Relativity Study Between Anterolateral Column Of Femoral Head And Prognosis, Joint-Preserving Procedures Curative Effect Of Steroid-induced Osteonecrosis Of The Femoral Head

Background.Steroid-induced Osteonecrosis of the Femoral Head(SONFH)is still one of unfathomed issues of Orthopaedics.Currently it has occupied assumably 50%of all Osteonecrosis of the Femoral Head(ONFH)cases,and has became a common disease with high incidence and risk of disabled.Collapse of femoral head is ubiquitous during the course of ONFH.It is the key of the conversion of the diseases.Once ONFH occurs,the clinical linchpin is how to predict and prevent collapse.Numerous factors are relative with the collapse of necrotic femoral head,presently cognition of collapse is still lack of entirety and accuracy.On the one hand,the clinical doctors are devoid of simple,convenient, feasible means to estimate prognosis and evaluate the Joint-Preserving Procedures curative effect.On the other hand,they are also short of effective measures to correct collapse and maintain the biomechanics stabilization of femoral head.According to acetabulum anatomic regions,acetabulum stress force distribution,femoral head stress force distribution,the characteristic of femoral head necrotic zone distribution and necrotic femoral head collapse,and the insufficiency of the anteroposterior x-ray view classification of osteonecrosis,illuming by Ohzono and Sugano,the author develops the frog leg view classification of osteonecrosis which was firstly established by LIU Shao Jun MD,and make a hypothesis that the anterolateral column of femoral head has a consanguineous relativity with prognosis and the Joint-Preserving Procedures curative effect of the SONFH.The author also assumes that the anteroposterior x-ray view classification combines with the frog leg view classification of osteonecrosis can reflect the conditions of the the anterolateral column of femoral head precisely,so that it can be used to estimate prognosis and evaluate the Joint-Preserving Procedures curative effect accurately.In order to testify the hypothesis above,the author carry out an clinic investigation.Method.All patients who were hospitalized in Department of Arthrosis Surgery of the 1^st affiliated hospital of GuangZhou University of Traditional Chinese Medicine were recruited strictly in the light of diagnosis criteria,bringing into criteria and excluding criteria devised in the project between January 2004 and December 2006.Then finally we get 35 SONFH cases(61 hips)which fulfilled the criteria above.All patients' general information,basic disease,usage of Steroid,single or bilateral involved,ARCO Stage, Anteroposterior x-ray view and Flog Leg x-ray view Classification,Modified Index of necrotic extent before collapse,Collapse Degree after collapse,grade of Bone Marrow Edema and Hip Joint Fluid,grade of hip pain,the occure time and degree of post-operation collapse were all registered detailedly.After that evaluate curative effect and put data into the statistical software SPSS13.0 to analyse the results.The termination of Kaplan-Meier survivorship analysis is defined as collapse more than 4 millimeter after operation.Findings.1.Total effective rate of this head-preserving procedures was 77.05%,among these excellent rate was 40.98%,good rate was 14.75%,fair rate was 21.31%.General poor rate was 22.95%.There was a high negative correlation between Type C2 and failure,the poor rate of all the cases with Type C2 was near 40%.Excluding Type C2 the other cases' effective rate was 86.84%,excellent rate was 52.63%,good rate was 15.79%,fair rate was 18.42%,poor rate was 13.16%.2.Traditional Chinese Medicine Syndrome-types Classification.Tagnancy of Qi and Blood Stasis type(TQBS)occupys 50%in all the studied cases.Wind Cold Damp impediment type,Phlegm-dampness type,Qi - deficiency and Phlegm - dampness type, Liver-Kiney deficiency type cannot be found alone.Type TQBS combined with the other four types frequently.Type TQBS mostly combined with Phlegm-dampness type,the combinative rate was 22.22%.3.Kaplan-Meier survivorship curves demonstrated that the rate of survival of the necrotic femoral head was about 80%for a mean of 24.64 months(range,13-38 months)follow-up at the end of the study.4.Spearman Rank Correlation Coefficient Assay:(1)Positive correlation was found between the preoperative anteroposterior x-ray view classification,frog leg view classification and postoperative collapse degree of the anterolateral column of femoral head.(2)Positive correlation was found between preoperative ARCO stages and postoperative collapse degree of anteroposterior x-ray view of femoral head.The correlation was not statistically significant between preoperative ARCO stages and postoperative collapse degree of frog leg view of femoral head.(3)Positive correlation was found between preoperative anteroposterior x-ray view collapse degree and postoperative cartilage degeneration.Negative correlation between preoperative anteroposterior x-ray view collapse degree and postoperative necrotic zone restoration,harmony of femeral head and acetabulum,stabilization of hip joint were observed.(4)Positive correlation was found between preoperative frog leg x-ray view collapse degree and postoperative cartilage degeneration.Negative correlation between preoperative frog leg view x-ray collapse degree and postoperative necrotic zone restoration, harmony of femeral head and acetabulum,stabilization of hip joint were observed.(5)Positive correlation was found between preoperative anteroposterior x-ray view Classification and postoperative cartilage degeneration.Negative correlation between preoperative anteroposterior x-ray view Classification and postoperative necrotic zone restoration,harmony of femeral head and acetabulum,stabilization of hip joint were observed.(6)Positive correlation was found between preoperative frog leg x-ray view Classification and postoperative cartilage degeneration.Negative correlation between preoperative frog leg x-ray view Classification and postoperative necrotic zone restoration,harmony of femeral head and acetabulum,stabilization of hip joint were observed.(7)Positive correlation was found between preoperative ARCO stages and postoperative cartilage degeneration.Negative correlation between preoperative ARCO stages and postoperative necrotic zone restoration,harmony of femeral head and acetabulum were observed.The correlation was not statistically significant between preoperative ARCO stages and postoperative stabilization of hip joint5.Multiple logistic regression analysis showed that the dangerous prognostic index was preoperative frog leg x-ray view Classification.The higer the preoperative frog leg x-ray view Classification,the worse the prognosis was.The preoperative frog leg x-ray view Classification increased per grade leaded to the prognosis increased 14.96 folds compared with the prognosis which the frog leg x-ray view Classification did not increase.6.COX regression analysis showed that the dangerous index was preoperative frog leg x-ray view Classification among those factors associated with the femoral head survivorship time.The higer the preoperative frog leg x-ray view Classification,the less the femoral head survivorship time was.The preoperative frog leg x-ray view Classification increased per grade leaded to the femoral head survivorship time decreased 6.937 folds compared with the time which the frog leg x-ray view Classification did not increase.Interpretation.1.Frog leg view x-ray classification can reflect the distribution of necrotic zone and collapse condition of anterolateral column of femoral head precisely.Positive correlation was found between integrality,stability of anterolateral column of femoral head and prognosis,Joint-Preserving Procedures curative effect of SONFH,the more integrated and stabile,the better the prognosis and curative effect were.The anteroposterior x-ray view classification combined with the frog leg x-ray view classification could reveal the total conditions of the the anterolateral column of femoral head more accurately compared with using the anteroposterior x-ray view classification alone.It also decreased the blind area of observation,was more effective to estimate prognosis and evaluate curative effect,it was propitious to treated SONFH with traditional medicine as well.2.If the grade of frog leg x-ray view classification did not exceed Type C1,and necrotic zone was contained medially by remained normal bone of anterolateral column of femoral head,forming contained restoration,thus prognosis would be good.If the grade of frog leg x-ray view classification achieved Type C2 and necrotic region was open without protection of normal bone of anterolateral column,forming open restoration,especially generating traversing femoral head necrotic portion,thus the prognosis would be poor.3.Joint-Preserving Procedures during peri-collapse period should aim at restoring the integrality and maintaining the stability of anterolateral column of femoral head,avoiding severe recollapse.4.Modified core decompression combined with non-vascularized fibula graft,impaction bone grafting and stabilization inner femoral head with titanium hollow compression screw procedure was only applicable to frog leg x-ray view classification equal and less than type C1,it was inapplicable to type C2.5.Orientation of core decompression shoud aim at the center of necrotic zone in femoral head anterolateral column preserving as much as possible normal bone of anterolateral femoral head portion.Depth of core decompression shoud achieve subchondral bone plate but never traverse through chondral.The degree of impaction bone grafting should be limited in recovering the shape of femoral head,eliminating the crescent sign,sidestep sign and crack sign in femoral head.Depth of impaction bone grafting should be limited in 5 millimeter.The peak of implanted fibula shuld be cut flat and drilled around its body with Kirschner wire(1.5 mm diameter).The titanium hollow compression screw stabilized femoral head inner should be located just behind or posterior and medial behind the fibula.