Advances in needle-knife for the treatment of early and middle stage Osteonecrosis of the Femoral Head

Yan Yan, Hai-Jun He

Wangjing Hospital,Chinese Academy of Chinese Medical Sciences,Beijing 100020,China.

Keywords:Needle-knife Osteonecrosis of the Femoral Head Mechanism Treatment method Efficacy evaluation Review

ABSTRACT Osteonecrosis of the Femoral Head (ONFH) is a refractory disease of orthopedics, and its incidence is gradually increasing. Often due to lack of timely intervention, the femoral head collapses, eventually causing hip pain and difficulty in activities. At present, the treatment of hip preservation after the collapse of osteonecrosis of the femoral head has received everyone's attention, but many hip-preserving measures are controversial in terms of efficacy and indications. Needle-knife therapy is a kind of hip-protection therapy with low risk, small trauma, bleeding, and less and shorter treatments. This article reviews the literatures related to needle-knife therapy for osteonecrosis of the femoral head, and summarizes the clinical treatment of osteonecrosis of the femoral head based on needle-knife, and prospects for its research

1. Introduction

Osteonecrosis of the femoral head ,ONFH, is a common refractory disease in the department of orthopedics, which often leads to the collapse of the femoral head, causing joint pain and movement disorder, and seriously affecting the quality of life of patients[1].According to relevant statistics, there are 2,500 to 3,000 new cases of ONFH in Japan, 15,000 to 20,000 new cases in the United States, and 100,000 to 200,000 new cases in China every year[2].As a traditional Chinese medicine therapy for ONFH, needle-knife has achieved satisfactory clinical effect for early and middle stage ONFH.This paper mainly discusses the mechanism and clinical treatment of early and middle stage ONFH with needle-knife, and prospects of its research.

2. Characteristics of needle-knife therapy

Currently, hip-spring therapy for ONFH is aimed at relieving local pain, restoring hip movement function, and avoiding or delaying artificial joint replacement[3]. Needle-knife is one of the characteristic therapies of traditional Chinese medicine. It has the characteristics of relatively short course of treatment, safe and reliable, less trauma, less bleeding and significant curative effect. Based on the bow-string theory and lever theory, the needleknife can destroy the structure of diseased soft tissue, remove the influence on peripheral blood vessels and nerves, and restore the mechanical balance of joint soft tissue by stripping, separating and releasing the soft tissue such as fascia and ligament of the lesion, etc.[4,5].In addition, in the process of needle-knife treatment, lesions can be damaged to a certain extent, vascular reconstruction of diseased tissue can be promoted, and certain stimulation can be generated at the diseased site to improve local tissue excitability and promote the recovery of diseased site[6]. Due to the characteristics of needle-knife, the treatment of the lesion can reduce the damage to the tissue, reduce the pain of patients, avoid cutting the skin, and achieve satisfactory treatment effect with the smallest wound[7].

3. Mechanism of needle-knife in the treatment of ONFH

3.1 Reduce internal bone pressure and improve blood supply

Some scholars[8]tested the relationship between intraosseous hyperte-nsion and changes in oxygen free radical content in patients with ONFH in various stages, and the results suggest that intraosseous hypertension is related to oxygen free radical damage. Clinically, reducing intraosseous hypertension or applying oxygen free radical scavengers could delay the course of ONFH. Zhao[9]showed that a needle knife can destroy the closed system of the bone marrow cavity and promote the regeneration of blood vessels to improve the circulation disorder of the femoral head and veins. At the same time, needle-knife can cut the malignant circulation chain of high pressure and oxygen free radical damage in the bone, so as to achieve a better curative effect. Zhang[10]found that when the muscle tension around the hip joint increases, the blood supply to the femoral head would be reduced. Based on this, the soft tissue around the hip is loosened with a needle knife to reduce muscle tension and intraosseous hypertension, restore blood flow to the femoral head, promote regeneration and reconstruction of blood vessels, and achieve the purpose of delay or recovery. Qu[11]used a needle knife to decompress the bone marrow cavity and hip joint cavity of ONFH patients, and meanwhile loosened the soft tissue around the hip joint. The results showed that the intracapsular pressure and internal bone pressure of ONFH patients were significantly reduced after the needle knife treatment, and the blood supply to the femoral head is improved, which is better than the simple decompression of the bone marrow cavity and hip joint by needle-knife alone.

3.2 Release adhesion, eliminate contracture and activate osteogenesis

Clinically, most patients with ONFH suffer from soft tissue adhesions and contractures, which limit joint movement. Needleknife has the effect of releasing adhesion and eliminating contracture. At the same time, the process of releasing the surrounding soft tissue will cause certain damage to the periosteal tissue, forming a pseudo-fracture-like effect, and promoting formation of new bone. Bao[12]believe that the use of a needle knife to loosen the spasm and adhering soft tissues in the necrotic area of the femoral head can effectively improve the function of joint movements, activate osteoblasts, promote their osteogenesis function, and accelerate formation of new bone. Han[13]showed that the application of a needle knife to the soft tissues near the femoral head for multiple spalling and releasing can cause slight damage to the bone, resulting in a pseudo-fracture-like effect, and osteoblasts can be activated, which can promote the formation of new bone, delays necrosis and collapse of the femoral head. At the same time, the necrotic bone tissue acts as a "bridge", which plays a good role in the regeneration and crawling of new bone.

3.3 Clear joint fluid and restore venous return

Song[14]thought that the inflammatory substances produced after the necrosis of the femoral head can cause the formation of synovial vascular crests, and then produce joint effusion. Meanwhile, under the stimulation of inflammatory substances, joint synovial membrane would also lead to edema exudation and accumulation of effusion. Chen[15]thought that the femoral head and venous reflux disorder caused bone marrow edema and increased joint effusion, which increased the intra-capsular pressure. At the same time, the increase in intra-capsular pressure increased the venous reflux disorder, and eventually led to further ONFH. Luo[16]found that the needle-knife formed a channel inside and outside the joint cavity by releasing the joint capsule to promote the drainage of fluid in the hip capsule, reduce or restore the pressure of the venous return system in the joint capsule, promote the blood reflux, and further achieve the purpose of promoting the femoral head self-repair.

4. Clinical application of needle-knife therapy for ONFH

4.1 simple needle knife treatment

Needle-knife therapy can release contracture soft tissue, reduce the internal pressure of joint capsule, restore the function of joint movement, and achieve the purpose of delaying the course of femoral head necrosis[12, 13, 16]. Ge[17]used a simple needle knife to treat 68 patients with ONFH. Compared with the control group who used acupuncture to treat ONFH patients, the total effective rate of the needle-knife group was 92.65%, which was better than the acupuncture group (61.54%),indicating that the curative effect of needle-knife on ONFH was better than that of acupuncture. Li[18]divided ONFH patients into experimental group and control group with needle knife and technique treatment respectively. The results showed that Harris excellent rate was higher on the 7th and 14th days after treatment than on the control group, after treatment for 3 months, 6 months of Harris is all over 85% suggesting that needleknife therapy has an accurate and lasting improvement in hip joint mobility in ONFH patients. Wang[19]divided 60 patients with femoral head necrosis into a treatment group (33 cases) and a control group (27 cases), and were given needle knife and core decompression treatment. The total effective rate of the treatment group was 93.75%, while the total effective rate of the control group was 74.07%, indicating that acupotomy had a better effect on avascular necrosis of the femoral head than pure core decompression.

4.2 Needle-knife combined with traditional Chinese medicine treatment

Under the effect of needle-knife, combined with traditional Chinese medicine, the whole body is adjusted based on the overall concept of traditional Chinese medicine and dialectical treatment to achieve warming liver and kidney, promoting blood circulation, resolving stasis and dampness. Both were combined to achieve the purpose of paying equal attention to internal and external medicine, and treating both the whole and the part[20]. Song[21]randomly divided 68 cases of femoral head necrosis into traditional Chinese medicine and traditional Chinese medicine + needle knife group. The results showed that the total effective rate of the traditional Chinese medicine plus needle knife group was 97.06%, which was better than the traditional Chinese medicine group (73.53%), which indicated that needle-knife therapy on the basis of ONFH treatment with traditional Chinese medicine could further improve the therapeutic effect. Niu[22]randomly divided 110 cases of femoral head necrosis patients into a traditional Chinese medicine group and a traditional Chinese medicine combined with needle knife treatment group. The results showed that the traditional Chinese medicine combined with needle knife group had better hip joint activity, Harris score, and VAS score than the traditional Chinese medicine group. It shows that the use of needle-knife release technique with the traditional Chinese medicine to promote blood circulation and tonify liver and kidney has a precise effect.

4.3 Needle-knife combined interventional therapy

Arterial embolism or compression occurs in the blood supply area of the femoral head, or due to the increase in intraosseous pressure, the microvascular blood vessels are compressed, and the intramedullary microcirculation is impaired, resulting in insufficient blood supply to the femoral head and eventually necrosis of the femoral head[23]. Interventional therapy is based on this, and appropriate drugs are used to make the femoral head blood supply area occluded, shortened blood vessels re-open, and thicken, in order to increase the blood supply of the femoral head area, and then achieve the therapeutic purpose[24]. At the same time, the needle-knife can improve the arterial perfusion of the femoral head by reducing the intra-capsular pressure and intraosseous pressure of ONFH patients, which are complementary to each other. Jin[25]randomly divided 120 patients with ONFH into experimental group (60 cases) and control group (60 cases). The experimental group was treated with interventional therapy combined with needle and knife. The control group was treated with simple interventional therapy. The effective rate was 93.33%, which was better than the control group (80%), suggesting that the effect of needle-knife combined with interventional therapy on ONFH was better than that of interventional therapy alone. Wang[26]divided 100 patients with ONFH into needle-knife combined intervention group and simple interventional therapy group. The results showed that the former was 94% effective, which was better than the latter (78%), indicating that needle-knife combined interventional therapy worth promoting to improve the treatment effect.

4.4 Triple therapy with needle knife

Zhao[27]randomly divided 40 patients into a triad group and a control group. The triad group used a needle knife, traditional Chinese medicine and lumbar sympathetic nerve damage, and the control group used a medullary heart decompression. Results show that the triad group in blood rheology is better than that in control group, triad group in improving blood supply and circulation of femoral head is better than that of pith decompression, which is worth promoting. Qu[28]randomly divided 180 patients with femoral head necrosis into triad group, the acupuncture group and the damage group. The results showed that the total effective rate of the triad group was 95%, which was higher than the other two groups. After one week of treatment, the joint function of the triad group was significantly improved, and the pain was significantly relieved. At the same time, no adverse reactions occurred in the triad group during the treatment. Jian[29]also obtained a satisfactory effect on 59 cases of ONFH patients with traditional Chinese medicine combined with hot compresses on the basis of needle knife treatment.

4.5 Needle knife combined with other multiple therapies

Some scholars have mainly used needle-knife, combined with various therapies to treat femoral head necrosis, and have achieved relatively satisfactory results. Hua[30]treated 130 patients with ONFH with medical ozone, joint cavity block, needle-knife and traditional Chinese medicine. The results showed that for early and mid-term ONFH, the total effective rate was 99.02%, indicating that needle-knife combined with multiple therapies for femoral head was effective and worth promoting. Zhao[31]used a needle-knife as the main treatment method for 80 patients with ONFH, combined with traditional Chinese medicine plus joint cavity injection and a highfocus therapy device, with a total effective rate of 98.75%. Sun[32]used a combination of needle knife, massage, injection, traditional Chinese medicine and functional exercise to treat 320 patients with ONFH, with a total effective rate of 97.2%, and the effect was obvious.

To sum up, needle-knife has a good clinical effect on the early and middle stage of femoral head necrosis, which can rapidly improve the symptoms, without obvious adverse reactions, and has an important clinical significance. Meanwhile, needle-knife combined with other therapies in the treatment of early and middle stage of femoral head necrosis has achieved satisfactory results, which is worth popularizing and applying.

5. Clinical evaluation of needle knife therapy for ONFH

At present, there is no uniform standard for evaluating the efficacy of a needle knife in the treatment of femoral head necrosis in China. "Traditional Chinese Medicine Diagnosis and Efficacy Standards"[33]is a combination of clinical symptoms and signs to determine the efficacy standards, which is in line with the theory of traditional Chinese medicine. When using a needle knife to treat ONFH, most domestic scholars will refer to this standard to formulate efficacy evaluation standards. The purpose of needle-knife therapy for ONFH is to improve hip joint activity and reduce pain. The Harris scoring standard[34]mainly includes pain, deformity, mobility, and daily activity ability, etc. It is one of the more widely used evaluation criteria for evaluating joint function activities in ONFH patients. At the same time, most scholars use the VAS scoring method in assessing pain, which is concise and clear, and can more directly reflect the efficacy of needle-knife therapy. For example, Shen[35]used the Visual Analogue Scale and Harris hip motion score as the evaluation criteria for the efficacy, and the results suggest that needle-knife therapy is effective in improving hip joint mobility and alleviating local pain. Wang [36]randomly divided 60 patients with femoral head necrosis into needle-knife and acupuncture groups. The results suggest that the needle-knife treatment of ONFH's Harris hip function score and effectiveness are better than conventional acupuncture treatment. There are also some scholars using other efficacy evaluation standards, such as Luo[16]evaluated the therapeutic effect of needle-knife therapy through hip abduction angle, hip effusion, pain index, and JOA hip joint score. It has obvious effects in reducing pain and restoring joint mobility.

Although the effect of needle-knife on early and mid-term femoral head necrosis is definite, the evaluation of the efficacy of needleknife on ONFH does not have a unified evaluation standard. As a result, the results of clinical studies conducted by many scholars cannot be compared horizontally. Chen[37]developed a clinical efficacy evaluation standard for femoral head necrosis in traditional Chinese medicine through a variety of research methods such as "literature research method", including hip pain intensity, hip flexion function, and walking distance. It is worthy of clinical application.

6. Discussion

In summary, needle-knife therapy is the most effective method for treating femoral head necrosis, but the standard of clinical efficacy still needs to be unified to improve the quality of needle-knife research. At the same time, the needs of patients for daily activities should be considered when evaluating needle-knife. The traditional needle knife is used as a closed treatment for blind vision. When choosing the position, direction and depth of needle insertion, the clinical needle knife operator is required to combine the physiological anatomy with the “needle feel” under the operation of the needle knife under blind vision[38], So once the operator is not proficient in operation or understands the local anatomy, it will cause damage to local vascular nerves and cause unnecessary disputes. With the development of ultrasound and other technologies, many scholars have introduced ultrasound into needle-knife therapy, and visualized a variety of diseases through needle-knife therapy. Its accuracy, safety, and clinical efficacy have been improved compared with traditional needle-knife[39, 40, 41]. In the treatment of necrosis of the femoral head with a needle knife, considering the anatomy of the hip joint and how to avoid important blood vessels and nerves during treatment, while ensuring the efficacy and safety, it is of great clinical significance to introduce visualization techniques such as ultrasound into the needle knife therapy. The visualization technology can be used to more accurately locate the lesion site, clarify the direction and depth of needle-knife insertion, and exclude the operator's hand feeling to determine the lesion site and operation method, which can improve the clinical efficacy, accuracy and safety. Needle-knife visualization therapy is one of our research directions to promote needle-knife treatment of femoral head necrosis, which is worthy of our hard exploration and research.