Arthrosis is a chronic disease of a joint of degenerate and dystrophic character with gradual destruction of a cartilage, progressing of pathological changes in the capsule, a sinovialny cover, adjacent bones and sheaves. It is shown by pains, morning constraint and restriction of mobility. Over time the symptomatology is aggravated, at late stages there are heavy dysfunction of an extremity. The diagnosis is exposed on the basis of the anamnesis, yielded survey and results of a X-ray analysis. Treatment is usually conservative, includes LFK, anti-inflammatory medicines, physiotreatment, blockade. At destruction of articulate surfaces endoprosthesis replacement is carried out.
Arthrosis – a chronic disease at which in a joint because of violation of exchange processes the progressing degenerate and dystrophic changes develop. Damage of an articulate cartilage is the cornerstone of a disease, however, pathological process at arthrosis takes not only a cartilage, but also the next anatomic educations: the capsule, sheaves, a sinovialny cover located under a cartilage bone structures and circumarticular muscles.
Arthrosis – the most widespread disease of joints. According to the American physicians, in the States this disease is observed approximately at 7% of the population. The Russian experts sound almost same figures – according to large-scale researches 6,43% of Russians have arthrosis. Men and women have arthrosis equally often, however among young patients some prevalence of men, and among elderly – women is observed. An exception of an overall picture – arthrosis of interphalanx joints which develops at women by 10 times more often than at men.
With age incidence sharply increases. So, according to researches of the American doctors, arthrosis comes to light at 2% of people more young than 45 years, at 30% of people from 45 to 64 years and at 65-85% at aged people of 65 years and is more senior. First place on prevalence is won by arthroses of small joints of a brush, the first plusnefalangovy joint, lumbar and cervical departments of a backbone, coxofemoral and knee joints. Owing to the negative impact on the standard of living and working ability of patients arthroses of large and average joints of extremities have the greatest clinical value.
In some cases the disease arises without the visible reasons, such pathology 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: changes, injuries of meniscuses, ruptures of sheaves, dislocations.
- Dysplasia: congenital dislocation of a hip, congenital anomalies of knee and talocrural joints, joints of the top extremities.
- Metabolism violations.
- Autoimmune diseases: rheumatoid arthritis, system red wolf cub.
- Nonspecific inflammation: sharp purulent arthritis.
- Specific inflammation: tuberculosis, gonorrhea, syphilis.
- Some endocrine diseases.
- Degenerate and dystrophic processes: Pertes's disease and others of an osteochondropathy, the cutting osteochondrite.
- Diseases and states at which the increased mobility of joints and weakness of the copular device is observed.
- Diseases of system of blood: the hemophilia which is followed by frequent hemorrhages in a joint.
Are among risk factors of development of arthrosis:
- Advanced age.
- Excessive weight (at obesity because of the raised loading the joint constantly is overloaded, articulate surfaces prematurely "wear out").
- Excessive load of joints or certain joint. It can be caused by working conditions, the wrong organization of trainings (especially in the presence in the anamnesis of injuries of joint), some diseases, and also consequences of diseases and injuries (for example, lameness because of which load of a healthy leg increases, and when using a cane – and on a hand).
- Surgeries on a joint, especially high-traumatic operations with removal of a large amount of fabrics therefore articulate surfaces become incongruent, and load of them increases.
- Hereditary predisposition (presence of arthrosis at the immediate family).
- Violation of endocrine balance in a postmenopause at women.
- Deficiency of minerals.
- Neurodystrophic violations in cervical or lumbar departments of a backbone (plechelopatochny rearthritis, a syndrome lumbar muscles).
- Influence of toxic substances.
- Adverse ecological situation.
- The repeating joint microinjuries.
Arthrosis – a polietiologichesky disease at the heart of which, regardless of the concrete causes, violation of normal education and restoration of cells of cartilaginous tissue lies. The cartilage smooth, elastic is normal articulate. It allows articulate surfaces to move freely from each other, provides necessary depreciation and, thereby, reduces load of adjacent structures (bones, ligaments, muscles and the capsule).
At arthrosis the cartilage becomes rough, articulate surfaces begin "to cling" the friend to the friend at the movements. The cartilage razvoloknyatsya more and more. From it small pieces which get into a cavity of a joint separate and freely move in articulate liquid, injuring a sinovialny cover. In superficial zones of a cartilage there are small centers of calcification. In deep layers sites of ossification appear. In the central area the cysts which are reported with a joint cavity around which because of pressure of intra articulate liquid ossification zones are also formed are formed.
Because of a constant travmatization the capsule and a sinovialny cover of a joint at arthrosis are thickened. On a sinovialny cover fibers appear, in the capsule the centers of fibrous regeneration are formed. Over time owing to thinning and violation of a normal form and function of a cartilage the adjacent surfaces of a bone are deformed, at their edges bone ledges appear. Because of the raised loading in ligaments and muscles there are centers of fibrous regeneration. The probability of damage of the copular and muscular device (stretchings, anguishes, gaps) increases, sometimes the joint "goes" to a condition of an incomplete dislocation. At considerable destruction of a cartilage of the movement are sharply limited, formation of ankiloz is possible.
Taking into account localization distinguish arthroses humeral, elbow, luchezapyastny, talocrural and other joints. Depending on weight of defeat allocate three stages of pathology:
- The first stage – the expressed morphological changes are absent, only the composition of sinovialny liquid is broken. Liquid supplies cartilaginous tissue with nutrients worse, resistance of a cartilage to usual loadings decreases. Because of an overload of articulate surfaces there is an inflammation, pains develop.
- The second stage – articulate a cartilage begins to collapse, regional bone growths at the edges of the articulate platform appear. Pains become constant, habitual, inflammatory process calms down, escalates. Weak or moderate dysfunction of circumarticular muscles is noted.
- The third stage – articulate the cartilage is thinned, there are extensive centers of destruction. Considerable deformation of the articulate platform with change of an axis of an extremity is noted. Because of violation of a normal ratio between anatomical structures of a joint and extensive pathological changes in connecting tissue of a ligament become insolvent and are shortened owing to what pathological mobility of a joint in combination with restriction of natural volume of movements develops. Circumarticular muscles are stretched or shortened, ability to reduction is weakened. Food of a joint and surrounding fabrics is broken.
The disease develops gradually, gradually. In the beginning patients are disturbed by the mild short-term pains without accurate localization amplifying at physical activity. In certain cases the crunch at the movements more often expressed at a gonartroza and arthrosis of a shoulder joint becomes the first symptom. Many patients with arthrosis note feeling of discomfort in a joint and passing rigidity at the first movements after a dormant period. Over time pains become more and more expressed, there is a noticeable restriction of movements. Because of the raised loading the joint from the opposite side begins to hurt.
Pains – the most constant symptom of arthrosis. The brightest symptoms of pains at arthroses are connection with physical activity and with weather, night pains, starting pain and sudden sharp pains in combination with blockade of a joint. A certain rhythm of pain is directly connected with load of a joint. At long loading (walking, run, standing) of pain amplify, and at rest abate. It is caused by decline in the ability of a cartilage to provide depreciation at the movements. Venous stagnation, and also increase in intra bone pressure of blood is the reason of night pains. Pains amplify under the influence of adverse weather factors: the increased humidity, the low temperature and high atmospheric pressure.
The most characteristic symptom of arthrosis is starting pain – the pain which is arising during the first movements after a condition of rest and passing at preservation of physical activity. Becomes the reason of starting pains at arthrosis detrit – a film from components of the destroyed cartilaginous tissue which accumulates on articulate surfaces. As a result of movements detrit moves from a cartilage to zavorota of articulate bags therefore pains disappear. Blockade are sudden sharp pains and impossibility to make the movements in a joint. Infringement of an articulate mouse – a piece of the cartilage or a bone which is freely lying in a joint cavity is their reason. Except the listed types of pain, at development of a jet sinovit in patients with arthrosis there can be also other pain – the constant which is aching, holding apart, not depending on movements.
The periods of aggravations alternate with remissions. Exacerbations of arthrosis often arise against the background of the raised loading, at aggravations sinovita come to light. Because of pains of a muscle of an extremity spazmirutsya reflex that causes restriction of movements. The crunch in a joint becomes more and more constant. At rest muscular spasms and unpleasant feelings in muscles and a joint develop. Because of the accruing deformation of a joint and the expressed pain syndrome lameness develops. At late stages of arthrosis deformation becomes even more expressed, the joint is bent, the contractures caused by rough changes of bones and surrounding structures are formed. The support is complicated, at movement the patient with arthrosis should use a cane or crutches. At a coxarthrosis of the patient cannot sit because of restriction of bending of a hip.
At survey at early stages visual changes do not come to light. The joint of a normal form, is possible insignificant hypostasis. At a palpation unsharp or moderate morbidity is defined. Movements almost in full. In the subsequent deformation becomes more and more noticeable, at a palpation the expressed morbidity comes to light, at the same time the patient, as a rule, accurately notes the most painful points. Thickenings are determined by edge of an articulate crack. The movements are limited, instability in a joint is found. The extremity axis curvature can come to light. At development of a jet sinovit the joint is increased in volume, has a spherical appearance, fluctuation is palpatorno defined.
The diagnosis is exposed on the basis of characteristic clinical symptoms and a radiological picture of arthrosis. At a gonartroza the X-ray analysis of a knee joint is carried out, at a coxarthrosis pictures of a coxofemoral joint and so forth are carried out. The radiological picture of arthrosis consists of signs of dystrophic changes in area of articulate cartilages and an adjacent bone. The articulate crack is narrowed, the bone platform is deformed and flattened, kistovidny educations, a subkhondralny osteosclerosis and osteofita come to light. In certain cases at arthrosis signs of instability of a joint are found: extremity axis curvature, incomplete dislocations.
Brightness of clinical manifestations not always correlates with expressiveness of radiological symptoms of a disease. However certain regularities nevertheless exist. So, osteofita arise at early stages and usually are the first radiological symptom of arthrosis. In the beginning edges of articulate surfaces are pointed, in process of development of a disease all of them are more thickened, forming bone thorns and outgrowths over time. Narrowing of an articulate crack appears later. At the same time because of instability of a joint the crack can get a wedge form. Approximately at the same time the osteosclerosis of a subcartilaginous zone of a bone develops, in a bone tissue, adjacent to a joint, there are kistovidny educations. Taking into account radiological signs experts in the field of traumatology and orthopedics allocate the following stages of arthrosis (Kellgren-Lawrence classification):
- 1 stage (doubtful arthrosis) – suspicion on narrowing of an articulate crack, osteofita are absent or are available in a small amount.
- 2 stage (soft arthrosis) – suspicion on narrowing of an articulate crack, osteofita accurately are defined.
- 3 stage (moderate arthrosis) – obvious narrowing of an articulate crack, are accurately expressed osteofita, bone deformations are possible.
- 4 stage (heavy arthrosis) – the expressed narrowing of an articulate crack, large osteofita, pronounced bone deformations and an osteosclerosis.
Sometimes x-ray pictures are not enough for exact assessment of a condition of a joint. For studying of bone structures carry out KT, for assessment of a condition of soft fabrics – MRT. At suspicion appoint consultations of the corresponding experts to existence of the chronic disease which caused secondary arthrosis: endocrinologist, hematologist, gynecologist and so forth. If necessary to carry out differential diagnosis of arthrosis with rheumatoid diseases of the patient direct to consultation to the rheumatologist.
Treatment of arthrosis
Main objective of treatment of patients with arthrosis is prevention of further destruction of a cartilage and preservation of function of a joint. Therapy is long, complex, includes both local, and general actions. One of the most important tasks of the orthopedic surgeon at treatment of the patient with arthrosis is optimization of load of a joint. It is necessary to exclude long walking, the repeating stereotypic movements, long stay standing, long stay in the fixed pose and carrying of weights. The huge role in minimization of load of articulate surfaces is played by decrease in body weight at obesity.
During remission of the patient direct to physiotherapy exercises. The set of exercises depends on an arthrosis stage. In initial stages swimming and bicycle sport is allowed, at the expressed arthrosis it is necessary to carry out specially developed set of exercises in a prone position or sitting. In the period of an exacerbation of arthrosis the semi-bed rest is appointed. At late stages walking with crutches or a cane is recommended.
Drug treatment in a phase of an exacerbation of arthrosis includes purpose of nonsteroid resolvents (diclofenac, an ibuprofen), sometimes – in combination with sedative medicines and miorelaksant. The dose of NPVP is selected individually, taking into account contraindications. Along with medicines for intake intramuscular injections and rectal candles are appointed. In a phase of remission of arthrosis it is not recommended to accept NPVP because of their negative impact on digestive tract and metabolism of a cartilage. At jet sinovita punctures of joints with the subsequent introduction of glucocorticosteroids are carried out. At the same time the number of introductions of GKS should not exceed 4 times within a year.
Hondroprotektor belong to cure of long reception for arthrosis, introduction of medicines to a joint is carried out according to a certain scheme. For local application the warming and anti-inflammatory ointments are used. For knocking over of a pain syndrome, reduction of an inflammation, improvement of microcirculation and elimination of muscular spasms of the patient with arthrosis direct to physiotreatment. In a phase of an aggravation appoint laser therapy, magnetotherapy and ultra-violet radiation, in a remission phase – an electrophoresis with dimeksidy, trimekainy or novocaine, with a hydrocortisone. Apply thermal procedures, sulphidic, radonic and sea bathtubs. For strengthening of muscles carry out electrostimulation. In a remission phase the sparing massage can be also appointed.
At destruction of articulate surfaces with the expressed malfunction replacement of a joint with an artificial implant is required. Most often in clinical practice the endoprosthesis replacement of a coxofemoral joint allowing to avoid a heavy invalidization of patients is carried out. Palliative operations for unloading of a joint are in certain cases performed: at a coxarthrosis – a chrezvertelny osteotomiya and a fenestration of a wide fastion of a hip, at a gonartroza – an arthrotomy of a knee joint with removal of impractical sites of articulate surfaces in combination with an osteotomiya and correction of an axis of a shin.