CLINICAL PRESENTATION, DIAGNOSIS, AND TREATMENT METHODS OF ASEPTIC NECROSIS OF THE FEMORAL HEAD

SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 200 CLINICAL PRESENTATION, DIAGNOSIS, AND TREATMENT METHODS OF ASEPTIC NECROSIS OF THE FEMORAL HEAD U.K. Narzikulov1, U.B. Sangilov2 Department of Traumatology, Orthopedics and Neurosurgery, Tashkent State Medical University, Tashkent, Uzbekistan1,2 https://doi.org/10.5281/zenodo.17518772 Abstract. Aseptic necrosis of the femoral bone in children occurs more frequently than aseptic necrosis of other bones. It is characterized by impaired joint function, leading to the development of coxarthrosis, contractures, and joint deformities. Therefore, timely diagnosis and the correct choice of treatment tactics allow patients to restore their ability to work more quickly. In 54 patients observed by us, we achieved positive results through both conservative and surgical treatment, as well as staged rehabilitation. Keywords: femur, aseptic necrosis, treatment. Introduction Aseptic necrosis of the femoral head is a severe orthopedic pathology that forces patients to live with this disease for their entire lives, leading to early termination of professional activity and disruption of a healthy lifestyle. According to many authors, the prevalence of this pathology ranges from 4 to 29 children per 100,000 [5]. At the early stages of the disease, specific symptoms are not always evident, and signs resembling other diseases—such as joint tuberculosis—are often observed. Therefore, late detection and delayed initiation of treatment aggravate degenerativedystrophic changes in the hip joint [2,7]. An untimely diagnosis and delayed treatment increase the disability rate among patients [2]. Identifying stage, I of this pathology is difficult, and the probability of disease progression to subsequent stages remains high [2,9]. The disease occurs more frequently in boys than in girls. Boys are generally more active, participating in various unorganized games, which often leads to injuries and results in impaired blood circulation in the hip joint area [2,8]. One of the causes of this is trauma sustained during unstructured sports activities. Some authors suggest the theory of idiopathic (unclear) origin of aseptic necrosis of the femoral head [2,7,4], while others claim that the patient’s age and circulatory disorders resulting from fractures in this area directly influence the development of aseptic necrosis of the femoral head [1,2]. Sertakova A.V. states that osteonecrosis represents a group of pathological conditions of unclear etiology, the outcome of which is a disruption of the metabolism of bone and cartilage tissue and microcirculation at the site of onset, leading to the development of secondary osteoarthritis of the adjacent joint. Other researchers, in their scientific articles, point to circulatory disorders in the hip joint area, abnormal development of the femoral artery, and increased intraosseous pressure as causes of this condition. In treating this pathology, the primary goal is to improve blood circulation in the joint area. Some authors insist on conservative treatment for stage I aseptic necrosis of the femoral head, while others support surgical intervention [5]. Proponents of surgical treatment emphasize that tunneling of the femoral head should first be performed, followed by tunneling beneath the acetabulum to reduce pressure and improve blood flow [1]. SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 201 Analyzing the numerous factors causing pathological changes, it should be noted that it is currently impossible to identify any single factor directly responsible for the development of aseptic necrosis of the femoral head. Several theories exist regarding the origin of Legg–Calvé– Perthes disease. One links the condition to arterial occlusion, another attributes it to impaired reparative bone function — that is, disruption of the osteogenesis process. In addition, some authors do not exclude the role of hereditary factors in the development of this pathology. In children, osteochondropathy of the femoral head is often observed after incorrect treatment of congenital hip dislocation, and early diagnosis of this disease remains a challenge. Diagnosis at the early stages of the disease is difficult, and in many cases, it leads to disability or requires long-term treatment, which, in turn, has negative economic consequences for the patient. Based on the data presented by the aforementioned authors and analysis of the factors leading to the disease, it can be concluded that aseptic necrosis of the femoral head is a multifactorial disease and remains one with an unclear etiology. Therefore, it continues to be a relevant and significant problem in orthopedics. Objective: To improve the outcomes of treatment for aseptic necrosis of the femoral head. Materials and Methods: Our study is based on the medical histories of 54 patients aged 2 to 18 years who were treated for osteochondropathy of the femoral head at the TashPMI (Tashkent State Medical University) clinic, both in inpatient and outpatient settings, during the period from 2020 to 2025. Among them, there were 21 girls and 33 boys. In 27 patients, the right side was affected, in 19 — the left, and in 8 — bilateral involvement was observed. Of the 54 patients, 36 received conservative treatment, and 18 underwent surgical intervention. Results: It should be noted that with the emergence of modern diagnostic methods in medical practice, such as MRI, clear criteria for establishing the diagnosis have become available. These methods, in turn, allow for the selection of the most appropriate treatment strategy. Research Methods: Clinical examination, radiography, and magnetic resonance imaging (MRI). Based on the data from domestic and foreign authors, both conservative and surgical treatment methods for this pathology have yielded positive outcomes. All treatment approaches aim at the complete restoration of the patient’s quality of life. It is impossible to deny the existence of both advantages and disadvantages of conservative and surgical methods. Therefore, efforts should focus on reducing disability among children and improving their quality of life through the use of both conservative and operative treatments. Clinical Examination: Aseptic necrosis of the femoral head is divided into five stages. In the first stage, clinical symptoms are mild. Diagnosing aseptic necrosis of the femoral head in children is relatively difficult. In the early stages of the disease, there are no characteristic clinical manifestations, and children move as if they were healthy. Over time, they begin to experience mild pain not in the hip area, but in the distal parts of the leg — namely, the knee or lower leg. When children start limping, parents notice it and seek medical help from local doctors. Patients are often misdiagnosed with soft tissue contusion, lymphadenitis, or “rheumatism,” and receive corresponding treatment. Such a case was observed in 11 patients from our control group who underwent antibiotic therapy. Seventeen patients came to us when shortening of the affected leg (by 1.0–1.5 cm) and noticeable limping had already developed. X-rays of the hip joint revealed stages II–III aseptic necrosis of the femoral head. These patients began to show limited mobility in the hip joint, with flexion of the affected leg restricted to about 45–50 degrees. The soft tissues of the lower leg were atrophied, and static scoliosis of the spine developed. At stage IV, pain appears in the groin area SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 202 and the lumbosacral region. All clinical signs become pronounced. Stage V is also called the stage of recovery. At this stage, the pain slightly decreases, but atrophy of the gluteal muscles and soft tissues of the thigh intensifies. Eleven patients with stage III–IV osteochondropathy of the femoral head were examined. In these patients, the clinical manifestations were clearly pronounced. Any movement in the hip joint area was accompanied by pain. Soft tissue atrophy was evident. The leg was externally rotated, and the gait was severely disturbed. The patient limped toward the side of the shortening. These patients could not walk for long periods, tired quickly, and needed to sit down. This condition is typical for patients older than five years. These patients also showed significant restriction in leg abduction due to tension in the adductor muscles of the thigh (the musculus adductor). Radiological Examination. The X-ray findings at the fifth stage of aseptic necrosis of the femoral head are generally uninformative. Necrosis itself cannot be visualized and can only be determined by clinical signs. At stage II, small cracks may be observed in the femoral head, and its shape begins to change. At stage III, the joint space widens, and the femoral head becomes deformed and flattened. At the same time, the angle of the femoral neck-shaft changes, the neck shortens, and fragments of various sizes begin to appear. At stage IV, bone fragmentation starts to merge, but the femoral head does not retain its round shape, and small cysts appear. Stage V is the recovery stage, in which the femoral head gradually begins to regenerate, but its shape is completely altered, deformed, and articulation is impaired. Among the 54 patients we observed, 11 were diagnosed with stage IV–V aseptic necrosis and underwent surgical treatment. MRI Examination. MRI was performed in thirteen young patients. The study revealed bone tissue edema and increased intraosseous pressure. Unlike X-ray imaging, MRI allows the detection of aseptic necrosis of the femoral head even at the earliest stage. Therefore, this examination plays an extremely important role in diagnosing this pathology. Conservative Treatment. Conservative treatment methods were used in patients with aseptic necrosis of the femoral head detected at an early stage. These included limited mobility, physiotherapy procedures, improvement of blood circulation, calcium supplementation, and vitamin therapy. One of the main principles of treatment for aseptic necrosis of the femoral head is the restriction of movement — the patient must walk on crutches without putting weight on the affected leg. However, this is often impossible in small children. Therefore, in addition to medical procedures, various orthopedic devices were used to restrict movement. During the treatment of our patients, we applied a staged approach, which allowed us to achieve positive results. In patients older than two years, tenotomy of the adductor muscles was performed to eliminate adduction contracture in the hip joint, which increased the degree of leg abduction. For this procedure, under general anesthesia, the surgical field was repeatedly treated with antiseptics and covered with a sterile drape. The patient’s leg was then flexed at the hip and knee joints, during which the adductor muscles tensed and became clearly visible under the skin. After removing the syringe needle, a percutaneous tenotomy was performed, and during the procedure, the leg abduction was gradually increased. Afterward, under the control of an EOP (electro-optical converter), tunneling of the femur was performed from the neck to the head using a Kirschner wire to relieve intraosseous pressure. This procedure was also performed percutaneously — that is, without tissue incisions. An aseptic dressing was applied to the wound. After surgery, a cotton dressing was applied to the leg, the leg was abducted from the hip joint, and the second stage of the Sheptun–Ter-Egiazarov plaster cast was applied, since the first SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 203 stage of plastering was not required after tenotomy. During this process, the tension of the adductor muscles had to be taken into account. The patient was discharged for outpatient follow-up the next day after surgery. In the outpatient setting, ten days after surgery, the third stage of the Sheptun– Ter-Egiazarov plaster cast was applied. For this, the fixation plate on the lower part of the leg, which held the cast, was removed, the leg was further abducted from the hip joint, and fixed again with the plate. At this third stage, the leg could be completely abducted to 85–90 degrees without difficulty. After leg abduction, a course of physiotherapeutic procedures was prescribed: paraffin therapy, massage, and electrophoresis with calcium chloride (one session), along with vitamin and calcium supplementation. The plaster cast was applied for three months, and three courses of physiotherapy, each lasting ten days, were conducted. It should be noted that all these procedures were performed in outpatient conditions. Of the 54 older patients (over eight years of age), nine children were admitted with a diagnosis of “reduction of the femoral neck–shaft angle as a complication of aseptic necrosis of the femoral head.” After osteotomy with bone tunneling, a hip plaster cast was applied for one month. After a month, the cast was removed, and physiotherapy procedures were prescribed to restore movement in the hip joint. These patients continued their treatment in an outpatient setting. In younger children with aseptic necrosis of the femoral head, after tunneling surgery and treatment with the Sheptun–Ter-Egiazarov plaster cast, an analysis of the results over a period of 6 months to 5 years showed positive treatment dynamics. It should be especially noted that a staged treatment approach allows for achieving good outcomes. After treatment, patients must avoid any injuries, be exempted from heavy physical labor and sports activities. Such patients require regular outpatient monitoring and continued therapeutic interventions. Conclusion. Osteochondropathy of the femoral head is one of the most severe orthopedic pathologies, representing a multifactorial disease. The earlier this condition is diagnosed and treatment begins, the more positive results can be achieved. Early surgical intervention for aseptic necrosis of the femoral head, combined with staged rehabilitation, provides good outcomes and improves the patient’s quality of life. REFERENCES 1. Bunov V.S., Teplensky M.P., Oleynikov E.V. Immediate changes in pulse blood filling in the articular ends of the iliac and femoral bones after their tunneling in Perthes disease // Genius of Orthopedics. 2022. Vol. 28, No. 4. pp. 475–480. 2. Narzikulov U.K. Our experience in treating osteochondropathy of the femoral head in children. Eurasian Journal of Medical and Natural Sciences. Vol. 5, No. 10, Part 2 (2025). 3. Sertakova A.V., Ulyanov V.Yu., Sadchikov D.D. Diagnosis and evaluation of the effectiveness of local intra-articular therapy for early stages of osteochondropathy of the femoral head: experimental study. Modern Problems of Science and Education. 2025. No. 3. 4. Tarasov N.I., Vybornov D.Yu., Lozovaya Yu.I., Trusova N.I., Koroteev V.V., Semenov A.V., Kardash E.V. Modern view on Legg–Calvé–Perthes disease in children. Russian Bulletin of Pediatric Surgery, Anesthesiology and Resuscitation. 2021. Vol. 11. No. S. p.147. 5. Khafizova D.M., Khasanova E.T. Osteochondropathy of the femoral head in children. Russian Pediatric Journal. 2024; 27(1S):65. SCIENCE AND INNOVATION INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 4 ISSUE 10 OCTOBER 2025 ISSN: 2181-3337 | SCIENTISTS.UZ 204 6. Shabaldin N.A. Molecular basis of the etiology and pathogenesis of Legg–Calvé–Perthes disease and prospects for targeted therapy (literature review). Orthopedics, Traumatology and Pediatric Reconstructive Surgery. 2022. Vol. 10, No. 3. pp. 295–307. 7. Floerkemeier T., Budde S., Willbold E., Schwarze M., Niehof M., Lichtinghagen R., Windhagen H., Weizbauer A., Reifenrath J. Do biomarkers allow a differentiation between osteonecrosis of the femoral head and osteoarthritis of the hip? A biochemical, histological and gene expression analysis. Osteoarthritis Cartilage. 2021. Vol. 29, No. 11. pp. 1614–1623. 8. Hsu S.L., Jhan S.W., Hsu C.C., Wu Y.N., Wu K.L.H., Kuo C.A., Chiu H.W., Cheng J.H. Effect of three clinical therapies on cytokine modulation in hip articular cartilage and bone improvement in rat early osteonecrosis of the femoral head. Biomed J. 2023. Vol. 46, No. 6. 9. Lin X., Zhu D., Wang K., Luo P., Rui G., Gao Y. Activation of aldehyde dehydrogenase 2 protects against ethanol-induced osteonecrosis of the femoral head in a rat model. Cell Proliferation. 2022. No. 55.