Aseptic osteonecrosis of the femoral heads. Causes, symptoms, treatment and consequences of aseptic necrosis of the femoral head

Influence of adverse factors environment coupled with large daily loads often leads to various pathological processes lower extremities, one of which is aseptic necrosis of the head femur. This is a serious pathology, which is manifested by tissue necrosis. Necrosis requires immediate therapy to avoid disability of the patient.

The mechanism of development of osteonecrosis

According to medical data regarding osteonecrosis of the femoral head, the root cause of the pathology is a wide variety of disorders that gradually lead to necrosis of the bone tissue. One of the favorite localizations of necrosis is the head of the femur. Necrosis can occur not only in adults, but also in childhood. The mechanisms of development of the anomaly are still not fully understood. There are two main theories for the occurrence of necrosis in the tissues of the thigh:

1. Traumatic. The trigger mechanism for necrosis is hip injury, ranging from a simple dislocation to a severe fracture with complications.
2. Vascular. The main theory, which received a lot of evidence and recognition. It has been proven that necrosis is most often associated with impaired blood supply to bone tissues. If the vessels supplying blood to the head of the bone, under the influence of various factors, have lost this function, local ischemia or circulatory disorders occur. This may be due to blockage of the vessel by a small thrombus or its direct narrowing. At the same time, there may be a thickening of the blood, which leads to a slow flow of biological fluid through the vessels. The resulting ischemia leads to the gradual death of osteocytes and osteoclasts of bone tissue, which causes a decrease in the processes of tissue formation, which weakens and loses strength. The result is the occurrence of microfractures of the bone trabeculae, which initially leads to compression of small and then large veins. Gradually, the blood begins to thicken, microthrombi are formed.

Over time, stagnation is noted in the arteries. As a result, the manifestations of ischemia are aggravated, increasing intraosseous pressure in the thigh area. This is how necrosis of bone tissue occurs, most pronounced in places of strong pressure on the head of the bone.

Some scientists put forward another theory regarding the mechanisms of development of necrosis - mechanical. According to this theory, the occurrence of necrosis is a consequence of the “overwork” of the thigh bone tissue. Impulses begin to flow into the brain about the problem that has arisen, and the brain tries to eliminate this by vasoconstriction. As a result, metabolic processes are only disturbed, blood stagnates, decay products accumulate.

Important! AT practical medicine there is no clear distinction between theories regarding the development of necrosis. It is generally accepted that all are relevant at the same time, simply complementing each other.

What can lead to necrosis

It must be understood that almost any predisposing factor that is associated with a violation of the integrity or blood supply of the bone can lead to the development of necrotic processes:

1. Injury. It can be a fracture, dislocation, surgery, and so on. The end result is a mechanical rupture or blockage of the vessels that feed the bone tissue. Gradually, the flow of blood with oxygen and nutrients to the thigh is disrupted. This usually occurs several months after the actual injury. The first manifestations of necrosis may occur only after 1.5 or 2 years.
2. Medicines. Long-term use of corticosteroids, which can constrict blood vessels for a long time, disrupting blood circulation processes in the femoral head, can lead to necrosis. With prolonged use, bone destruction leading to osteoporosis can be associated with this adverse effect. With an increase in the load on the weakened areas, microtraumas (fractures of the bone crossbars) occur, which have a chronic character. The result is a disturbed blood flow to the thigh and head. These pathological processes are also characteristic of the abuse of painkillers or non-steroidal anti-inflammatory drugs.
3. Alcohol. With the systematic use of alcoholic beverages, a violation of fat and protein metabolism in the body occurs, causing the activation of atherosclerosis processes. The walls of the arteries lose their elasticity and thicken, which serves as a prerequisite for necrosis. When drinking alcohol in a short period of time in large doses, circulatory disturbance occurs immediately.
4. Diseases. The category includes mainly autoimmune diseases - lupus erythematosus, hemorrhagic vasculitis or scleroderma. These diseases can lead to the accumulation of immune complexes on the walls of arteries, which provoke the development of immune inflammation. As a result, elasticity and local blood circulation of the vessel suffer, necrosis occurs.
5. Caisson disease. It belongs to a separate category, since it is associated with a decrease in the pressure of the inhaled mixture (gas) when immersed in the ground or water. Most often characteristic of miners or divers. With rapid or incorrect immersion, the resulting gas bubbles can easily enter the bloodstream and lead to blockage of any vessel, causing ischemia and necrosis.
6. Problems with the spine. Violation of innervation in the spine can lead to vascular spasm and malnutrition of the femoral tissue. It often happens with intervertebral hernias.

In addition to the above, acute pancreatitis, anemia (sickle cell) and ionizing radiation can lead to avascular necrosis in the thigh. It should be noted that about 30% of all cases have no clear cause. Often a situation arises when several predisposing factors simultaneously influence the development of necrosis.

Types and stages of aseptic necrosis of the thigh

The first necrotic foci in the bone tissue appear 2–4 days after ischemia. If the necessary measures are taken and the ischemia is eliminated, the blood supply to the bone will be restored, and the necrosis will disappear. If this is not done, the ischemic process will worsen, leading to further development of necrosis.

In medicine, there are several official classifications of femoral necrosis, but the most popular is the staging of the disease based on the changes that occur in the bone during the course of the pathology. It should be borne in mind that such a classification is very conditional, since there are no clear boundaries for the transition of necrosis from one stage to another.

In addition to the listed stages, in medical practice it is customary to distinguish several forms of avascular necrosis of the femoral head:

1. Central. The location of the necrosis zone directly in the central part of the head is characteristic.
2. Peripheral. It is manifested by a lesion of the outer part of the head, which is located directly under the cartilaginous tissue of the joint.
3. Segmental. Necrosis occupies a compact area of ​​the bone and somewhat resembles a cone in shape. This is usually the upper or upper outer part of the femoral head.

Another form of necrosis is a complete lesion of the femoral head. This happens in almost 40% of cases, usually causing a person's disability.

Clinical manifestations of necrosis

Symptoms characteristic of necrosis occur almost at the very beginning of the development of the disease, are associated with the staging of the disease:

1. Stage one. It manifests itself as the very first and main sign of necrosis - pain syndrome. At first, pain occurs only after intense physical exertion or is associated with bad weather. After a period of rest, it disappears on its own. As the pathological processes progress, it becomes constant. Limitation of movements at this stage of necrosis is usually not observed. Main localization pain with necrosis - the thigh area. Characterized by the spread of pain in the lower back or groin, sometimes the pain gives to the buttock or knee. It can often occur quite suddenly and be so intense that at a doctor's appointment a person can accurately name the day and hour of the onset of pain. After a few days, the pain subsides and reappears only after physical exertion.
2. Stage two. The pain becomes constant and pronounced. It does not disappear at rest, increases during exercise and is poorly controlled by conventional analgesics. At the same time, muscle atrophy is noted in the buttock area from the side of the lesion and on the thigh. Gradually, there is a restriction of movements, mostly circular, which begin to cause increased pain and prevent you from taking the sore leg to the side or leading to a healthy one.
3. Stage three. The pain syndrome at this degree of necrosis acquires constancy, intensifying even after a small load. Mobility hip joint sharply limited, which prevents a person from moving freely. It is difficult to even put on socks on your own or pull the affected leg to your chest. When walking, marked lameness is noted, and atrophic processes extend to the lower leg. The leg usually takes on a shortened appearance. If limb lengthening is noted, this is a poor prognostic sign. Patients are forced to walk with assistance or a cane.
4. In the fourth stage of necrosis, the pain becomes almost unbearable, occupying all the thoughts of the patient. Muscular atrophy reaches 5-8 cm, and circular movements become absolutely impossible. Attempts to move the foot forward and backward are limited, and independent foresight is almost impossible. This is practically a disability that requires serious and rather complex treatment. Should apply for medical care at the very beginning of the development of symptoms of necrosis.

According to a large amount of scientific research and medical data, the aseptic form of necrosis is quite common in children. Particular attention should be paid to the symptoms characteristic of necrosis in a child.

Basic diagnostic methods

The main problem in the diagnosis of necrosis lies in the symptoms, which are also characteristic of other diseases, so the final diagnosis is often delayed. With a competent approach to diagnosis, the problem can be eliminated in the shortest possible time.

The very first rule in the diagnosis of necrosis is to find out the causes of the anomaly. This is followed by an external examination, which reveals signs of functional and atrophic disorders and a possible shortening of the limb on the side of the lesion. The next step is appointment instrumental methods, each of which in necrosis has its own diagnostic significance.

Radiography

With necrosis, an x-ray allows you to get an idea of ​​​​the immediate state of the bone tissue of the hip joint. Usually, if necrosis is suspected, 2 x-rays of the thigh (lateral and direct) are performed, which reveal the following manifestations:

• Stage I: there are practically no changes characteristic of necrosis, sometimes areas of osteoporosis are noted;
• Stage II: areas of necrotic tissue are visible, signs of bone crushing and small cracks in its structure (on the femoral head), there is a slight expansion of the joint space;
• Stage III: areas of tissue resorption on the femoral head are clearly visible, which loses its shape and often consists of several fragments, the femoral neck is thickened and shortened, and bone growths are visible along the edges of the acetabulum, the interarticular gap is narrowed slightly;
• Stage IV: there is a strong deformity of the femoral head, which acquires a short and wide appearance, the joint space is sharply narrowed, and the acetabulum has coarse growths, flattened and shortened.

It must be borne in mind that x-rays with necrosis do not provide data on the state of the vessels. At the initial degree of necrosis, it is uninformative, often leading to an erroneous diagnosis or refusal of treatment.

CT

With necrosis, computed tomography allows you to examine not only the bones, but also the tissues of the vascular bundles. The obtained images clearly show the smallest changes in all structures of the musculoskeletal system, characteristic of necrosis. This is strikingly different this method from x-ray.

Magnetic resonance imaging

MRI is excellent for diagnosing necrosis at the earliest stages of development, allowing even the smallest manifestations of the disease to be detected. In the pictures, intraosseous edema of the hip joint and its inflammation can be clearly seen. On MRI, all vessels are well and contrast visible.

Other events

An ultrasound procedure can serve as this, which allows a good view of the hip joint from the inside and reveals the first manifestations of vascular problems during necrosis.

Applies and laboratory diagnostics necrosis, which mainly acts as an auxiliary method that helps to detect the content of calcium, magnesium, osteocalcin and phosphorus in the blood. With necrosis, their concentration is disturbed, which becomes another diagnostic sign.

At biochemical research blood at a necrosis specific fragments of an inflammation are found. Assign tests for pyridinoline and deoxypyridinoline. Their detection indicates the destruction of bones and cartilage, characteristic of necrosis. Even in the analysis of urine, manifestations of bone necrosis can be detected.

Treatment of necrosis with medicines

For necrosis use pharmaceutical preparations quite effective, but only in the early stages, when the marker of bone formation and the level of calcium are still within the normal range.

For necrosis, the most effective and proven drug groups are usually used:

1. vascular drugs. They help to improve local blood supply by dilating small vessels and normalizing blood outflow. They inhibit the adhesion of erythrocytes and platelets, preventing the formation of blood clots ("Xanthinol", "Kurantil").
2. NSAIDs. With necrosis, nonsteroidal drugs help relieve pain and inflammation. Relieve reflex muscle spasm, helping to improve blood circulation ("Xefocam", "Diclofenac").
3. Calcium metabolism regulators. They prevent the loss of calcium and accelerate the recovery processes of bone tissue, suppressing the increased activity of osteoclasts and reducing the destruction of collagen during necrosis (Ksidifon, Bonviva).
4. Mineral preparations, calcium and vitamin D. Help to compensate for the lack of calcium, improve its absorption in the intestines along with phosphorus and contribute to their better absorption (“Osteogenon”, “Calcium D3 Nycomed”).
5. Precursors of vitamin D3. With necrosis, they contribute to the improvement mineral metabolism and accelerate the synthesis of bone proteins, increasing its strength ("Alfacalcidol").
6. Chondroprotectors. They allow to restore cartilage tissue in case of necrosis of the hip joints, relieve pain and inflammation, improve calcium metabolism (Struktum, Artra).
7. Vitamins of group B. Contribute to the improvement of osteoblasts and protein synthesis in bone tissues ("Neurobion", "Milgamma").

In addition to the listed drugs, muscle relaxants are prescribed for necrosis, which allow you to relieve muscle spasm, which will help reduce pain and normalize blood flow. As an example, the well-known drugs "Mydocalm" and "Sirdalud" can be cited.

Complementary Therapies

Any therapeutic measures are based on a certain regimen. This also applies to the treatment of aseptic necrosis, in which it is very important to comply with orthopedic rules. With necrosis, there are only a few prescriptions, so remembering them will not be difficult at all:

• you need to try to walk more often at an average pace for 15 - 20 minutes and try to climb up the stairs;
• with necrosis, it is useful to exercise in the pool and swim;
• it is necessary to develop a set of exercises on an exercise bike together with an instructor;
• you need to try to get rid of extra pounds;
• in case of necrosis, one should go in for sports, but exclude inertial loads from the training complex - running, jumping and lifting weights.

With necrosis, it is not recommended to stay in bed for a long time, use crutches or a cane for a long time, which threatens with the progression of muscle atrophy, disruption of normal motor stereotypes and increased pain.

Important! With long walks during the treatment of necrosis, you should not forget about the cane.

Remedial gymnastics has been used as one of the most popular methods of treatment in the field of orthopedics for many years. Classes also help with necrosis in the hip joint. A specially designed set of exercises allows you to stop the progressive deterioration of blood circulation and prevent further atrophic processes characteristic of necrosis.

Usually, exercises are chosen to strengthen the muscles and ligaments on both legs at once. In case of necrosis, there must be no strong pressure on the femoral head, active flexion and extension are allowed only if indicated, with the consent of the gymnastics instructor.

As an illustrative example, we can consider an exercise when the patient, lying on his back, straightens his leg and raises it slightly. Next, the limb should be held on weight for several minutes until fatigue appears. If pain occurs, classes should be stopped. Additionally, a special massage is prescribed to relieve pain, speed up and increase blood flow, which is especially important.

Surgery methods

Surgical intervention is carried out according to strict indications, when conservative therapy is ineffective or the patient enters a medical institution in a serious (neglected) condition. Many special techniques have been developed to effectively cope with necrosis. Consider the most effective:

1. Decompression. It consists in drilling neat channels in the area of ​​​​the femoral head in areas where there is no blood flow. The drill is carried out along the neck and greater trochanter. This manipulation allows you to increase blood supply due to the growth of new vessels in the resulting channels. In parallel, intraosseous pressure decreases, which contributes to the rapid removal of pain.
2. Transplantation of a piece of bone. It is shown at I or II stages of necrosis, allows you to quickly remove the pain syndrome. The main goal is to strengthen the femoral head and increase local blood flow. The operation itself is based on the removal of a dead tissue area, followed by transplantation of a small segment of the fibula, which will serve as a source of additional blood supply and will strengthen the femoral head.
3. Endoprosthetics. Appears to be very effective medical method aseptic necrosis. It consists in the complete replacement of the damaged joint with an artificial one. To do this, a special titanium or zirconium pin is placed in the prepared joint cavity and fixed. The second part of the articular joint is also subjected to surgical excision. A concave bed is placed in it, allowing the femoral head to rotate as freely as possible, due to which the functionality of the affected joint is fully restored.

The specific method of surgical intervention is selected individually depending on the patient's condition and certain clinical manifestations of necrosis. Based on research and a number of special tests, the doctor chooses the most effective method surgical treatment, which allows you to return to a person the opportunity to move freely and independently after aseptic necrosis.

Principles of postoperative rehabilitation

The symptoms and treatment of hip necrosis may vary, but rehabilitation is a must and is of great importance, especially after surgery. Rehabilitation helps the patient to get back on his feet faster and restore the functions of the affected limb after necrosis. At the very beginning of recovery, the patient must realize that movement is vital, since prolonged rest leads to loss of muscle mass, which will aggravate necrosis.

It is not advisable to start motor activity abruptly with necrosis. Walking with a cane is recommended for 4 to 6 weeks after surgical treatment of necrosis. Useful walking on the stairs lasting no more than 15 minutes. A huge role is played by special physical education, which teaches you to walk again and competently load the hip joint (exercise therapy).

For a complete recovery, electrical muscle stimulation, thermal physiotherapy and massage are prescribed, which allow you to return functionality to the affected leg in a short time, and the patient - freedom of movement. The most important thing is to act consistently, under the strict supervision of the attending doctor.

Rehabilitation measures are also important in conservative therapy, since after removing the main symptoms of necrosis with medications, it is equally important for the patient to learn how to dose the load regimen correctly, returning functionality to the diseased leg. This will help to consolidate the results of treatment and significantly reduce the likelihood of a possible recurrence of necrosis.

Diet for osteonecrosis of the hip

A proper diet will help prevent destructive processes in the bone and cartilage tissue of the thigh, relieve pain and speed up recovery from osteonecrosis. The menu includes several useful products that must be present in the human diet:

• fish products: salmon, tuna, mackerel;
• linseed oil (2-3 tsp per day);
• dairy products: kefir, curdled milk, cottage cheese;
• rye bread and whole wheat grains;
• vegetables: lettuce, carrots, broccoli, cucumbers and sweet peppers;
• lean meat (rabbit) and egg white;
• fruits and berries: oranges, lemon, pomegranates, peaches, blackberries, apples;
• green tea, beans, buckwheat grain and mushrooms.

Do not forget about the prohibitions in this disease. Should get rid of bad habits, then eliminate corn oil, fats and artificially synthesized oils from the diet. You can not eat offal, fatty meats and egg yolks, which will only exacerbate the pathological processes and slow down the recovery period.

Help folk recipes

Alternative recipes for osteonecrosis of the thigh can help to cope with unpleasant symptoms and stop the progression of the pathology. Necrosis should be treated with their help only at the initial stages of pathology development. You can use recipes from the people only after consulting with your doctor, who will help you choose the most effective and safe ones.

Among the most popular recipes for necrosis, the following are most often distinguished:

1. Tincture with saber. It helps to speed up blood flow and relieve pain in the thigh area with aseptic necrosis. To prepare it, you need to take 50 g of dry grass and pour 1 bottle of vodka, then close it tightly and put it in a dark place for 4 weeks. After you need to express the finished infusion and take 30 drops daily. To obtain the maximum therapeutic effect, the finished infusion can be rubbed into the affected joint.
2. Ointment with mint. With necrosis, it helps to cope with pain, it is prepared quite simply. It is necessary to take mint, eucalyptus, aloe leaf (50 g each), finely chop and mix thoroughly. Fill with water and put on fire. Cook should not be very long, until a homogeneous mass is obtained, then cool. A warm mass should be applied to a sore spot before going to bed as a compress at night. Repeat until the pain subsides.
3. Animal fat. Need to take in equal amounts lard with nutria fat. They will need to melt a little to mix until smooth. The ointment can be rubbed into the affected joint every day in the evenings and left overnight. The full course of treatment should be at least 1 month.

Another interesting and no less effective medical prescription with necrosis - a bath with turpentine. To prepare it, you need to add ½ tsp to hot water. gum turpentine. Additionally, you can add pine branches, finely chopped Jerusalem artichoke and a bag of sea salt. Then you need to let the water cool a little and brew. When the water is tolerable to the touch, you should take a bath for 10 minutes, dry yourself thoroughly and draw an iodine grid on the hip joint. You can also add honey on top. The optimal number of such procedures is at least 12.

The listed recipes have been tested on their own experience by patients with necrosis of the thigh and received the largest number positive feedback.

Forecast

Avascular necrosis of any localization is enough serious disease threatening the development of gangrene with subsequent disability and deterioration in the quality of life. Most specialists try not to delay the appointment of a full course complex therapy. If treatment is started in a timely manner, the prognosis will be quite favorable, and the patient will be able to maintain the functionality and mobility of the hip.

Aseptic necrosis of the head of the hip joint is a very serious pathology of the musculoskeletal system, which requires immediate complex treatment. The greatest danger of necrosis lies in the possible disability due to loss of mobility in the hip joint. The outcome of the disease and the return of a person to a full life directly depend on a competent approach to treatment tactics.

The hip bone is one of the most complex in the body. It consists of a head and a glenoid cavity, representing a complex mechanism. With its help, the body keeps balance, it is possible to sit and move around.

The subchondral area of ​​the bone tissue, where there is no necrosis, is well innervated and provided with blood flow. For this reason, it is often prone to inflammation and, in the future, destruction. The most commonly affected is the hip joint. A well-known orthopedist said: do not use painkillers in the treatment of joint diseases - this will lead to disability.

Treatment of aseptic necrosis of the head of the hip bone is based on the rules:

• reduce pain;
• relieve inflammation in the femur;
• resumption of motor function of the joint;
• maintaining the achieved result by rationalizing the lifestyle.

Treatment of aseptic necrosis of the hip joint will be of high quality and effective if detected earlier. The patient is able to detect the first signs of malaise on their own. They notice restrictions in the movements of the joint, pain, swelling. Treatment of the femoral bone is divided into conservative and surgical.

Conservative treatment of aseptic lesions of the femoral head is long in time, can last several years. The first step is to help the patient feel better. Use of painkillers in various forms release (ointments, tablets, injections, powders, patches). Doctors recommend nimesulide, diclofenac, ibuprofen and combinations with others active ingredients. Treatment of necrosis of the head of the joint drugs begin immediately.

The next step is to improve blood circulation in the affected area of ​​the bone. Use vasodilators (no-shpa, vitamin PP alone or in combination called "nikospan"). For additional nutrition of bone and cartilage tissue, chondroprotectors (glucosamine and chondroitin) are recommended. It is worth noting that these drugs adversely affect the gastric mucosa, it is recommended to take only after meals. Important are the drugs that are used for the regeneration of the femur (various combinations of calcium with vitamin D3). In combination with the above, calcitonins (miacalcic) play an active role in the treatment of aseptic necrosis. Means help new bone tissue grow faster, reduce the manifestations of pain, make the treatment of necrosis of the head of the joint of the disease not so long.

It will be necessary to remove or limit the mechanical movement of the hip joint as much as possible. Methods are used to achieve:

• hip immobilization;
• bed rest;
• hoods and orthopedic devices;
• splints and plaster bandages.

Which method to choose, how long the immobilization will last, is decided by the attending physician. On average, the process lasts from 6 to 18 months.

Physical therapy and rehabilitation are considered important. It will be useful to lose weight, excess weight puts a load on a joint already damaged by aseptic necrosis.

Often, doctors prescribe electrophoresis with novocaine or lidocaine on the affected area of ​​the thigh, providing an additional analgesic effect on the legs and spine. The country has an abundance of sanatoriums and clinics that specialize in the rehabilitation of such patients. You can take the course here physiotherapy exercises, mud wraps and massages. Exercise will help stretch the ligaments, providing an opportunity to work out damaged joints and avoid stiffness. Exercises and massage are performed under the supervision of a specialist.

Exercises can be performed at home. They are prescribed sparing and careful. It is better to start with a simple leg lift, holding on weight for a while. Important recognized: swimming in the pool, leisurely walks, weight loss and the use of canes instead of crutches. To prevent re-injury, after discharge home, it is required to ensure the safety of the patient. First of all, remove carpets and runners from the floor so that the patient does not slip.

It is important to note that a conservative method in the treatment of necrosis of the head of the hip joint does not help to avoid the disease by 100%. It is possible to slow down the process of development of the disease and the death of organ cells. Use the method rationally only in the first three stages diseases.

Surgical intervention in the treatment of aseptic necrosis of the hip joint

Often surgical intervention on a femur affected by necrosis, it is used together with conservative treatment. The decision depends on the stage of the course of the disease and the neglect of the disease. The average rate of assigning operations is 15%.

• Transplantation of a specific area of ​​the femur. During the operation, a piece of healthy bone (mainly from the fibula) is taken from the patient and transplanted into the affected area. As a result, the blood supply to the head of the joint improves. The chance of survival is high.
• Endoprosthetics of the head of the hip joint. It is used in the later stages, when other methods are ineffective. The diseased joint is completely removed from the thigh, replaced by a prosthesis. The operation removes the pain, the patient can walk normally. Rehabilitation takes a long time, the patient requires outside help.
• Decompression of the femoral head (tunnelization). With a special device, the surgeon drills a hole in the head of the hip joint. During the operation, the pressure inside decreases, blood flow improves as a result of the formation of new vessels. The effectiveness of the operation is 70%.
• Arthrodesis. Creation of artificial fusion of some thigh bones to reduce pain. The operation is performed when the patient is prohibited from hip arthroplasty. The procedure is extremely inefficient. As a result, the patient develops a curvature of the spine in the lumbar region.
• Arthroplasty. The operation is considered a kind of plastic surgery. It is aimed at preventing the development of ankylosis (immobility of the joint) or at restoring an already immobile one. During the intervention, manipulations are performed:

1. Removal of bone or fibrous callus.
2. Restoration of the anatomical shape of the affected joint.
3. Prevention of reunion of the hip bone.

More often, the operation is performed under spinal anesthesia, reducing the number of complications when the patient comes out of anesthesia. After the manipulation, it is possible to apply a plaster fixing bandage of the thigh for a short period. It is permissible to start rehabilitation 14 days after the operation.

• Osteotomy. Surgical intervention is carried out to eliminate the deformity using an artificial fracture. Fix the broken bone with screws or special plates. Gypsum is almost not applied. As a result of the operation, complications are possible in the form of suppuration, displacement of debris, and malunion. To prevent, it is prescribed to carefully follow the rules of asepsis in the operating room and at home.

Folk methods in the treatment of the disease

People in the past centuries used extensively folk ways treatment of various diseases, including the development of the initial stages of aseptic necrosis of the hip joint. When choosing a method, weigh the pros and cons well, no one can return the lost time.

Compresses:

• Beat the egg white vigorously with 1 tablespoon of millet flour. The mixture is applied to the diseased joint, covered with polyethylene and wrapped with a warm blanket. The compress can be left overnight. In the morning, wash your skin with warm water.
• The lightest is cabbage compress. Spread a little honey on a cabbage leaf, apply to a sore spot, secure with a compress cloth, and wrap it. You will sleep peacefully at night. Substances that are in the cabbage leaf will help relieve swelling from the head of the joint.
• Make yogurt from homemade milk (store-bought yogurt is not suitable). Pour a few tablespoons of curdled milk into a cup, add the same amount of pre-ground eggshell. Mix intensively, apply to the affected areas of the joint as a compress. Leave overnight. Treatment is carried out 5 nights in a row.

Rubbing:

• Almost every person at home has a flowerpot with Kalanchoe. Pick a small amount of young leaves of the plant, finely chop. Pour the resulting slurry with the same volume of ethyl alcohol. Insist in a dark and cool place for 7 days. The effect of rubbing is amazing.
• Take 10 tablets of acetylsalicylic acid, crush, pour 10 ml of camphor alcohol and iodine. Stir and add 300 ml of ethyl alcohol. Insist for 14 days in a dark place. Use the mixture to rub the diseased hip joint.

Nettle bath. This procedure is effective in the early stages of joint disease. Pick fresh nettles with a total weight of 4 kilograms. Dip in a bucket of water and boil for 30 minutes. Strain the broth into the bathroom, add ordinary water to the required volume. The water temperature should not exceed 40 degrees. Get in the bathroom. The procedure lasts no more than 20-25 minutes.

Internal reception:

• Take a large head of garlic and 2-3 large lemons. Grind them in a meat grinder, pour 250-300 ml of chilled boiled water. Let it brew for 10-12 hours (preferably overnight). In the morning, start taking 1 teaspoon before meals.
• Freeze 1 liter of water and let it melt. Cut into melted water big lemon whole, add chopped garlic and 2 teaspoons of honey. Insist 14 days in the closet. ready mix strain and drink 30-50 ml in the morning on an empty stomach.
• Buy nettle leaves, elder flowers, willow bark, and parsley root. Take the components in equal parts, cut and mix. Pour two tablespoons of the mixture into a separate bowl, pour 500 ml of boiling water over low heat for 5 minutes. Wait until it cools down, strain. The amount of decoction is required to drink during the day. Every day it is necessary to prepare a new portion of the remedy.

Consequences of aseptic necrosis of the head of the hip joint

Aseptic necrosis of the head of the hip joint is a serious and dangerous disease. Treatment is painful and lengthy. A neglected disease worsens the life of the patient, in most cases leads to disability. A recumbent lifestyle is predicted, the inability to serve oneself independently and, at best, limitation of movement in the hip joint.

At the slightest symptoms of the disease, you should consult a doctor at the nearest medical institution. Timely started treatment reveals a quite optimistic prognosis, the younger the patient, the easier it is to achieve a full recovery. At times, it is impossible to diagnose the disease in the early stages, because patients do not pay attention to discomfort and consider it temporary.

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Aseptic necrosis (osteonecrosis, avascular necrosis) of the femoral head is a multifactorial disease that consists in impaired microcirculation and subsequent necrosis of the bone tissue located subchondrally 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 blood vessels with drops of fat, blood clots, nitrogen bubbles (caisson disease), sickle red blood cells;

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

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

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 liver diseases, 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) of the area of ​​the head that was supplied by the damaged artery occurs.

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; patients with arthritis or bronchial asthma take corticosteroid hormones (metipred, prednisolone, etc.) for a long time;
• 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 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

Aseptic necrosis, Legg-Calve-Perthes disease (avascular necrosis of the femoral head) is serious illness hip joint. The disease occurs as a result of changes, violations of the structure of bone tissue, as well as due to the manifestation of fatty degeneration of the bone marrow, impaired blood microcirculation. In this case, that part of the femoral head, which is deprived of blood supply, dies.

Since this disease is extremely common at the present time, we, together with the editors of the site www.site, decided to devote our conversation today to this disease and talk on the topic: aseptic necrosis of the femoral head, treatment to consider.

Why does aseptic necrosis (AN) occur?

The causes of necrosis are different and genetically determined. Very often, the disease develops due to injury or thrombosis of the artery, resulting in a violation of the blood supply to the femoral head. The most common cause is a hip fracture or hip dislocation.

After 2-3 months. after injury, AN begins to develop. Although the first symptoms of the disease appear much later, approximately 1 to 2 years after the injury.

Also, aseptic necrosis of the femoral head can be provoked by long-term use of certain drugs, such as glucocorticoid hormones. They are usually used in the treatment bronchial asthma, rheumatism.

Often the disease occurs against the background of regular, excessive alcohol consumption. The fact is that alcohol is the culprit of damage to blood vessels. This can cause ischemia of the femoral head, and subsequently can cause the development of its necrosis.

Workers of certain professions associated with exposure to high pressure, such as divers, miners, etc., are also susceptible to diseases.

Symptoms of aseptic necrosis of the femoral head

Pain is the first symptom of AN. It is deployed in the area of ​​the hip joint when the weight of the body is transferred to the leg damaged by the disease. The pain radiates to the inguinal, gluteal region, along the front surface of the thigh.

With the development of the disease, its progression, lameness may appear, there is a violation of the work, mobility of the joint. Subsequently, the pain persists even at rest, disrupting a good sleep, causing insomnia.

Treatment of the disease

In the presence of pain, other symptoms of AN, you should consult a doctor. The doctor will conduct a special physical examination, find out the presence of other chronic diseases will ask you about medicines that you accept. For a more accurate confirmation of the diagnosis, it may be necessary to conduct an additional laboratory and instrumental examination.

In the treatment of the disease, the main attention is paid to the process of restoring normal blood circulation in the area of ​​the head of the femoral bone and bone tissue. When prescribing treatment, the duration of the disease, its severity, general state sick.

1st period A: The course of this period is from several days, it is 6 months. from the moment of occurrence severe pain in the thigh area. At this stage, vascular disorders occur. Treatment of the disease at this stage is to observe rest. You should walk less, if possible, use a cane. You can not overload a sore leg, you need to rest more often, lie more.

2nd period of illness- from 6 to 8 months. from the onset of severe pain. During this period, destruction, necrosis of bone tissue occurs, and deformation of the femoral head occurs. During this period, therapeutic exercises are prescribed, as well as taking vasodilating drugs. It is also useful to use special massage and hirudotherapy procedures.

3rd period of illness: more than 8 months from the onset of severe pain. This period of the disease is characterized by a smooth transition of AN into coxarthorosis. Treatment is similar to the treatment of coxarthrosis. Apply therapeutic exercises, massage.

Also, at all stages of the course of the disease, apply medicines for the treatment of AN:

Vasodilators, chondroprotectors - glucosamine, chondroitin sulfate.

Non-steroidal anti-inflammatory drugs - diclofenac, ketoprofen, indomethacin, butadione, meloxicam, celebrex, as well as their analogues. They are used to reduce pain.

Vasodilator drugs - trental, teonikol. They are recommended for the treatment of aseptic necrosis.

Preparations for stimulating the restoration of bone tissue - alpha D3 TEVA, calcium D3 forte, oksidevit, osteomag, etc.

When conducting conservative treatment pain is eliminated inflammatory process, the process of destruction of bone tissue is suspended. In the event that treatment has not been effective, degenerative joint damage or collapse of the femoral head may require surgery. The operation is aimed at increasing the blood supply to the femoral head and is performed by decompression of the femoral head or hip arthroplasty.

In any case, it is necessary to treat aseptic necrosis of the femoral head under the supervision of a doctor, who will prescribe the necessary method of treatment. Be healthy!

Svetlana, www.site
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