Aseptic necrosis of the femoral head. Symptoms and treatment of aseptic necrosis of the femoral head. Aseptic necrosis of the head of the hip joint - symptoms and treatment of the disease, prevention

The treatment tactics for aseptic necrosis are somewhat different from the treatment tactics for coxarthrosis. The main emphasis in the treatment of joint infarction is primarily on restoring blood circulation to the head femur and on the restoration of bone tissue (in contrast to coxarthrosis, in which the main goal of therapy is the restoration of cartilage).

In addition, the treatment tactics for aseptic necrosis depend on the duration of the disease: it is very important to treat the patient taking into account how much time has passed since the onset of the disease, since the onset of severe pain.

1st period of illness: duration of illness - from several days to 6 months since its inception strong pain. This is the stage of vascular disorders.

At this stage, the patient must maintain as much peace as possible: try to walk less, and when walking, it is imperative to use a cane (how to use a cane correctly is discussed below). You need to take advantage of every opportunity to lie down and relax. You should not put stress on your leg by standing for long periods of time, and, of course, you should avoid carrying heavy objects, jumping, and running.

Instead, in order to avoid atrophy of the thigh muscles, and at the same time “pump” the blood vessels, the patient must do at least 40 minutes a day strength exercises to strengthen the leg muscles (we will talk about exercises later). Without special therapeutic exercises, the patient will not have a single chance of recovery or at least a noticeable improvement in well-being.

Among the medications, the patient can benefit from non-steroidal anti-inflammatory drugs and vasodilators. In addition, good results can be achieved novocaine blockades lumbar spine, decompression of the head of the femur or greater trochanter (more on this method of treatment below), as well as massage and the use of medicinal leeches (hirudotherapy).

2nd period of illness: duration of illness - from 6 to 8 months from the onset of pain. At this time, destruction of the bone beams occurs, “crushing” and deformation of the femoral head.

At this stage, the patient can put a little more weight on the leg. For example, leisurely walking for 30-50 minutes a day (with breaks), as well as walking up stairs, is useful. Exercise on an exercise bike (at a calm pace) or slow cycling, and leisurely swimming, especially in salty sea water, bring certain benefits.

The following therapeutic measures are necessary: ​​strengthening physiotherapy and vasodilators. Decompression of the femoral head or greater trochanter, massage, and hirudotherapy will still be helpful.

In addition, to these procedures at this stage it is necessary to add the use of drugs that stimulate the restoration of bone tissue (see below).

3rd period of illness: duration of illness - more than 8 months. At this time, in most patients, aseptic necrosis “smoothly” turns into coxarthrosis (arthrosis of the hip joint).

Treatment of this stage of aseptic necrosis is almost 100% identical to the treatment of coxarthrosis: gymnastics, massage, use of vasodilators and chondroprotectors (glucosamine and chondroitin sulfate).

Below we will talk about the main methods of treating avascular necrosis in more detail.

Part 2. Basic methods of treating avascular necrosis

1. Non-steroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs): diclofenac, piroxicam, ketoprofen, indomethacin, butadione, meloxicam, Celebrex, nimulid and their derivatives prescribed to relieve pain in the groin and thigh.

And although NSAIDs no treatment aseptic necrosis, they can sometimes bring tangible benefits to the patient: timely prescribed anti-inflammatory drugs, due to their analgesic effect, prevent reflex spasms of the thigh muscles that occur in response to severe pain.

And when the reflex spasm that arose in response to pain goes away, the thigh muscles relax. As a result, blood circulation to the affected area is partially restored.

However, non-steroidal anti-inflammatory drugs have one danger: a patient with avascular necrosis taking these drugs stops feeling pain, stops taking care of the leg and loads it in the same way as if it were healthy. And such behavior can lead to rapid progression of destructive processes in the head of the femur.

Therefore, a patient taking non-steroidal anti-inflammatory drugs must remember that the sore leg at this time must be spared and protected from stress (more information about non-steroidal anti-inflammatory drugs is described in Chapter 20).

2. Vasodilators.

Vasodilators , such as trental(aka agapurine, pentoxifylline) And theonicol (xanthinol nicotinate), are very useful for the treatment of avascular necrosis.

They eliminate stagnation of blood circulation, help restore the head of the femur by improving arterial blood flow and relieving spasm of small blood vessels. In addition, the use of vasodilators helps reduce nighttime “vascular” pain in the damaged joint.

An additional advantage of vasodilators is their almost complete “harmlessness” - when used correctly, they have virtually no serious contraindications.

They just should not be used in acute cases of myocardial infarction and “fresh” hemorrhagic strokes, when the effect of vasodilators can increase bleeding from burst cerebral vessels. It is also undesirable to use vasodilators with low blood pressure, because they slightly reduce the pressure, and with a tendency to bleeding: nasal, uterine, hemorrhoidal.

But vasodilator drugs improve the well-being of patients during the recovery period after stroke or myocardial infarction, help with poor patency of blood vessels in the legs, obliterating endarteritis and diabetes, bring relief to hypertensive patients when the pressure is moderately elevated.

Those suffering from hypertension should keep in mind that while using vasodilators, it is necessary to reduce the dose of other drugs used to reduce high blood pressure. Otherwise, the effect of two different medications is additive and can lead to an excessively sharp drop in pressure, causing fainting or collapse.

In general, to prevent any unexpected similar reactions to vasodilator drugs, I recommend that my patients use these drugs only at night for the first three days. Having thus checked his individual tolerance to vasodilators, the patient subsequently switches to the prescribed two or three times a day of medication.

By the way, one side effect Vasodilator medications are normal and almost mandatory. When using them, a feeling of heat and redness of the face very often appears, associated with the active expansion of small blood vessels. There is no need to be afraid of this effect of the drug: such a reaction usually does not cause any harm to health.

Vasodilators for aseptic necrosis should be taken 2 times a year, in courses of 2 to 3 months.

3. Drugs that stimulate bone tissue restoration.

These drugs can be very useful for avascular necrosis. Doctors usually prescribe products containing vitamin D to their patients ( natecal D3, alpha D3 TEVA, calcium D3 forte, oxidevit, osteomag etc.) With aseptic necrosis, vitamin D preparations promote better absorption of calcium from the intestine, due to which the amount of calcium in the blood increases sharply. More high concentration calcium in the blood prevents its return from bone tissue into the blood and, accordingly, promotes its accumulation in the bones - in particular, in the head of the damaged femur.

In addition, calcitonins can provide significant benefits in aseptic necrosis ( myacalcic, alostin, calcitonin-ratiopharm, sibacalcin). These are very effective medications that stimulate bone formation and eliminate bone pain. They significantly reduce the release of calcium from bones and stimulate the activity of “building” cells (osteoblasts), promoting the entry of calcium into bone tissue.

Calcitonins have almost no contraindications, and only sometimes side effects develop hypersensitivity reactions: nausea, flushing, increased blood pressure, which disappear when the drug is discontinued or its dose is reduced. However, there is still one limitation for the use of calcitonins: they should be recommended with caution to those patients who have low calcium levels in the blood - drugs in this group can further reduce its amount, and this is fraught with the development of hypocalcemic crises, occurring with loss of consciousness and convulsions.

To avoid such complications, before starting to take calcitonins, it is advisable to take a blood test for calcium. If the amount of calcium in the blood is higher than normal, calcitonins are ideal for the patient; if calcium is normal, calcitonins can be used, but in combination with calcium supplements (at a dose of at least one gram per day). In cases where the amount of calcium in the blood is clearly reduced, it is better not to prescribe calcitonin or to prescribe it after preliminary treatment with vitamin D preparations, and always in combination with calcium (at a dose of at least two grams of calcium an hour or two before taking calcitonin).

And you should immediately stop taking the drug when the first signs of hypocalcemia appear: spontaneous muscle twitching, a feeling of “running goosebumps” in the arms and legs, changes in the sensitivity of the limbs.

4. Chondroprotectors - glucosamine and chondroitin sulfate.

Glucosamine and chondroitin sulfate belong to the group of chondroprotectors - substances that nourish cartilage tissue and restore the structure of damaged joint cartilage.

As mentioned above, in case of aseptic necrosis, chondroprotectors are effective only in 3rd period of illness, with a disease duration of more than 8 months - when aseptic necrosis gradually transforms into coxarthrosis(arthrosis of the hip joint).

For To achieve the maximum therapeutic effect, chondroprotectors must be used in courses, regularly, over a long period of time. Practically It makes no sense to take glucosamine and chondroitin sulfate once or from case to case.

In addition, in order to get the maximum effect from the use of chondroprotectors, it is necessary to ensure that the body receives adequate, that is, sufficient doses of drugs daily throughout the course of treatment. A sufficient daily dose of glucosamine is 1000-1500 mg (milligrams), and chondroitin sulfate is 1000 mg.

Scientists are currently arguing over whether it is better to take glucosamine and chondroitin sulfate - simultaneously or separately. Opinions were divided. Some scientists argue convincingly that glucosamine and chondroitin sulfate should be taken together, at the same time. Others also argue convincingly that glucosamine and chondroitin sulfate, when taken simultaneously, interfere with each other and should be taken separately. Perhaps there is a clash of interests between those manufacturers who produce single-drug products containing only glucosamine or only chondroitin sulfate with those manufacturers who produce two-in-one drugs containing a combination of glucosamine and chondroitin sulfate. Therefore, the question of the joint or separate use of glucosamine and chondroitin sulfate remains open.

Although my personal observations indicate that both single drugs and combination drugs are useful, the only question is who produces them and how well they are produced. That is, a drug produced “on the knee” by some dubious company, and even with violations of technology, is unlikely to be useful, regardless of whether it contains glucosamine, or chondroitin sulfate, or both. And vice versa, any chondroprotector produced “according to the rules” will be useful. But a high-quality combination drug containing both glucosamine and chondroitin sulfate, in my opinion, is still more useful than any single drug.

Currently (in 2016) on our pharmaceutical market chondroprotectors are most widely represented by the following proven drugs:

Artra, made in USA. Available in tablets containing 500 mg of chondroitin sulfate and 500 mg of glucosamine. To achieve the full therapeutic effect, you need to take 2 tablets per day.

Dona, made in Italy. A monotherapy containing only glucosamine. Release form: solution for intramuscular injection; 1 ampoule of solution contains 400 mg of glucosamine sulfate. The solution is mixed with an ampoule of a special solvent and injected into the buttock 3 times a week. The course of treatment is 12 injections 2-3 times a year. In addition, there are DONA preparations for oral administration: powder, packaged with 1500 mg of glucosamine in 1 sachet; You need to take 1 sachet of the drug per day; or capsules containing 250 mg glucosamine; You need to take 4-6 capsules of the drug per day.

Structum, made in France. A monopreparation containing only chondroitin sulfate. Release form: capsules containing 250 or 500 mg of chondroitin sulfate. Per day you need to take 4 tablets containing 250 mg of chondroitin sulfate, or 2 tablets containing 500 mg of chondroitin sulfate.

Teraflex, made in Great Britain. Release form: capsules containing 400 mg of chondroitin sulfate and 500 mg of glucosamine. To achieve a full therapeutic effect, you must take at least 2 tablets per day.

Chondroitin AKOS, made in Russia. A monopreparation containing only chondroitin sulfate. Release form: capsules containing 250 mg of chondroitin sulfate. To achieve a full therapeutic effect, you must take at least 4 capsules per day.

Chondrolone, made in Russia. A monopreparation containing only chondroitin sulfate. Release form: ampoules containing 100 mg of chondroitin sulfate. To achieve a full therapeutic effect, it is necessary to carry out a course of 20-25 intramuscular injections.

Elbona, made in Russia. A monotherapy containing only glucosamine. Release form: solution for intramuscular injection; 1 ampoule of solution contains 400 mg of glucosamine sulfate. The solution is mixed with an ampoule of a special solvent and injected into the buttock 3 times a week. The course of treatment is 12 injections 2-3 times a year.

As you can see from the above list, the choice of chondroprotectors in pharmacies is quite large. What exactly to choose from all this variety? Consult your healthcare provider. Personally, I really like Arthra - it is a good, proven and balanced drug.

From injectable drugs(that is, for injections) I most often use Don. But in powder or capsules, according to my observations, Dona is less effective.

In any case, if used correctly, any proven chondroprotectors will bring clear benefits for the treatment of aseptic necrosis, which has already turned into arthrosis. And what is important, preparations containing glucosamine and chondroitin sulfate have almost no contraindications. They should not be used only by those who suffer from phenylketonuria or have hypersensitivity to one of these two components.

They also have very few side effects.. Chondroitin sulfate sometimes causes allergies. Glucosamine may occasionally cause abdominal pain, bloating, diarrhea or constipation, and very rarely - dizziness, headache, leg pain or swelling of the legs, tachycardia, drowsiness or insomnia. But in general, I repeat, these drugs very rarely cause any discomfort.

Duration of treatment glucosamine and chondroitin sulfate may vary, but most often I suggest my patients take chondroprotectors daily for 3-5 months. After at least six months, the course of treatment must be repeated, i.e. One way or another, glucosamine and chondroitin sulfate are recommended to be taken approximately 90 - 150 days a year for 2-3 years.

Keep in mind! In addition to the chondroprotective drugs listed above, you can find dietary supplements containing glucosamine and chondroitin sulfate on sale: for example, Sustanorm Life formula, chondro, stoparthritis and others. These dietary supplements are not full-fledged medicines, since they have not yet been medically tested and are not registered as medicines! They have yet to undergo clinical trials to prove their clinical effectiveness!

5. Hirudotherapy (treatment with medicinal leeches).

Hirudotherapy is a fairly effective treatment method for many diseases. By sucking, the leech injects a number of biologically active enzymes into the patient’s blood: hirudin, bdellins, Elgins, destabilase complex and etc.

These enzymes resolve blood clots, improve metabolism and tissue elasticity, and increase the body's immune properties. Thanks to leeches, blood circulation improves and blood stagnation in the affected organs is eliminated.

In case of aseptic necrosis, enzymes injected with medicinal leeches can significantly improve blood circulation in the damaged femoral head.

To achieve maximum effect, you need to conduct 2 courses of hirudotherapy per year. Each course consists of 10 sessions. Sessions are carried out at intervals of 3 to 6 days. In this case, leeches should be placed on the lower back, sacrum, lower abdomen and sore hip.

In one session, 6 to 8 leeches are used. At the beginning of treatment with leeches, a temporary exacerbation often occurs (usually after the first 3-4 sessions). And improvement usually becomes noticeable only after 5-6 sessions of hirudotherapy. But the patient reaches the best form 10-15 days after completing the full course of treatment.

Contraindications to hirudotherapy treatment: This method should not be used to treat people with hemophilia and persistent low blood pressure, pregnant women and young children, frail and elderly patients.

6. Therapeutic massage.

There is no need to expect any super miracles from a massage - therapeutic massage is used only as an additional method of treating aseptic necrosis.

But by improving blood circulation, back massage and massage of the thigh muscles still bring tangible benefits for aseptic necrosis - provided that the massage is performed Right, gently, without rough influences.

It is important to know: after inept intervention, the patient’s condition may worsen rather than improve. Pain and muscle spasms in the affected leg may increase.

In addition, it may increase arterial pressure, nervousness and overexcitation of the nervous system appear. This usually happens when the massage is too active and forceful, especially if the massage therapist’s manipulations themselves are rough and painful.

Normal massage should be performed smoothly and gently, without sudden movements. It should give the patient a feeling of pleasant warmth and comfort, and in no case should it provoke pain or bruising.

In general, many insufficiently skilled massage therapists justify the appearance of bruises and sharp pain from their effects by saying that they massage diligently and deeply. In fact, they are simply not qualified enough, they act with inflexible, tense fingers and at the same time seem to “tear” the skin and muscles. If you do the massage correctly, with strong but relaxed fingers, you can knead the muscles quite deeply and thoroughly, but without pain, discomfort and bruises.

Dear readers, when entrusting your joints or back to a massage therapist, try to remember that the procedure should be painless, causing warmth, comfort and relaxation. And if you find a massage therapist who achieves such an effect with his actions, consider yourself lucky.

However, it is necessary to remember the standard contraindications to massage treatment.

Massage is contraindicated when:

• all conditions accompanied by an increase in body temperature
• inflammatory diseases of the joints in the active phase of the disease (until stable normalization of blood counts)
• bleeding and tendency to it
• for blood diseases
• thrombosis, thrombophlebitis, inflammation of the lymph nodes
• the presence of benign or malignant tumors
• aneurysms of blood vessels
• significant heart failure
• for severe skin lesions in the massaged area
• massage is contraindicated for women on menstruation days.

7. Physiotherapeutic treatment.

From my point of view, most physical therapy procedures are poorly suited for the treatment of avascular necrosis. The fact is that the hip joint is a “deep-lying” joint. That is, it is hidden under the thickness of the muscles, and most physiotherapeutic procedures simply cannot “get” it. Therefore, they cannot radically influence the course of aseptic necrosis.

And although sometimes such procedures can still bring some relief to the patient (thanks to improved blood circulation and reflex analgesic effects), in general, physiotherapeutic procedures for aseptic necrosis bring little benefit: doctors prescribe them either out of ignorance or to simulate vigorous activity.

Only laser therapy and thermal treatment (ozokerite, paraffin therapy, mud therapy) can bring some benefit.

Laser therapy- good and enough safe method treatment (in the absence of contraindications), but still one cannot expect to cure avascular necrosis with laser alone. Laser therapy is precisely an additional method of treatment as part of complex therapy. The course of treatment is 12 sessions, performed every other day.

Contraindications to laser use: tumor diseases, blood diseases, hyperfunction of the thyroid gland, infectious diseases, physical exhaustion, bleeding, myocardial infarction, stroke, tuberculosis, liver cirrhosis, hypertensive crisis.

Thermal treatment (ozokerite, paraffin therapy, mud therapy) used to improve blood circulation in the damaged femoral head. For thermal effects on the body, substances are used that can retain heat for a long time, slowly and gradually releasing it to the patient’s body: paraffin (a product of petroleum distillation), ozokerite (mountain wax), healing mud(silt, peat, pseudovolcanic).

In addition to the temperature effect, such coolants also have a chemical effect on the patient’s body: during the procedure, biological penetration occurs into the body through the skin. active substances And inorganic salts, helping to improve metabolism and blood circulation.

Contraindications to heat therapy: spicy inflammatory diseases, cancer, blood diseases, inflammatory diseases kidneys, bleeding, purulent lesions organism, hepatitis, exacerbation of inflammatory rheumatic diseases.

The principle of this procedure is to pierce the femur with a thick needle. A puncture, one or two, is most often made in the area of ​​the greater trochanter of the femur (the trochanter is located on the lateral surface of the thigh, in the “breeches” area, where any of us feels a protruding bone - this protrusion is the trochanteric tubercle).

Decompression has two goals: to increase blood supply to the area by growing new blood vessels inside the newly formed canal (puncture) and to reduce intraosseous pressure inside the femoral head. Reducing intraosseous pressure helps reduce pain in approximately 60-70% of patients with aseptic necrosis.

In addition to puncture of the greater trochanter, there is also operating method decompression: a channel is drilled through the greater trochanter and neck of the femur directly into the femoral head, into an area where there is no blood flow. The effectiveness of this technique is slightly higher than that of a needle puncture, but this procedure is more complicated and is usually performed in a hospital setting.

9. Manual therapy

Manual therapy for aseptic necrosis is performed extremely rarely, mainly only when we are sure that the necrosis was caused by a pinched joint. For example, if a joint is pinched during an injury, strong blow, or if the infringement remains after an imperfectly reduced dislocation of the hip joint. And such variants of aseptic necrosis, as you remember, occur infrequently - in 10% of cases. With most other types of necrosis (when it is caused by alcohol consumption, taking corticosteroid hormones, radiation, pancreatitis, anemia, etc.), there will be very little benefit from manual therapy.

Manual therapy, when it is still necessary, for aseptic necrosis should Always be carried out with the utmost caution - since rough manual influences can lead to fracture of bone beams weakened by the disease. And then the condition of the femoral head will deteriorate sharply. Even manual therapy of the lumbar spine can lead to unpleasant consequences if the doctor performs manipulations on the lumbar vertebrae according to “classical principles”, leaning on the patient’s sore leg while adjusting the vertebra.

10. Medicinal ointments and creams.

Medicinal ointments and creams are often advertised as guaranteeing cure for joint diseases. Unfortunately, as a practicing physician, I have to disappoint you: I have never encountered cases of healing of advanced arthrosis, arthritis, and especially aseptic necrosis with the help of any medicinal ointment. But this does not mean that ointments are useless. Although ointments and creams cannot cure avascular necrosis, their use sometimes significantly alleviates the patient's condition.

For example, I sometimes recommend warming or irritating ointments to my patients in order to improve blood circulation in the joint. For this purpose, I periodically prescribe menovazin, gevkamen, espol, finalgon, nicoflex or other similar ointments.

It has been proven that the irritation of skin receptors that occurs when rubbing these ointments leads to the production of endorphins - our internal painkillers “drugs”, due to which pain is reduced and painful spasm of the periarticular muscles is partially eliminated; In addition, warming ointments help increase blood circulation in the affected joints.

Ointments based bee venom (apisatron, ungapiven) and snake venom ( viprosal) also have an irritating and distracting effect, but, in addition, being absorbed in small quantities through the skin, they improve the elasticity of ligaments and muscles, as well as blood microcirculation. However, there are more side effects from their use: such ointments quite often cause allergies and inflammation of the skin at the sites of their application. You should also know that they are contraindicated for women during menstruation and for children.

Ointments based on non-steroidal anti-inflammatory substances ( indomethacin, butadionic, doltit, voltaren-gel, fastum etc.), unfortunately, do not act as effectively as we would like - after all, the skin allows no more than 5-7% of the active substance to pass through. And this is clearly not enough to develop a full anti-inflammatory effect. But these ointments extremely rarely cause the side effects that occur from the internal use of non-steroidal anti-inflammatory drugs in tablets, suppositories or injections.

11. Using a stick or cane.

If conditions permit, it is advisable to use a stick or cane when moving. Leaning on a stick when walking, patients with aseptic necrosis greatly help their treatment, since the stick takes on 20-40% of the load intended for the joint.

However, in order for the stick to be useful, it is important to choose it exactly according to your height. To do this, stand up straight, lower your arms and measure the distance from your wrist (not your fingertips) to the floor. This is exactly the length the cane should be. When buying a stick, pay attention to its end - it is advisable that it be equipped with a rubber nozzle. Such a stick cushions and does not slip when people lean on it.

remember, that if your left leg hurts, then the stick should be held in your right hand. And vice versa, if your right leg hurts, hold the stick or cane in your left hand.

Important: Train yourself to transfer your body weight to the stick exactly when you take a step with your bad leg!

12. Reducing the harmful load on the joint

A person suffering from aseptic necrosis needs to try avoid fixed positions. For example, prolonged sitting or standing in one position, squatting or in a bent position (say, when working in the garden or vegetable garden). Such postures impair blood flow to diseased joints, as a result of which the condition of the femoral head also worsens.

You should also try to put as little stress on the sore leg as possible at first, avoid jumping, running, squats, long-term walking and carrying heavy objects.

It is necessary to develop such a rhythm of motor activity so that periods of load alternate with periods of rest, during which the joint should rest. The approximate rhythm is 20-30 minutes load, 5-10 minutes rest. You need to unload the sore leg in a lying or sitting position. In the same positions you can perform several slow exercises to restore blood circulation in the legs after exercise (see below).

13. Therapeutic gymnastics.

Therapeutic exercises are the main method of treating aseptic necrosis. Without it, we will not succeed in combating the progressive deterioration of blood circulation in the head of the femur and in the fight against rapidly increasing atrophy of the thigh muscles.

Almost no person suffering from aseptic necrosis will be able to achieve real improvement in their condition without therapeutic exercises.

After all, in no other way is it possible to strengthen muscles, “pump” blood vessels and activate blood flow as much as this can be achieved with the help of special exercises.

At the same time, gymnastics is almost the only method of treatment that does not require financial costs for the purchase of equipment or medications. All the patient needs is two square meters of free space in the room and a rug or blanket thrown on the floor. Nothing more is needed except consultation with a gymnastics specialist and the desire of the patient himself to do this gymnastics. True, there are big problems with desire - almost every patient has to be literally persuaded to engage in physical therapy. And it is most often possible to convince a person only when it comes to the inevitability of surgical intervention.

The second “gymnastic” problem is that even those patients who are committed to physical therapy often cannot find the necessary sets of exercises. Of course, on the Internet there are sets of exercises for patients with aseptic necrosis, but the competence of a number of authors is questionable - after all, some do not have them medical education. This means that such “teachers” themselves do not always understand the meaning of individual exercises and the mechanism of their action on sore joints. Often, gymnastic complexes are simply thoughtlessly copied from one article to another. At the same time, they contain such recommendations that you can just grab your head!

For example, many authors prescribe a patient with aseptic necrosis to “spin the bicycle vigorously” or do active leg swings, squats at a fast pace, etc. Patients often follow such advice without first consulting a doctor, and then are sincerely perplexed as to why they feel worse .

In fact such overly vigorous exercises cause fractures of weakened bone beams the head of the femur, and the head of the femur quickly collapses - “crushes”.

To avoid such problems, from all the exercises you need to choose only those that strengthen the muscles and ligaments of the sore leg, but do not put pressure on the sore head of the femur.

That is, instead of the usual fast dynamic exercises, active flexion and extension of the legs, we need to do static exercises.

For example, if, while lying on your back, you slightly lift your straightened leg up and keep it suspended, then after a minute or two you will feel fatigue in the muscles of your leg and abdomen, although the joints are in in this case did not work (did not move or load). This is an example of a static exercise.

Another variant. You can very slowly raise your straightened leg to a height of 15 - from the floor and slowly lower it. After 8 to 10 such slow exercises, you will also feel tired. This is an example of a gentle dynamic exercise. This movement algorithm is also very useful.

It’s a completely different matter if the exercise is performed quickly and energetically, with maximum amplitude. By swinging your legs or actively squatting, you place increased stress on the head of the femur, and its destruction accelerates. But the muscles, oddly enough, are strengthened much worse with such movements. We conclude: to strengthen muscles and ligaments, exercises (for aseptic necrosis) must be done either statically, fixing the position for a certain time, or dynamically, but slowly.

By the way, it is slow dynamic and static exercises that most of my patients do not like to do, since they are especially difficult to perform. But this is how it should be: when chosen correctly, these exercises strengthen those muscles and ligaments that have atrophied in a person due to illness. Therefore, at first, be patient. But, having endured the first 2 - 3 weeks, you will be rewarded with an improvement in the condition of your leg and general well-being, increased strength and increased performance.

14. Surgical treatment aseptic necrosis.

Surgical treatment for aseptic necrosis is carried out if conservative therapy has failed.

As experience shows, if correct therapeutic treatment was started on time (in the first year of illness); more than half of the patients manage to improve or stabilize their condition within a few months and do without surgery.

But if time is lost, the percentage of lucky people who can do without surgery drops sharply. Those patients who begin to be treated only a year or two after the onset of a joint infarction are most often forced to operate on the hip joint.

Typically, for aseptic necrosis, two types of operations are performed.

Most often performed endoprosthetics, that is, the complete replacement of a deformed hip joint with an artificial one (more than 90% of all operations for aseptic necrosis are endoprosthetics).

It looks something like this: the part of the femur on which the head of the joint is located is cut off. A pin made of titanium, zirconium (or other materials) is inserted into the cavity of the femur, with an artificial articular head at the end.

The pin is fixed inside the cavity of the femur with a kind of cement or glue (sometimes using the “dry” fixation method). At the same time, another articulating surface of the hip joint is operated on: part of the acetabulum is removed from the pelvic bone, and a concave polyethylene bed is placed in its place. high density. In this bed, under pressure, the titanium head of the joint will further rotate.

As a result of successful endoprosthetics, pain in the joint disappears and its mobility is restored. However, the following must be taken into account. Firstly, such operations are technically complex. Secondly, with endoprosthetics the risk of complications and infection is quite high. In addition, if the operation is not performed perfectly and the joint is poorly “fitted,” disturbances in its fixation occur, and the prosthesis becomes loose very quickly. In this case, a repeat operation may be required after 1-2-3 years, and it is unknown whether it will be more successful than the previous one.

But the most important thing is that in any case, even with the impeccable work of the surgeon, the artificial joint becomes loose and requires replacement after a maximum of 12-15 years.

The fact is that the leg (pin) of the artificial joint is subject to constant overload, and after some time its fixation inside the femur is disrupted. At some point, after an unsuccessful movement or load, the leg of the joint can completely loosen the niche inside the femur, and then it begins to “shaker.” From this moment on, the dynamic operation of the entire structure is disrupted, and loosening occurs at a particularly rapid pace - excruciating pain resumes and the need for repeated endoprosthetics arises.

Now imagine: if the patient had his first operation at the age of 35-45, then at a maximum of 55-60 years he will need a repeat operation with all possible consequences: infections, complications, etc.! Moreover, each operation is a serious stress and burden for the body. Naturally, it is more advisable to undergo endoprosthetics for patients over 50-60 years of age.

For young people, if they need surgery, it seems to me that it is wiser to do arthrodesis hip joints, although this operation is now rarely performed. When performing arthrodesis, the ends of the articulating bones are cut off and then connected to each other so as to ensure their future fusion. Fusion of the bones leads to a decrease or disappearance of pain, but the joint completely loses mobility.

It is clear that the lack of mobility of the hip joint significantly reduces a person’s ability to work. When walking, he is forced to compensate for the immobility of the hip joint by increased movement of the lower back and knee, that is, he walks at an unnatural pace. As a result, due to overload, changes in the lumbar spine very often develop and back pain appears. In addition, after arthrodesis and fusion of bones, all those operated on find it difficult to walk up the stairs and not very comfortable to sit.

Now, I think it is clear to you that surgery on the hip joint does not solve all problems at once, and sometimes even creates new ones. And while there is a possibility, we should try to avoid surgery or delay it for as long as possible. In addition, the operation is quite expensive, and after it a fairly long period of recovery is required. Therefore, I always tell those of my patients who have a chance to do without surgery: direct the energy and resources that are necessary for the operation to therapeutic treatment - and perhaps you will be able to avoid the operating table altogether.

Article by Dr. Evdokimenko for the book “Pain in the Legs”
Published in 2004.
Edited in 2011.

Fragment of RESEARCH REPORT N 632\056\022 “DEVELOPMENT OF NEW METHODS OF MEDICAL REHABILITATION OF ORTHOPEDOTRAUMATOLOGICAL PATIENTS WITH SEVERE DISORDERS OF THE FUNCTION OF THE LOWER LIMB FOR USE IN A POLYCLINIC CONDITION”

Head: Professor M.A. Berglezov

DEFINITION. Asetic necrosis of the femoral head (ANFH), avascular necrosis (ICD-10), “Avascular necrosis of the femoral head (ANFH)” or “Avascular necrosis (AVN)” is a consequence of impaired blood flow and necrosis of the bone marrow elements of the femoral head. The disease usually develops due to the use of corticosteroids, joint trauma, alcohol abuse, pancreatitis, sickle cell anemia, ionizing radiation, etc. In the absence of an obvious cause of ANFH, the diagnosis is formulated as idiopathic necrosis of the femoral head, but the number of such diagnoses in Lately decreases with the expansion of medical capabilities. X-ray diagnostics makes it possible to determine the late stages of the disease when the femoral head is fragmented or deformed. In most cases, the orthopedic prognosis is unfavorable - severe deforming arthrosis of the hip joint, for which endoprosthetics, joint arthrodesis or corrective osteotomies are often used as the methods of choice for surgical treatment. Early diagnosis is possible only with the use of magnetic resonance imaging (MRI) of the hip joint and gives hope for a favorable outcome of the disease with the use of conservative or surgical treatment.

STORY. Aseptic necrosis of the femoral head (AFH) in adults was described as an independent disease several decades ago. The messages concerned the description of individual observations, which were interpreted as patients with “Osteochondritis dessecans” (Bergman E., 1927; Freund E., 1939). As clinical experience accumulated, the disease began to be compared with Perthes disease in children and it was proposed to use the same term. However, later many researchers began to pay attention to the fact that the disease in children and adolescents is much easier than in adults and, thanks to better blood supply and greater reparative capabilities, ends with the restoration of bone tissue and often even with the preservation of the shape of the femoral head, which, usually not observed in adults. V.Ya. Fridkin and I.G. Logunova (1950), when studying the X-ray picture of ANFH, pay attention to the features of its manifestation in adults (characteristic localization of the necrotic focus in the upper outer segment of the femoral head, a longer process of bone tissue restructuring and incomplete restoration of the bone structure and shape of the head). At the plenum of the All-Union Anti-Rheumatic Committee of the USSR in 1959, aseptic necrosis of the femoral head in adults was classified as a disease group that includes all non-infectious joint lesions of a dystrophic nature. At the international congress of orthopedists and traumatologists in Paris (1966), the issue of ANFH in adults was part of the program; issues of etiology, pathogenesis and treatment of the disease were discussed. Most researchers clearly supported the vascular origin of the disease (Bosch S., Bickee W., Merle D.). It was also emphasized that factors contributing to the development of the disease may be: trauma, including repeated microtraumatization; joint dysplasia; long-term use of medications, primarily corticosteroids and cytostatics. WITH widespread use A number of authors associate the use of steroid drugs with the recent increase in the number of patients with this pathology (Shultsev G.P., 1969; Wang I.S. et all, 1978; Salame G., 1991; Berglezov M.A. et al., 1997). Alcohol abuse plays a significant role in the development of ANFH.

EPIDEMIOLOGY. The disease is most common in young and middle-aged men (8:1) (more than 2/3 of all cases) and accounts for 1.5-2% of all orthopedic pathologies (V.P. Prokhorov, 1981, 1989; T.A. Revenko, 1971). There are no epidemiological data on ANFH in Russia. In the United States, 15,000 cases of ANFH are diagnosed annually. According to our data (statistics of visits to the orthopedic clinic of the CITO for adults), ANFH is detected in 2.3% of patients and is the cause of long-term progressive disability in 7% of orthopedic patients with impaired function of the lower extremities. Bilateral damage occurs, according to various authors, in 50% of cases (Prokhorov V.P., 1976, 1981; Patterson R.I., Bickel W., Dahlln D.C., 1964; Berglezov et al., 1989). The most common causes of non-traumatic ANFH are corticosteroid therapy and alcohol abuse. So Ohzono K. et all (1991) observed 87 patients (115 hip joints), in whom the causes of avascular necrosis were: corticosteroid therapy (69 patients), alcohol (18), idiopathic (25).

Research conducted in the research and outpatient department of the CITO in 1980-1989. (G.Salyame, 1991), 103 patients (148 joints) with ANFH revealed that the most common form of ANFH is non-traumatic (58 patients), corticosteroid (15), with alcoholism – 12.

For the period from 1995 to 1997 According to the results of a consultative examination with CITO, ANFH at various stages of the disease is detected in 2.34% of patients. Moreover, there has been a tendency towards an increase in the number of applications in recent years. An examination of 35 patients with initial symptoms of ANFH revealed: the ratio of men to women was 8:1, 26 people (74%) were aged from 22 to 45 years. Etiologically, ANFH was more common due to alcohol abuse (10 people), the corticosteroid form of ANFH was in 8 people, traumatic in 5, idiopathic (no clear connection with risk factors) in 12.

Table 1.

Distribution of patients depending on the etiological form of ANFH according to data from English-speaking authors and their own observations.

For clarity, in table. 1 these data are presented as percentages. The structure of etiological forms of non-traumatic ANFH in different regions of the world (USA, Japan, Russia) has significant differences, which consist in the predominance of “alcoholic” forms of ANFH in our country. In addition, in recent years in Russia there has been a tendency towards an increase in ANFH of alcohol etiology.

ANFH also occurs in the following diseases:

Chronic and acute pancreatitis;

Systemic lupus erythematosus;

Caisson disease, vascular diseases;

Ionizing radiation;

Sickle cell anemia (Sebes J.I., 1989).

PATHOGENESIS. Two points of view are equally widely represented in the literature: traumatic and vascular. It is known that aseptic necrosis of bone tissue can be caused by various reasons: violation of the integrity of the arteries by twisting or compression, embolism, prolonged spasm of the arteries, venous stasis and other mechanical effects. ANFH as a result of joint trauma (dislocation, fracture of the metaepiphysis zone) or surgical intervention has been studied quite fully, and the mechanism of its occurrence is due to a violation of the arterial and venous blood flow zone (Fig. 1).

Figure 1. Diagram of the blood supply to the femoral head.

The issue of studying the pathogenesis of so-called non-traumatic ANFH is more complicated. V.P. Gratsiansky (1955) pointed out that as a result of microtrauma, joint overload and other unfavorable factors, processes of “overfatigue” occur in bone tissue. Impulses from the focus go to the cerebral cortex and cause corresponding return signals, causing vascular spasm or stagnation of blood and lymph, metabolic disorders, and accumulation of decay products in the bone. This leads to a change in the physicochemical and structural-dynamic properties of the bone, leading to the slow destruction of bone beams, further obstruction of local blood circulation and progression of the process. This theory of “chronic microtrauma” is currently supported by many researchers.

Welfling J. (1967) concluded that all necrosis of the femoral head is of ischemic origin, resulting from arterial embolism. According to the vascular theory, aseptic necrosis of the femoral head is the result of changes in local blood circulation, which may result in interruption of arterial circulation or obstruction of venous outflow. Changes in the disorder of venous circulation in the affected diaphysis of the thigh of patients with aseptic necrosis allowed some authors (Shumada I.V., 1990; Ayrolles Chr., 1962) to suggest that the primary change is venous insufficiency with a subsequent transition of the process to the arterial system. A. Fournie (1963), using phlebograms obtained by him, was the first to show that when the hip joint is damaged, there are significant changes in the venous outflow of both a morphological and dynamic nature. Due to morphological changes, the normal outflow paths are poorly traced, a more dense venous network is revealed, and the varicose type of venous system predominates. Research by N.M. Mikhailova, M.N. Malova (1982) allowed us to state a sharp expansion of the veins, slow blood flow and stasis, increased activity of the prothrombin index, increased coagulation and blood viscosity.

Blood flow disturbances are manifested by an increase in intraosseous blood pressure, which aggravates ischemic disorders. According to Arlet J. and Float (1968), one of the causes of osteonecrosis of the femoral head is an increase in intraosseous pressure in the proximal end of the femur.

Hungerford D. and Leung P. (1983) suggested the following hypothesis for the development of ANFH. In their opinion, the femoral head is a closed compartment and therefore the bone is very sensitive to any ischemic fluctuations. Against the background of increased intraosseous pressure, vascular thrombosis occurs, ischemia progresses, leading to necrosis of the bone beams. Bone destruction subsequently occurs where ischemia and load on the femoral head are more pronounced. According to Solomon L. (1970), analgesics and anti-inflammatory drugs, as well as alcohol, lead to protection from pain and relief from the inflammatory state. This is combined with osteonecrosis and overload of a certain area of ​​the femoral head, which leads to destruction of the subchondral bone and local osteoporosis. Experimental studies, compared with histological studies of surgical material (Stetsula V.I., Moroz N.F., 1988), have shown that when blood flow in the epiphysis zone is disrupted, foci of osteonecrosis form on days 3-5, which are replaced by osteogenic tissue during revascularization. tissue and in the process of differentiation are transformed into normal bone tissue. Under unfavorable conditions (joint overload), a perifocal zone of fibrosis develops at the border of the area of ​​osteonecrosis and surrounding tissues, and then, against the background of secondary circulatory disorders, a zone of perifocal bone sclerosis is formed. Histologically, during this period, the bone beams are devoid of osteocytes, the spaces between them are filled with protein masses, and the area of ​​osteonecrosis is delimited by fibrous tissue (Fig. 2).

Figure 2. Anatomical preparation. Stage 2 ANGBC

The osteonecrosis zone collapses, accompanied by fractures of the subchondral bone plate with detachment of the articular cartilage from the osteonecrosis zone with local mechanical damage, degeneration and detachment. At later stages, they form in the zone of reactive changes and in the area of ​​the focus of osteonecrosis, a closing bone plate, cyst-like restructuring and other changes characteristic of deforming arthrosis are formed.

Segmental damage to the upper anterior portion of the femoral head is supported by the static load of this area. Destruction of articular cartilage leads to the development of synovitis (reactive arthritis) of the hip joint. J. Koski et all, when measuring the width of the joint space, found that on average it is 5.1 mm with a difference between the right and left joint of no more than 0.3 mm. An increase in these indicators by more than 7 and 1 mm (respectively) indicates synovitis of the hip joint. A study of 18 patients (G. Salame) with ANHP using ultrasonography showed that asymmetry of the joint space was detected in all patients. The expansion of the joint space can be observed on conventional x-rays in stages 2 and 3 of the disease.

The common cause that unites all non-traumatic cases of osteonecrosis is osteopenia. In this case, in the anterosuperior part of the femoral head, which bears most of the load, a fracture occurs due to “fatigue” of osteopenic trabeculae. It is hypothesized that the accumulation of broken trabeculae may obstruct arterial blood flow and cause bone necrosis.

The combination of osteoporosis, mechanical pressure, medication, inflammation and pain results in subchondral trabecular fracture and subsequent destruction and degenerative arthritis of the hip joint. All patients had pronounced impairments in the function of movement, caused by pain, limitation of movements in the joint, malnutrition and impaired muscle function.

Laboratory studies of patients indicate impaired capillary blood flow, increased intraosseous pressure, hypercoagulation syndrome, and impaired vegetative regulation in these patients.

DIAGNOSTICS.

The choice of treatment for ANFH primarily depends on the stage of the disease at the time of diagnosis. Currently in Russia, the 5-stage characteristic of pathological changes has received the greatest recognition (Reinberg S.A., 1964; Rits I.A. et al., 1981). At the first stage necrosis, X-ray examination does not give positive results. The head of the femur retains its original shape, and the bone structure is also unchanged. Histological examination reveals a picture of necrosis of the spongy substance of the head and its bone marrow. Some authors call this stage “pre-X-ray”, “silent” or “theoretical”. Although the second definition is incorrect, since clinically already at this stage there may be pain, limitation of movements in the joint, muscle atrophy, etc. This suggests that the absence of radiological signs of the disease does not exclude the presence of a pathological process and requires further research and dynamic observation. Second stage An impression fracture is characterized by many microscopic fractures against the background of pathological changes in (necrotic) bone tissue. Radiologically, at this stage, the head of the femur is homogeneously darkened and there is no structural pattern, its height is reduced compared to the healthy side, the surface in some places has the appearance of compacted facets, and the joint space is widened. An MRI scan can identify a necrotic defect in the femoral head. Third stage characterized as a resorption stage or "sequestration". The head becomes even more flattened and consists of separate structureless isolated fragments irregular shape and size, the joint space widens even more. The neck of the femur is shortened and thickened. In the fourth stage, designated as the reparation stage, the cancellous bone substance of the head is restored. Radiologically, sequestration-like areas are no longer visible, the shadow of the femoral head is outlined, but the structure of the bone is not yet visible; rounded cyst-like clearings can be observed for a long time. Finally, fifth, final stage (stage of secondary deforming arthrosis) characterized by a number of secondary changes such as deforming arthrosis. The bone structure of the head at this stage can be traced, but its shape is significantly changed, it is flattened, expanded in diameter, so the articular cavity does not cover it, and the congruence of the articular surfaces is disrupted. Marginal bone growths and secondary dystrophic cysts are visible.

Some authors adhere to a different division of the stage. Thus, Serre H. and Simon L. identify only three stages of the process; A.A. adheres to the same classification. Korzh et al. (1982). There is a division of the disease into 6 stages (Mankin H.J., 1992) and even 7.

This division into stages is relative, since the process develops dynamically, one stage passes into another and does not have strictly defined boundaries. However, from a practical point of view, such a division is necessary. Each stage characterizes the degree and depth of the pathological process, shows in which direction it is developing, i.e. makes it possible to predict, to some extent, the further development of the process. Depending on this, the issue of tactics and choice of treatment method is decided. Plain radiography has a relative diagnostic value at the stage of destruction of the structure of the femoral head (especially considering the poor quality of the images). The information content of an x-ray examination increases when using special laying according to Launstein (Figures 3 and 4).

Figure 3. Radiographs of P., 25 years old, 3 (1) and 8 (2) months from the onset of the disease. Stages 2-3 and 4 of ANFH. Survey radiographs (1 and 2) and Launstein radiographs (1a and 2a).

Figure 4. X-ray of patient 4 X-ray of P., 32 years old. Stage 5 ANGBC.

IN initial stage clinical manifestations and special research methods such as magnetic resonance imaging and computed x-ray tomography (CT) are of great importance for the disease. The sensitivity of MRI studies reaches 90–100% in the initial stages of the disease. (Figure 5).

Figure 5. Patient D., 35 years old. ANGBC stage 1-2. A - Launstein radiograph, B - MRI frontal plane, C - MRI horizontal plane.

The localization and size of destruction foci are determined using computed x-ray tomography (Figure 6).

Figure 6. X-ray CT scan of P., 25 years old. After 3 (A) and 6 (B) months from the onset of the disease. ANGBC stages 2 and 3.

Ultrasonography, radionuclide studies and therapeutic and diagnostic puncture with measurement of intraosseous pressure have a certain diagnostic value.

Intraosseous pressure.

Measurement of intraosseous pressure in 49 patients with pain syndrome due to dysplastic coxarthrosis (16), ANFH (21) and post-traumatic osteodystrophy (12) of the lower limb indicates a significant difference in this indicator during dystrophic processes in the metaepiphyseal zone depending on the etiological factor: a decrease from the norm ( 40-60 mmHg) with dysplastic coxarthrosis, and its increase with destructive processes in bone tissue (Table 2).

Table 2.

Dynamic and static scintigraphy in patients with aseptic necrosis of the femoral head and dysplastic coxarthrosis.

An examination using static and dynamic scintigraphy was carried out on 57 patients with aseptic necrosis of the femoral head (Ghassan Salameh) aged 17 to 45 years and various stages of the disease. Analysis of the study results showed that at all stages and in all forms of AGNB, when performing static scintigraphy, hyperfixation of the RPF is noted (Fig. 7).

Figure 7. Scintigram of the hip joints. Left-sided ANGBC 2 st. Hyperfixation of radiopharmaceuticals on the affected side (B).

The intensity of radiopharmaceutical fixation depends on the activity of the process and determines the level of local blood flow and bone mineralization.

Table 3.

Values ​​of dynamic scintigraphy indicators at various stages of ANFH.

Dynamic scintigraphy indicators characterizing local blood flow in the proximal parts of CD depend on the stage of the disease: in the early stages there is a sharp increase in all phases of blood flow, while in the later stages they decrease (Table 3, Figure 8).

Figure 8. Dynamic triphasic scintigraphy. Left-sided ANGBC 2 st. A sharp increase in all phases of blood flow on the affected side (B).

The basis for special research methods is pain in the hip joint, especially pain in groin area with irradiation along the femoral nerve to the knee joint. Often the pathology of the hip joint manifests itself in the form of vague referred pain in knee joint. Particular attention should be paid to patients who are potentially at risk:

men aged 20 to 50 years

patients who have had hip injury or surgery

patients suffering from collagenosis (RA, SLE, arteritis)

patients taking corticosteroids for a long time

patients who abuse alcohol

patients with various types of anemia

patients with pathology of the blood coagulation system.

patients receiving radiation or chemotherapy.

Patients with acute and chronic pancreatitis.

TREATMENT.

Treatment of ANFH should be complex and differentiated depending on the stage and clinical manifestation disease, and the prognosis of the disease depends on early diagnosis of the disease, the prevalence of osteonecrosis and adequate treatment tactics. The possibility of bilateral involvement of the hip joints in most patients should be taken into account.

Despite the success of surgical treatment (transtrochanteric rotational osteotomy, preventing collapse of the femoral head in 95% of cases, developed by Sugioka (Japan); subchondral autoplasty of the femoral head, proposed by Imamaliev A.S., Zorya M.V.), ANFH is primarily a problem outpatient orthopedics. The duration of the disease (from 1.5 to 2 years) requires great patience from the doctor and the patient and the implementation of the necessary complex of medical rehabilitation, taking into account the stages of the process and the orthopedic situation. Complete restoration of the joint, as a rule, does not occur (we have observed isolated cases of complete restoration of the bone structure without collapse of the head in patients with central necrosis of the femoral head). However, in most cases it is possible to achieve a completely acceptable outcome of the disease: prevention of damage to the contralateral joint; decrease destructive processes in the femoral head and secondary coxarthrosis; vicious installations of the hip in the position of flexion, adduction and excessive rotation; minimal limitation of range of motion in the hip joint; good functional state of muscles and mild pain syndrome. Since we have not found time characteristics of the duration of each stage of the disease in the literature, we indicate them below based on our own observations (Table 5).

The complex of medical rehabilitation for ANFH includes:

Compliance with the optimal orthopedic regimen and therapeutic exercises;

Drug therapy;

Decompression tunneling and prolonged intraosseous blockades;

Intra-articular injection therapy;

Gait correction, incl. using multichannel electromyostimulation;

Electromyostimulation;

Physiotherapy (EHF therapy, laser therapy, magnetic therapy).

Orthopedic mode. Compliance with the orthopedic regimen is of particular importance. We do not share the opinion of some authors who propose a regimen of maximum joint unloading (crutches) for a long period and adherence to bed rest in the initial period of the disease. Our work experience and research conducted in the laboratory of biomechanics of the CITO indicate that walking on crutches for more than 2–3 months leads to progressive malnutrition and dysfunction of the main muscle groups, the formation of persistent pain and vegetotrophic disorders, and a violation of the motor stereotype. This aggravates the orthopedic status of patients and leads to severe dysfunction of the lower extremities, which in turn aggravates the course of ANFH, provokes the development of a pathological process in the contralateral joint, and causes problems in adjacent joints and the spine. We believe that the patient’s walking should not be limited; it is enough to simply exclude inertial loads on the joint (running, jumping, lifting weights); a cane should be used only for the first 3–4 weeks from the onset of pain and when walking long distances. On the contrary, measured walking (15–20 minutes) at an average pace, walking up stairs, exercise on an exercise bike, and swimming ease the course and shorten the first stages of the disease. Measures aimed at reducing excess body weight are necessary.

Aseptic necrosis (osteonecrosis, avascular necrosis) of the femoral head is a multifactorial disease consisting of impaired microcirculation and subsequent necrosis of a section of 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. 50% of patients have bilateral damage to the hip joints, and 15% of them develop aseptic necrosis of another localization (femoral condyles, head humerus). The disease is characterized by rapid progression and without proper treatment leads to pronounced violation static-dynamic function of the joint and, as a consequence, to permanent disability.

TO local violation microcirculation and the development of a zone of bone necrosis can result from a number of reasons, the most common of which are the first three:

1) damage to the vessels supplying the head of the femur during 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-shaped erythrocytes;

3) thrombosis in coagulopathies (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.

There is idiopathic aseptic necrosis, which develops spontaneously, without visible reasons, and a secondary one, which is associated with the following pathological conditions: long systemic therapy glucocorticosteroids, excessive alcohol consumption, systemic lupus erythematosus and other connective tissue diseases, chronic renal failure, organ transplantation, sickle cell anemia and other hemoglobinopathies, coagulopathies, decompression disease, chronic liver diseases, inflammatory bowel diseases, pancreatitis, hyperlipidemia, gout, pregnancy , radiation sickness, atherosclerosis and other vascular diseases, smoking, Cushing's syndrome, allergic reactions and hypersensitivity, sarcoidosis, chemotherapy and chemical intoxication, tumors. 65% of patients with aseptic necrosis of the femoral head have a history of glucocorticosteroid therapy or chronic alcoholism, while idiopathic osteonecrosis is detected in only 15-20% of patients. A significant predisposing factor is the individual characteristics of the vascular anatomy, in particular the collateral-poor lateral vessels of the femoral epiphysis supplying the upper outer segment of the head.

The triggering factor for pathogenesis is a sharp decline or cessation of microcirculation in the segmental area of ​​the epiphysis of the bone, leading to its infarction, i.e., death of bone marrow cells, stroma and osteocytes. A much larger zone of edema appears around the area of ​​necrosis. Reparative processes begin in bone tissue. However, due to discoordination of spasm and vascular paresis, 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 the discharge of incoming arterial blood into venous system diaphysis. These changes significantly inhibit repair, making it ineffective, as a result of which new areas are exposed to necrosis and decompensation occurs. Under the influence of mechanical load, microfractures occur in the subchondral bone, leading to a decrease in its strength. Without underlying mechanical support, hyaline cartilage rapidly undergoes progressive, irreversible degeneration. Violation of the superficial structure of the femoral head leads to a change in the mechanical load transmitted to hyaline cartilage 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 time frame for the development of femoral head collapse ranges from several weeks to several years.

The first clinical manifestation is pain, most often localized in the groin area, less often in the hip, knee joint, and lumbosacral spine.

At first, the pain is periodic, disappearing after rest, and then becomes constant, its intensity gradually increases, intensifying with little physical activity. At a later stage of the disease, pain may occur at night. In some patients, the onset of the disease is sudden. The pain is not accompanied by an increase in body temperature or swelling of the 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 patient returning to normal physical activity. For several months and sometimes years, normal range of motion in the joint may be maintained. First of all, there is a limitation of rotational movements and abduction, then there is a limitation of movements in the sagittal plane, and ultimately a persistent flexion-adduction 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 affected side. 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 tend to develop more slowly.

Changes in laboratory parameters are nonspecific.

It is mandatory to perform an 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 avascular necrosis and allows identifying pre-radiological changes in 90% of patients.

An early radiological sign is a change in bone density in certain areas of the femoral head: you can usually see a very delicate line of reduced 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, most often in 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 revealed, 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 zone of sclerosis. Subsequently, secondary changes characteristic of deforming arthrosis occur: beak-shaped bone growths, saddle-shaped deformation of the head, cystic formations, narrowing of the joint space.

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

Non-operative treatment is symptomatic and is indicated when surgical intervention is not possible. It includes long-term (up to 6 months) limitation of axial load on the affected limb, taking NSAIDs, and physiotherapy (alternating electromagnetic field). In case of 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 to prevent it, surgical decompression of the osteonecrosis zone is performed by removing 1-2 cylindrical columns of bone 8-10 mm in diameter, followed by replacing this area with bone allo- or autografts, in the latter case, both 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 collapse of the femoral head, it is indicated total endoprosthetics hip joint (Fig. 1).

Rice. 1.

Traumatology and orthopedics. N. V. Kornilov

The question of the etiology, that is, the root causes, of necrosis of the hip joint still remains open. This pathological process occurs under aseptic conditions, which complicates detection possible reasons diseases.

This article will be useful to people who regularly subject their legs to sufficient physical activity, since they are in the “risk group” for this pathology, that is, mainly athletes, as well as miners and divers. Their work is associated with constant pressure changes, which can also affect the functioning of the hip joint.

The information in the article will be useful for detecting the disease in the early stages, since treatment methods differ depending on the stage that occurs in the body. Below we explain what aseptic necrosis of the head of the hip joint is - symptoms and treatment of the disease, its prevention.

Aseptic necrosis of the head of the hip joint - characteristics

Avascular necrosis (other names: aseptic osteonecrosis, infarction) of the hip joint is the death of individual sections of bone tissue in the upper extremity of the femur due to disruption of the normal supply of oxygen and nutrients to this area.

This leads to a decrease in vital function, and then to the death of living cells and the formation of necrotic foci. In the affected hip joint, the mechanical characteristics of all tissues, as well as motor function, are reduced.

The patient experiences severe nagging pain, which intensify when walking and physical activity on the joint. Even at rest, the pain never goes away completely and only stops medications. In the most severe cases necrosis of the femur can lead to gangrene.

The hip joint is one of the largest joints in the human body. It consists of the acetabulum, located on the pelvic bone, and the round head of the femur, which moves in the acetabulum.

Blood supply to the head occurs through three small arteries - the obturator, lateral and medial. When blood flow decreases or stops in any of these arteries, necrosis of the tissues that it fed develops.

Blood flow can decrease or stop for several reasons: with mechanical compression or twisting of the artery, with blockage of the artery lumen with a thrombus, with prolonged spasm of the artery, with increased blood viscosity, with stagnation of venous blood and difficulty in its outflow.

As a result of ischemia of adjacent tissues, the bone in the area of ​​the hip joint becomes fragile, sparse, cavities appear in it, and its mechanical properties deteriorate. When a load is placed on a diseased joint, the bone can become deformed and “crumple,” which leads to detachment of the articular cartilage and the development of severe arthrosis. With severe development of the disease, the acetabulum is also involved in the pathological process.

It should be said that in terms of clinical manifestations, avascular necrosis of the femoral head is very similar to arthrosis of the hip joint (coxarthrosis) and when diagnosing, it can be difficult for a doctor to make an accurate diagnosis. The main difference between hip necrosis and arthrosis is the speed of its development.

If arthrosis develops over a long period, sometimes lasting several years, then hip avascular necrosis occurs and proceeds quite quickly, within several weeks or even days, depending on the degree of reduction in blood supply to the hip joint.

There are 4 stages of aseptic osteonecrosis:

1. Minor bone changes, rare pain radiating to the groin, complete preservation of mobility in the hip joint. Lasts about 6 months - initial manifestations. The spongy substance (bone beams) of the bone tissue in the head of the femur dies, but its shape does not change.
2. The appearance of cracks on the head of the femur, occupying from 10 to 30% of its entire surface. The pain in the area of ​​the affected joint intensifies. Lasts 6 months - the stage of an impression (compressed) fracture: when loaded on a certain area of ​​the femoral head, the bone beams break, then wedge into each other and become crushed.
3. The acetabulum is involved in the process of damage, up to 50% of all articular tissues are affected. The pain becomes deep and constant, joint mobility is greatly reduced. From 1.5 to 2.5 years - the resorption stage.

   The healthy tissue surrounding the necrosis zone slowly reabsorbs the dead bone fragments. At the same time, connective tissue grows deep into the head of the femur (plays a supporting role in all organs) and islets cartilage tissue. As a result, conditions are created in the femoral head for the growth of new vessels. However, at the same time, the growth of the femoral neck is disrupted, so it shortens.

4. Motor function The joint is almost completely reduced due to the destruction of the femoral head. Severe pain does not stop, the muscles of the thigh and buttocks atrophy. From 6 months or more - the outcome stage (secondary deforming arthrosis occurs).

   The sprouted connective tissue and islands of cartilage turn into bone tissue, due to which the spongy substance of the femoral head is restored. However, in this case, secondary changes are formed: the beam (cellular) structure of the bone is rebuilt (deformed), and it also adapts (accustoms) to new conditions and loads.

In addition, the acetabulum is also deformed and flattened. Therefore, its normal anatomical contact with the femoral head is disrupted. In the area of ​​the affected hip joint or lumbar spine there is constant pain that does not disappear even at rest.

The muscles of the thigh and lower leg are atrophied (volume decreases to 5-8 cm). There are no circular movements in the affected leg, and forward and backward movements are sharply limited. Gait is significantly impaired: patients cannot move independently, or only with support (cane).

The duration of each stage of aseptic necrosis of the femoral head is individual, since much depends on the influence of provoking factors, timely treatment and the presence of concomitant diseases.

However, aseptic necrosis does not always affect the entire head of the femur at the same time. Therefore, there is a classification based on the location of the necrosis focus.

• Peripheral (9-10% of cases) form: the outer part of the femoral head, which is located directly under the articular cartilage, is affected.
• Central (2% of cases) form: a zone of necrosis forms in the center of the femoral head.
• Segmental (46-48% of cases) form: a small area of ​​bone necrosis in the form of a cone occurs in the upper or upper outer part of the femoral head.
• Complete damage to the entire femoral head (observed in 40-42% of patients).

Causes of the disease

The reasons for this may be different - some of them are still unknown. Necrosis of the femoral head is death of the bone without any infection. If treatment appropriate to the stage of the disease is not carried out in time, irreversible destruction of the hip joint occurs, which leads to the accelerated development of arthrosis, even if there is no circulatory disturbance in the cartilage.

Destruction occurs mainly due to a decrease in the strength of the femoral head dying under the cartilage, and the cartilage breaks, which can lead to arthrosis. If left untreated, 85% of patients experience failure of the femoral head and arthrosis of the hip (Coxarthrose). The causes of this disease can be divided into several large groups:

• Vascular. There is a change in microcirculation. In this case, several options for the development of avascular necrosis can occur.
• Multifunctional reasons that are associated with a huge load on the joint. This can happen due to the wrong choice of profession. By the way, excess weight can also be the cause of such loads.
• Exchange disorders.
• Genetic factors, which include age, gender, and so on.

An interesting fact is that none of the reasons alone can cause avascular necrosis. Combining with each other, they can provoke this disease. Hip avascular necrosis has various causes.

It is important to carefully study the symptoms of the disease and consult a doctor for medical help in order to begin timely and correct treatment. The reasons listed below indicate the exact development of necrosis of the hip head. The disease may appear due to the following factors:

1. alcohol abuse;
2. regular physical overload and microtraumas - especially among athletes;
3. injuries of the hip joint, fractures, dislocations leading to mechanical damage to the femoral artery;
4. arterial thrombosis;
5. past inflammatory diseases;
6. some systemic diseases (Bechterew's disease, rheumatoid arthritis, systemic lupus erythematosus, etc.);
7. decompression sickness – in people working in conditions of pressure changes (divers, miners);
8. long-term use of corticosteroid drugs;

In 80% of cases, osteonecrosis is bilateral. In addition to the head of the hip joint, it quite often progresses in the knees, shoulders, elbows and ankles. Osteonecrosis can appear several months or even years after the injury or pathological conditions that provoked it.

Necrosis of the hip joint - symptoms

Clinically, the deterioration of the mechanical characteristics of tissues and dysfunction of the joints make themselves felt by severe pain. Although, as practice shows, often, aseptic necrosis of the femoral head develops over a fairly long period of time and if, for example, it was caused by an injury, the very first symptoms may appear in the patient only one and a half to two years after it.

At first, a person is bothered by pain in the area of ​​the hip joint precisely at the moment the body’s center of gravity moves to the affected joint, but subsequently these sensations cover the groin and buttock area.

Further development of the disease is associated with a significant disorder in the mobility of the joint, lameness occurs, and in more advanced cases, pain bothers the person even in a state of complete immobility. Necrosis of the hip joint is more common in men than women.

The disease appears between the ages of twenty and fifty. The symptoms of necrosis are similar to those of arthrosis of the hip joint. But the difference between them is that necrosis develops very quickly, and coxarthrosis develops slowly. The main symptoms of necrosis of the hip joint:

• Pain in the groin, in the anterior and lateral areas of the thigh, which radiates to the knee. Pain appears when standing on your leg, walking, or getting up from a chair or sofa;
  There is constant pain in the knee. After exertion, the pain begins to radiate to the buttock or lower back area;
• A person begins to limp when walking;
• A couple of days after the onset of the disease, the sore leg becomes motionless;
• After 14 days, the thigh muscles begin to atrophy. Because of this, the muscles dry out and the leg becomes thinner than a healthy one;
• The affected leg is shortened or lengthened.

The shortening of the leg is clearly visible when the patient is lying down. This defect can also be seen by placing the patient on his stomach and bringing his heels together. When examining, an important criterion is position; the person needs to lie straight.
A difference in leg length of half a centimeter or one centimeter is normal “physiological”. To compensate for the defect, place an additional special insole in shoes with short feet.

At the initial stage, the main symptom of asthenic necrosis is pain, which appears spontaneously. It is concentrated in the hip joint and radiates to the groin, knee joint, lower back and sacrum.

The pain may make it difficult to walk and sit. Gradually they become more intense and prolonged, especially at night. The ability to move joints does not change. Body weight is distributed evenly across both limbs.

Stage 2 osteonecrosis is characterized by constantly increasing pain, especially after physical activity. The range of motion of the joints decreases slightly. There is significant death of the thigh muscles (the girth of the affected thigh is smaller than the healthy one).

The load of body weight is gradually transferred to the healthy leg. At stage 3 of the disease, even minimal exertion causes a significant increase in pain. Movement of the joint is limited. The muscles are significantly atrophied. The affected leg may become somewhat shorter.

Stage 4 osteonecrosis is characterized by the appearance of pain, which is the most pronounced. There is a gait disturbance. Muscle atrophy is clearly expressed. The amplitude of movements is zero.

Diagnosis of pathology

Diagnosis begins with a study of the patient’s complaints, medical history and physical (examination, palpation of the joint and study of its function) examination. To clarify and confirm the diagnosis, it is necessary to conduct additional laboratory and other research methods, including radiography of both hip joints and magnetic resonance imaging of the hip joints.

During the appointment, we review the patient’s complaints about the hip and analyze possible factors risk of necrosis of the femoral head. An accurate history of hip pain and a thorough clinical examination. The examination criteria are:

• hip mobility
• sensation of hip mobility
• pain areas in the hip
• positions that can cause pain
• Muscle mass and strength of the gluteal hip muscles
• gait

In orthopedics, a number of different hardware diagnostic methods are used. X-rays and magnetic resonance imaging (MRT) confirm the diagnosis of the hip. There is no preliminary preparation before examining the hip joint. Indications for hardware diagnostics of the hip joint:

1. Acute or chronic pain in the hip joint and/or groin area, radiating to the lower back, knee or buttocks.
2. Recent or past injuries (fracture, dislocation).
3. Monitoring the effectiveness of treatment. The timing is determined depending on the chosen method.
4. Preparation for hip replacement with an artificial prosthesis.
5. Assessment of the condition of blood vessels in the hip joint (only on CT or MRI).

Gives an idea of ​​the condition of the bone. Whereas circulatory disorders do not have specific radiological signs. X-rays can show changes in the joint only from the third and fourth stages of the disease.

Digital X-rays are a modern low-emission examination method, but they are not very suitable for diagnosis in the early stages of the disease, because X-rays show only changes in bone structure.

The bone beams begin to break down only weeks after necrosis (death of bone cells due to insufficient blood circulation) has occurred. Therefore, necrosis of the femoral head cannot be detected using x-rays in the early stages of the disease.

MRI can make a diagnosis in the early stages. Making a diagnosis at an early stage is also the only way restoration or at least preservation of the hip joint.

Computed tomography, like X-rays, only determines changes in bone structure and is therefore effective only in the later stages of the disease. All three methods have been successfully used to determine the nature and extent of necrosis of the femoral head and to establish accurate analysis and treatment plan.

Obviously, it will be unnecessary to repeat that the earlier the development of hip necrosis is detected, the greater the patient’s chances of saving the joint without resorting to surgery.

Treatment

When treating the disease, it is necessary to place special emphasis on restoring blood circulation to the femoral head, as well as restoring bone tissue. Moreover, a lot depends on the duration of the illness. If these are the first stages of the disease, then in this case you can quickly and easily cure it. Usually there are three large periods of the disease.

The first period lasts from several days to six months. This is the stage of vascular disorders. At the first stage, it is advisable for the patient to remain completely calm - it is necessary to walk less, lie down and rest more. It is not recommended to overload the leg by standing for long periods of time.

Moreover, refrain from running and jumping for a certain period. Along with these recommendations, the patient is usually prescribed mild physical exercise. Every day he should perform strength exercises that strengthen the leg muscles for forty minutes. It is worth noting that without therapeutic exercises the patient will not be completely cured.

Aseptic necrosis of the head of the left femur During the first period of the disease, the doctor usually prescribes anti-inflammatory drugs. Another excellent medicine is vasodilators. Some use medical leeches and perform a massage.

The second period of illness can last from six months to eight months. At this time, deformation of the femoral head occurs. The patient can put a little more weight on the leg. It is generally recommended to walk for at least half an hour a day.

It is important to take breaks every ten to fifteen minutes. It is advisable to exercise on an exercise bike and pay due attention to swimming. Therapeutic gymnastics and massage help very well. To achieve complete recovery, decompression of the femoral head is performed.

The third period of the disease can last more than eight months. During this period, aseptic necrosis develops into coxarthrosis or arthrosis of the hip joint. Moreover, the treatment of this disease completely coincides with the treatment of aseptic necrosis. During this period, it is also recommended to do massage, gymnastics and use vasodilators.

Drug treatment

Treatment of the disease is carried out using drug therapy, therapeutic exercises and massage, as well as surgical intervention. The method of treatment in a particular case should be prescribed by the attending doctor on an individual basis, after examining the patient and conducting all the necessary studies. Treatment of necrosis with drug therapy is as follows:

1. To relieve inflammation, non-steroidal anti-inflammatory drugs are used. For example, the doctor may prescribe the use of diclofenac, indomethacin, piroxicam or butadione. The listed medications relieve pain in the hip and groin. Such drugs cannot cure the underlying disease, but they prevent reflex muscle spasms during pain. Their effectiveness is observed for the first six months of illness;
2. To eliminate stagnation in blood circulation, vasodilators are prescribed. For example, treatment is carried out with trental, theonicor. Thanks to such medications, arterial blood flow improves and spasms in small vessels are eliminated. Vessels begin to hurt less at night. Their effectiveness is observed for the first time six to eight months of necrosis of the head of the hip joint;
3. To restore bone tissue, preparations with vitamin D are used - calcium D3 forte, oxidevit and others. They help accumulate calcium in the area of ​​the head of the affected femur;
4. Medicines belonging to the group of calcitonins help the formation of bone tissue and relieve pain inside the bones. Treatment is carried out with the help of myacalcin, sibacalcin, alostin;
5. Necrosis can also be treated with chondroprotectors, which nourish cartilage tissue and restore the structure of the damaged cartilage.

Without consulting a doctor, it is better not to resort to treatment of necrosis using the described medications, so as not to harm your health. Treatment of ANFH should be complex and differentiated depending on the stage and clinical manifestation of the disease, and the prognosis of the disease depends on early diagnosis of the disease, the prevalence of osteonecrosis and adequate treatment tactics.

It should be noted that conservative methods treatment of this disease do not lead to a complete cure, they can only slow down, sometimes very significantly, the progression of the disease and maintain joint mobility for many years.

But nonetheless, necrotic process in the affected joint will not disappear anywhere and will, albeit slowly, continue its destructive activity. Unfortunately, it does not exist today medical supplies and devices for physiological treatment, which would completely destroy the necrotic process in the hip joint.

Physiotherapy

Physiotherapeutic treatment for this disease is carried out in combination with other procedures. Particular attention should be paid to laser therapy and thermal treatment. Laser therapy is an effective treatment method.

However, the disease cannot be completely cured with laser alone, so it must be carried out in combination with other methods and procedures. The course of treatment is at least twelve sessions. Laser therapy is strictly prohibited for those patients with stroke, tuberculosis, cirrhosis of the liver, as well as tumor and infectious diseases.

Thermal treatment includes mud therapy and paraffin therapy. This treatment method is carried out to improve blood circulation in the damaged femoral head. With this method of treatment, substances are used that retain and release heat to the patient.

In addition to the temperature effect, chemical exposure brings a positive effect. To improve metabolism and blood circulation, biologically active substances penetrate the body through the skin. However, heat therapy is strictly contraindicated for people suffering from hepatitis and blood diseases.

Without special therapeutic exercises, it is very difficult to cope with necrosis of the femoral head. It helps to cope with the progressive deterioration of blood circulation in the affected area of ​​​​the thigh, as well as the increasing atrophy of the thigh muscles. It is important to carefully select exercises to strengthen the muscles and ligaments of the legs. Gymnastics should be done without pressure and active movements with the legs.

For example, you can perform the following static exercise: lying on your back, raise your straight leg to a small height. You need to keep your leg suspended for some time. Although the joints are not involved in the work, the person will feel tired.

A set of therapeutic exercises that the patient should perform at home should be suggested by the attending physician. In addition to therapeutic exercises, you need to do muscle massage. For it to be beneficial, the massage must be performed competently and effortlessly. Thanks to proper massage blood circulation improves.

In addition to all of the above, you must strictly adhere to the orthopedic regimen. It is recommended to move on crutches and to remain in bed for the first time. To avoid muscle hypertrophy and to eliminate pain, it is important to do the following:

Walk at an average pace for twenty minutes, climb the stairs, visit the pool, or go swimming in the river, ride an exercise bike, take a cane with you for long distance walks, try to lose excess weight. Lifting heavy objects, jumping and running is prohibited.

Avascular necrosis of the femoral head is also treated with massage. However, you should not place high hopes on therapeutic massage, since it is just an additional method in combination with other treatments.

The positive effect of a massage will only appear if the main condition is that it is performed correctly. You need to know that with the wrong massage, the patient’s well-being can only worsen. A massage should evoke only positive feelings - comfort and pleasant warmth. For aseptic necrosis, massage is usually recommended twice a year, ten sessions every other day.

And even massage has contraindications. Thus, it is not recommended to perform it for blood diseases, bleeding, as well as all conditions that are accompanied by an increase in body temperature. On critical days, massage is especially not recommended for women.

Surgery

A competent specialist must determine what treatment to prescribe. The choice of methods depends on how far the disease has progressed, on the person’s age and the characteristics of his body. Today there are no drugs that can restore blood circulation in a damaged joint.

Basically, aseptic necrosis of the femoral head is treated surgically.
In the early stages, the main objectives of the operation are to restore blood supply to the joint tissues and eliminate stagnation of venous blood. If stage 2 of the disease is diagnosed, the objectives of surgical intervention are as follows:

1. change the position of the head of the femoral joint in relation to the acetabulum so as to eliminate the load on the most affected part of the head;
2. improve blood flow in the joint and reduce blood pressure inside the bone;
3. increase the mechanical strength of the affected parts of the head.

For the treatment of femoral bone necrosis, several surgical methods. Surgeries that restore blood flow in the joints are often indicated:

• Decompression surgery. A channel is drilled in the area of ​​the femoral head where there is no blood flow. Thanks to this, the blood supply to this part of the leg increases, as new vessels begin to grow in the resulting canal (puncture). Intraosseous pressure in the femoral head decreases, which relieves pain;
• An autograft is made from the fibula. A piece of the fibula, which is located on a vascular pedicle, is transplanted inside the puncture. Thanks to this graft, blood flow improves and the femoral neck is strengthened;
• During the operation, the damaged joint is replaced with an artificial joint. A titanium or zirconium pin with an artificial head at the edge of the joint is inserted and fixed into the femoral cavity. At the same time, surgery is performed on the second articulating part of the joint. A concave bed is inserted into it, which helps the new head rotate in it. If the operation is performed correctly, the pain disappears and the joint becomes mobile.

If you start treating necrosis in a timely manner, you can fully recover after a couple of months of therapy. If the situation starts, one of the methods of surgical intervention described above will be required.

Osteonecrosis talus are treated with chondroplasty - an operation to replace a damaged area of ​​​​the elements of the tibia. The tunneling method (drilling the affected area) is also used.

Hip and knee replacement is performed in 90% of patients diagnosed with aseptic necrosis of the hip joint if they are scheduled for surgery. This is the process of replacing a damaged joint with a graft.

With effective prosthetics, the patient’s pain disappears and the amplitude of limb movement is completely restored. But there are some risks of complications and infection. In addition, if the surgeon does not fit the prosthesis correctly, it can quickly become loose, and then a repeat operation is inevitable.

If the operation is performed correctly, the implant will need to be replaced after 12-15 years. The main thing is to diagnose aseptic necrosis of the head of the hip joint or other joints as early as possible in order to avoid surgical intervention.

Conservative treatment, started in a timely manner and under the strict supervision of a specialist, gives good results. Any operation brings new problems and complications and requires long-term rehabilitation.

Neglect of one’s health and failure to take timely measures in the presence of symptoms of the disease reduce the chances of recovery. It will take more effort and financial costs to restore the functionality of the joints.

Prevention

Hip joint necrosis does not have any precise prevention measures. Most patients suffer from this disease without true reasons its occurrence. But, there is a recommendation to consume less alcoholic beverages and corticosteroid drugs, which provoke the onset of the disease.

If you have received any injury to the hip joint, you must urgently consult a doctor for proper medical help so that the lumen of the hip arteries does not narrow. Now you know what joint necrosis is, why it appears, what stages of development it has, how it is diagnosed and what methods it can be cured.

It is important to consult a doctor at the first symptoms of the disease in order to begin the correct, timely and effective treatment. For any injuries to the hip joint, you should immediately seek qualified medical help to prevent narrowing of the lumen of the femoral artery.

Sources: moisustav.ru moisustavy.ru binogi.ru bezperelomov.com medotvet.com koksartroz.ru

megan92 () 2 weeks ago

Tell me, how does anyone deal with joint pain? My knees hurt terribly ((I take painkillers, but I understand that I am fighting the effect, not the cause...

Daria () 2 weeks ago

I struggled with my painful joints for several years until I read this article by some Chinese doctor. And I forgot about “incurable” joints a long time ago. So it goes

megan92 () 13 days ago

Daria () 12 days ago

megan92, that’s what I wrote in my first comment) I’ll duplicate it just in case - link to professor's article.

Sonya 10 days ago

Isn't this a scam? Why do they sell on the Internet?

julek26 (Tver) 10 days ago

Sonya, what country do you live in?.. They sell it on the Internet because stores and pharmacies charge a brutal markup. In addition, payment is only after receipt, that is, they first looked, checked and only then paid. And now they sell everything on the Internet - from clothes to TVs and furniture.

Editor's response 10 days ago

Sonya, hello. This drug for the treatment of joints is indeed not sold through the pharmacy chain in order to avoid inflated prices. Currently you can only order from Official website. Be healthy!

Sonya 10 days ago

I apologize, I didn’t notice the information about cash on delivery at first. Then everything is fine if payment is made upon receipt. Thank you!!

Margo (Ulyanovsk) 8 days ago

Has anyone tried it? traditional methods joint treatment? Grandma doesn’t trust pills, the poor thing is in pain...

Andrey A week ago

No matter what folk remedies I tried, nothing helped...

Ekaterina A week ago

I tried drinking a decoction of bay leaves, it didn’t do any good, I just ruined my stomach!! I no longer believe in these folk methods...

Maria 5 days ago

I recently watched a program on Channel One, it was also about this Federal program to combat joint diseases talked. It is also headed by some famous Chinese professor. They say that they have found a way to permanently cure joints and backs, and the state fully finances the treatment for each patient.

Aseptic necrosis of the femoral head (AFH) - severe chronic illness, caused by insufficiency of local circulation, which leads to the destruction of bone tissue in the femoral head.

Statistics

Of all bone and muscle diseases, aseptic necrosis of the femoral head accounts for 1.2 to 4.7%. According to various authors, mainly men aged 30-50 years are affected (about 7-8 times more often than women).

Moreover, in 50-60% of cases, both legs are affected: the process that began on one side, a year later in 90% of cases, occurs on the other.

Interesting facts and history

• The first reports of a disease similar to aseptic necrosis of the femoral head appeared in the 20-30s of the last century.
• For a long time this disease was compared with Perthes disease (destruction of the femoral head in children), suggesting the use of the same term. However, it was noticed that in children the disease is milder, the bone tissue is often restored while maintaining the shape of the femoral head, and the site of the lesion does not have a clear location.
• Only in 1966, at an international congress of orthopedists in Paris, avascular necrosis of the femoral head (AFH) was recognized as a separate disease.
• ANFH is the most common cause of hip replacement. Moreover, the results are significantly worse than with a similar operation for arthrosis of the hip joint (a disease associated with deformation and limited mobility of the joint).
• ANFH is more common in people of young and working age, leading to the development of disability and decreased quality of life.
• Conservative treatment of the disease (with the help of medications) is ineffective.
• Often, 2-3 years after the onset of the disease, surgical treatment is performed.

Anatomy of the femur and hip joint

On the part of the femur that is closer to the body, there is the head of the femur - a spherical protrusion. The neck extends from the head - a narrowed section that connects the head with the body of the femur. At the junction of the neck and the body of the tubercle there is a bend and two bony protrusions - the greater and lesser trochanter.

The head of the femur has an articular surface that serves to connect with the acetabulum (the socket on the pelvic bone), and together they form the hip joint. The femoral head and acetabulum are covered with cartilage tissue.

The hip joint itself is hidden under soft tissues (articular capsule), which produce joint fluid that nourishes the cartilage tissue and ensures the sliding surfaces of the joint.

Structure and layers of bone tissue

Structural unit of bone - osteon, consisting of bone plates (from 5 to 20) of a cylindrical shape, located symmetrically around the central bone canal. Vessels and nerves pass through the canal itself.

There are spaces between the osteons that are filled with internal interosseous intercalary plates - this is how the cellular structure of the bone is formed.

Osteons form crossbars (trabeculae or beams) of bone substance. They are located in accordance with the direction in which the bone experiences the greatest load (during walking, movements) and stretching by the attached muscles. This structure ensures bone density and elasticity.

Moreover, if the crossbars lie tightly, then they form compact substance(middle layer), if it is loose, then form spongy substance(inner layer) of bone. The outside of the bone is covered periosteum(outer layer), penetrated by nerves and vessels that go deep into the bone along the perforating osteon channels.

Mechanism of development of aseptic necrosis

There are currently two main theories:

• Traumatic theory- when the integrity of the bone is compromised due to injury (fracture, dislocation).
• Vascular theory: under the influence of various factors, the vessels supplying the femoral head with blood narrow for a long time or become clogged with a small blood clot. As a result, local circulation is impaired (ischemia). In addition, the viscosity of the blood increases, so its flow slows down.

All these changes increase the phenomenon of ischemia in the femoral head and increase the pressure inside the bone. As a result, bone tissue dies (necrosis develops) in the place of greatest load on the femoral head.

However, some scientists put forward another theory for the development of ANGBC - mechanical. It is believed that due to various reasons, “overwork” of the bone occurs. Therefore, impulses go from the bone of the femoral head to the brain, causing reverse signals that lead to compensatory vasoconstriction (an attempt to return to the original state). As a result, metabolism is disrupted, blood stagnates and decay products accumulate in the bones.

In practice, there is no clear distinction between the theories. Moreover, they often complement each other, acting simultaneously.

On a note!

As a rule, the first foci of necrosis in the bone appear 3-5 days after ischemia. However, under favorable conditions, the blood supply is restored, and the destroyed bone tissue is replaced with new tissue. Whereas with further overload of the femoral head, the course of the process worsens, leading to the development and severe course of the disease.

Causes of aseptic necrosis

Trauma (dislocation, fracture) or surgery

Leads to mechanical damage (rupture) or blockage of the lumen of blood vessels with a blood clot (formation of blood clots). As a result, blood flow to the head of the femur is disrupted. Moreover, the disease begins to develop several months after the injury, and its first signs appear after 1.5-2 years.

Long-term use of corticosteroids (hormonal drugs) for the treatment of rheumatic diseases (psoriatic or rheumatoid arthritis), bronchial asthma and others.

It is considered the most common cause of ANFH. What's happening? Hormones constrict blood vessels for a long time, disrupting local circulation in the head of the hip bone.

In addition, long-term use of corticosteroids gradually breaks down bone (osteopenia), leading to the development of osteoporosis (low bone density). As a result, when loaded, the bone crossbars experience “overwork” and break (chronic microtrauma), cutting off the flow of arterial blood to the femoral head.

Systematic alcohol abuse

The metabolism of fats and proteins in the body is disrupted, and cholesterol is deposited in the walls of the arteries - atherosclerosis develops. As a result, the walls of the arteries thicken and lose their elasticity, and the blood supply to the femoral head is disrupted.

Drinking alcohol in large doses at once

There is an acute decrease in blood supply to the head of the femur.

Taking painkillers and non-steroidal anti-inflammatory drugs

A side effect is the destruction of bone crossbars and the development of osteoporosis. Therefore, with the slightest disturbance in blood circulation or increased load on the femoral head, ANFH develops.

Autoimmune diseases: systemic lupus erythematosus or scleroderma, hemorrhagic vasculitis and others.

Immune complexes are deposited in the vascular wall, causing immune inflammation. As a result, the elasticity of the vascular wall and local blood circulation are impaired. When combined with the use of glucocorticoids for the treatment of these diseases, severe forms of ANFH develop.

Caisson disease

It occurs due to a rapid decrease in the pressure of the inhaled gas mixture (for divers, miners). Therefore, gases in the form of bubbles penetrate into the blood and clog small vessels (embolism), disrupting local circulation.

Presence of problems in the lumbosacral spine

If the innervation is disrupted (for example, intervertebral hernias) a spasm of the blood vessels that nourish bone tissue occurs.

Aseptic necrosis also develops in other diseases: chronic or acute pancreatitis, ionizing radiation, sickle cell anemia (hereditary disease). Unfortunately, the mechanism of ANFH formation in these diseases has not been fully studied.

However, in 30% of cases of ANFH, the cause of the disease remains unidentified. And often several factors act together, leading to a rapid and severe course of the disease.

Types and stages of aseptic necrosis of the femur

Stages of aseptic necrosis of the femoral head

Symptoms The leading sign of the onset of the disease is pain. Moreover, it manifests itself in different ways.

At the beginning of the disease, pain most often occurs only after physical activity or during bad weather, but disappears with rest. Gradually the pain becomes constant.

Sometimes after a period of exacerbation it disappears, but reappears when exposed to a provoking factor.

However, sometimes the pain appears suddenly. Moreover, it is so strong that some patients can name the day and even the hour of its occurrence. For several days, patients can neither walk nor sit due to pain. Then the pain subsides, appearing or intensifying after physical activity.

Usually, at the beginning of the disease, pain occurs in the hip joint, spreading (radiating) to the groin or lumbar region, knee joint, and buttock. However, pain may primarily appear in the lower back and/or knee joint, misleading the doctor and leading away from the correct diagnosis.

There are no restrictions of movement in the affected joint at this stage.

Stage II(6 months) - impression (compressed) fracture: when there is a load on a certain area of ​​the femoral head, the bone beams break, then wedge into each other and become crushed.

Symptoms The pain is constant and severe and does not disappear even with rest. Moreover, after physical activity it intensifies significantly.

At this stage, muscle atrophy (thinning of muscle fibers) appears on the thigh and buttock on the affected side.

There are restrictions on circular movements. Moreover, the pain intensifies when trying to perform circular movements in the sore leg, move it to the side, or bring it to the healthy leg.

Stage III (from 1.5 to 2.5 years) - resorption

The healthy tissue surrounding the necrosis zone slowly reabsorbs the dead bone fragments. At the same time, connective tissue (plays a supporting role in all organs) and islands of cartilaginous tissue grow deep into the head of the femur. As a result, conditions are created in the femoral head for the growth of new vessels. However, at the same time, the growth of the femoral neck is disrupted, so it shortens.

Symptoms The pain is constant, intensifying even after slight exertion, but with rest it decreases somewhat.

The mobility of the joint is sharply limited: it is difficult for the patient to walk, pull his leg to his chest, or put on socks. There is pronounced lameness when walking, and muscle atrophy extends from the thigh to the lower leg (below the knee). Patients have difficulty moving, relying on a cane.

In addition, the leg on the affected side is shortened. Whereas in some patients (10%) it lengthens - a bad sign for the prognosis of the disease.

IV stage(from 6 months or more) - outcome (secondary deforming arthrosis occurs).

The sprouted connective tissue and islands of cartilage turn into bone tissue, due to which the spongy substance of the femoral head is restored.

However, in this case, secondary changes are formed: the beam (cellular) structure of the bone is rebuilt (deformed), and it also adapts (accustoms) to new conditions and loads.

In addition, the acetabulum is also deformed and flattened. Therefore, its normal anatomical contact with the femoral head is disrupted.

Symptoms In the area of ​​the affected hip joint or lumbar spine there is constant pain that does not disappear even at rest. The muscles of the thigh and lower leg are atrophied (volume decreases to 5-8 cm). There are no circular movements in the affected leg, and forward and backward movements are sharply limited. Gait is significantly impaired: patients cannot move independently, or only with support (cane).

The duration of each stage of ANFH is individual, since much depends on the impact of provoking factors, timely treatment and the presence of concomitant diseases.

However, aseptic necrosis does not always affect the entire head of the femur at the same time. Therefore, there is a classification based on the location of the necrosis focus.

There are four main forms (types) of ANGBC:

• Peripheral(9-10% of cases) form: the outer part of the femoral head, which is located directly under the articular cartilage, is affected.
• Central(2% of cases) form: a zone of necrosis forms in the center of the femoral head.
• Segmental(46-48% of cases) form: a small area of ​​bone tissue necrosis in the form of a cone occurs in the upper or upper outer part of the femoral head.
• Complete damage to the entire femoral head (observed in 40-42% of patients).

Symptoms of aseptic necrosis

Diagnosis of aseptic necrosis

Meanwhile, with early diagnosis and receipt timely treatment for ANFH there is a high chance of avoiding surgery.

Moreover, the choice of research method depends on the stage of the disease at the time of examination.

Hardware methods for diagnosing aseptic necrosis

Indications

• Acute or chronic pain in the hip joint and/or groin area, radiating to the lower back, knee or buttocks.
• Recent or past injuries (fracture, dislocation).
• Monitoring the effectiveness of treatment. The timing is determined depending on the chosen method.
• Preparation for hip replacement with an artificial prosthesis.
• Assessment of the condition of blood vessels in the hip joint (only on CT or MRI).

X-ray of the hip joint

Methodology

Pictures are taken in two projections:

• Straight. The patient is placed on a special table in a supine position with legs straightened, and the feet are turned inward (fixed in the required position using bolsters). If joint mobility is impaired, the patient is placed on his stomach and asked to lift the opposite side of the pelvis, which is fixed with bolsters.


• Side. The patient is placed on a special table in a supine position, and the leg being examined is bent at the root joint and moved to the side at an angle of 90°.

Stage I

There are no changes indicating aseptic necrosis. The structure and shape of the femoral head are not visually changed. However, sometimes areas of osteoporosis (bone resorption) or osteosclerosis (bone hardening - a sign of inflammation) are visible.

Stage II

Areas of dead bone tissue (necrosis) and small cracks (bar fractures) on the head of the femur are visible. There is an impression (crushing) in the bone. The joint space is unevenly widened.

Stage III

Areas of bone resorption on the femoral head are identified. Therefore, it loses its shape and consists of separate fragments, and the femoral neck is shortened and thickened. At the same time, minor bone growths are visible at the edges of the acetabulum, and the joint space itself is moderately narrowed.

IV stage

The head of the femur is greatly modified: it is short and wide. In this case, the joint space is sharply narrowed, the acetabulum is deformed and flat, and there are coarse growths on its edges. Therefore, the contact of the articular surfaces of the femoral head and the acetabulum is disrupted.

Computed tomography (CT)

Using CT, the structure of the femoral head and cartilage, surrounding soft tissues, and the condition of the blood vessels (if necessary) are determined.

Methodology

The assistant helps the patient sit on a special tomograph table in a supine position, then leaves the room.

• Moves the table, positioning the study area in the tomograph frame (gantry).
• Includes ray tube, which, making circular movements, captures the reflection x-rays and transmits information to a computer where it is processed.

Signs of avascular necrosis on CT

Magnetic resonance imaging (MRI)

The technique makes it possible to detect in the early stages even a small focus of changes that has arisen in the femoral head, and also detects intraosseous edema and inflammation of the hip joint.

Therefore, MRI (NMR) is the most commonly used and informative method for the diagnosis of aseptic necrosis.

Methodology

The physician's assistant helps the patient lie down inside the magnetic resonance imaging tube, then leaves the room.

The examination time is 10-20 minutes, and you must lie still throughout this time in order to obtain a high-quality image. While a series of layer-by-layer photographs are being taken, a uniform knocking sound is heard - normal operation devices.

When it is necessary to evaluate blood vessels, a contrast agent is administered intravenously to the patient before the examination.

Signs of avascular necrosis on MRI

Laboratory methods for diagnosing aseptic necrosis

Moreover, they are used both for diagnosis and for assessing the effectiveness of treatment.

Whereas the indicators of a general blood test for ANFH are not informative, since they remain within normal limits.

Determination of minerals in the blood

One of the most important microelements in the body and the main components of bone, as it participates in the construction of the skeleton.

Calcium level in venous blood- 2.15-2.65 mmol/l.

However, it should be remembered that when the level of calcium in the blood drops, it begins to be washed out of the bones, compensating for the deficiency. That is, the process of destruction in the bone has already begun, and the result of the analysis creates the appearance that the person is healthy.

Therefore, when bone is destroyed, the level of calcium in the blood may remain within normal limits or decrease.

Phosphorus and magnesium

They work closely with calcium, improving its penetration into bone tissue.
However, if there is an excess of phosphorus in the body, calcium is washed out of the bones. The normal ratio of calcium and phosphorus is 2:1.

The norm of phosphorus in venous blood in adults is from 0.81 to 1.45 mmol/l

The norm of magnesium in venous blood in adults is from 0.73 to 1.2 mmol/l

With aseptic necrosis, their level can either remain within normal limits or decrease.

Biochemical indicators of bone tissue destruction

With aseptic necrosis, both bone beams and collagen are destroyed, which, when disintegrating, forms several fragments - markers (specific substances). First, they enter the bloodstream, then are excreted unchanged in the urine.

Main markers of ANGBC

Indicators of increased bone formation

Norm of osteocalcin

If necessary, other markers of bone tissue formation are determined (alkaline phosphatase, sex hormones, and others), but they are not specific for ANFH.

Treatment of aseptic necrosis

Drug treatment (without surgery)

Medicines for the treatment of aseptic necrosis of the femoral head

Rehabilitation during drug treatment of aseptic necrosis

Therefore, it is recommended to walk with a cane only during the first 4-6 weeks of illness during long walks. Whereas walking at an average pace for 15-20 minutes or on steps shortens recovery time.

Physical therapy is carried out, exercises for which are selected individually by a doctor-instructor. Then the patient will perform them independently at home.

To compensate for the lack of physical activity, electrical muscle stimulation (ESM) is used. Therapeutic devices are used that deliver an electrical signal to the muscles around the hip joint with a specific frequency and amplitude. Moreover, during the procedure, electrodes are applied to the skin at acupuncture points (biologically active points), thereby achieving an analgesic effect.

When is surgery needed for aseptic necrosis?

Moreover, there are a considerable number of methods and approaches to surgical treatment. However, most of them do not always lead to a cure, but significantly shorten the recovery period and the patient’s return to active life.

All surgical interventions are performed under epidural (drugs are injected into the lumbar region) or general anesthesia.

Operations for aseptic necrosis

Indications - Stage I-II of the disease and severe pain syndrome.

Goals: reducing intraosseous pressure and pain, creating conditions for restoring local blood flow and sprouting new blood vessels.

Methodology

Using a drill, additional holes are created in the head of the femur (their number is determined by the size of the necrosis focus). After removing the drill, dark blood is released from the holes. This reduces intraosseous pressure.

The operated limb is unloaded for 2-4 months (walking on crutches), depending on the size of the lesion.

The method at stages I and II of the disease is most justified, since the effectiveness, according to various authors, ranges from 40 to 90%. Moreover, on CT or MRI already after 3-4 months, signs of bone tissue restructuring appear.

Musculoskeletal graft transplant

Indications- I-II stage of the disease, elimination of pain.

Goals: increasing local blood flow, strengthening the femoral head and eliminating pain.

Methodology

A section of dead bone tissue is removed, and a small piece of fibula or from the anterior outer surface of the thigh (trochanteric area) along with a vessel is transplanted in its place. This provides additional blood supply and strengthens the femoral head.

If the operation is unilateral, walking on crutches is allowed, but without putting stress on the operated joint. In case of a one-stage bilateral operation, bed rest is observed for about 2 months.

Flaws - Blood clots sometimes form in the transplanted vessel, so a positive effect is not always achieved.

Intertrochanteric osteotomy

Indications - II-III degree of the disease.

Goals- removing the worn part of the femoral head from under the load, redistributing it to other areas.

There are several types of this operation, and sometimes surgeons combine them.

Methodology- The femur is cut (obliquely or transversely) at the level of the trochanters (protrusions on the femur). Then a part of the bone in the form of a wedge is excised at the required angle, and the bone fragments are fixed using orthopedic structures (plates, screws of special devices) in the most favorable physiological position.

In this case, the area of ​​the articular surface subjected to load increases. While the focus of necrosis shifts to the least loaded area of ​​the hip joint. Thus, conditions are created for the restoration of the dead area of ​​bone tissue.

In addition, during the operation, the bone is dissected along with venous vessels and nerve endings. As a result, stagnation of venous blood is reduced, pain is eliminated and muscle spasm is reduced.

After the operation, a plaster cast is applied for 6 weeks, covering the hip and knee area.

6 weeks after surgery, partial load on the operated joint is allowed using crutches. After 10 weeks, full weight-bearing is possible if the control image shows fusion of the bone fragments.

Flaws

It is not always possible to move the affected area to the least loaded area, and sometimes the range of motion in the affected joint is somewhat limited.

Arthrodesis

Indications: elderly age the patient or the presence of diseases that do not allow arthroplasty or replacement of the hip joint with a prosthesis.

Goals: eliminating pain by immobilizing the joint (artificial fusion).

Methodology

First, areas of dead bone tissue of the femoral head and articular cartilage (if necessary, the head and neck of the femur) are removed, exposing and preparing the bone for the next stage of the operation.

After the operation, a plaster cast is applied for 3 months, which starts from the nipples, then covers the entire operated leg, and the healthy one up to the knee.

After 3 months, another plaster cast is applied for 3-4 months, but not involving the healthy limb. Walking is allowed 4-6 months after surgery. However, using an orthopedic device that grips the patient’s body, starting from the chest and ending with the toes of the operated leg.

Flaws- Arthrodesis is a mutilating operation that leads to immobilization of the joint. Therefore, due to the redistribution of the load, pelvic distortion and lateral curvature of the lumbar spine develop.

Arthroplasty

Indications- II-III degree of the disease.

Goals: increased range of motion, decreased pain and lameness, improved blood supply to the femoral head.

There are several types of arthroplasty, which are used depending on the changes that have occurred in the hip joint.

Methodology

The essence of the operation is the modeling of new articular surfaces of the hip joint.

First, the dead area of ​​the bone tissue of the femoral head is cleaned out. Then a spacer is installed between the articular surfaces, which will act as cartilage. Such pads are made from the patient’s own tissue (iliac crest along with the vessel and muscle, skin, cartilage) or articular parts taken from a corpse (sometimes the entire joint) and other materials.

Endoprosthetics - replacement of the hip joint with an artificial prosthesis

Indications - III-IV degree of arthrosis.

Goals: restoration of movement in the affected joint, elimination of pain.

The materials used to make the prosthesis are absolutely compatible with human tissue.

The choice of the type and method of fixation of the prosthesis depends on age, weight, concomitant diseases, degree physical activity sick.

Methodology

After cutting the soft tissue, the surgeon removes the affected femoral head and acetabulum. In their place, an artificial cup and a leg with a spherical head are installed.
Then the surgical wound is sutured, and a drainage is installed in it to drain the leaking blood.

In the postoperative period, to reduce the risk of blood clots in the vessels, blood thinning drugs are prescribed for 20-30 days (Clexane, Fraxiparine). The dosage of medications depends on the patient's weight.

Rules of conduct for the first 3-4 weeks after endoprosthetics

It is necessary to reduce the risk of prosthesis dislocation. Therefore, you should not bend the operated leg at a right angle (more than ninety degrees), squat down or cross your legs.

You can only sit on chairs in which the flexion at the hip joint is less than 90°C, while moving the operated leg slightly forward. While lying on your back, your leg can be slightly bent at the knee joint.

To provide security at night while sleeping in a supine position, place one or two pillows between your legs.

It is not advisable to lie on the affected side during the first month after surgery; you can lie on the healthy side by placing a small pillow between your knees.

Rehabilitation after hip surgery

First stage

It starts from the first days after surgery.

Goals: relaxation of periarticular muscles and improvement of blood circulation in lower limbs to prevent the formation of clots (thrombi) in the lumen of the veins.

Dosed therapeutic exercises are carried out under the supervision of a doctor-instructor. The complex is selected individually with a gradual increase in the number of exercises and range of motion. In the future, the patient performs them independently 2-3 times a day.

On the second or third day after the operation, the doctor-instructor helps the patient get out of bed. Then he teaches him how to walk correctly with the help of crutches on a horizontal surface, as well as up and down stairs. In addition, it teaches you how to sit, sit, get up and lie in bed correctly.

Second phase

Begins 2-3 weeks after surgery.

Goals: restoration of muscle endurance and increased joint mobility.

The patient continues to independently perform the therapeutic exercises learned with the instructor. Or he trains on special training equipment, but under the guidance of an instructor.

In addition, electrical stimulation of muscles, massage and drug treatment (vascular, chondroprotectors, vitamins) are prescribed.

After 2-4 months after most operations on the hip joint (except arthrodesis), the patient is able to move independently without crutches. However, at first, you sometimes have to use a cane until you gain confidence in balance.

Moreover, when endoprosthetics or arthroplasty of the second hip joint is to be performed, it is impossible to put full weight on the operated leg. Because there is a risk of prosthesis loosening or arthroplasty failure. Therefore, the entire waiting period before the second operation (about 6 months) until the operated leg has fully recovered, it is necessary to use a cane when walking.

Nutrition for aseptic necrosis (diet)

"Lubricant" for joints

First of all, foods rich in omega-3 fatty acids: fish (salmon, mackerel, herring, tuna, halibut), flaxseed oil (2-3 teaspoons per day). Moreover, it is advisable to consume at least four days a week fish dishes 150-200 grams, combining with vegetables: lettuce, sweet pepper, broccoli.

Omega-3 fatty acid They “lubricate” our joints like machine oil. Since they enhance the processes of bone tissue formation, they maintain the elasticity of tendons, ligaments, cartilage and joint capsules. In addition, they slow down the breakdown of collagen fibers and reduce inflammation in the joints.

You can also use Not fatty varieties meat (poultry, rabbit) and egg white- building materials for the body.

Brightly colored vegetables and fruits are a source of antioxidants

Under the influence of damaging factors, free radicals are formed in our body - unstable molecules that are missing one electron. Therefore, trying to find the missing particle, they “steal” it from other healthy molecules, damaging them - a vicious circle. This is how most diseases arise and aging occurs.

However, there are substances that provide the missing electron by stabilizing the molecule - antioxidants. Therefore, products containing them are useful for everyone.

In nature, they are brightly colored, as if calling to be eaten: oranges, Bell pepper, carrots, lemons and others.

Pomegranates and green tea are especially rich in antioxidants. Moreover, they reduce pain. Therefore, for severe pain, it is recommended to use 2-3 tbsp. l. undiluted pomegranate juice per day.

Taboo in aseptic necrosis

It is necessary to eliminate or sharply limit alcohol consumption and quit smoking.

You should limit or exclude from your diet foods containing “harmful” fats. Because they exacerbate inflammatory processes: artificially synthesized oils (for example, margarine), lard, corn oil.

Also unhealthy are fatty meats, egg yolks and offal. Because they contain arachidonic acid, which stimulates the formation of compounds that cause the development of inflammatory processes.

Minerals are the key to strong bones

The most significant are calcium, magnesium and phosphorus, since they are the basis of bone tissue.

Sources of calcium- low-fat fermented milk products (kefir, cottage cheese, yogurt), rye bread, beans, spinach, blackberries, peaches, legumes, whole wheat grains and others.

Moreover, it is important to remember that coffee (more than 2-3 cups per day) reduces the absorption of calcium in the intestines and also contributes to its leaching from the bones.

Phosphorus found in green peas, apples, cucumbers, walnuts, fish, peanuts, whole wheat grains, mushrooms.

Magnesium enters the body upon consumption rye bread, walnuts, pumpkin, bran, beans, buckwheat, mint, chicory.

Moreover, as with any diet, in this case it is important not to overdo it, but to observe moderation in everything, eating a balanced diet.

Consequences of aseptic necrosis