Steroid-induced necrosis of the femoral head
Introduction
Introduction to steroid-induced femoral head necrosis Femoral head necrosis, also known as aseptic necrosis of the femoral head, or avascular necrosis of the femoral head, is a common disease, due to a variety of causes of local femoral head poor blood supply, resulting in further ischemia, necrosis of bone cells, A lesion of trabecular bone fracture and collapse of the femoral head. Hormone-induced femoral head necrosis is a femoral head necrosis caused by prolonged use of hormones. basic knowledge Sickness ratio: 0.0001% Susceptible people: no special people Mode of infection: non-infectious Complications: osteoarthritis
Cause
Hormone femoral head necrosis
With the development of medicine, hormones have become more and more widely used in clinical practice, and steroid-induced femoral head necrosis has been reported more and more at home and abroad. Femoral head necrosis is a recognized complication of hormones in a wide range of applications in recent years. The incidence of steroid-induced femoral head necrosis has now exceeded the femoral head necrosis caused by trauma.
Disease factors (50%):
The mechanism of steroid-induced femoral head necrosis is not very clear. It is generally believed that long-term accumulation of hormones in the body leads to increased blood viscosity, increased blood lipids, fat embolism, fatty liver, microvascular occlusion of the bone, ischemia, reduced bone synthesis, calcium Absorption disorders, accumulation of osteoporosis and microfractures, eventually leading to steroid-induced femoral head necrosis.
Drug factors (20%):
The use of glucocorticoids such as dexamethasone for 7 days resulted in necrosis of the femoral head. After the use of hormones, the onset time was different, and there was a report of femoral head necrosis less than 2 months after the use of hormones.
Prevention
Hormone-induced femoral head necrosis prevention
First, diseases that often use hormonal drugs.
1) Collagen diseases: systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis, nodular arteritis, scleroderma, rheumatoid arthritis.
2) Skin disorders: pemphigus, eczema, urticaria, hand and foot spasm, exfoliative dermatitis, erythema multiforme.
3) Blood disease: leukemia, purpura.
4) Respiratory diseases: asthma, bronchial pneumonia, chronic bronchitis, tuberculous pleurisy.
5) Nephropathy, nephritis, kidney transplantation, bone marrow transplantation, acute and chronic hepatitis.
Second, how to prevent femoral head necrosis caused by hormones.
1) Stop hormones as soon as possible or reduce the dose of hormones.
2) When using hormones, the traditional Chinese medicine such as Chenglin orthopedics for promoting blood circulation and removing blood stasis is used at the same time to prevent femoral head necrosis.
Complication
Hormone femoral head necrosis complications Complications osteoarthritis
The femoral head collapses, the joint space narrows, and finally leads to osteoarthritis, which causes the patient's hip joint dysfunction and causes disability.
Symptom
Hormone femoral head necrosis symptoms Common symptoms Myasthenia gravis muscle pain Abdominal tenderness
1, early symptoms:
Most patients have clinical symptoms that are not obvious. They are only seen in thigh muscle weakness and adductor muscle pain. Individual patients have limb pain in distant areas. Some patients may experience intermittent hip pain after exertion, alternating hip pain or Mildly limp. During clinical examination, mild tenderness was observed in the hip and groin area, and both the 4-word test and the Toma sign were positive. Due to the absence of typical clinical symptoms and X-ray findings in the early stage, the rate of misdiagnosis is high. In patients with steroid-induced femoral head necrosis admitted to our hospital, the rate of early misdiagnosis is over 85%. More common misdiagnosed diseases are rheumatic rheumatoid hip arthritis, sciatic N pain, hip sprain and contusion, chronic lumbar muscle loss, lumbar hyperplasia and so on. Some patients were confined to the knee joint due to complications, and were misdiagnosed as knee joint disease.
2, the symptoms of the middle and late:
Most of the steroid-induced femoral head necrosis is intermittent, insidious onset. With the evolution of the disease in the middle and late stages, the development of slow hip pain is the main clinical symptom. The activity is aggravated and the rest is not obvious. About one-quarter of the patients had intermittent seizures, which showed sudden severe pain and sudden disappearance. During the onset of hip pain, individual patients had no effective analgesic. Hip pain has the following characteristics: 1 Pain area: Most patients have pain in the groin, the medial side of the femoral part, and the second part of the anterior hip, there are some patients with more than two parts, and often with radiation pain Or it is difficult to distinguish between pain. 2 The nature of pain: clinical common pain episodes may be acute severe pain, or chronic dull pain. The typical episodes of pain are acupuncture-like radioactive pain, some are limited to the hips, and some are also radiated to the knee joints.
3 pain time:
From the clinical observation, it is found that more than half of the patients with bone diseases can indicate the exact time of the pain episode. The more common pain episodes are after the activity, or the hip joints undergoing abduction and rotation in the middle and late stage of dying and before going to sleep. The functions such as elevation have evolved from gradual restriction to obvious obstacles, and the interstitial squats that have begun to develop have evolved into persistent limps. In advanced patients, the sound of the joints often occurs during joint movement. The range of joint activity is gradually reduced due to pain, the range of passive activities is also constrained, limbs are shortened, muscle atrophy, hips may have subluxation signs, 4 words experiment and Toma's Significant positive.
Sign
In the early stage, there was only local tenderness (starting point of the adductor muscle, midpoint of the groin, starting point of the sartorius muscle, lateral trochanter of the hip joint, and common gluteal muscle), and the "4" test and the Thomas sign were positive. Late hip joints are restricted in all directions, limb shortening, flexion adduction contracture deformity, muscle atrophy, subluxation signs in the hip, and Trendelenburg sign positive.
Examine
Examination of steroid-induced femoral head necrosis
X-ray performance
The posterior anterior, lateral, or tomographic slices of the hip should be photographed, and the two hips must be photographed to match the density. Significant signs of early lesions are often found on lateral and tomographic slices. Clinically, X-ray findings can be divided into 4 phases.
Stage I: subchondral dissolution period. The shape of the head is normal, and only in some areas (such as the weight-bearing area), cystic changes or "new moon signs" appear under the cartilage.
Stage II: head necrosis. The shape of the head is still normal, and the density increase zone is visible in the outer or outer upper and middle of the head, and a hardening zone sometimes appears around the head.
Phase III: Head collapse period. There is a step-like collapse or a double-peak sign on the head, a subtle fracture line under the cartilage, a flattened weight-bearing area, and peripheral osteoporosis.
Stage IV: head dislocation period. The necrotic area continues to develop inward and downward, with flat head, hyperplasia, hypertrophy, dislocation to the upper part, narrow joint space, and hyperplasia of the acetabular edge.
ARCO staging combined with X-ray, CT, MRI, bone scan and bone biopsy
Stage 0: The bone biopsy results were consistent with ischemic necrosis, but all other tests were normal.
Stage I: positive for bone scan or positive for MRI or both, depending on where the femoral head is involved, the lesion is subdivided into medial, central, and lateral.
IA: Femoral head involvement <15%.
IB: The femoral head is affected by 15% to 30%.
IC: femoral head involvement >30%.
Stage II: abnormal X-ray film (spotted head of femoral head, osteosclerosis, cyst formation and osteoporosis), no femoral head collapse on X-ray films and CT films, bone scan and MRI positive, acetabular no change, dependent stocks The location of the bone involvement, the lesion is subdivided into the medial, central and lateral.
IIA: Femoral head involvement <15%.
IIB: The femoral head is affected by 15% to 30%.
IIC: Femoral head involvement >30%.
Stage III: New Moon, depending on the location of the femoral head, the lesion can be subdivided into medial, central and lateral.
IIIA: New Moon Sign <15% or Femoral Head Collapse> 2mm
IIIB: 15% to 3% of the new moon sign or 2 to 4 mm of the collapse of the femoral head.
IIIC: New Moon Sign > 30% or femoral head collapse > 4mm.
Stage IV: X-ray shows that the articular surface of the femoral head is flattened, the joint space is narrowed, the acetabulum is hardened, cystic changes and marginal callus.
The extent of involvement in the femoral head was determined by MRI. The collapse of the femoral head relied on the positive lateral radiograph. The percentage of the new lunar sign refers to the length ratio of the length of the new lunar sign to the articular surface of the femoral head.
Diagnosis
Diagnosis and differentiation of steroid-induced femoral head necrosis
Diagnostic criteria
First, we must observe the symptoms of femoral head necrosis, usually there will be pain in the knees and joints, hips, waist, this pain is indirect, and sometimes it will continue. The form of pain is usually dull pain, dull pain, etc. There is also a sense of numbness in the place of pain. After the break, the pain will be alleviated and the labor will be aggravated. Hip dysfunction, abduction and internal rotation are severely restricted, flexion and extension are unfavorable, squat is difficult, and it is not possible to stand for a long time. There is a phenomenon of limp, the form is generally the diagnostic criteria for progressive and short-acting hormonal femoral head necrosis.
Second, the diagnosis of femoral head necrosis depends on the cause of the disease. There are many causes of femoral head necrosis, long-term heavy drinking, osteoporosis, history of hip trauma, because the disease treatment for long-term use of hormone drugs, etc., the above-mentioned situation is a susceptible population of femoral head necrosis, in daily life It is necessary to pay more attention to whether there are symptoms related to femoral head necrosis. This can be used as a diagnostic criteria for the diagnosis of femoral head necrosis with reference to steroid-induced femoral head necrosis.
Third, the diagnosis of femoral head necrosis depends on the results of medical instruments. When the patient is diagnosed, the changes in the femoral head can be visually observed through the imaging film. There is no small or broken bone texture at the femoral head. Symptoms such as flatness or collapse. When the symptoms are mild, CT or MRI can be used as much as possible to observe the femoral head more clearly. Slight roughness can also be detected. If X-ray film is used, early femoral head necrosis is easily missed by steroid-induced femoral head necrosis. Diagnostic criteria.
