Synonymous
Idiopathic aseptic necrosis of the femoral head
Definition
One considers all acquired illnesses in the area of the femoral head, which cause the dying of femoral head areas and / or the complete femoral head because of a defect circulation of the femoral head (= ischemia) to be a necrosis of the femoral head. As a rule, a necrosis of the femoral head in adolescence results as a complication after the treatment of an innate or traumatic dislocation of the hip, fractured femoral necks or pelvises. It leads to movement restrictions and severe pain appearing interval-likely. The final stage of a necrosis of the femoral head can represent the so-called coxarthrosis (hip joint arthrosis).
Age
Mostly between the 35th and 45th years of life
Sex distribution
Male > female, up to 50% also on both sides
Frequency
Appearance approx. 1:1000 - 1:5000
Cause
As described in the definition already, a necrosis of the femoral head arises from a too low circulation of the femoral head, called medical: ischemia. Has to be said that the circulation of the femoral head is generally to be seen anatomically as critical. The supply of the hip head with blood is carried out via an artery laid out individually from the femoral neck. Due to the individually laid out arterial supply, a so-called "low germ" of the arterial supply for the femoral head is seen as causally and decisively for the course of a disease,
One distinguishes in the area of the necrosis of the femoral head:
The primary (idiopathic) necrosis of the femoral head and
The secondary necrosis of the femoral head
While one can not prove any accompanying or underlying illnesses at the primary necrosis of the femoral head and can prove only an increased dismay of the male sex except for the frequent mutual appearance of the illness in addition in the age between 35 and 45, direct connections with other illnesses are known in the area of secondary necroses of the femoral head. At the two sub-forms cause and causality are most largely unknown, though.
Primary (idiopathic) hip head necrosis
The ideal-typical man is concerned of this form of the necrosis of the femoral head at the age between 35 and 45 years. The illness frequently does not only confine itself to one femoral head. The frequently strong emotional and social load of the patients can be explained by this and the fact that the illness usually appears in the time period of the greatest (professional) efficiency.
Secondary necrosis of the femoral head
One starts out from a direct connection with other illnesses. The underlying causes are multilayered and can be due to the following illnesses.
Known causes
Hip joint injuries of a different kind
Sickle cell anemia (blood illness which is genetically caused and inheritable)
Caisson sickness (= at quick pressure drop or at stays in heights appearing decompression illness, also called: diver's paralysis or pressure airsickness. A formation of nitrogen bubbles in the vessel system and a circulation disturbance as a consequence from these are carried out)
Gauchers` disease (hereditary sugar metabolism illness which among other things can lead to organ extensions)
Lupus of erythematodes (autoimmune illness with attack of heart, liver, kidney and joints)
Vessel illnesses (e.g. thrombosis)
Connective tissue diseases
Cortisone therapy (both as a local joint injection, as also as a systemic therapy)
Ray treatments in the pelvis area
Cytostatic therapy (at tumor diseases)
Rheumatic illnesses
Unfavorable habits, such as misuse of alcohol
The picture on the left side shows a disturbed femoral head circulation of an animal. While the femoral neck seems vigorously well supplied with blood, no more circulation can be proved in the upper femoral head area. Seen medically one describes this in principle "dead" area as a necrotic or avital.
Risk factors
Hyperuricemia (too high urine acid values in the blood)
Misuse of alcohol and nicotine
Hyperlipidemia (too high bare greases)
Clinic
The clinical symptoms amount to a movement restriction with pains appearing interval-likely. The symptoms of the illness frequently change due to strain and stimulation condition of the joint. So the pains can accumulate in the area of the inguinal region and the buttocks and radiate in up to the thigh or the knee themselves so that attempt, finish and straining pains appear. Furthermore resting pain and backache also can appear into far advanced stages.
Diagnosis
Case history (medical history)
A case history is made by a checking in the family area as well as about a case history of one's own at which pains are come in particularly on earlier hip joint illnesses or operations but also on accidents in the area of other joints or metabolism illnesses.
Pains
Localization of the pains and analysis the same with regard to radiation, duration, Progredienz and intensity
Function restriction:
Capacity, limping, movability, length of the painless way of walking, perhaps necessary walking-aids, ...
Special joint case history:
Accidents, rheumatic illnesses (rheumatism, chronic polyarthritis, psoriasis arthritis, possible hip joint operations, pains in the area of other joints, metabolism illnesses, ...
Radiograph of the hip joint in two levels
CT (computed tomography)
MRI (magnet resonance imaging, nuclear resonance scanning)
The MRI pictures show the zones of necrosis marked with the red arrows into the labeled areas. The femoral head already appears cystically enlarged. This conveys the impression of a chambered area. There is the danger that the femoral head breaks down.
Forecast
Since the illness goes individually different, a scientifically well-founded forecast does not let itself go and stands with respect to course of a disease, temporal progression or with regard to an operative success. Besides the individual course of a disease It is important to mention that - besides the individual course of a disease – the disease can come to complete interruption or progress again.
Therapy
As a rule, one cannot give causally therapy at a hip head necrosis. One can at best limit the illness-related extents or slow down the process of the necrosis in the early stage under circumstances also completely hold it back. Possible attainable therapy aims are always dependent on the respective illness stage. Aims in the area of the treatment of the necrosis of the femoral head are therefore:
Limiting the ischemical necrosis, the delay of the femoral head destruction, the alleviation of pain, an improvement on the movability, the walking performances and therefore in considerable way of also the quality of life.
There are different therapy possibilities
Conservative therapy
The conservative treatment of the necrosis of the femoral head of the adult exhausts itself in symptomatic treatments and as a rule limits itself on cases which must be described as not operabel or on patients with a far advanced necrosis of the femoral head.
Besides an advice and therefore also an informing with regard to the illness, its course and the possibilities of influencing the course positively, here the following therapies are being planned.
It is necessary to try to turn off the negative amplifiers, like influencing cortisone therapies and misuse of alcohol.
a ) medicinal therapy
The medicinal therapy is symptomatic and serves the pain reduction. This can be achieved by different peripheral analgesics or antiphlogistics. As a trial medication, which positively influence the circulation, be given, such as ACE.
b ) Physical therapy
The physical therapy is symptomatic and serves the receipt of muscles and joint functions in a special way. Therefore you can use:
Physiotherapy
Mobilization, muscle strengthening, muscle stretching
Thermal therapy
Electrical, Hydro- and Balneotherapy
Shock wave therapy
C ) Orthopedics technical treatments
Cane or forearm walking aids, so-called buffer heels
Relieve orthesis (orthopedic supporting aids to relieve the femoral head)
Operative therapy
General indication criteria
Etiology (cause) of the necrosis, stage of the illness, extension of the necrosis
Ages, general condition, accompanying illnesses
Compliance of the patient (motivation of the patient)
Operative therapies are dependent on the illness stage, so to speak on the extension of the necrosis in a special way. After these different operation methods were introduced, furthermore the therapy possibilities of the different stages shall be explained.
Frequent operation methods
One distinguishes between the methods listed followingly::
Joint preserving operations
Medullary decompression, perhaps with splinter sculpture
Intertrochanteric osteotomy (also see Perthes` disease)
Joint substitute
Endoprosthesis
Joint preserving operations
a ) Medullary decompression, splinter sculpture:
On the medullary decompression with possible splinter sculpture will be fallen back in the early stage, since in further advanced stages the success probability of this operation method sinks. This operation form serves the decompression of the mark zone and furthermore the mechanical support of the zone of necrosis.
In the context of the operation, furthermore you can try to stimulate the development of new vessels by means of a drilling of the femoral head. Since the success chances are dependent on the individual syndrome also here a forecast with regard to the success probability cannot be made.
Possible consequences and complications:
General risks and complications:
As in the case of all operations complications in the form of hematoma development, wound healing disturbance, wound infection, deep vein thrombosis of the leg, embolism, vessel injuries and nerve injuries can appear. As a rule, general risks more frequently appear as special complications.
Special complications:
Special complications include for example a missing revascularization (= missing growth of blood vessels in the numb area) of the necrosis, osteointegration of the bone splinter (non-appearance of the growth of the bone splinter into the surrounding bone fabric), joint perforations.
b ) Intertrochanteric osteotomy:
With the help of the intertrochanteric osteotomy one tries to improve the joint congruence in further advanced stages of the necrosis of the femoral head by a rearrangement, a so-called three- dimensional change in the position, of the deformed femoral head. The damaged femoral head zone can be shifted out of the straining with that. By the improved congruence or the reached relief of the necrosis an alleviation of the troubles is in general reached. Also here the success view diminishes the farther the necrosis is advanced.
Possible consequences and complications:
General risks and complications:
As in the case of all operations complications in the form of hematoma development, wound healing disturbance, wound infection, deep vein thrombosis of the leg, embolism, vessel injuries and nerve injuries can appear. As a rule, general risks more frequently appear as special complications.
Special complications:
By reorganizing the joint it can come to leg length differences in particular. Due to a shift, the muscles, particularly the buttocks muscles, are also used differently. One then talks about a gluteal insufficiency (= weakness of the buttocks musculature with a typical waddling walk). The rearrangement can have a widening of the hip silhouette as a consequence. The osteotomy does not always heal without complications so that a delay can appear. So-called pseudarthrosis (= formation of false joints), implant failure, correction loss, also persistence of pain counts as one of the special complications.
Endoprothetic hip joint substitute:
In more advanced stages the destroyed joint parts are operatively removed. The destroyed joint parts are removed and replaced by artificial ones at an advanced destruction of the hip joint through which the function of the hip joint improves and pain liberation is caused. Artificial hip joints are incumbent the risk of the loosening with the time so that one should only then take into consideration on the endoprothetic hip joint substitute if the destruction of the hip joint has already further progressed and the patient suffers from very severe pains.
You will find further, more detailed information under the category: artificial hip joint
Follow-up treatment after operative measures:
After taking up operative treatment radiograph controls become necessary to be able to judge osteotomy (= rearrangement) or to be able to judge the installation of the endoprosthetic hip joint substitute around for example. Furthermore it requires a special rest as well as a specific thrombosis prophylaxis, which principally has to be considered at every operation.
To strengthen the muscles or to build up muscle parts specifically in the case of an osteotomy, a post-operative physiotherapy can be consulted as a follow-up treatment. As a rule, an early mobilization takes place in which the straining construction is based on the individual.
So that the luxation of the hip joint is prevented if possible especially after an endoprosthetic operation, the patient should be informed about the possibility of the increased sitting (= luxation prophylaxis). Regarding this also permissible and unfavorable movements and strainings should be discussed.
There should occur post-operatively clinical and x-ray controls carried out regularly and prophylaxis operated with regard to the calcification in the muscle area of the hip, for example medicinal by NSAR (= Indomethacin ) or by ray treatment.
Step scheme therapeutical procedure
Orientation criteria
Necrosis stage, extension of the necrosis, etiology of the necrosis of the femoral head (cause), pains, ages of the patient, pressure of suffering, accompanying illnesses
The measures mentioned below are possibilities of the treatments, so to speak suggestions. The attending doctor must always include individual events to be able to obtain a best possible treatment, however. The criteria mentioned above have always to be included.
Stage 1 and 2:
The possibility of drilling into the necrosis to at first cause a bleeding and for longer-term achieve the growth of new blood vessels in these stages. A sedate aim is therefore the new supply of necrotic hip joint areas with blood. You must post-operatively calculate with an approximately six-week relief, the one should partial straining approximately follow just as long. A full straining can be calculated approximately after 10 to 12 weeks in which individual differences can enter also here.
Stage 2 and 3:
In these stages, as a rule, you decide for an intertrochanteric displacement osteotomy. A sedate aim is turning the necrosis out of the straining. Furthermore corresponding further treatment measures can be taken up. The post-operative relief duration lies in the area of 4 to 5 months.
Stage 4, secondary coxarthrosis
As a rule, here only a total endoprosthesis of the hip joint can help. As a rule, one goes back to not cemented artificial limbs. Since the illness as a rule appears quite early, the total endoprosthesis represents one of the last measures. Artificial joints cannot be exchanged unlimitedly. Therefore further therapies must be thought about at first. You find more information here: endoprosthetic replacement of the hip joint, artificial hip joint
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