destruction of bone tissue.

About mechanical theory

The vascular theory of causes is complemented by a "mechanical" theory. According to it, the head of the femur experiences "overwork".

Impulses about this are sent to the cerebral cortex.

Feedback signals lead to vasospasm or blood stasis, metabolic disorders, accumulation of decay substances in the bone.

As a result, the physicochemical and structural properties of the bone change, which is gradually destroyed with difficulty in local blood circulation.

Metabolic disorders and pathological conditions

Among them, as the causes of the disease lead:

• prolonged use of alcoholic beverages;
• long-term use of corticosteroids in high doses; arthritis sufferers or bronchial asthma take corticosteroid hormones for a long time (metipred, prednisolone, etc.);
• chronic pancreatitis;
• large doses of radiation exposure;
• decompression sickness;
• osteomyelitis;
• sickle cell anemia and other diseases,
• injuries (thigh bruise, hip dislocation, hip fracture, etc.).

One of the causes of the disease is a congenital defect in the form of a dislocation of the hip (hip dysplasia).

Symptoms and diagnosis of the disease

stages aseptic necrosis of the head of the hip joint with distinctive symptoms:

1. Initial. Pain is the starting point clinical manifestation. It grows to a maximum and becomes unbearable in the first two or three days. Usually appears in the groin, rarely in the thigh, knee joint, lower back. The joint retains its full mobility.
2. Second- impression fracture. The patient has constant severe pain in the joint even at rest. For a period of several days to six months, vascular disorders develop. Possible atrophy of the thigh muscles. The sore leg seems to decrease in volume. Movement is limited. There is a slight lameness in the gait.
3. Third- secondary arthrosis. For 6-8 months, bone beams are destroyed, the head of the femur is deformed. There is severe pain in the joint. Movement is limited in three directions. When walking, starting pain, average lameness, desire for support are noted.
4. Fourth. When the disease lasts more than 8 months, complete destruction of the head occurs. Constant pain in the joints of the hip and knee, in the lower back. Movement is severely limited. Atrophy of the muscles of the buttocks and thighs is strongly pronounced. The diseased leg becomes shorter, in a more severe version it lengthens.

Diagnostic methods

to widely used ways of diagnosing a disease relate:

1. MRI. Early stage detected by magnetic resonance or computed tomography. This diagnostic method almost 100% detects the disease when the X-ray "does not see" it. Therefore, during the first weeks of the disease, diagnosis by MRI is a priority.
2. Radiography. Aseptic necrosis on an x-ray becomes noticeable only at 2-3 stages of the disease. When the disease has an "experience" of more than a year, its signs are very clearly manifested in the pictures. At this stage, a tomogram is not needed.
3. radioisotope scanning. This method shows the unequal absorption of a radioactive drug by pathological and normal bone tissues. The injected dose of the drug serves as a "label" of the abnormal zone in the bone. The result is a 2D image showing the affected areas of the bone.

Radiographs of patients with various stages of aseptic necrosis of the femoral head: from a - the initial stage, to e - complete destruction of the bone.

Treatment and relief of pain in conservative ways

Medical therapy

To the main drug groups used to treat the disease include:

• Anti-inflammatory nonsteroidal drugs , for example, indomethacin, piroxicam, butadione, etc. They help to reduce pain in the thigh and groin. This group of drugs does not cure the disease. But due to the analgesic effect, reflex muscle spasm is prevented in case of pain. These drugs are especially effective in the first six months of the disease.
• Vasodilators e.g. trental, theonicor. They eliminate stagnation in blood circulation. As a result, arterial blood flow is activated and spasms of small vessels are relieved. Vascular night pains in the affected joint are reduced. Effective in the first 6-8 months of illness.
• Bone restorers. Means with vitamin D help to stimulate the recovery process (calcium D3 forte, oxidevit, natecal D3, etc.). These drugs promote the accumulation of calcium in the head of the affected femoral bone.
• Calcitonins effectively stimulate bone formation and eliminate bone pain. These include miakaltsik, sibacalcin, alostin, etc.
• Chondroprotectors(chondroitin sulfate and glucosamine) provide nutrition to cartilage tissue and restore the structure of destroyed cartilage. Treatment gives an effect in the period of the disease from 8 months.

Therapeutic gymnastics and massage

One of the most important methods of treatment of necrosis of the femoral head is physiotherapy. Without it, it is impossible to overcome the progressive deterioration of blood circulation in the area of ​​the femoral head and the growing atrophy of the thigh muscles.

It is necessary to choose exercises to strengthen the muscles and ligaments of the sore leg. Moreover, there should be no pressure on the head of the femoral bone without active flexion-extension of the legs.

An example of a static exercise is a slight straight leg raise in a supine position. The leg is supported by weight. Fatigue will appear, although the joints do not work. A set of exercises should be carefully considered with your doctor.

Massotherapy applied as additional method treatment. But if you perform it competently, without rough pressure, it will bring real benefit. When massaging the thigh muscles and back, blood circulation improves.

Orthopedic rules

It is very important to observe the orthopedic mode. Many experts oppose prolonged use of crutches and bed rest early in the disease.

In their opinion, this threatens:

• progressive muscle hypertrophy,
• the formation of pain resistant syndrome,
• violation of motor stereotypes.

For alleviate the course and reduce the duration of the disease needed:

• walking up to 20 min. at an average pace
• walking up stairs
• swimming,
• exercise bike,
• the use of a cane in the first weeks and during long walks,
• fight against overweight.

It is necessary to exclude inertial loads on the joint in the form of weight lifting, jumping, running.

Operative treatment of the disease

Surgical intervention is resorted to when conservative means are ineffective.

Decompression of the femoral head

The surgical method of decompression consists in drilling a channel into the area of ​​the femoral head with no blood flow. The drill passes along the greater trochanter and neck of the femur.

Decompression Goals:

• an increase in the blood supply to this area due to the growth of new vessels in the formed channel (puncture),
• decrease in intraosseous pressure in the femoral head.

By lowering the pressure, pain is reduced in 70% of patients.

Transplantation of an autograft from the fibula

Unlike decompression, a fragment of the fibula located on the vascular pedicle is transplanted into the drilled cavity. Such a transplant from one's own body improves blood flow and strengthens the femoral neck.

Endoprosthetics of the hip joint

It consists in the complete replacement of the damaged hip joint with an artificial one. A titanium pin (or made of zirconium) with an artificial head on the edge of the joint is inserted into the formed cavity of the femoral bone and fixed.

At the same time, the second articulating part of the joint is operated, inserting a concave bed for rotating a new head in it. Correctly performed surgery eliminates pain and restores joint mobility.

Timely initiated and competently performed treatment of necrosis of the head of the hip joint in most patients improves within a few months of therapy.

In another part of the patients, the condition stabilizes, which does not lead them to surgical measures.

Video: What systemic diseases can provoke the development of HBK necrosis