Osteoarthritis (OA), also known as osteoarthrosis, degenerative joint disease or occasionally hypertrophic arthritis, is a common joint pathology that seriously endangers the life and movement of middle-aged and elderly people. Its pathology is characterized by articular cartilage damage, reactive hyperplasia of articular margins, subchondral and perichondral bone, and the main clinical manifestations are slowly developing joint pain, stiffness, and enlargement with limited joint motion. The incidence of the disease increases with age, according to the X-ray survey: the incidence is 10% in the age group of 15 to 24 years, and up to 80% in the age group of >50 years, of which about 1/8 have symptoms and activity disorders. The incidence of OA and the type and number of joints involved differ with the region, occupation, lifestyle and genetic factors, in the Chinese OA is more frequent in the knee joint, hip rare.
(I) Etiology
According to the presence or absence of local and systemic pathogenic factors, osteoarthritis can be divided into two categories: primary and secondary. Primary osteoarthritis refers to those whose cause is still unclear, due to degeneration of joint cartilage, resulting in joint dysfunction, such as genetic factors, environmental factors, especially the aging process, normal wear and tear, chronic injury, obesity, diet, etc., may be the pathogenic factors. Secondary osteoarthritis refers to osteoarthrosis in which the degeneration and degeneration of articular cartilage from structural changes leads to joint dysfunction, such as trauma, inflammation, metabolism, etc. With the development of medical science and in-depth research on bone and joint, many osteoarthritis originally considered primary may be secondary to other disorders, and primary osteoarthritis may be further reduced.
(ii) Pathology
Osteoarthritis is not only a disease of the articular cartilage, but also involves the bone, synovium, and periarticular support structures. In its pathology, there is both degenerative degeneration and morphological repair of the joint, including repair of joint shape, redistribution of stresses on weight-bearing surfaces and reconstruction of stability.
In the early stages of OA, localized areas of articular cartilage soften and gradually rupture and fall off, a process called exfoliation. As the rupture surface expands, increased joint motion leads to increased wear and tear of the cartilage, exposing the underlying bone cortex. In these areas, repeated motion causes the subchondral bone to polish and become a shiny ivory-like surface, a process known as “osteochondrosis”. In severe cases, bone spurs may form around the joint and free bodies may be found in the joint.
(C) Diagnosis
1. Medical history: History of fracture, dislocation, articular cartilage injury, strain or deformity, and other orthopedic diseases. Gradual onset in middle-aged and elderly people may have no obvious history of trauma.
2. Clinical manifestations: The most significant symptom of osteoarthrosis is pain, and usually the symptoms and signs are limited to localization.
(1) Pain: Initially, the joints feel mildly inconvenient, and pain occurs after excessive exercise, which can be relieved after rest. When changing from one posture to another, the pain is inconvenient and painful at the beginning of the activity (such as when walking from sitting to standing), but the pain is relieved and the joints feel comfortable after a period of activity, but when overacting and walking a longer distance, the joints feel painful and restricted. When walking up and down steps, stairs, or on the bus, I feel pain and strain, and I need to grab the handrail with my hands to assist me in doing so. However, the pain may decrease after rest. In the late stage, the pain and muscle spasm increase and are persistent, and cannot be relieved quickly after rest. In this stage, nocturnal pain is common, as the cartilage is not innervated and insensitive to pain, and the pain comes from intra-articular and peri-articular structures. The pain comes from the intra-articular and peri-articular structures. Due to the damage of cartilage, the villi proliferate, causing joint adhesions, synovial congestion, thickening of the joint capsule, shortening of the joint capsule due to fibrosis, and pain caused by the stimulation of the nerves in the capsule when the joint moves;
(2) Frictional sound: In the early stage, a mild frictional sensation can be palpated when the joint moves, while in the late stage, a distinct sand-like frictional sensation can be palpated and accompanied by significant pain;
(3) joint effusion: secondary to synovitis, moderate joint effusion may occur;
(4) Restriction of movement: In the late stage, joint movement is restricted to varying degrees with increasing pain;
(5) Joint deformity: knee flexion or valgus deformity may occur, especially valgus deformity;
(6) Intra-articular free body: interlocking phenomenon occurs when the joint moves, especially in the knee joint.
3. Laboratory tests: normal or no special findings
4.X-ray performance
(1) Early stage: There are only mild degenerative changes in the articular cartilage, but there are no obvious changes on the X-ray;
(2) Progressive stage: further wear and tear of articular cartilage, irregularity of cartilage surface, narrowing of joint space, lip-like osteophytes at joint edges, osteosclerosis of joint surface, and degenerative cystic translucent areas in weight-bearing areas;
(3) Late stage: Increased cartilage destruction, joint space narrowing, and increased osteosclerosis at the joint edge, especially in the weight-bearing area. The joint is unstable and may have a tendency of subluxation. Free bodies can be seen in the joints.
5.Treatment
Treatment of osteoarthrosis varies with the location and degree of deformity. For the elderly, the wear and tear of articular cartilage, this degenerative change is a normal physiological response, but it does not mean that treatment is not needed. When people walk, gravity is shifted to both lower extremities and their weight is increased 3-4 times. Therefore it is best to use a cane to protect the joints. The use of a cane or crutches can reduce the weight bearing on the joints by 50%. Obese people should reduce their weight to reduce the pressure on the weight-bearing joints in order to protect the joints and prolong their life. The treatment is not to remove the bone but to relieve the pain and relieve the muscle spasm.
(1) Physical therapy should emphasize the following two points in the treatment: appropriate reduction of the burden of the weight-bearing joint, which is to reduce the pressure on the joint surface; reasonable functional exercise, which aims to improve the ability of the joint surface to withstand pressure.
(2) Drug treatment mostly uses anti-inflammatory and analgesic drugs, but also can be injected into the joint hormone to control the symptoms, injected into the sodium glass and other drugs to improve the condition of the joint cartilage surface.
(3) No matter which surgical method is used, the primary goal is to reduce pain or no pain; secondly, to make the patient have a stable joint; thirdly, to have a satisfactory range of motion. In short, to give the patient a joint that is close to normal, without pain and with movement.
For early stage patients, osteotomy and muscle release are commonly used to correct the deformity, change the line of force, improve blood circulation, reduce pain and promote joint surface repair; for advanced patients, joint fusion or arthroplasty can be used to eliminate or reduce symptoms and improve joint function. In recent years, artificial joint replacement has been used to treat osteoarthritis with satisfactory results, eliminating or reducing symptoms and restoring normal joint function. According to the American College of Rheumatology, the incidence of osteoarthritis in people over 65 years of age in the United States accounts for 80% of the total number of people, amounting to 16 million, and about 300,000 or more joint replacement surgeries are performed each year due to osteoarthritis.
I. Hip osteoarthritis
Osteoarthritis of the hip joint can be divided into two types, namely primary and secondary. Primary osteoarthritis of the hip joint refers to unknown causes, no genetic defects, no systemic metabolic and endocrine abnormalities; no history of trauma, infection, congenital deformity of the hip joint; mostly seen in obese patients over 50 years of age; often most joints are damaged, with slow development and a good prognosis, and primary osteoarthritis of the hip joint is less common in China. Secondary osteoarthritis of the hip joint refers to the presence of certain pathologies in the hip joint before the onset of the disease, such as hip fracture, dislocation, congenital dysplasia of the acetabulum, flat hip, slippage of the femoral head, Legg-Calve-Perthes disease, ischemic necrosis of the femoral head, hip joint infection, rheumatoid arthritis, etc.; secondary osteoarthritis of the hip joint is often limited to a single joint, the lesion progresses more rapidly, the onset of The prognosis is worse than that of primary osteoarthritis. It should be noted that the distinction between these two types of hip osteoarthritis in the early stages of the disease has practical implications for the choice of treatment and prognosis.
Despite the aforementioned differences between these two types of hip osteoarthritis, the clinical manifestations and pathological changes of these two types of osteoarthritis are the same in the later stages. The main manifestations are.
1, pain: early on, the site can be in the front or side of the hip or the inner thigh, often radiating to the sciatic nerve travel area, near the knee joint, due to the pain is very strong, often ignored the hip joint lesions;
2, stiffness: often appear in the early morning after waking up or during the day after a period of joint inactivity, and after activity joint pain is reduced, stiffness disappears, another characteristic is the short duration, generally not more than 15 minutes;
3.Dysfunction: In severe cases, flexion, external rotation and internal deformity may occur, and patients often find it difficult to walk, go up stairs or stand up from a sitting position;
4.X-ray performance: the joint space is narrowed to varying degrees, irregular, the joint surface is not smooth, even the subchondral bone contact, the femoral head becomes flattened, the neck becomes short and thick, the outer upper edge of the acetabulum and the bottom of the acetabulum are bony hyperplasia, which can cover most of the femoral head and make the acetabulum appear deeper. The femoral head may be subluxed outward and upward, and a cystic zone may appear in the weight-bearing area of the acetabulum and femoral head, accompanied by osteosclerosis in the weight-bearing area.
Treatment is the same as above.
Second, osteoarthritis of the knee joint
Osteoarthritis of the knee is a common disease and one of the main causes of knee pain. knee x-rays of people over 50 years of age often show signs of osteoarthritis, but they are not always symptomatic. This is normal whether primary or secondary, and is most often seen in women.
The occurrence of osteoarthritis of the knee is often associated with the following factors.
1, injury: intra-articular fracture, meniscal injury, patellar dislocation and other causes of articular cartilage damage;
2. Excessive weight bearing: excessive weight bearing on the joint surface due to obesity or internal or external deformity of the knee joint;
3. Infection or inflammation causing destruction of articular cartilage;
Subchondral bone necrosis, such as dry brittle osteitis occurs intra-articular free bodies, causing damage to the articular cartilage surface.
X-ray performance: early X-ray film is often negative, occasionally lateral film can be seen on the upper and lower edges of the patella with small bone spur hyperplasia. Later, the joint space is narrowed, the subchondral bone plate is dense, the joint edge and the intercondylar ridge are proliferated, and the subchondral bone is sometimes seen as small cystic changes, mostly round, with dense bone in the cyst wall. There is a significant difference between standing and recumbent x-rays of the affected knee.
It is classified into 5 levels according to its severity.
1, narrowing of the joint space;
2. Loss of joint line;
3. Mild bone wear;
4. Moderate bone wear;
5.Severe bone wear and joint subluxation.