The Stress Factors In Femoral Head Osteonecrosis In Adult

Objective:The purpose of the present study was to review the medical records of the femoral head osteonecrosis, analysed a series of the stress factors in femoral head with correlating to the prognosis of the femoral head osteonecrosis, try to searching the available methods predicting collapse of the femoral head in the early stages of osteonecrosis, and the crux inducing to biomechanic instability of hip, improved the present predicting methods, which would be useful to resolve these biomechanic problems. A preliminary clinical study was done to determine whether SHEN MAI CHEN GU troche would prevent collapse and progression in patients with osteonecrosis of the femoral head.Methods:1. Study objects: 172 patients(282 hips) were diagnosed the osteonecrosis of the femoral head in our the center of hip diseases from 1997 to 1999, There were 134 males and 38 females with a mean age of 41 years (range 14-70 years), 110 patients with double hips(63.95%);Osteonecrosis was idiopathic in 38 hips of 23 patients(12.7%), related to steroid use in 85 hips of 43 patients(25.16%), and related to alcohol abuse in 114 hips of 61 patients(35.4%), related to traumatic hip in 44 hips of 44 patients(25.58%). There were 127 patients (238 hips) with the nontraumatic osteonecrosis of the femoral head According to the Association Research Circulation Osseous international staging system. 8 hips were in stage Ⅰ, 20 hips were in stage Ⅱ, 107 hips were in stage Ⅲ a, 46 hips were in stage Ⅲ b, 22 hips were in stage Ⅳ. According to Classification with anteroposterior x-ray views of the femoral head: 15 hips were in type A, 45 hips were in type B, 81 hips were in type C1, 96 hips were in type C2. According to Classification with lateral x-ray views of the femoral head: 10 hips were in type A, 47 hips were in type B, 55 hips were in type C1, 125 hips were in type C2. follow-up of three to seven years.2. Establishing Classification with lateral views of hips and definition of Stress regions of femoral head : According to the present methods of predicting collapse of the femoral head , Author improved the classification with anteroposterior x-ray views of the femoral head and established the classification with lateral x-ray views of hips. According to the methods of the definition of acetabulum anatomic regions (Lateral roof, anterior horn, medial roof,posterior horn) , Author established the methods of the definition of stress distributing regions of femoral head and divide femoral head into roof and lateral, anterior horn , The roof horn was defined as a span of 40° around the femoral head plumb axis, the lateral horn was located lateral of roof horn, the anterior horn was located anterior of roof horn.3. Collection the multi-factor data and statistics analysis: According to case history and follow-up clinical, the data were collected which of pathogeny, age, the stage of the femoral head osteonecrosis, the classification with anteroposterior x-ray views of the femoral head and lateral views, whether collapsed of the femoral head which definition of Stress regions. Lesion size of osteonecrosis of the femoral head (>15%, 15%-30%, 30%-60%, >60%), the extent of collapse of the femoral head(<1mm, l-2mm, 2-3mm, >3mm), distributing of bonemarrow edema of hip(femoral head, neck, proximal femoral), subluxation of hip, subsequently collapsed. Statistical analysis was performed with Crosstabs Chi-square Test and Logistic regression with use of SPSS soffware(version 13) to assess the differences collapsed of the femoral head and no collapsed in bone marrow edama of hip, and the relation of multi-factor data and subsequently collapsed or subluxation of hip. 4. SHEN MAI CHEN GU troche has an effect upon the collapse of the femoral head: There were 55 patients(62 hips) with the early stages of osteonecrosis of the femoral head in all of the case history that had be treated to took SHEN MAI CHEN GU troche. Natural history group was retrospectively matched according to the etiology, stage, and size of the lesion to a group of all patients who did not underwent treated SHEN MAI CHEN GU troche during the same time period. After matching of the two groups, There were 44 hips of 43 patients in Shen Mai Chen Gu group(herb group), with male: females is 37:6 , which related to steroid use in 13 hips and related to alcohol abuse in 27 hips and was idiopathic in 4 hips, 17 hips were in stage I (ACRO stage system ) , 27 hips were in stage II. one hip was less than 15% in lesion of osteonecrosis of the femoral head , 23 hips were 15%-30% , 17 hips were 30%-60%, 3 hips were more than 60%. There were 51 hips of 38 patients in natural history group, with male: females is 34:4 , which related to steroid use in 17 hips and related to alcohol abuse in 28 hips and was idiopathic in 3 hips, 21 hips were in stage I (ACRO stage system) , 27 hips were in stage II. two hips were less than 15% in lesion of osteonecrosis of the femoral head , 22 hips were 15%-30% , 19 hips were 30%-60%, 5 hips were more than 60%. A prospective case-controlled study of the two groups, with a mean duration of follow-up of four years, was then performed. During treated in Shen Mai Chen Gu group, patients took 24 Shen Mai Chen Gu troches in everyday. There was a period of treatment in three monthes. Patients were took Weight-bearing control method ( There were avoided to take weigth-bearing in hip of disease during one year and restricted to take weigth-bearing after one year, took completely weigth-bearing after 1.5 or 2 years.). The study of two groups criterion were that Collapse was defined as any dome depression of >2 mm and Radiographic Progression. Statistical analysis was performed with Mann-Whitney U Test and Kaplan-meier survivorship with use of SPSS softare(version 13) to assess the differences between the two grops. The Kaplan-meier survivorship was set that the collapse was depression of more than 2mm as the end point, and 95%confidence intervals for all hips in each group. Significance was set at p<0.05. Result:1. The relativity between the classification with lateral views of hips and the prognosis of femoral head osteonecrosis: The results were that 167 hips were in Type C with the classification with anteroposterior x-ray views of hip, 181 hips were in Type C with the classification with lateral views of hips. There were 47 hips(58%) in type Cl according to the classification with anteroposterior views of hip which were in type C2 (the type of the high risk of collapse Recording to the classification with lateral views. The results show that the sensitivity of the risk of collapse in the classification with anteroposterior views was less than in the classification with lateral views. There were 78 hips in type C2 according to the classification with anteroposterior and lateral views, which the rate of subsequently collapsed of the femoral head was 83.3% and highest in all types, which the rate of subluxation of hip was 64.1% and highest in all types. The Logistic regression analysis results that the classification with lateral views was selected, and the capability of this classification related the subsequently collapsed of the femoral head was 79.6%, There was significant more than which of the classification with anteroposterior views, P<0.001. 2. Between The integrity of Stress regions of femoral head and the stability of hip : There were significant relativity between whether or not integrity of lateral horn of thefemoral head and the subsequently collapsed of the femoral head , and the capability of this classification related the subsequently collapsed of the femoral head was 81.4%. PO.001. There were significant more capability to predict collapse of the femoral head. Whether or not integrity of anterior horn of the femoral head and the the classification with anteroposterior views of hip were significant relatively to the subluxation of hip,P<0.001.3. Related the bone marrow edama to the collapse of the femoral head: In the cases of osteonecrosis of the femoral head, there were 70 hips of 40 patients with MRI scaning, and 24 hips with bone marrow no edama were 6 hips in collapse of the femoral head, 42 hips with bone marrow edama were 24 hips in collapse of the femoral head. Statistical analysis was performed with Crosstabs Chi-square Test and Crosstabs RC Chi-square Test. There was significant difference in the collapse between whether or not with bone marrow edama,P<0.05. There was significant relatively between the bone marrow edama and collapse of the femoral head. There was no significant difference in between the distributing regions of bone marrow edama and collapse of femoral head, P>0.05.4. SHEN MAI CHEN GU troche has an effect upon the collapse of the femoral head: The results show that there were 9 hips(20.4%) with Radiographic Progression and 5 hips(l 1.3%) with depression collapse of >2mm in the herb group, and there were 23 hips with Radiographic Progression and 21 hips with depression collapse of >2mm in the natural history group. There was significant difference between two groups with Mann-Whitney U Test. The Statistical analysis results show that the SHEN MAI CHEN GU troche were significant an effect to prevent collapse of the femoral head (P<0.001)and restrain the radiographic progression of hip (P<0.001). The Kaplan-meier survivorship was set that the collapse was depression of more than 2mm as the end point, and 95% confidence intervals for all hips in each group. Significance was set at p<0.05. The survivorship in the herb group was significantly higher than in the natural history group.Conclusions:The subsequently collapsed of the femoral head and the subluxation of hip have an important effect on stability of hip. There were more accurate to predict biomechanic stability of hip according to Establish the Classification with lateral views of hips and definition of Stress regions of femoral head. These results may provide baseline information for predicting the collapse of the femoral head and determining the treatment modality of early stage and metaphase osteonecrosis .The bone marrow edama was knew as pathological mechanism of osteonecrosis of the femoral head , it is strongly correlated with the collapse of femoral head and may represent concomitant edema due to collapse, but not be the result of the extension of osteonecrosis.Shen Mai Chen Gu troche has an efficacious to prevent the collapse of the femoral head and the radiographic progression of hip to treated early stages of osteonecrosis of the femoral head with the Weight-bearing control method, it might be an efficiency to enhance biomechanic characteristic of the femoral head or with the Weight-bearing control method together.