Arthrosis is a chronic progressive joint disease with gradual destruction of cartilage, an increase in pathological changes in the capsule, synovial membrane, adjacent bones and ligaments. It is manifested by pain, morning stiffness and limited mobility. Over time, the symptoms worsen, in the later stages there are severe disorders of limb function. The diagnosis is made on the basis of anamnesis, examination data and radiography results. Treatment is usually conservative, includes exercise therapy, anti-inflammatory drugs, physiotherapy, blockades. When the articular surfaces are destroyed, endoprosthetics are performed.
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Arthrosis is a chronic disease in which progressive degenerative–dystrophic changes develop in the joint due to metabolic disorders. It is the most common joint pathology, diagnosed in 6-7% of the population. With age, the incidence increases dramatically. The disease is detected in 2% of people younger than 45 years, in 30% – from 45 to 64 years and in 65-85% – aged 65 years and older. Arthrosis of large and medium joints of the extremities has the greatest clinical significance due to its negative impact on the standard of living and ability to work of patients.
In some cases, the disease occurs for no apparent reason, is called idiopathic or primary. There is also secondary arthrosis – developed as a result of some pathological process. The most common causes of secondary arthrosis:
- Injuries: fractures, meniscus injuries, ligament tears, dislocations.
- Dysplasia: congenital dislocation of the hip, congenital anomalies of the knee and ankle joints, upper extremities.
- Connective tissue weakness: diseases and conditions in which there is increased joint mobility and weakness of the ligamentous apparatus.
- Autoimmune diseases: rheumatoid arthritis, systemic lupus erythematosus.
- Nonspecific and specific inflammation: acute purulent arthritis, tuberculosis, etc.
- Metabolic disorders and some endocrine pathologies.
- Degenerative-dystrophic processes: Perthes’ disease and other osteochondropathies, dissecting osteochondritis.
- Diseases of the blood system: hemophilia, accompanied by frequent hemorrhages in the joint.
The risk factors for the development of arthrosis include:
- Elderly age, endocrine balance disorders in postmenopausal women.
- Overweight (in case of obesity, due to increased load, the joint is constantly overloaded, the articular surfaces prematurely “wear out”).
- Excessive load and repeated microtrauma caused by working conditions, improper organization of training (especially if there is a history of joint injuries), certain diseases, as well as the consequences of diseases and injuries.
- Intra-articular interventions, especially highly traumatic operations with the removal of a large number of tissues, as a result of which the articular surfaces become incongruent, and the load on them increases.
- Hereditary predisposition (the presence of arthrosis in the next of kin).
- Neurodystrophic disorders in the cervical or lumbar spine (shoulder arthritis, lumbosacral muscle syndrome).
Arthrosis is a polyethological disease, which, regardless of the specific causes of occurrence, is based on a violation of the normal formation and restoration of cartilage tissue cells. Normally, articular cartilage is smooth and elastic. This allows the articular surfaces to move freely relative to each other.
With osteoarthritis, the cartilage becomes rough, the articular surfaces begin to “cling” to each other during movements. Small pieces are separated from the cartilage, which fall into the joint cavity and move freely in the articular fluid, injuring the synovial membrane. Small foci of calcification appear in the surface areas of the cartilage. Areas of ossification appear in the deep layers.
In the central zone, cysts are formed that communicate with the joint cavity, around which, due to the pressure of intra-articular fluid, ossification zones are also formed. Due to constant traumatization, the capsule and synovial membrane of the joint thicken with arthrosis. Villi appear on the synovial membrane, foci of fibrous degeneration form in the capsule.
Over time, the adjacent surfaces of the bone are deformed, bony protrusions appear on their edges. Due to the increased load in the ligaments and muscles, foci of fibrous degeneration occur. The probability of damage to the ligamentous-muscular apparatus increases. With significant destruction of cartilage, movements are sharply limited, the formation of ankylosis is possible.
Taking into account the localization in traumatology and orthopedics, arthrosis of the shoulder, elbow, wrist, ankle and other joints are distinguished. Depending on the severity of the lesion , there are three stages of pathology:
- The first stage – there are no pronounced morphological changes, the composition of the synovial fluid is disturbed. The fluid supplies the cartilage tissue with nutrients worse, the resistance of the cartilage to normal loads decreases. Due to the overload of the articular surfaces, inflammation occurs, pain appears.
- The second stage – articular cartilage begins to collapse, marginal bone growths appear along the edges of the articular area. The pain becomes constant, habitual, the inflammatory process then subsides, then worsens. There is a mild or moderate impairment of the function of the periarticular muscles.
- The third stage – articular cartilage is thinned, there are extensive foci of destruction. There is a significant deformation of the articular area with a change in the axis of the limb. Ligaments become untenable and shorten, pathological mobility of the joint develops in combination with a restriction of the natural volume of movements.
Symptoms of arthrosis
The disease develops gradually, gradually. In some cases, the first symptom is a crunch during movements, more often expressed in gonarthrosis and arthrosis of the shoulder joint. Many patients with arthrosis note a feeling of discomfort in the joint and transient stiffness during the first movements after a period of rest. But the most constant symptom of arthrosis is pain.
Initially, patients are concerned about mild short-term pain without a clear localization, which increases with physical exertion. Over time, pain sensations become more pronounced, there is a noticeable restriction of movements. Due to the increased load, the joint begins to ache from the opposite side. The most striking signs are:
- Starting pain. It occurs during the first movements after a state of rest and passes while maintaining motor activity. It is caused by detritus – a film of components of destroyed cartilage tissue that settles on the articular surfaces. With movements, detritus moves from the cartilage into the inversions of the articular bags, so the pain disappears.
- Connection with physical activity. With prolonged exertion (walking, running, standing), the pain increases, and at rest it subsides. This is due to a decrease in the ability of the cartilage to provide cushioning during movements.
- Connection with the weather. The pain increases under the influence of adverse weather factors: high humidity, low temperature and high atmospheric pressure.
- Night pains. The cause is venous congestion, as well as an increase in intraosseous blood pressure.
- Joint blockages. Accompanied by sudden sharp pains. The cause of the blockade is the infringement of the articular mouse – a piece of cartilage or bone lying freely in the joint cavity.
Periods of exacerbations alternate with remissions. Exacerbations of arthrosis often occur against the background of increased stress, in this phase synovitis is detected, accompanied by another pain – constant, aching, bursting, independent of movements. Due to pain, the muscles of the limb reflexively spasm, which causes limited mobility.
Other symptoms of arthrosis
As the disease progresses, there is an increase in already existing manifestations and the emergence of new symptoms due to the gradual destruction of the joint:
- The crunch becomes more and more constant over time.
- At rest, muscle cramps appear, unpleasant sensations in the muscles and joint.
- Due to the increasing deformation and pronounced pain syndrome, lameness develops.
- With coxarthrosis at a late stage, the patient cannot sit due to the restriction of hip flexion.
When examined at early stages, visual changes are not detected. The joint is of normal shape, slight swelling is possible. With palpation, blurred or moderate soreness is determined. Movement is almost complete. Subsequently, the deformation becomes more and more noticeable, palpation reveals pronounced soreness, while the patient, as a rule, clearly marks the most painful points.
Thickening is determined along the edge of the articular gap. Movements are limited, instability in the joint is detected. A curvature of the limb axis may be detected. With the development of reactive synovitis, the joint is enlarged in volume, has a spherical appearance, soft tissues look “bulging”, palpation is determined by fluctuation (swell).
In the later stages of arthrosis, the deformation becomes even more pronounced, the joint bends, contractures are formed due to gross changes in bones and surrounding structures. Support is difficult, when moving a patient with arthrosis has to use a cane or crutches. The ability to work is limited, disability is possible.
The diagnosis is made by an orthopedic surgeon based on the characteristic clinical signs and X-ray picture of arthrosis. With gonarthrosis, an X-ray of the knee joint is performed, with coxarthrosis, pictures of the hip joint are taken, etc. The X-ray picture of arthrosis consists of signs of dystrophic changes in the area of articular cartilage and adjacent bone.
The articular gap is narrowed, the bone area is deformed and flattened, cyst-like formations, subchondral osteosclerosis and osteophytes are revealed. In some cases, signs of joint instability are detected: curvature of the limb axis, subluxations. The brightness of clinical manifestations does not always correlate with the severity of radiological signs of the disease, however, certain patterns still exist.
Taking into account radiological signs, specialists in the field of traumatology and orthopedics distinguish the following stages of arthrosis (Kellgren-Lawrence classification):
- Stage 1 (doubtful arthrosis) – suspected narrowing of the articular gap, osteophytes are absent or are present in small quantities.
- Stage 2 (mild arthrosis) – suspected narrowing of the articular gap, osteophytes are clearly defined.
- Stage 3 (moderate arthrosis) – obvious narrowing of the articular gap, there are clearly pronounced osteophytes, bone deformities are possible.
- Stage 4 (severe arthrosis) – pronounced narrowing of the articular gap, large osteophytes, pronounced bone deformities and osteosclerosis.
Sometimes X-rays are not enough to accurately assess the condition of the joint. CT is performed to study bone structures, and MRI is performed to visualize soft tissues. If there is a suspicion of a chronic disease that caused secondary arthrosis, consultations of appropriate specialists are prescribed: an endocrinologist, a hematologist, etc. If it is necessary to differentiate arthrosis with rheumatic diseases, the patient is referred for consultation to a rheumatologist.
The main goal of treating patients with arthrosis is to prevent further destruction of cartilage and preserve the function of the joint. Therapy is long-term, complex, includes both local and general measures. It is usually performed on an outpatient basis. During the period of exacerbation, especially in the late stages and with the development of persistent recurrent synovitis, hospitalization is possible.
One of the most important tasks of an orthopedic surgeon in the treatment of a patient with arthrosis is to optimize the load on the joint. It is necessary to exclude prolonged walking, repetitive stereotypical movements, a long stay on your feet, a long stay in a fixed position and carrying weights. A huge role in minimizing the load on the articular surfaces is played by a decrease in body weight in obesity.
During the period of remission, the patient is referred to physical therapy. The set of exercises depends on the stage of arthrosis. In the initial stages, swimming and cycling are allowed, with severe arthrosis, a specially designed set of exercises should be performed in a lying or sitting position. During the period of exacerbation of arthrosis, a semi-bed rest is prescribed. In the later stages, walking with crutches or a cane is recommended.
Medical treatment is carried out in the phase of exacerbation of arthrosis, selected by a specialist. Self-medication is unacceptable due to possible side effects (for example, the negative effect of nonsteroidal anti-inflammatory drugs on the gastric mucosa). Therapy includes:
- NSAIDs. Patients are prescribed diclofenac, ibuprofen and their analogues, sometimes in combination with sedatives and muscle relaxants. The dose is selected individually, taking into account contraindications. Along with medications for oral administration, intramuscular injections and rectal candles are used.
- Hormonal agents. With reactive synovitis, joint punctures are performed, followed by the introduction of glucocorticosteroids. The number of injections of GCS should not exceed 4 times during the year.
- Chondroprotectors. They belong to medicines for long-term use. The introduction of drugs into the joint is carried out according to a certain scheme. For topical use, warming and anti-inflammatory ointments are used.
To relieve pain, reduce inflammation, improve microcirculation and eliminate muscle spasms, a patient with arthrosis is referred to physical therapy:
- In the acute phase. Laser therapy, magnetotherapy and ultraviolet irradiation are prescribed,
- In remission. Electrophoresis with dimexide, trimecaine or novocaine, phonophoresis with hydrocortisone is shown.
In addition, thermal procedures, sulfide, radon and sea baths are used. Electrical stimulation is performed to strengthen the muscles. In the remission phase, gentle massage can also be used.
Operations for arthrosis are carried out in the late stages of the disease, with the development of severe complications that limit the patient’s ability to work. They can be radical or palliative:
- Radical interventions. In case of destruction of articular surfaces with pronounced dysfunction, replacement of the joint with an artificial implant is required. Hip replacement is most often performed to avoid severe disability of patients.
- Palliative techniques. They are used to unload the joint. With coxarthrosis, a transversal osteotomy and fenestration of the wide fascia of the thigh are performed, with gonarthrosis, arthrotomy of the knee joint is performed with the removal of non–viable areas of the articular surfaces in combination with osteotomy and correction of the axis of the lower leg.
Arthrosis is a chronic slowly progressive disease. It usually takes several decades from the appearance of the first symptoms to the appearance of pronounced functional disorders. Full recovery is impossible, but the timely start of treatment, the implementation of the doctor’s recommendations can significantly slow down the progression of the disease, maintain activity and ability to work.
Preventive measures include injury prevention, preparation of a well-thought-out training regime for athletes, weight loss in obesity, and minimally invasive joint operations. It is necessary to treat endocrine, metabolic and rheumatic diseases in a timely manner, which can cause arthrosis. People with a hereditary predisposition should follow a regime of moderate physical activity, but exclude excessive stress on the joints.