Clinic Study On Pre-collapse Nontraumatic Osteonecrosis Of The Femoral Head

Objective:Pre-collapse nontraumatic osteonecrosis of the femoral head(NONFH)is the best opportunity for preservation of the femoral head.However,on treatment of pre -collapse NONFH there is significant debate in the orthopaedic community about the best approach to relieving symptoms and halting or delaying disease progression.The purpose of the present study was to review the medical records of pre-collapse NONFH and analyse a series of risk factors with correlating to the survivorship of pre -collapse NONFH,try to search the available methods to predict the survivorship of pre-collapse NONFH.A preliminary clinical study was done to analyse survivorship and radiographic outcome of pre-collapse NONFH were treated with compound Sheng Mai Cheng Gu capsule and protecting weight-bearing method.Discuss nonsurgical treatment options for pre-collapse NONFH.Methods:(1)Study objiects:54 patients(65 hips)were diagnosed pre-collapse NONFH from First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine from January 1999 to March 2006,All of the cases were treated to take compound Sheng Mai Cheng Gu capsule with protecting weight-bearing.There were 41 males and 13 females with a mean age of 38.39 years old(range,22 to.69 years),49 patients with bilateral involvement.With regard to etiology,44.44%(24 patients)of the cases were associated with steroid use,44.44%(24 patients)were associated with alcohol consumption,and 11.11%(6 patients)were idiopathic.(2)Methods of therapy:①Medication:All of the patients took 12 granule compound Sheng Mai Cheng Gu capsule in everyday,period of treatment was 1.5 to 2 years.②Weight-bearing control method:The patients were allowed to walk in gear when the extent of osteonecrosis of the femoral head was less than 30%,necrotic lesions occupy the medial two-thirds or less of the weight-bearing portion,no bone marrow edema and no pain.The patients were protected to walk with crutch for 3 to 6 months when the extent of osteonecrosis of the femoral head was more than 30%,necrotic lesions occupy more than the medial two-thirds of the weight-beating portion,no bone marrow edema and no pain.The patients were not allowed to walk with wheel-chair for 3 to 6 months when the extent of osteonecrosis of the femoral head was more than 30%,necrotic lesions occupy more than the medial two-thirds of the weight-bearing portion,bone marrow edema was detected and pain was felt or not.(3)Risk factors for survivorship of pre-collapse NONFH:①Osteonecrosis stage:65 hips were evaluated and classified according to the the grading system of the Association Research Circulation Osseous(ARCO)with the use of plain radiographs and additional application of MRI.10 hips were classified as stageⅠ,8 hips were in stageⅠA and 2 hips were in stageⅠB.55 hips were classified as stageⅡ,9 hips were in stageⅡA among 14 hips were in stageⅡB between 32 hips were in stageⅡC.②Pain: Based on grading scale of pain,pain grading were divided into no pain(grade 0),mild pain(grade 1),moderate pain(grade 2)and severe pain(grade 3).29 hips in grade 0,18 hips in grade 1,14 hips in grade 2 and 4 hips in grade 3.③Necrotic extent:On the basis of the index of necrotic extent method to quantify the extent of osteonecrosis of the femoral head,hips were classified into three categories:grade 1(≤30%),grade 2(30% to 60%),grade 3(＞60%),there were 33 grade-1 hips among 19 grade-2 hips between 13 grade-3 hips.④Necrotic location:According to the 2001 revised criteria from Japanese,necrotic lesions are classified into four types,based on their location on T1-weighted images.Type A lesions occupy the medial one-third or less of the weightbearing portion,7 hips as Type A.Type B lesions occupy the medial two -thirds or less of the weight-bearing portion,20 hips as Type B.Type C1 lesions occupy more than the medial two-thirds of the weight-beating portion but do not extend laterally to the acetabular edge,27 hips as Type C1.Type C2 lesions occupy more than the medial two-thirds of the weight -bearing portion and extend laterally to the acetabular edge, 11 hips as Type C2.⑤Bone marrow edema:According to distribution of bone marrow edema(BME)on T1- and T2-weighted MR images,and fat suppression images,hips were classified into four categories:no BME(grade 0),distributing to femoral head (grade 1),distributing to femoral neck(grade 2),distributing to proximal femoral (grade 3).32 hips in grade 0,14 hips in grade 1,11 hips in grade 2 and 8 hips in grade 3.(4)Measures of clinical efficacy:Measures of clinical efficacy included radiographic stabilization of osteonecrosis and the Harris hip score.Kaplan-meier survivorship was set that joint-preserving procedures or total hip arthroplasty as the end point,Kaplanmeier survival curves were determined for all hips. (5)Clinical and radiographic follow-up:Every 3 months,the patients underwent clinical and radiographic examination,and X-ray were obtained at 3-month intervals. Follow-up continued until worsening of pain surgery.All hips were followed up for at least 24 months.The mean clinical and radiographic follow-up period after the initial diagnosis was 37 months(range,24-112 months).(6)Statistical analysis:Statistical analysis was performed with use of SPSS software (version 13),The Kaplan-meier survivorship was set that joint-preserving procedures or total hip arthroplasty as the end point,and 95%confidence intervals for all hips in each group,Significance was set at P＜0.05.Results:After the mean duration of clinical and radiographic follow-up of thirty-seven months,the mean baseline Harris hip score for survival hips(n=54)that were not operated was 89(range,80 to 100);there were 19 hips with radiographic progression to collapse,The rate of survival without collapse for all hips was 70.77%(46 hips survivorship in 65 hips)The mean time of collapse after the initial diagnosis was 11.52 months(range,1-37 months).The overall rate of survival without operation for all hips was 83.08%(54 hips survivorship in 65 hips);Kaplan-meier survivorship curve,with joint-preserving procedures or total hip arthroplasty as the end point, survivorship analysis respectively according to pain,osteonecrosis stage,necrotic extent,necrotic location and bone marrow edema showed there was significant difference relatively in every group,P＜0.05.The rate of survival without operation was more than 90%when the patients were not or mild pain,ARCO stage was classified as stageⅠA,ⅠB,ⅡA,ⅡB,necrotic location was type A and type B,the index of necrotic extent was less than 30%,bone marrow edema was no or mild.The rate of survival without operation was about 60%when necrotic location was type C1,the index of necrotic extent was 30%to 60%.The rate of survival without operation was 38%when necrotic location was type C2.The rate of survival without operation was less than 0.2%when the patients were moderate or severe pain,bone marrow edema was moderate or severe.Pain,ARCO stage,necrotic location,necrotic extent and bone marrow edema were important indexs for predicting the rate of survival of precollapse NONFH.Conclusions:The early clinical results associated with compound Sheng Mai Cheng Gu capsule and protecting weight-beating were encouraging in terms of the survival rates and effective for halting or limiting the progresssion of pre-collapse NONFH.All survivors were rated as good to excellent.We propose that the best strategies to treat pre-collapse with compound Sheng Mai Cheng Gu capsule and protecting weight- bearing is that the patient will be allowed to walk in gear when the patient is not pain, ARCO stage was classified as stageⅠA,ⅠB,ⅡA,ⅡB,necrotic location was type A and type B,bone marrow edema was not detected.The patient will be protected to walk with crutch for 3 to 6 months when the patient is not pain,ARCO stage was classified as stageⅠC,ⅡC,necrotic location was type C,bone marrow edema was not detected.The patient will be suggested to do operation and not allowed to walk with wheelchair for 3 to 6 months postoperation when the patient feels pain,ARCO stage was classified as stageⅠC,ⅡC,necrotie location was type C,bone marrow edema was detected.The analysis indicated that collapse of the femoral head does not necessaryly determine a poor prognosis,and even after collapse occurs,subsequent cessation of collapse can be expected in a certain percentage of hips.Hips with less than 2 mm collapse and necrotic lesions occupying less than the medial 2/3 of the weightbearing area have a high chance of cessation of collapse and improvement of symptoms with no surgical intervention.