Post-traumatic arthritis is an inflammatory lesion of the joint caused by its traumatization. It may develop immediately or some time after the injury. It is manifested by pain, edema, local hyperemia and hyperthermia. Synovitis and movement restriction are possible. Pathology is diagnosed on the basis of complaints, medical history, results of physical examination and additional studies: radiography, CT, MRI, ultrasound, laboratory tests. Treatment is conservative, NSAIDs, chondroprotectors, physiotherapy are used. In case of inefficiency, operations are sometimes shown.
Meaning
Post-traumatic arthritis accounts for about 15% of the total number of arthritis, it is detected in half of patients with a history of serious intra-articular injuries. Tissue damage is always accompanied by aseptic inflammation, however, acute phenomena often go unnoticed against the background of the main symptoms and do not require separate treatment. In clinical practice, chronic forms of the disease that occur a year or more after traumatization are more significant. Pathology is more often diagnosed in men 20-50 years old and women 30-60 years old.
Causes
Most often, post-traumatic arthritis occurs after intraarticular fractures, meniscus injuries and ligament ruptures. Less often, the disease develops against the background of bruises and sprains. Sometimes the trigger factor is repeated minor injuries or a single minor damage to a previously injured joint. The immediate cause is domestic, sports and street injuries, car accidents, etc.
In addition, the disease can develop after surgical interventions, especially the removal of menisci, which entails a violation of the congruence of articular surfaces. The first place in prevalence is occupied by knee injury, the second by the ankle. Post-traumatic arthritis of the shoulder, elbow and hip joints may occur. The interphalangeal, metacarpophalangeal, metatarsophalangeal and intervertebral joints rarely suffer.
The probability of the disease increases with immune disorders, the presence of severe somatic pathologies and diseases of the musculoskeletal system. With the involvement of the lower extremities, obesity plays a significant role, because of which the leg constantly suffers from overloads.
Pathogenesis
At the cellular level, inflammation develops even after minor injuries. Cells begin to produce cytokines, prostaglandins and other biologically active substances. In mild cases, the process is quickly stopped. In severe lesions, along with the release of inflammatory mediators, necrosis of chondrocytes is observed, due to destruction due to mechanical action. Nearby intact cells undergo autolysis.
Due to damage to cartilage tissue, inflammatory changes persist for a long time, become chronic, provoke degeneration. Cartilage tissue is replaced by connective tissue. Articular surfaces lose their smoothness, which causes constant microtraumatization and maintenance of the inflammatory process. Due to the decrease in the cushioning properties of cartilage, pressure and vibrations are transmitted to the underlying bone.
This leads to subchondral osteosclerosis and the appearance of growths that impair joint mobility. Osteoarthritis is formed. Despite the fact that the changes described above take many years, the most important is the first year after the injury – it is during this period that pathological changes occur in the cartilage, synovia and underlying bone, leading to the development of chronic arthritis.
Classification
Taking into account the peculiarities of the course and nature of the changes, there are three forms (stages) of post-traumatic arthritis:
- Spicy. It is diagnosed during the first 2 months. It acquires clinical significance in small lesions accompanied by pronounced manifestations of arthritis. As a rule, it has an aseptic character, with wounds and after operations it can transform into purulent arthritis.
- Subacute. It is formed in the period from 2 months to 1 year after a traumatic injury. Indicates a high probability of subsequent chronization of the pathological process. It requires complex therapeutic measures.
- Chronic. The most common option. Manifests after a year or more (sometimes after decades). It is characterized by a gradual onset and undulating course with slow progression, deterioration of joint function and transformation into osteoarthritis.
Symptoms
The clinical picture is determined by the severity of the injury and the form of the disease. A patient with acute post-traumatic arthritis complains of joint pain. The general condition is satisfactory. The examination reveals swelling of soft tissues, redness of the skin and local hyperthermia. Hemarthrosis is possible, sometimes replaced by synovitis. Palpation is painful, movements are limited. The severity of the manifestations does not correspond to the severity of the damage.
With purulent post-traumatic arthritis, against the background of open lesions, rapidly increasing intense pains are observed, which after a while become twitching or pulsating, deprive of a night’s sleep. The joint is edematous, hot, hyperemic. Movements and groping are sharply painful. The function is significantly reduced due to the pain syndrome. Along with the swelling in the affected area, the swelling of the underlying segment is determined, caused by compression of the lymphatic vessels.
There is a pronounced general intoxication with febrile temperature, chills, and often hectic fever. Patients complain of bruising, severe weakness, headache. In severe cases, disturbances of consciousness are possible. Objectively, the limb is edematous, especially in the joint area. In the affected area, the skin is hyperemic, below – cyanotic. Palpation and movements are sharply painful.
Subacute post-traumatic arthritis is more often observed against the background of quite serious injuries. After the disappearance of acute phenomena caused by trauma, the joint remains edematous, painful, hyperemic. Due to the persisting symptoms, the rehabilitation period is lengthened, difficulties arise in the development of the limb. Synovitis is possible.
For a chronic traumatic process, mild symptoms are typical. Patients note minor soreness, which increases over months or years. The pain syndrome may disappear and then reappear. Edema is small, hyperemia is often absent. The joint crunches when moving. Subsequently, the pain becomes permanent, causing a decrease in mobility. Deformations occur. Pain contracture is replaced by a persistent restriction of movements due to the overgrowth of bone and fibrous tissue.
Complications
Traumatic purulent inflammation can be complicated by phlegmon of the limb. A dangerous negative consequence that poses a threat to the patient’s life is the spread of infection with the development of sepsis. The negative consequences of chronic arthritis are arthrosis, contractures and ankylosis. Limited mobility and reduced support function can lead to partial or complete disability.
Diagnostics
The definition of the acute phase of post-traumatic arthritis is the responsibility of traumatologists. Chronic changes are detected by orthopedists or rheumatologists. The examination program includes diagnostic measures such as:
- Radiography. In acute aseptic processes, it is prescribed to exclude damage to solid structures, there are no non-traumatic changes. With purulent inflammation, narrowing or expansion of the articular gap, erosion of the subchondral bone, periarticular osteoporosis are detected. For the chronic process, along with osteoporosis, erosions and narrowing of the articular gap, periarticular cysts are characteristic.
- Ultrasonography. Confirms synovitis or hemarthrosis, allows you to estimate the amount of fluid. It visualizes soft tissues well, which makes it possible to determine the degree of interest of paraarticular structures, to identify signs of inflammation that are not accompanied by clinical symptoms.
- CT and MRI. They are carried out at the final stage of the diagnostic search. They are prescribed to clarify the severity and nature of the pathological process with insufficient information content of basic techniques, the need to choose the tactics of surgical intervention.
- Laboratory tests. According to the general blood examination and synovial fluid microscopy, the presence of inflammation is confirmed. In patients with chronic pathology, changes in the UAC are often absent. If infection is suspected, culture is carried out on nutrient media to determine the type of pathogen and its sensitivity to antibiotics.
Traumatic inflammation is distinguished from other types of arthritis: rheumatoid, gouty, psoriatic, etc. Within the framework of differential diagnostics, data from visualization techniques are taken into account, the level of rheumatoid factor, uric acid, and other laboratory parameters are examined.
Treatment
Conservative therapy
Therapeutic algorithms are made taking into account the form and severity of the disease. The main goals are to prevent the transition of acute form to chronic or slow down the progression at the stage of chronization, eliminate pain and improve joint function. According to the indications, immobilization is carried out. As part of drug therapy, prescribe:
- NSAIDs. Recommended for both acute and chronic post-traumatic arthritis. Eliminate pain, suppress inflammation. They are used in the form of tablets, intramuscular injections and topical remedies.
- Antibiotics. They are indicated for signs of infection. Initially, broad-spectrum drugs are used, then the antibiotic therapy scheme is adjusted taking into account the result of microbiological examination.
- Glucocorticoids. They are used in the chronic course of the disease. They are necessary when NSAIDs are ineffective. They are injected into the joint cavity or paraarticular tissues in short courses (no more than 3 injections) with a break between courses of at least six months.
- Chondroprotectors. Activate the metabolism of cartilage tissue, promote its recovery, reduce the number of inflammatory mediators, normalize the composition of synovial fluid.
Patients are prescribed physiotherapy, massage and physical therapy. In case of traumatic injuries in the acute phase, electrophoresis with novocaine is effective, after the elimination of acute phenomena – laser therapy, magnetotherapy, balneotherapy, applications with ozokerite and paraffin.
Surgical treatment
It is indicated for septic post-traumatic arthritis, the development of complications. Patients with empyema and severe intoxication require emergency arthrotomy followed by drainage. With sepsis, joint resection is necessary. Patients with contractures undergo capsulotomy, arthrolysis or arthroplasty. If it is impossible to restore function, the limb is fixed in a functionally advantageous position by arthrodesis or endoprosthetics is performed.
Forecast
With the correct selection of therapeutic measures, the absence of changes that provoke permanent injury of the joint, acute and subacute arthritis that have arisen against the background of traumatic injuries can result in complete recovery. With chronic processes, prolonged remissions are possible. At the same time, this type of disease is prone to faster progression compared to other forms of arthritis.
Prevention
The main method of prevention is timely adequate treatment of traumatic injuries. In case of any damage to the joint, it is necessary to consult a traumatologist. During the recovery period, it is important to follow all the doctor’s recommendations. People who have suffered appropriate injuries and episodes of acute arthritis should avoid overloading the joints, control body weight, perform exercise therapy complexes, and receive anti-relapse treatment according to indications.
