A 53-year-old woman with a one-year post-surgical presentation of ischemic necrosis of the femoral head (AVN) was successfully managed over three years using a Liver/Kidney-tonifying and blood-invigorating herbal strategy to avoid hip replacement.

Case ID: CHC-0059

Case Summary

This case describes a 53-year-old woman who developed avascular necrosis (ischemic necrosis) of the femoral head one year after undergoing internal fixation surgery for a femoral neck fracture. Refusing a second orthopedic surgery, she sought conservative TCM treatment. The original report documented a conventional diagnosis of ischemic necrosis of the femoral head (ARCO Stage IIB) and a TCM assessment of Bone Erosion (Gu Shi) driven by Blood Stasis, Liver and Kidney Deficiency, and Qi/Blood Insufficiency. She was managed through a highly persistent, three-year integrative approach utilizing heavy Kidney-tonifying and blood-moving herbal decoctions, culminating in the successful clinical repair of the necrosis and full restoration of mobility.

Patient Presentation

• Patient: 53-year-old female (Surname: Lin).
• Main Complaint: Hip pain with restricted flexion and extension for 1 year following femoral neck fracture surgery.
• History: The patient fell from a bicycle on April 27, 2018, suffering a left mid-femoral neck fracture. She underwent internal fixation with hollow screws at another hospital on the same day. One year post-operation, she developed severe hip pain, limited mobility, and limped using crutches. Her pain worsened significantly upon weight-bearing. Follow-up imaging showed the screws had partially migrated outward, the fracture ends were absorbed and shortened, and she had developed femoral head necrosis (ARCO Stage IIB: ~30% femoral head involvement). Rejecting the orthopedic surgeon’s recommendation for a second surgery (likely hip replacement), she sought TCM hip-preserving treatment.
• Associated Symptoms: Dull and lusterless complexion, poor spirit, sore and weak lower back and knees, limb fatigue, and poor appetite and sleep.

Examination and Diagnosis

• Conventional Diagnosis: Ischemic necrosis of the femoral head (Avascular Necrosis – AVN).
• TCM Tongue and Pulse: The tongue was pale and dark with petechiae (瘀点 – stasis spots) on the edges, and a thin, white coating. The pulse was stringy, choppy, and weak (脉弦涩无力).

TCM Assessment

The original practitioner interpreted the presentation as Bone Erosion driven by Blood Stasis, Liver and Kidney Deficiency, and Qi and Blood Insufficiency (骨蚀 – 瘀血阻滞，肝肾亏虚，气血不足).

According to the holistic principles of yin and yang Chinese Medicine the initial trauma and subsequent invasive surgery severely disrupted the local blood vessels, causing profound localized Blood Stasis. Because the blood could not flow to nourish the bone, the bone tissue began to “starve” and erode. Furthermore, the prolonged post-operative immobilization exacerbated her systemic circulation, depleting her underlying Qi and Blood. In TCM, the Kidneys govern the bones and the Liver governs the sinews; the patient’s long-term pain and lack of mobility eventually drained her foundational Liver and Kidney essence. The pale-dark tongue with petechiae and the choppy pulse provided objective confirmation of this deep, localized blood stasis complicated by systemic weakness.

Treatment Approach

The primary treatment principle was to invigorate blood and resolve stasis, warm and tonify the Liver and Kidneys, and strengthen the sinews and bones (活血化瘀，温补肝肾，强筋壮骨). The strategy involved a multi-year phased approach: initially focusing heavily on breaking up the stasis and relieving pain, then transitioning to deep, long-term essence and bone tonification using heavy animal-derived medicinals.

Herbal Formulas and Interventions

• Initial Formula (Phase 1): A 16-herb decoction merging Taohong Siwu Tang (to move blood), Shaoyao Gancao Tang (to relax spasms/pain), and Yougui Wan (to warm Kidney Yang).
  • Dang Gui (10g), Chi Shao (10g), San Qi (6g), Chuan Xiong (6g), Tao Ren (10g), Hong Hua (6g), and Di Long (Earthworm, 5g) forcefully broke up localized stasis and opened the collaterals.
  • Huang Qi (20g) and Ren Shen (10g) strongly tonified Qi to push the blood.
  • Zhi Fu Zi (10g), Shan Yu Rou (10g), Lu Jiao Jiao (Deer Antler Glue, 10g), Gui Zhi (10g), Gu Sui Bu (10g), Di Huang (15g), and Niu Xi (10g) warmed the Kidney Yang and directly stimulated bone regeneration. (30 doses, taken daily).
  • External Therapy: Low-frequency pulse therapy combined with topical bone-strengthening liquids and Bogu San (Bone-Knitting Powder).
• Mid-to-Late Stage (Phase 2 – Continued for 1 Year): After one month, the pain was significantly relieved. The patient shifted to outpatient care. The formula was adjusted to focus heavily on Yougui Wan, adding Ge Jie (Gecko powder, 5g) to deeply tonify the Kidneys. After one year of this regimen (taking the herbs 5 days a week), the hip pain completely disappeared, and she could walk without crutches.
• Setbacks and Re-injury (Years 2 & 3):
  • In the second year, she slipped and fell on her left knee, tearing the cruciate and collateral ligaments and meniscus.
  • In the third year, she fell again, suffering an avulsion fracture of the 5th metatarsal.
  • Despite these severe secondary traumas, her femoral head AVN did not worsen. She was treated for the acute injuries with modified Taohong Siwu Tang and external herbal pastes, recovering successfully each time.
• Consolidation Stage (Up to April 2023): To permanently stabilize the hip, the practitioner alternated between Huqian Wan (Hidden Tiger Pill – to strongly nourish Yin and strengthen bones) and Yougui Wan (to warm Yang).

Follow-Up

• By April 2023 (five years after the initial injury), follow-up DR and CT scans showed that the original necrotic areas of the femoral head had significantly repaired.
• The patient’s spirit and sleep were excellent, all lower back and hip pain was eliminated, and her lower limbs were strong enough to walk normally, handle daily self-care, and perform housework.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the successful long-term conservative reversal of surgical-induced avascular necrosis.

AVN is notoriously difficult to reverse, often culminating in total hip arthroplasty (joint replacement). Professor Zhao recognized that the root of bone necrosis is ischemia (lack of blood). The initial treatment strictly utilized blood-invigorating herbs to forcefully re-establish microcirculation. However, the true clinical breakthrough in the long-term phase was the reliance on “flesh and blood products” (血肉有情之品) like Lu Jiao Jiao (Deer Antler Glue), Ge Jie (Gecko), and Di Long (Earthworm). In classical TCM, when the deep essence of the bone is damaged, plant-based herbs are often insufficient; animal-derived medicinals are required to directly replenish the Marrow and physically rebuild the necrotic bone tissue. This three-year persistence yielded a complete functional recovery.

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Source Original source: Traditional Chinese Medicine Bureau of Guangdong Province Original title: 【以案说医】招仕富：股骨颈骨折内固定术后股骨头缺血性坏死治疗验案 Practitioner: Professor Zhao Shifu (招仕富) Publication date: 2024-09-04 Original language: Chinese ChineseHerb.org version: English translation and editorial adaptation