Musculoskeletal ultrasound monitoring of blood supply changes in shock wave therapy for early and mid-stage femoral head necrosis

doi:10.3877/cma.j.issn.1674-134X.2026.03.004

Abstract

Abstract:

Objective

To monitor the impact of extracorporeal shock wave therapy on the blood supply and microcirculation of the femoral head in patients with early-to-mid-stage osteonecrosis of the femoral head (ONFH) using musculoskeletal ultrasound and T2-weighted MRI for verification, so as to provide clinical data for the treatment of ONFH with shock waves.

Methods

Sixty patients diagnosed with osteonecrosis of the femoral head (ONFH) (ARCO stageⅠto Ⅲ A) in Shock Wave Therapy Center of Ningxia Hui Autonomous Region People’s Hospital were randomly divided into the medication treatment group (medication group) and the shockwave treatment group (shockwave group) using a computer-generated block randomization scheme. Inclusion criteria: patients diagnosed with ONFH, Association Research Circulation Osseous (ARCO) stages Ⅰto Ⅲ A (collapse <2 mm). Exclusion criteria: abnormal coagulation function, thrombosis in the treatment area, severe cognitive impairment, severe arrhythmia, pregnancy, local infection, etc. VAS score was assessed before treatment, after shockwave treatment (within one week), and at three, six and nine months after treatment to analyze inter-group differences and observe treatment efficacy. Musculoskeletal ultrasound examinations were performed in the shockwave group before and after treatment to record data such as blood flow resistance index (RI), vascular filling, and peak systolic velocity (PSV) of the medial and lateral circumflex femoral arteries, lateral femoral ascending branch, transverse branch, and descending branch on the affected side. MRI was used to verify the regression of edema and changes in the necrotic zone, confirming the treatment outcome. Shapiro-Wilk test was performed to evaluate normality. Measurement data were described as

x ¯

±s, and one-way analysis of variance was applied.

Results

There was no statistically significant difference in baseline data between the two groups before treatment (all P>0.05). Both the shockwave group and the conventional medication group showed significant pain relief after treatment. Although the onset of action in the shockwave group was slower, it had a longer duration of efficacy. The analgesic effect of the shockwave group was significantly better than that of the medication group in the later stages. Six and nine months after treatment, VAS scores in the shockwave group (2.7±1.2, 3.0±1.3) were lower than those in the medication group (4.0±1.1, 4.6±1.3), with statistically significant differences (t=4.12, 4.68, both P<0.05). Three and six months after treatment, musculoskeletal ultrasound examination of the five arteries related to the femoral head showed increased flow velocity and decreased vascular resistance, indicating a significant increase in blood flow in the femoral head of patients treated with shockwaves. Musculoskeletal ultrasound at three and six months after treatment in the shockwave treatment group showed a significant increase in PSV of the medial circumflex femoral artery, lateral circumflex femoral artery, and their branches compared to before treatment (all P<0.01), with a significant decrease in RI (all P<0.05), indicating improved blood flow. MRI T2-weighted imaging in six and 12 months after treatment showed reduced edema zone signals, with no significant changes in the hypointense zone, suggesting improvement in venous stasis or no significant increase in the necrotic area of the femoral head after shockwave treatment.

Conclusions

Extracorporeal shock wave therapy has significant therapeutic effects on patients with ONFH in ARCO stagesⅠ, Ⅱ, and some cases of stage Ⅲ A. The pain relief effect is superior to or at least comparable to that of the drug treatment group. Shock wave therapy can effectively improve the blood supply of the femoral head, increasing blood flow velocity and reducing vascular resistance in all five relevant vessels. MRI suggests that extracorporeal shock wave therapy stabilizes the condition of patients with ONFH in ARCO stagesⅠand Ⅱ, delaying the need for surgical intervention. Shock wave therapy for the femoral head in ARCO stagesⅠand Ⅱ has demonstrated good clinical outcomes and is worth promoting.

Key words: Extracorporeal shock wave, Femur head necrosis, Ultrasonograrhy

Xichun Sun, Lijuan Zhao, Qinghu Ma, Dongsheng Niu, Desheng Chen, Yuqi Liang, Tao Ma, Cong Wang, Suoli Cheng. Musculoskeletal ultrasound monitoring of blood supply changes in shock wave therapy for early and mid-stage femoral head necrosis[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2026, 20(03): 283-290.

/ / Recommend

Add to citation manager EndNote|Ris|BibTeX

URL: https://zhgjwkzz.cma-cmc.com.cn/EN/10.3877/cma.j.issn.1674-134X.2026.03.004

https://zhgjwkzz.cma-cmc.com.cn/EN/Y2026/V20/I03/283

Figures/Tables 6

Figure 1 Selection of body surface projection points of the proximal femur Note: The patient lies in a supine position, and three to five sites are chosen on the body surface that are projections of the proximal femur, including the femoral head, femoral neck, greater trochanter, bilateral sties of the femoral neck, and the sites near the medial and lateral circumflex femoral arteries

Figure 2 Schematic diagram of the anatomy of the blood supply artery of the right femoral head and the monitoring sites for musculoskeletal ultrasound. A is angiography of the medial and lateral circumflex femoral arteries, and the three branches of the lateral circumflex femoral artery (ascending branch, transverse branch, descending branch); B is musculoskeletal ultrasound image showing the caliber, flow velocity, and resistance index

Table 1 Baseline comparison among each group

分组Groups	例数 Number of cases	年龄［岁，（ $x ¯$ ±s）］ Age（year）	女性占比 Female ratio（%）	BMI ［kg/m²，（ $x ¯$ ±s）］	病程［月，（ $x ¯$ ±s）］ Course of disease（month）	WOMAC评分（ $x ¯$ ±s）	VAS评分（ $x ¯$ ±s）
冲击波组 Shockwave group	30	59.3±9.8	33.7	25.8±1.9	16.7±7.2	83.7±9.1	4.8±1.5
药物组 Medication group	30	59.9±9.0	40.0	25.4±1.6	16.2±7.3	78.9±9.0	5.0±1.6
统计值 Statistical values		t=0.24	χ²=0.29	t=0.86	t=0.26	t=1.98	t=0.42
P值		＞0.05	＞0.05	＞0.05	＞0.05	＞0.05	＞0.05

Table 1 Baseline comparison among each group

分组Groups	例数 Number of cases	年龄［岁，（ $x ¯$ ±s）］ Age（year）	女性占比 Female ratio（%）	BMI ［kg/m²，（ $x ¯$ ±s）］	病程［月，（ $x ¯$ ±s）］ Course of disease（month）	WOMAC评分（ $x ¯$ ±s）	VAS评分（ $x ¯$ ±s）
冲击波组 Shockwave group	30	59.3±9.8	33.7	25.8±1.9	16.7±7.2	83.7±9.1	4.8±1.5
药物组 Medication group	30	59.9±9.0	40.0	25.4±1.6	16.2±7.3	78.9±9.0	5.0±1.6
统计值 Statistical values		t=0.24	χ²=0.29	t=0.86	t=0.26	t=1.98	t=0.42
P值		＞0.05	＞0.05	＞0.05	＞0.05	＞0.05	＞0.05

Table 2 Comparison of VAS scores between the two groups at different time points

分组 Groups	例数 Number of cases	治疗前 Before treatment	治疗结束后 After treatment	结束后3个月 Three months after treatment	结束后6个月 Six months after treatment	结束后9个月Nine months after treatment
冲击波组 Shockwave group	30	4.8±1.5	2.4±1.0	2.4±1.2	2.7±1.2	3.0±1.3
药物组 Medication group	30	5.0±1.7	2.4±1.1	2.4±1.1	4.0±1.1	4.6±1.3
t值		0.42	0.11	0.10	4.12	4.68
P值		＞0.05	＞0.05	0.03	0.012	0.017

Table 3 The examination results of bone ultrasound of patients undergoing shock wave therapy

	时间点 Time points	血管内径（mm） Lumen diameter	流速（cm/s） Peak systolic velocity	阻力指数 Resistive index
旋股内侧动脉 Medial circumflex femoral artery	治疗前 Before treatment	2.700±0.300	35.000±0.400	0.810±0.200
	治疗结束后3个月 Three months after treatment	2.900±0.300	95.200±0.300	1.000±0.200
	治疗结束后6个月 Six months after treatment	2.900±0.800	59.400±0.500	1.000±0.300
	F值	1.23	12.34	9.87
	P值	＞0.05	0.002	0.007
	时间点 Time points	血管内径（mm） Lumen diameter	流速（cm/s） Peak systolic velocity	阻力指数 Resistive index
旋股外侧动脉Lateral circumflex femoral artery	治疗前 Before treatment	3.300±0.500	0.310±0.100	0.820±0.300
	治疗结束后3个月 Three months after treatment	3.300±0.900	66.000±3.000	1.000±0.300
	治疗结束后6个月 Six months after treatment	3.300±1.000	66.000±3.300	1.000±0.500
	F值	0.89	10.56	8.92
	P值	＞0.05	0.004	0.011
	时间点 Time points	血管内径（mm） Lumen diameter	流速（cm/s） Peak systolic velocity	阻力指数 Resistive index
旋股外侧动脉升支Ascending branch of the lateral circumflex femoral artery	治疗前 Before treatment	2.100±0.100	0.200±0.020	0.800±0.300
	治疗结束后3个月 Three months after treatment	2.400±0.200	59.000±0.600	0.780±0.200
	治疗结束后6个月 Six months after treatment	2.400±0.500	47.000±0.500	1.000±0.100
	F值	2.45	15.78	11.34
	P值	＞0.05	＜0.001	0.003
	时间点 Time points	血管内径（mm） Lumen diameter	流速 Peak Systolic Velocity	阻力指数 Resistive Index
旋股外侧动脉横支Lateral circumflex femoral artery transverse branch	治疗前 Before treatment	2.500±0.200	0.250±0.040	0.770±0.100
	治疗结束后3个月 Three months after treatment	2.500±0.500	39.900±0.090	1.000±0.200
	治疗结束后6个月 Six months after treatment	2.500±0.700	41.000±0.800	1.000±0.100
	F值	1.01	14.23	12.01
	P值	＞0.05	＜0.001	0.002
	时间点 Time points	血管内径（mm） Lumen diameter	流速（cm/s） Peak systolic velocity	阻力指数 Resistive index
旋股外侧动脉降支Descending branch of lateral circumflex femoral artery	治疗前 Before treatment	3.000±0.600	0.330±0.100	0.790±0.200
	治疗结束后3个月 Three months after treatment	2.900±0.800	64.300±0.300	1.000±0.400
	治疗结束后6个月 Six months after treatment	2.900±1.000	61.000±0.500	1.000±0.300
	F值	1.56	13.67	10.23
	P值	＞0.05	0.001	0.005

Table 3 The examination results of bone ultrasound of patients undergoing shock wave therapy

	时间点 Time points	血管内径（mm） Lumen diameter	流速（cm/s） Peak systolic velocity	阻力指数 Resistive index
旋股内侧动脉 Medial circumflex femoral artery	治疗前 Before treatment	2.700±0.300	35.000±0.400	0.810±0.200
	治疗结束后3个月 Three months after treatment	2.900±0.300	95.200±0.300	1.000±0.200
	治疗结束后6个月 Six months after treatment	2.900±0.800	59.400±0.500	1.000±0.300
	F值	1.23	12.34	9.87
	P值	＞0.05	0.002	0.007
	时间点 Time points	血管内径（mm） Lumen diameter	流速（cm/s） Peak systolic velocity	阻力指数 Resistive index
旋股外侧动脉Lateral circumflex femoral artery	治疗前 Before treatment	3.300±0.500	0.310±0.100	0.820±0.300
	治疗结束后3个月 Three months after treatment	3.300±0.900	66.000±3.000	1.000±0.300
	治疗结束后6个月 Six months after treatment	3.300±1.000	66.000±3.300	1.000±0.500
	F值	0.89	10.56	8.92
	P值	＞0.05	0.004	0.011
	时间点 Time points	血管内径（mm） Lumen diameter	流速（cm/s） Peak systolic velocity	阻力指数 Resistive index
旋股外侧动脉升支Ascending branch of the lateral circumflex femoral artery	治疗前 Before treatment	2.100±0.100	0.200±0.020	0.800±0.300
	治疗结束后3个月 Three months after treatment	2.400±0.200	59.000±0.600	0.780±0.200
	治疗结束后6个月 Six months after treatment	2.400±0.500	47.000±0.500	1.000±0.100
	F值	2.45	15.78	11.34
	P值	＞0.05	＜0.001	0.003
	时间点 Time points	血管内径（mm） Lumen diameter	流速 Peak Systolic Velocity	阻力指数 Resistive Index
旋股外侧动脉横支Lateral circumflex femoral artery transverse branch	治疗前 Before treatment	2.500±0.200	0.250±0.040	0.770±0.100
	治疗结束后3个月 Three months after treatment	2.500±0.500	39.900±0.090	1.000±0.200
	治疗结束后6个月 Six months after treatment	2.500±0.700	41.000±0.800	1.000±0.100
	F值	1.01	14.23	12.01
	P值	＞0.05	＜0.001	0.002
	时间点 Time points	血管内径（mm） Lumen diameter	流速（cm/s） Peak systolic velocity	阻力指数 Resistive index
旋股外侧动脉降支Descending branch of lateral circumflex femoral artery	治疗前 Before treatment	3.000±0.600	0.330±0.100	0.790±0.200
	治疗结束后3个月 Three months after treatment	2.900±0.800	64.300±0.300	1.000±0.400
	治疗结束后6个月 Six months after treatment	2.900±1.000	61.000±0.500	1.000±0.300
	F值	1.56	13.67	10.23
	P值	＞0.05	0.001	0.005

Figure 3 Bilateral hips images of the patient with ONFH (osteonecrosis of the femoral head) in the shockwave therapy group after treatment. A is X-ray image of pelvis at anteroposterior position, showing no articular surface collapse; B is coronal T2-weighted MR image at three months after the treatment for right hip, showing reduced signal intensity and narrowed range of the edema zone; C is coronal T2-weighted MR image at six months after the treatment for right hip, showing partial regression of the edema zone and stable necrotic area without expansion

References 22

［1］	Sharma L. Osteoarthritis of the knee［J］. N Engl J Med, 2021, 384（1）: 51－59.
［2］	Kumar P, Aggarwal S, Jindal K, et al. Core decompression combined with intraosseous ibandronate for pre-collapse osteonecrosis of the femoral head: report of a novel technique, its safety and early outcomes in five cases［J］. J Orthop Case Rep, 2021, 11（12）: 96－100.
［3］	Iwasa M, Ando W, Uemura K, et al. Association between magnitude of femoral head collapse and quality of life in patients with osteonecrosis of the femoral head［J］. Mod Rheumatol, 2023, 33（2）: 416－421.
［4］	梅轶芳. 中国骨关节炎流行病学研究现状及规范［J］. 中国实用内科杂志, 2019, 39（8）: 663－665.
［5］	Liao PC, Chou SH, Shih CL. A systematic review of the use of shockwave therapy for knee osteoarthritis［J］. J Orthop, 2024, 56: 18－25.
［6］	Huh JT, Zheng A, Kheyfets B, et al. Osteoarthritis and chondrocytes: on the road from mechanisms to treatment［J/OL］. J Dent Res, 2025: 220345251385964. DOI: 10.1177/00220345251385964.
［7］	Romeo P, Lavanga V, Pagani D, et al. Extracorporeal shock wave therapy in musculoskeletal disorders: a review［J］. Med Princ Pract, 2014, 23（1）: 7－13.
［8］	Wu YT, Yu HK, Chen LR, et al. Extracorporeal shock waves versus botulinum toxin type a in the treatment of poststroke upper limb spasticity: a randomized noninferiority trial［J］. Arch Phys Med Rehabil, 2018, 99（11）: 2143－2150.
［9］	Auersperg V, Trieb K. Extracorporeal shock wave therapy: an update［J］. EFORT Open Rev, 2020, 5（10）: 584－592.
［10］	中华医学会骨科学分会关节外科学组. 骨关节炎诊疗指南（2018年版）［J］. 中华骨科杂志, 2018, 38（12）: 705－715.
［11］	Khadour FA, Khadour YA, Khouly OI, et al. Combined low-intensity pulsed ultrasound and extracorporeal shock wave therapy reduces pain and inflammation in knee osteoarthritis patients［J/OL］. Sci Rep, 2025: 30807. DOI: 10.1038/s41598－025－30807－7.
［12］	Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence［J］. Osteoarthritis Cartilage, 2007, 15（9）: 981－1000.
［13］	An S, Li J, Xie W, et al. Extracorporeal shockwave treatment in knee osteoarthritis: therapeutic effects and possible mechanism［J/OL］. Biosci Rep, 2020, 40（11）: BSR20200926. DOI: 10.1042/BSR20200926.
［14］	Zhao Z, Jing R, Shi Z, et al. Efficacy of extracorporeal shockwave therapy for knee osteoarthritis: a randomized controlled trial［J］. J Surg Res, 2013, 185（2）: 661－666.
［15］	Liu Q, Guo W, Li R, et al. Efficacy of various core decompression techniques versus non-operative treatment for osteonecrosis of the femoral head: a systemic review and network meta-analysis of randomized controlled trials［J/OL］. BMC Musculoskelet Disord, 2021, 22（1）: 948. DOI: 10.1186/s12891－021－04808－2.
［16］	Wang C-J. An overview of shock wave therapy in musculoskeletal disorders［J］. Chang Gung Med J, 2003, 26（4）: 220－232.
［17］	孔繁荣, 梁玉江, 秦树光, 等. 体外冲击波修复重建骨组织结构治疗股骨头缺血性坏死的临床应用［J］. 中国骨伤, 2010, 23（1）: 12－15.
［18］	Zhang Q, Liu L, Sun W, et al. Extracorporeal shockwave therapy in osteonecrosis of femoral head: a systematic review of now available clinical evidences［J/OL］. Medicine, 2017, 96（4）: e5897. DOI: 10.1097/MD.0000000000005897.
［19］	Wang C-J, Cheng J-H, Huang C-C, et al. Extracorporeal shockwave therapy for avascular necrosis of femoral head［J］. Int J Surg, 2015, 24（Pt B）: 184－187.
［20］	Hernigou P, Verrier S, Homma Y, et al. Prognosis of hip osteonecrosis after cell therapy with a calculator and artificial intelligence: ten year collapse-free survival prediction on three thousand and twenty one hips［J］. Int Orthop, 2023, 47（7）: 1689－1705.
［21］	Hong Z, Zhang Y, Chen J, et al. Adipose-derived stromal vascular fraction injection following core decompression and biochemistry artificial bone graft implantation in osteonecrosis of the femoral head［J］. Int Orthop, 2023, 47（6）: 1481－1486.
［22］	Osawa Y, Takegami Y, Kato D, et al. Hip function in patients undergoing conservative treatment for osteonecrosis of the femoral head［J］. Int Orthop, 2023, 47（1）: 89－94.

[1]	Xiaoyang Song, Hong Han, Shenghu Zhou, Yongjie Qiao, Haoqiang Zhang, Lirong Sha, Jinpeng Lou, Peng Liu, Zhenhao Liu, Qifeng Song. Treatment of osteonecrosis of femoral head with bioceramic rod combined with bone morphogenetic protein [J]. Chinese Journal of Joint Surgery(Electronic Edition), 2026, 20(02): 242-247.
[2]	Yi Zhang, Donglai Li, Yeyong Zhang, Gongteng Wang, Shufeng Li. Role of acetaldehyde dehydrogenase 2 in nontraumatic osteonecrosis of femoral head [J]. Chinese Journal of Joint Surgery(Electronic Edition), 2026, 20(02): 222-226.
[3]	Qi He, Yuehui Zhou, Yuxuan Xue, Yutong Ji, Haibin Wang, Chi Zhou. Therapeutic value of Wei deficiency-blood stasis-marrow atrophy theory in steroid-induced femoral head osteonecrosis [J]. Chinese Journal of Joint Surgery(Electronic Edition), 2026, 20(01): 87-96.
[4]	Hongda Wang, Xingyu Shan, Haoqiang Zhang, Zhimin Tian, Huanxi Li, Chunnuo He, Kaipeng Zhuang, Shenghu Zhou, Ping Zhen. Application of artificial bone repair materials in osteonecrosis of femoral head [J]. Chinese Journal of Joint Surgery(Electronic Edition), 2026, 20(01): 77-86.
[5]	Jianan Huang, Junzheng Yang, Hua Zhang, Baihao Chen, Chuyi Chen, Qi He, Peng Chen. Mechanism and research progress of circular RNA in regulating steroid-induced osteonecrosis of femoral head [J]. Chinese Journal of Joint Surgery(Electronic Edition), 2025, 19(06): 755-760.
[6]	China Association of Rehabilitation Medicine · Specialty Committee of Bone and Joint Rehabilitation, China Association for Promotion of Chinese Medicine Research · Branch of Orthopaedics and Traumatology, Liming Cheng, Taixian Li, Wei He, Youwen Liu, Haijun He, Weiguo Wang, Dongyang Qian, Rongtian Wang, Weiheng Chen. China experts consensus on interventional vascular therapy of osteonecrosis of femoral head [J]. Chinese Journal of Joint Surgery(Electronic Edition), 2025, 19(06): 654-660.
[7]	Yaolin Zhang, Teng Wang, Xi Yang, Huan Luo, Yongqing Xu. Research progress of bone morphogenetic protein 2 in hip preservation treatment for femoral head necrosis [J]. Chinese Journal of Joint Surgery(Electronic Edition), 2025, 19(04): 472-477.
[8]	Zhangzheng Wang, Liang Mo, Wei He, Chi Zhou, Zhenqiu Chen, Bin Fang, Yuhao Liu. Pathological study on correlation of pain duration and cartilage degeneration degree in femoral head necrosis [J]. Chinese Journal of Joint Surgery(Electronic Edition), 2025, 19(01): 65-75.
[9]	Ganlin He, Xiangnong Chen, Ping Li, Jiayi Zhen, Jingxia Li, Waiyi Zou, Duorong Xu. Influencing factors of femoral head necrosis after allogeneic hematopoietic stem cell transplantation in leukemia [J]. Chinese Journal of Joint Surgery(Electronic Edition), 2024, 18(04): 450-456.
[10]	Zhimin Tian, Chunnuo He, Huanxi Li, Haoyue Wu, Peng Liu, Yongjie Qiao, Shenghu Zhou, Pingheng Lan, Yang Guo, Haoqiang Zhang. Advances in animal models of femoral head necrosis [J]. Chinese Journal of Joint Surgery(Electronic Edition), 2024, 18(03): 383-389.
[11]	Xiaojie Ma, Guihui Zhang, Runze Li, Qiuru Wang, Dailing Chen, Qingwei Ma, Lei Zhang, Changjun Chen. Mechanistic exploration of Selenomethionine in reversing glucocorticoid-mediated osteoblast apoptosis and osteogenesis inhibition for treating glucocorticoid-induced osteonecrosis of the femoral head in rats [J]. Chinese Journal of Injury Repair and Wound Healing(Electronic Edition), 2025, 20(05): 412-420.
[12]	Yuanzhao Wang, Mingfang Weng, Xinghui Sun. Ureteral upper segment rupture after extracorporeal shock wave lithotripsy for ureteral upper segment stone: a case report [J]. Chinese Journal of Endourology(Electronic Edition), 2025, 19(02): 240-242.
[13]	Jing Chen, Tianqi Liu, Lili Wang, Liquan Yin. Extracorporeal shock wave therapy for muscle spasm after stroke：a Meta-analysis [J]. Chinese Journal of Brain Diseases and Rehabilitation(Electronic Edition), 2024, 14(06): 334-340.
[14]	Jinfeng Zhao, Lingyi Wang, Dongchun Jiang. Regulatory effects of extracorporeal shock wave stimulation of Zusanli acupoint combined with Jianyu acupoints on gastrointestinal motility and autonomic nerve function in patients with diabetic gastroparesis [J]. Chinese Journal of Digestion and Medical Imageology(Electronic Edition), 2025, 15(05): 539-545.
[15]	Wenfeng Zhao, Jianye Jia, Yi Zhang, Ming Xia, Yang Dong, Conghui Han, Sitong Jin, Jianbo Li, Zhigang Jia, Pengfei Liu, Changbao Xu, Yue Cheng. Current status of extracorporeal shock wave lithotripsy for managing upper urinary tract calculi in pediatric patients [J]. Chinese Journal of Clinicians(Electronic Edition), 2025, 19(04): 243-247.

Please choose a citation manager

Content to export