Steroid-induced osteonecrosis of the femoral head

　　With the development of medicine, the clinical application of steroids has become more and more extensive, and the reports of steroid-induced osteonecrosis of the femoral head have also increased in China. Osteonecrosis of the femoral head has been recognized as a complication of the widespread use of steroids in recent years, and the incidence of steroid-induced osteonecrosis of the femoral head has now exceeded that caused by trauma. The mechanism of steroid-induced osteonecrosis of the femoral head is not yet fully understood. It is generally believed that long-term accumulation of steroids in the body causes an increase in blood viscosity, an increase in blood lipids, fat embolism, fatty liver, blocking the microvascular blood supply of the bone, ischemia, reduced bone formation, calcium absorption disorders, osteoporosis, and the accumulation of microfractures, eventually leading to steroid-induced osteonecrosis of the femoral head. The shortest time for dexamethasone, a corticosteroid, to cause osteonecrosis of the femoral head is 7 days. The onset time after the use of steroids varies, with reports of osteonecrosis of the femoral head occurring within less than 2 months after the use of steroids.

　　Some patients may experience intermittent pain in the hip joint after exertion, alternating pain in both hips, or mild limping. The femoral head collapse, narrowing of the joint space, eventually leading to osteoarthritis, causing functional impairment and paralysis of the hip joint in patients.

　　1. Early symptoms

　　Most patients show no significant clinical symptoms, only weakness and pain in the muscles of the thigh and adductor muscles. Some patients may experience limb pain in remote areas. Some patients may have intermittent pain in the hip joint after exertion, alternating pain in both hips, or mild limping. During clinical examination, there may be slight tenderness in the hip and inguinal region, and the 4-letter test and Thomas sign may be positive. Due to the absence of typical clinical symptoms and signs and X-ray findings in the early stage, the misdiagnosis rate is relatively high. Among the patients with steroid-induced osteonecrosis of the femoral head treated in our hospital, the early misdiagnosis rate reached more than 85%. Commonly misdiagnosed diseases include rheumatoid arthritis, sciatic N pain, hip joint sprains and contusions, chronic lumbar muscle strain, lumbar spondylosis, etc. Some patients may be misdiagnosed with knee joint disease due to concomitant symptoms localized in the knee joint.

　　2. Symptoms in middle and late stages

　　Hormone-induced osteonecrosis of the femoral head is mostly intermittent and insidious in onset. With the evolution of the middle and late stage of the disease, the main clinical symptom is the slow development of hip joint pain, which is exacerbated during activity and not obvious at rest. About one quarter of the patients present with intermittent attacks, which are characterized by sudden severe pain followed by sudden disappearance. During the period of hip joint pain onset, some patients may have conventional analgesics ineffective. The characteristics of hip joint pain onset are as follows: 1. Pain location: The majority of patients have pain onset in the inguinal region and the inner side of the thigh, followed by the anterior and posterior parts of the anterior arm, and some patients may have more than two locations, so it is often difficult to distinguish from radiation pain or referred pain. 2. Pain nature: The clinical pain onset can be acute severe pain or chronic hidden pain. The typical onset of pain is a needle-like radiating pain, some localized to the hip, and some extending to the knee joint.

　　3. Pain duration

　　From clinical observations, it is found that more than half of the patients with bone diseases can point out the exact time of pain onset. The most common time for pain onset is after activity, or in the middle and late stages of fatigue and before going to bed. The hip joint adduction, abduction, rotation, flexion, extension, and lifting functions of the middle and late stage patients gradually develop from limited to obvious dysfunction, and from intermittent limping to persistent limping. Late-stage patients often have a popping sound when the joint moves, due to pain, the range of joint movement gradually decreases, the range of passive movement is also significantly limited, limb shortening, muscle atrophy, the affected hip may appear semi-dislocation signs, 4-word test and Thomas sign are significantly positive.

　　1. Prevention

　　Avoid the abuse of hormones. Because now, common cold, fever, and joint pain can all use hormones, which will increase the probability of osteonecrosis of the femoral head indirectly. Therefore, hormone drugs should be used with caution.

　　Diseases commonly using hormone drugs:

　　1. Collagen diseases: systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis,结节性动脉周围炎perivascular arteritis, scleroderma, rheumatoid arthritis.

　　2. Dermatological diseases: pemphigus, eczema, urticaria, tinea pedis and tinea manuum, exfoliative dermatitis, erythema multiforme.

　　3. Hematological diseases: leukemia, purpura.

　　4. Respiratory system diseases: asthma, bronchopneumonia, chronic tracheitis, tuberculous pericarditis.

　　5. Nephritis, nephrosis, post-transplantation of renal transplantation, post-transplantation of bone marrow transplantation, acute and chronic hepatitis, etc.

　　Avoid intra-articular injections of hormones. Hormones can cause significant damage to joint cartilage, leading to cartilage destruction. Therefore, do not go for 'closed needle' injections due to pain.

　　When hormones must be used, the total amount and duration of hormone use should be minimized as much as possible. Patients with long-term hormone use should regularly visit the hospital for follow-up. If hip joint pain and dysfunction occur, it should be considered that it may be hormone-induced osteonecrosis of the femoral head, and detailed examinations should be conducted at the hospital in a timely manner.

　　③ When using corticosteroid hormones for a long time, the application of Xuesaitong, Zhibi tuo, and Alendronate sodium can increase the blood flow of the femoral head, improve the bone tissue structure, and prevent or slow down hormone-induced femoral head necrosis.

　　Second, nursing

　　Femoral head necrosis functional exercise:

　　After the patient is diagnosed with femoral head necrosis, the doctor will always ask the affected limb to limit weight-bearing, rest in bed, and undergo surgery or non-surgical therapy. In non-surgical therapy, femoral head necrosis needs 1 to 3 years of repair, and those with faster repair may only need half a year. However, long-term non-weight-bearing bed rest is not easy to implement and is not recommended. Functional exercise can prevent muscle atrophy due to disuse and is an effective means to promote early recovery of function. Functional exercise should be mainly automatic and supplemented by passive exercise, gradually increasing from small to large and from few to many, and appropriate sitting, standing, and lying exercise methods should be selected according to the stage, shape, functional restriction of the surrounding soft tissues of the hip joint, and physical condition of the femoral head ischemic necrosis.

　　1, Sitting position method: Sit on a chair, hold the knees with both hands, keep the feet as wide as the shoulders, simultaneously fully abduct and adduct the left leg to the left and the right leg to the right. Perform 300 times a day, divided into 3-4 sessions.

　　2, Standing leg raising method: Hold a fixed object with one hand, keep the body upright, raise the affected leg, make the body and thigh form a right angle, and the thigh and calf form a right angle, repeat the action. Perform 300 times a day, divided into 3-4 sessions.

　　3, Lying leg raising method: Lie on your back, raise the affected leg, make the lower leg and thigh form a straight line, and form a right angle with the body, repeat the action. Perform 100 times a day, divided into 3-4 sessions.

　　4, Squatting under support method: Hold a fixed object with one hand, stand upright, separate the feet, squat down and then stand up, repeat the action. Perform 3-4 times a day.

　　5, Internal rotation and abduction method: Hold a fixed object with one hand, and make full internal rotation, abduction, and circular motion with both legs separately. Perform 300 times a day, divided into 3-4 sessions.

　　6, Continue the training of crutch walking or cycling exercise.

　　X-ray manifestations:

　　The anteroposterior, lateral, or tomographic views of the hip joint should be taken, and it is necessary to take the views of both hips for comparison of density. Important signs of early lesions are often found on lateral and tomographic views. Clinically, X-ray manifestations can be divided into 4 stages.

　　Ⅰ stage: Subchondral dissolution stage. The head shape is normal, with cystic changes or 'crescent sign' under the cartilage in some areas (such as weight-bearing areas).

　　Ⅱ stage: Head necrosis stage. The head shape is still normal, and areas of increased density can be seen on the outer or outer upper part and the middle of the head, with occasional hardening bands around the area.

　　Ⅲ stage: Head collapse stage. The head shows stepped collapse or double-peak sign, with fine fracture lines below the cartilage, the weight-bearing area becomes flattened, and there are signs of osteoporosis around the area.

　　Ⅳ stage: Head dislocation stage. The necrotic area continues to develop inward and downward, the head becomes flat, hyperplastic, and hypertrophic, and can dislocate outward and upward. The joint space becomes narrow, and the acetabular margin becomes hyperplastic and hardened.

　　ARCO staging combined with X-ray, CT, MRI, bone scan, and bone biopsy.

　　Stage 0: The results of bone biopsy are consistent with ischemic necrosis, but all other checks are normal.

　　Stage I: Positive bone scan or MRI or both, depending on the location of the femoral head involvement, the lesion can be further divided into medial, central, and lateral.

　　Stage Ia: 15% involvement of the femoral head.

　　Stage Ib: 15% to 30% involvement of the femoral head.

　　Stage Ic: 30% involvement of the femoral head.

　　Stage II: Abnormal X-ray film (femoral head spotted manifestation, bone sclerosis, cyst formation, and osteoporosis), no femoral head collapse on X-ray and CT films, positive bone scan and MRI, no change in the acetabulum, depending on the location of the femoral head involvement, the lesion can be further divided into medial, central, and lateral.

　　Stage Iia: 15% involvement of the femoral head.

　　Stage Iib: 15% to 30% involvement of the femoral head.

　　Stage IIc: 30% involvement of the femoral head.

　　Stage III: Crescent sign, depending on the location of the femoral head involvement, the lesion can be further divided into medial, central, and lateral.

　　Stage IIIa: Crescent sign 15% or femoral head collapse 2mm

　　Stage IIIb: Crescent sign 15% to 3% or femoral head collapse 2 to 4mm.

　　Stage IIIc: Crescent sign 30% or femoral head collapse 4mm.

　　Stage IV: X-ray shows the articular surface of the femoral head becomes flat, the joint space becomes narrow, the acetabulum appears ossification, cystic change, and marginal bone spurs.

　　The range of involvement of the femoral head is determined by MRI, the collapse of the femoral head depends on the anteroposterior X-ray film, and the percentage of the crescent sign refers to the length of the crescent sign to the length of the femoral head joint surface.

　　1. Dietetic recipes for avascular necrosis of the femoral head:

　　1. Mung bean and Job's tears porridge:25g mung bean, red bean, and Job's tears. Wash the two beans and Job's tears, first cook the two beans until they bloom, then add Job's tears to cook into a thin porridge, add white sugar and serve after it is cooked, take two doses a day. It can clear heat and detoxify, reduce swelling and relieve pain, suitable for the early stage of the disease, with pain in the iliac and knee joints, local burning heat, and dry and bitter sticky mouth.

　　2. Lonicera and lotus seed porridge:15g lonicera, 30g lotus seed, a little white sugar. Wash the lonicera clean, boil it in water for 5 minutes, remove the residue and take the juice, add lotus seed and cook until the lotus seed is fully cooked, add white sugar and mix well before serving. Take two doses a day, which can clear heat and detoxify, suitable for the early stage of the disease, with internal disturbance of heat toxin, local burning pain, and dysfunction.

　　3. Motherwort and jujube soup:50g motherwort, 250g jujube, 10g star anise, 50g brown sugar. Boil motherwort in water to extract the juice, add anise, jujube, and sugar, and boil until the juice is removed and the residue is left. Take it in the morning and evening, and also eat jujube. It can promote blood circulation and qi, remove blood stasis and relieve pain, suitable for the middle stage of the disease, with persistent pain in the iliac and knee joints, and exacerbated after fatigue.

　　4. Placenta shezi powder:Placenta and shezi each 250g, Chenpi 30g. Dry and grind the above medicine into powder for reserve use. Take 3g each time, twice a day, served with yellow wine or honey. It can benefit the kidney and strengthen the bones, warm the meridians and dispel cold, suitable for the late stage of the disease, with aversion to cold, weakness and fatigue of the limbs.

　　What is the best food for avascular necrosis of the femoral head:

　　Milk, dairy products, sheep liver, pork liver, shrimp shell, beans, seaweed, egg products, yogurt, cod liver oil, fruits and vegetables rich in vitamins

　　Thirdly, what not to eat for femoral head necrosis:

　　High-fat foods (such as beef, pork fat, etc.), as well as foods that are too sour, alkaline, salty, and artificial foods, preserved foods, fried and fried foods, sweet foods such as sweet cakes, sweet pastries, candies, ice cream, chocolate, etc., eat less pepper, chili, and avoid or eat less tomatoes, spinach, amaranth, lotus root, eggplant, potatoes, etc., avoid drinking alcohol and carbonated drinks, drink less strong tea and coffee, avoid eating shellfish, dried fruits, foods with monosodium glutamate and preservatives.

　　The early treatment of hormone-induced femoral head necrosis is effective because the necrotic area of the femoral head is small, the deformation of the femoral head is small, and the limping and dysfunction are mild. Secondly, patients can be diagnosed early and the application of hormones can be stopped in time to block further deterioration. During the treatment process, patients should use crutches, reduce weight-bearing, and persist in reasonable functional exercises. During the repair process of necrotic bone, capillaries, new tissue, and calcium need to be continuously regenerated, and only by using crutches and reducing weight-bearing can this process be successfully completed, and at the same time, it can also significantly reduce the opportunity for deformation of the femoral head. Factors affecting the efficacy are delayed diagnosis and late treatment. Efficacy is related to age, as elderly people have varying degrees of arteriosclerosis, hyperlipidemia, slow blood circulation, especially poor peripheral circulation, so the regeneration ability of various tissues is low, and once osteonecrosis of the femoral head occurs, repair is quite difficult. Some patients mistakenly believe that increasing exercise can cure the disease, so they increase their exercise intensity when the hip joint hurts, such as running with one leg hopping, etc. Some patients stay in bed and not move, resulting in muscle atrophy, bone demineralization, and aggravating the condition. All of the above are adverse factors in the treatment of femoral head necrosis. Through a large number of clinical practices, patients with femoral head necrosis treated strictly according to traditional Chinese medicine methods have restored their working ability to varying degrees, and patients can completely achieve self-care. 97% of the patients have preserved their own femoral heads, avoided the pain of surgery, and reduced the chance of disability.

　　When using corticosteroids for a long time, the application of Xuesaitong, Zhibi tuo, and Alendronate Sodium can improve blood flow to the femoral head, improve bone tissue structure, and prevent or slow down osteonecrosis of the femoral head caused by hormones.