Figure 1. Cross section of the femoral head.
TREATMENT OF AVASCULAR NECROSIS OF THE FEMORAL HEAD WITH CHINESE HERBS
Avascular Necrosis of the Femoral Head (AVN-FH) refers to a progressive weakening of the knobby head of the thigh bone (femur), resulting in eventual collapse of the bone structure if not remedied in time. This disorder involves disrupted circulation (hence the term avascular), leading to death (necrosis) of bone cells that maintain the solid bone matrix. It is seen in children and young adults as the result of injuries and various genetic bone disorders, and it may occur later in life as the result of abuse of drugs (corticosteroids and alcohol are the main culprits) and secondary to chronic diseases (e.g., systemic lupus) that affect the vascular system. The disorder is sometimes referred to as aseptic necrosis, meaning that it does not involve a bone infection. It is usually diagnosed after a person complains of pain and restricted motion of the hip, where the pain is worsened with activity and improved by rest; one or both hips can be involved; in cases other than traumatic injury, one side is affected first, and the other may develop the condition later. Surgical replacement of the femoral head is the primary therapy, undertaken when day-to-day activities become impaired.
The femur sustains considerable force while holding up the body in upright position, and can be exposed to much higher forces when the body weight comes down on one leg, such as when running (yielding about 5 times the impact of body weight when standing). The femur structure is designed to withstand these pressures by the development of a thick outer layer of compact bone. Upon close examination, the femur bone reveals lines of compression along the pathways in which force is transmitted (see Figure 1; the femoral head is the protrusion at the upper right of the illustration). These lines appear as a result of formation of struts, called trabeculae-hardened material laid down by the cells of the initially soft bone. If the blood circulation is severely restricted or blocked, the trabeculae will eventually deteriorate, collapsing the femoral head and producing osteoarthritis of the hip at an early age (individuals with this disorder often present with osteoarthritis by age 40). It is estimated that more than 10,000 new cases of AVN-FH are diagnosed in the U.S. each year.
The arterial supply to the femoral head is principally provided by an arterial ring at the base of the femoral neck with branch vessels reaching upward to the femoral head, and by arteries of the round ligament that attaches at the femoral neck. These large vessels approaching the femoral head terminate in small arterioles at its surface. Blockage of circulation may occur via damage to the main arteries or clogging of the arterioles. Examination of the bone by x-ray, MRI, or CT scan, reveals the status of the bone trabeculae, allowing staging of the disease progression. At stage I, there are only spotty changes; at stage II there are somewhat larger patches and general haziness of the trabeculae as they are degenerating; at stage III there is evident necrosis, with slight collapse of the femur head, showing an enlargement of the joint space; at stage 4, the femur head is flattened and deformed and may be collapsed; the joint space also collapses, becoming narrowed, as seen in osteoarthritis.
From the perspective of traditional Chinese medicine, gushi (gu = bone; shi = corroded), as the disorder is described, involves bone weakening and impaired circulation. Therefore, it is treated primarily with herbs that strengthen and repair the bone, most of which are classified as kidney yang tonics, and herbs that vitalize blood circulation and resolve blood stasis, such as those listed in the following table.
Herbs Used to Treat Avascular Necrosis of the Femoral Head (AVN-FH)
| Common Name Pin Yin Name | Botanical Source Part Used | Materia Medica Classification Reasons for Use in AVN-FH |
| Achyranthes niuxi | Achyranthes bidentata root | vitalize blood; achyranthes also nourishes blood and brings blood down from upper to lower body |
| Astragalus huangqi | Astragalus membranaceous root | tonify qi; astragalus also raises sinking qi and aids circulation of blood |
| Carthamus honghua | Carthamus tinctoria flower | vitalize blood; carthamus is considered specific for treating trauma and painful joints |
| Cibotium gouji | Cibotium barometz rhizome | tonify yang; cibotium is commonly used for pain and weakness of the lower body |
| Cnidium chuanxiong | Ligusticum walichii rhizome | vitalize blood; cnidium also alleviates pain and nourishes blood |
| Cordyceps dongchong xiacao | Cordyceps sinensis mycelium | tonify yang; cordyceps is used for degenerative conditions and alleviates pain of the lower body |
| Deer Antler/Gelatin lurong/lujiaojiao | Cervus nippon antler or its gelatin | tonify yang; antler and its gelatin are used for nourishing the bones and alleviating pain |
| Dipsacus Xuduan | Dipsacus asper root | tonify yang; dipsacus also vitalizes blood circulation and is commonly used to treat broken bones |
| Drynaria gusuibu | Drynaria fortunei rhizome | tonify yang; drynaria is also important for vitalizing blood, and is a key herb for repairing bone |
| Epimedium yinyanghuo | Epimedium sagittatum whole plant | tonify yang; epimedium is considered valuable for treating joint pain of the lower body |
| Eucommia duzhong | Eucommia ulmoides bark | tonify yang; eucommia is mainly used for weakness and pain of the lower body |
| Loranthus sangjisheng | Loranthus parasiticus stem | nourish yin; loranthus is used to treat soft bones and to alleviate pain of the lower body |
| Lycium fruit gouqizi | Lycium chinense fruit | nourish blood; lycium is used for weakness and soreness of the lower body |
| Millettia jixueteng | Spatholobus suberectus stem | vitalize blood; millettia also nourishes blood and treats pain of the lower body |
| Polygonatum huangjing | Polygonatum sibericum root | nourish blood; polygonatum also tonifies qi and essence, and is used for lower body pain |
| Salvia danshen | Salvia miltiorrhiza root | vitalize blood; salvia also nourishes the blood and enhances circulation in the arterioles and capillaries |
| Tang-kuei danggui | Angelica sinensis root | nourish blood; tang-kuei also vitalizes blood circulation and alleviates pain |
| Tortoise shell guiban | Chinemys reevesii plastron | nourish yin; tortoise shell is used to strengthen bones and nourish blood |
| Turtle shell biejia | Amyda sinensis dorsal shell | nourish yin; turtle shell is thought to nourish the bone marrow |
Several clinical reports have appeared in Chinese medical literature describing therapies for AVN-FH, with herb therapies being a key feature. All of the reports claim a high degree of success (typically 90% or more of patients show improvement) in alleviating symptoms of pain and stiffness and showing at least partial reversal of the bone deterioration observed by x-ray. The report involving the largest number of patients is by Wang Lulin of the Dongya Institute of Osteopathy in Beijing (1). Of the 1286 patients examined and treated, most were in the age range of 18-59 years, with about half the cases involving both sides. The suspected causes were outlined as follows:
| Suspected Cause or Predisposing Factor | Number of Cases (%) |
| Chronic use of steroids | 669 (52.0) |
| Trauma to hip | 376 (29.2) |
| Childhood maldevelopment of hip | 87 (6.8) |
| Alcoholism | 46 (3.6) |
| Remaining cases, undetermined factors | 108 (8.4) |
| Total | 1286 (100) |
Most of the patients had well-advanced disease, at stage III or stage IV (1,051 cases were at these stages). The formula applied was not described, but the main herbs were said to be cordyceps, which represents the bone-nourishing kidney yang tonics, and tang-kuei, which represents the blood vitalizers. The herbs were made into pills, each dose being 6 grams, taken three times daily for three months as a therapeutic course, which would be repeated as necessary to gain the maximum results. The treatment times ranged from 3 months to 2 years, with a median duration of 10 months. On average, clinical symptoms were said to be partially or completely eliminated during the first three months, and an improvement in bone condition- determined by x-ray-would occur within about six months. The few failures or marginal results occurred mainly with elderly patients who had stage-IV disease progression. The author interpreted the positive effects of treatment this way:
The capability of repair of femoral head necrosis is closely related to the patient's age, constitution, and degree of necrosis. In children and youngsters, the capability of repair is relatively strong, and if the necrotic femoral head is not collapsed, basic cure of the disease can be expected after herb treatment. Even if the necrotic head is collapsed, its shape after repair is usually better [in these young patients] than that of the middle-aged or old patients. The duration of treatment to repair the damage depends upon the severity of the necrosis, and is significantly shorter in the cases of stages I and II than that in cases of stages III and IV. For the cases at stages I and II, the symptoms can be expected to disappear with the necrotic femoral head recovered to its original shape.
This view about the capability of repair among different patients was echoed by other researchers in their summarization of results.
A more comprehensive therapeutic regimen was described by Lu Wenzhi of the First Municipal Hospital of Qiqihaer in Heilongjiang Province (2). According to his report, 230 patients with femoral head necrosis were treated by a combination of herb therapy, foot massage, leg traction, and exercises. The herb therapy involved pills containing a mixture of more than 30 different herbs, including astragalus, ho-shou-wu, cibotium, eucommia, sea horse, cordyceps, lycium fruit, tang-kuei, turtle shell, tortoise shell, pearl, scorpion, agkistrodon, achyranthes, and cloves. The formula is aimed at nourishing the bone, warming the circulation, and alleviating pain and spasm. These herbs were prepared as a honey pill (6 grams herb materials, 3 grams honey) to be taken two pills at a time, once per day, preferably swallowed down with water that was used to boil an egg and a slice of fresh ginger, to enhance the efficacy of the herbs in pill form. A course of treatment was 3 months, to be repeated as necessary; most patients utilized 1-4 courses of therapy.
Massage therapy was focused on the affected leg, with some attention paid to stimulating acupuncture points, such as yongquan (KI-1), sanyinjiao (SP-6), the two xi points, taixi (KI-3) and xiaxi (GB-43), and zusanli (ST-36). The meridians of the leg, such as kidney, spleen, and gallbladder, all pass through the hip area. The massage was vigorous, and would last for 20-30 minutes, to be administered 1-2 times per day, for one week, in order to get a course of therapy started. This could be repeated as necessary. The goals of the massage are: to enhance circulation through the meridians up to the affected part, relying mainly on the shu (stream) points; to enhance the yang-qi; warm the meridians; free up the circulation of qi and blood; strengthen the tendons and bones; and promote the health of the joints.
For several hours per day, the patient would lie in bed and stretch out the leg to a point of comfort in the hip and retain that position for 2 or more hours. This would be accomplished by tying the person's ankle to the foot of the bed and then having the patient stretch himself out by pulling at the head of the bed to get the best position for the hip, and then lie in that position, readjusting as necessary. The purpose of this self-traction is to reduce local pressure on the femoral head to avoid further collapse, reduce severe pain due to dead bone pieces in the joint cavity, and reduce recurrent pain that might still be present during the initial process of treatment.
In addition, the patient would be encouraged to do exercises for the hip joint. The amount of exercise would depend on the ability and tolerance of the individual and would be limited to avoid damage to the blood vessels at the affected hip. Recommended actions included a passive motion of the hip joint while in bed by moving the rest of the body, and a regular joint exercise involving active movement of the leg along three directions, such as side, up, and angled, as well as by bending and stretching; these latter exercises could be done while standing or in bed, as necessary. In addition, a pedaling exercise, using a stationary bike with adjustable resistance, was recommended. The purpose of all these exercises include: improving blood circulation through the hip; maintaining strength and flexibility; and assuring that the bone recovery occurs in the context of enabling increased movement of the joint.
In another report, focusing mainly on treatment of femoral head necrosis in children, the herbal therapy was prepared and administered at the Qufu Municipal Hospital of TCM in Shandong Province (3). The formula included tang-kuei, millettia, salvia, carthamus, pyrite, drynaria, astragalus, loranthus, tu-huo, coix, epimedium, cyperus, centipede, and borneol. The fibrous herbs were boiled with water, then the water decoction was concentrated and dried; this extract was next mixed with the carthamus, centipede, pyrite, and borneol, which had been ground into fine powder. The resulting mixture was put in capsules for oral administration, at 400 mg/capsule, 1-2 capsule a time, three times a day, with three months as a course of treatment. Most patients underwent 1-3 course of therapy, with an average duration of 7 months. Some of the patients also were treated with a type of traction to alleviate pressure at the affected joint, and with local application of heat and herbs, and massage (these local therapies were not described in detail). According to the author of the report, some alleviation of symptoms was usually noted during the first month and those with earlier stage of disease were better able to gain complete or near complete recovery.
A report from the Wendeng Hospital of Orthopaedics and Traumatology in Shandong Province described treatment where the majority of patients were adults (4). Herb therapy was the main method used, and the formula administered was: 10g salvia, 10g cnidium, 10g deer antler gelatin, 10g angelica, 10g sinapis, 15g achyranthes, 15g drynaria, 20g astragalus, 5g calamus (gum), 15g epimedium, and 30g polygonatum (total: 150 grams; 25 doses). These herbs are ground to powder and taken in doses of 6 grams a time, with warm water, twice a day. Three batches of this formula (75 doses, about a five week quantity) make a course of treatment, which is followed by a one-week interval between two courses.
In a laboratory animal study of AVN-FH, performed at the Laboratory of Neurology & Morphology, Institute of Orthopedics and Traumatology in Beijing, the tested formula (called the femoral head necrosis decoction) contained tang-kuei, cnidium, dipsacus, drynaria, asarum, eupolyphaga, and pyrite (5). The authors stated:
The experiment indicated that femoral head necrosis decoction can relieve pain, improve endurance during movement, reduce inflammation, stimulate trabecular formation and ossification, and activate the healing process. Further study is required to demonstrate the mechanism of action of the herbs.
Pyrite (zirandong), included in the above formulation and in the formula used for the study focusing on childhood AVN-FH, is natural ferrous sulfide, a mineral, that also contains a small amount of copper. It is traditionally used to unite fractured bones, disperse stagnant blood, and control pain. Potentially, several other minerals may also be of value in helping repair the damaged femoral head, including calcium, the dominant bone constituent. A broad-spectrum mineral supplement that includes calcium, iron, and copper among other ingredients may be a suitable modern substitute. Several of the formulas mentioned included animal materials, known in China as chong (literally, crawling creatures), such as eupolyphaga, scorpion, centipede, and agkistrodon; these are understood as aids to clearing the obstructed circulation and alleviating pain. Other animal materials, including sea horse (no longer available for use due to endangered species status), turtle and tortoise shells (from animals raised in ponds), deer horn glue, and pearl, are used as tonics.
Most of the ingredients of the formulas in this report are available outside of China. Combinations similar to the ones mentioned are made in prepared form, as pills or tablets, and formulas containing such ingredients can be provided in the form of dried hot-water extracts, to be made into instant teas. Therefore, it is possible to utilize treatment strategies of the type described for those who wish to attempt resolution of AVN-FH without resorting to surgery. However, as indicated in the Chinese reports, in older patients and those with more advanced disease, the extent of repair to the femoral head may be substantially limited.
Three clinical reports on treatment of AVN-FH from China involved complex therapeutic measures that cannot be duplicated outside China, including introduction of herb extracts into the femur head arteries by use of a catheter. The treatments were administered at the Yizhou Kuitun Hospital in Xinjiang Province (6), the Luoyang Hospital of Traditional Chinese Orthopaedics and Traumatology in Henan Province (7), and the Second Hospital of the Guangxi College of TCM in Nanning City of Guangxi Province (8). The key herb in these treatments was salvia; the catheter method was said to produce quicker results than oral therapies. Salvia, as well as the other herbs, can be used orally outside China.
The Institute for Traditional Medicine (ITM) has prepared several formulations that are suited to AVN-FH. They may be administered under the guidance of qualified health professionals, such as acupuncturists, trained in the use of Chinese herbs. As an example of a treatment approach using the ITM formulary, the following items might be included (the suggested doses are for adults, and based on using the combination of items listed, but not using any other supplements, such as over-the-counter dietary products):
The total amount of herb materials (powders and extracts) in this large number of tablets is about 20 grams, somewhat higher than the amounts for adults mentioned in the clinical reports (12-18 grams). The average body weight of Westerners is higher than that of their Chinese counterparts (at least, during the time when the therapies were administered; Chinese body weights have been catching up with Western weights more recently). This therapy also provides additional materials, such as glucosamine sulfate, bromelain, and the broad spectrum of minerals and vitamins, which were not part of the Chinese treatments. Glucosamine sulfate may substitute for turtle and tortoise shell, and some other animal ingredients in the Chinese formulations. For children, the dose of herb formulas would be reduced, and the Boswellamine and Bromelgin might be deleted; Calmagnium could be replaced by a formulation aimed at childhood requirements.
The primary herbs of this treatment are drynaria, dipsacus, deer antler, salvia, rehmannia, and tang-kuei. These herbs invigorate the yang and nourish the kidney, vitalize the blood and nourish the blood, and help repair bone. A three-month course of therapy might be tried in order to determine whether or not this approach is adequate for any individual. Additional therapeutic measures, including massage and/or acupuncture, exercises, and self-traction might additionally be employed to optimize the outcome.
December 2002