Preliminary Clinical Study Of Later Stage Collapse To Non-traumatic Femoral Head Necrosis By Hip-preserving

BackgroundFemoral head necrosis is one kind of progressive disease, which does not have the intervention or the intervention defeat, most patients femoral heads would collapse inevitably. After the collapse, the condition will progress in 2-4 years to the osteoarthritis stage and lead to joint disability, As the disease progresse very quickly after collapse, the majority of patients to the doctor had developed to later period of the necrosis and hip-preserving treatment is very difficult.At present, the main treatment of the later period femoral head necrosis is artificial joint replacement. It can quickly relieve pain and improve function in patients. However, multiple patients with femoral head necrosis in young and middle aged, studies have shown that the long-term efficacy is not satisfactory in young patients with joint replacement. The main problem is prosthesis loosening and may result in multiple arthroplasty. Moreover, the high cost of joint replacement and arthroplasty caused to patients heavy economic burden. Thus, for younger patients if they can preserve hip,it would have important clinical value and economic value.Many factors affect the efficacy of hip preserving, such as necrosis of the area, location, degree of collapse, pathogenic factors,the status of articular cartilage is an important factor. Our clinical found that the articular cartilage of young patients can still remain relatively good condition after the collapse of about half a year, despite the collapse of the femoral head after the disease progressed very quickly, but ensure a higher success rate of hip. With the time, the subsidence of the increase, the beginning of articular cartilage degeneration, reduced the efficacy of hip preserving. Once the subsidence of the increase (greater than 4mm), collapsed more than six months,the disease progress to the late stage of necrosis of the hip, and the treatment is very difficult. But most young patients are at this stage of disease when they see the doctors, so there is still clinic value of preservating the hip. In order to study this phase, we put forward the concept of later stage collapse, and as a theoretical point of view, we investigate the char-acteristics and treatment approach of this stage to improve the efficacy of hip preserving.1 Research of Later stage collapse of non-traumatic femoral head necrosis1.1 Concept of later stage collapse:it means the time of collapse of femoral head necrosis is longer than 6 months and the degree of collapse is greater than 4mm, without significant joint space narrowing of the pathological stage.1.2 Nature pathological features of later stage collapse:the inside and outside instability of the femoral head. The former refers to the instability after collapse within articular cartilage, subchondral bone, sequestrum, and normal bone.The latter refers to cartilaginous instabi-lity, such as subluxation.1.3 The therapeutic principles and treatment:select the patients for hip preserving, improve blood circulation, correct the collapse, reconstruct the internal and external instability of the femoral head, and repair articular cartilage, promoting cartilage repai. Transplantation of vas-cularized bone-flap graft(TVBG)is a suitable alternative method, and vascularized great trochanter bone flap transposition is an ideal method.1.4 Evaluation of the effect of later stage collapse after treatment. It is should be included by clinical evaluation and imaging evaluation. Clinical evaluation of the main content includes pain, range of motion and joint function. X ray evaluation should include the station of repair of femoral head, the concentric relationship between the femoral head and acetabulum, the stability of the hip joint and the joint space.1.5 Chinese medicine and mothod can improve the hip-preserving efficacy of later stage collapse2 Clinical analysis of effect on Chinese medicine combined with vascularized great trochanter bone flap transposition in later stage collapse of femoral head necrosis 2.1 MethodsAccording to the diagnostic criteria on later stage collapse, from January 2003 to December 2007,34 patients were collected from our hospital who were diagnosed as femoral head necrosis in 38 hips and treated with Chinese medicine combined with a transverse femoral artery branch of the greater trochanter transplantation. The average follow-up was 45.5 months. Make record of the general situation, causes, time of the pain appear, Chinese Medicine sydrone and records the result of preoperative and final follow up, such as pain score, range of motion, Harris score, necrotic area, the type of Anteroposterior and Frog-bit of X-ray, degree of collapse of Anteroposterior and Frog-bit, the repair of femoral head, the concentric relationship between the femoral head and acetabulum, the stability of the hip joint and the joint space. Harris score is the craterin to curative effect. Calculate Harris score high rate of clinical improvement and radiographic observation of progress in the last follow-up analysis on the preoperative clinical factors. Collecting date by Excel 2000 and analyse correlative date according to the software SPSS 13.0.2.2 Results2.2.1 Of the 34 case's final followed up for the Harris score:63.16% of the patients had satisfactory results, which accounted for 15.79% as excellent, as good in accounting for 47.37%, and can be accounted for 21.05% as moderate and poor accounting for 15.79%.2.2.2 Clinical improvement and radiological indicators of progress indicators when last follow-up.Compared to pre-operative, it improved at the last follow-up, such as Harris score, pain score, range of motion, Degree of collapse of Anter-oposterior and Frog-bit, the repair of femoral head, the concentric relationship between the femoral head and acetabulum, the stability of the hip joint. there are 19 hips(44.7%) comparatively good way of repairing and unsatisfactory by 19 hip(50%) and poor repair of 2 hips(5.3%). There is no obvious joint space narrowing of 17 hips (44.7%),15 hips with mild narrowing(39.5%) and significantly narrower of 6 hips(15.8%).2.2.3 The corelation analysis between factors on preoperative and Harris score with the last follow-up single factor.The Harris score of Preoperative, pain score, range of motion, necrotic area, type of Frog-bit, time of Collapse, which affects the Harris score of the final follow up. The more preoperative Harris score is, the higher the Harris score of the final follow up. The lower preoperative pain score is the higher the Harris score of the final follow up. The better the range of motion in preoperative is, the higher the Harris score of the final follow up. The smaller necrotic area is, the higer the Harris score of the final follow up. Type C2 of Frog-bit is better than C1 in Harris score of the final follow up. The shorter time of collapse,the higher the Harris score of the final follow up. there is no statistion significance in age,cause, type of Anteroposterior, degree of collapse of the Frog-bit and type of TCM with the Harris score of the final follow up.2.3 Conclusions2.3.1 The concept of later stage collapse is a summary of clinical experience, bases on hip cartilage degeneration on the curative effect of hip preserving,As a concept put forward and described, its contents will help to deep understanding of the later stage hip preserving treatment.2.3.2 Pathological features of the later stage collapse is the breakdown of articular cartilage degeneration and internal and external instabi- lity of the femoral head, the key is to treat articular cartilage repair and promoting cartilage repair, reconstruction of blood circulation, co-rrect the collapse, reconstructing the biological mechanical the inter-nal and external stability of femoral head.2.3.3 Chinese Medicine combined with external femoral artery of the greater trochanter transplantation is the treatment of advanced osteonecrosis of femoral head collapse and effective method of clinical observation, it can reduce pain, improve joint range of motion and the Harris score. It help to correct the degree of collapse, improve head acetabular relations and improve joint stability and promote necrosis of repair and obtain better insurance hip preserving efficacy.2.3.4 Treatment on later stage collapse should follow the principle of individual. Many clinical factors will affect the efficacy of hip preserving. Clinical studies have shown that preoperative Harris score, pain score, range of motion, necrotic area, frog-bit type, collapsing time and effect are related.2.3.5 It is important that combing of clinical and imaging to evaluate the efficacy of hip preserving, and it's unrealistic to entirely correct the collapse. The most important point in evaluate the efficacy is mortar harmony, joint stability, restoration of femoral head and joint space.