Osteoarthritis (OA) is one of the most common joint diseases. It is a chronic joint disease characterized by degeneration and destruction of joint cartilage and osteophytes. The disease is associated with aging, obesity, inflammation, trauma, joint overuse, metabolic disorders, and genetics.
OA is more prevalent after middle age and is more common in women than men. The prevalence of the disease is 10%-17% in people aged 40 years, 50% in people aged 60 years or older, and up to 80% in people aged 75 years or older. The disease has a certain rate of disability.
The disease is divided into primary OA and secondary OA according to the cause. the former refers to OA of unknown origin, and genetic and physical factors have a certain relationship, mostly seen in the middle-aged and elderly; the latter refers to secondary to joint trauma, congenital or genetic diseases, endocrine and metabolic diseases, inflammatory joint disease, endemic joint disease, other bone and joint. Diseases, etc. Sometimes it is difficult to distinguish primary OA from secondary OA. consultation and physical examination can help determine the cause. Imaging tests can help to diagnose secondary OA. The disease is divided into symptomatic OA and radiological OA according to whether there are clinical symptoms. the former is accompanied by obvious clinical symptoms of OA, while the latter has no clinical symptoms only x-ray OA performance.
I. Clinical manifestations
1, common symptoms and signs
The disease is common in the knee, hip, hand (distal interphalangeal joint, the first carpometacarpal joint), foot (the first metatarsophalangeal joint, heel), spine (cervical and lumbar spine) and other weight-bearing or more active joints.
(1) Joint pain and pressure pain: The most common manifestation of this disease is localized pain and pressure pain in the joints. The weight-bearing joints and hands are most likely to be involved. The pain is usually mild or moderate in the early stage. It improves with rest and worsens with activity. As the disease progresses, persistent pain may occur. It may lead to restriction of movement. There may be localized pressure pain in the joints, especially when there is swelling in the joints. The pain may increase in cold, wet and rainy days.
(2) Enlargement of the joint: In the early stage, there is limited swelling around the joint, but as the disease progresses, there may be diffuse swelling of the joint, thickening of the bursa or joint effusion. In the later stage, bone flab can be detected in the joint area.
(3) Morning stiffness: Patients may experience stiffness in the morning or after the joint has been stationary for a period of time, which may be relieved after activity. The duration of morning stiffness is usually a few minutes to ten minutes, and rarely exceeds 0.5 hours.
(4) Joint friction sound (feeling): Mostly seen in the knee joint. Due to the destruction of cartilage and roughness of the joint surface, a bone friction sound (sensation) occurs when the joint is moved.
(5) Restricted joint movement: joint weakness and restricted movement due to joint swelling and pain, reduced activity, muscle atrophy, soft tissue contracture, etc. It occurs slowly, with early manifestations of joint immobility. Later, the range of motion of the joint decreases. Also town because of the free body or cartilage fragments in the joint when the activity of the “lock” phenomenon.
2, the performance characteristics of different parts of OA
(1) hand: the most common involvement of the distal phalangeal joint, manifesting as a common joint disease on the extensor side of the joint. Group of people over the age of help Ming. More painful extension joint surface 0.06.015 of both sides of the bony enlargement. Called Heberden (Heberden) nodes. And the proximal finger extensor side appears is called Bouehard (Bouehard) nodes. It may be accompanied by mild erythema, pain and tenderness of the node. When the first carpometacarpal joint is involved, osteophytes at its base may result in square hand deformity, while finger joint hyperplasia and lateral subluxation may result in snake-like deformity.
(2) Knee: Involvement of the knee pod joint is the most common in clinical practice. Risk factors include obesity, knee trauma and meniscectomy: the main manifestation is knee pain, which is aggravated by activity, more pronounced after descending stairs, and relieved after rest. In severe cases, internal or external knee deformity may occur. The joint is locally swollen, painful and limited in flexion and extension, and most of them have bone friction sounds.
(3) Hip: more men than women are involved in the hip joint. Unilateral more than bilateral. The pain is mostly localized as intermittent dull pain, which may become persistent with the development of the disease. In some patients, the pain can be radiated to the groin, inner thighs and buttocks. The hip joint movement disorders are mostly in internal rotation and external booth, followed by limitation of internal retraction, external rotation and extension. Gait abnormalities may occur.
(4) Foot: The metatarsophalangeal joint is often involved, and local pain, pressure pain and bony large may appear, as well as deformities such as kitchen exostosis in the town. Bone spurs may appear on the bottom of the foot, causing difficulty in walking.
(5) Spine: involvement of the cervical spine is more common, and the third and fourth vertebrae of the lumbar spine are the most frequent sites. There may be hyperplasia and osteophytes of the vertebral body and posterior synovial joints, causing local pain and stiffness, and corresponding radiological pain and neurological symptoms in the town when the local blood vessels and nerves are compressed. Cervical spine involvement compressing vertebral a basilar artery can cause symptoms of cerebral blood supply deficiency. Intermittent claudication and cauda equina syndrome can occur when lumbar spine osteophytes lead to spinal stenosis.
3, the performance of special types of OA characteristics of this type of OA is primary OA
(1) primary systemic OA: the distal interphalangeal joints, the proximal interphalangeal joints of the first carpometacarpal joint as the preferred site. Knee, hip, metatarsophalangeal joints and spine can also be involved. Symptoms are episodic and may include effusion, redness and swelling of the affected joints. They are classified into two categories based on clinical and epidemiological features.
(1) Nodular type: the distal interphalangeal joints are mainly involved, and it is more common in women, with family clustering.
The non-nodular type: the proximal interphalangeal joints are predominantly involved, and the gender and family clustering are not obvious, but there is often recurrent peripheral arthritis. Severely affected patients may have increased erythrocyte sedimentation rate (ESR) and increased C-reactive protein (CRP).
(2) Erosive inflammatory OA: common in postmenopausal women. Mainly involving the distal and proximal interphalangeal joints and carpometacarpal joints. There are familial and recurrent acute attacks. Pain and tenderness in the affected joints eventually lead to joint deformity and ankylosis. Synovial examination of the patient reveals marked proliferative synovitis, immune complex deposits and vascular opacification. A small number of patients eventually develop rheumatoid arthritis (RA). X-rays show marked osteoid production and subchondral osteosclerosis. In the late stage, bone erosion and bony ankylosis of the joint are evident.
(3) Diffuse idiopathicskeletalhyperostosis (DISH): a specific type of spinal osteophyte, which is more common in middle-aged and elderly men, with more obese people. The lesion involves the entire spine, especially the cervical spine, with diffuse osteophytes, extensive hyperplasia and ossification of the spinal ligaments, and adjacent osteo-cortical hyperplasia. However, the small vertebral joints and intervertebral discs remain intact. ～In general, there are no obvious symptoms, but a few patients may have symptoms such as shoulder and back pain, stiffness, numbness of fingers or lumbar pain, and the corresponding manifestations of spinal stenosis may appear when the lesion is serious. x-ray can be seen characteristic calcification of the anterior longitudinal and posterior longitudinal ligaments of the vertebral body, mainly in the lower thoracic segment, usually four or more consecutive vertebral bodies, which may be accompanied by extensive osteophytes.
4.Auxiliary examination
(1) laboratory tests: patients with synovitis may have mildly elevated CRP and ESR. Patients with secondary OA may H{present abnormalities in the experimental narrow tests of the primary disease. Synovitis may be present with joint effusion. ～Generally, the joint fluid is clear, yellowish, and has a normal or slightly decreased viscosity, but the mucin is well coagulated. It may show mild leukocytosis, with predominantly single nucleated cells. Synovial fluid analysis can help to exclude other joint diseases.
(2) Imaging: Imaging not only helps to confirm the diagnosis of OA, but also helps to assess the severity of joint damage, evaluate disease progression and response to treatment, and early detection of disease or related complications. x-ray is a routine examination, and the characteristic radiological manifestations are: subchondral bone sclerosis, subchondral cystic changes and bone formation, joint space narrowing, etc. In severe cases, joint deformation and subluxation. These changes are an important basis for the diagnosis of OA. There is no strict correlation between the severity of radiological manifestations and the severity of clinical symptoms and functional status, and many joints with significant imaging changes do not have typical symptoms. Many joints with significant imaging changes do not have typical symptoms, while joints with typical symptoms have only minor imaging changes. The narrowing of the joint space is not only due to reduced articular cartilage content, but meniscal damage and cartilage compression are also important. Magnetic resonance imaging is not commonly used and is only useful for detecting lesions in joint-related tissues. For example, cartilage damage, synovial fluid leakage, subchondral bone marrow edema, synovitis and meniscal or ligament damage; it can also be used to rule out tumors and ischemic osteonecrosis. Ultrasound helps to detect small amount of joint exudate, synovial proliferation, bony bulge, carcass fossa cyst, inflammatory reaction, and also helps to identify erosive and non-erosive OA of the hand.
Second, the main points of diagnosis
1, diagnostic criteria: the diagnosis of OA is based on the patient’s symptoms, signs, imaging and laboratory tests. The current use of the American Sleepy Rheumatism Association 1995 revised diagnostic criteria, the criteria include clinical and radiological criteria (see Table 1-3). Among them, the hand OA classification criteria in particular radiological changes. Its sensitivity is 92% and specificity is 98%. The sensitivity and specificity of the knee OA classification criteria were 91% and 86%, respectively. The sensitivity and specificity of the hip OA classification criteria were 91% and 89%, respectively. The classification criteria are more significant for distinguishing OA from inflammatory arthropathy, but have limited significance for the diagnosis of early OA.
2.Differential diagnosis
This disease needs to be differentiated from the following diseases.
(1) RA: mostly symmetrical small arthritis. The proximal interphalangeal and metacarpophalangeal joints and wrist joints are mainly involved. The morning even obvious. There may be subcutaneous nodules. The rheumatoid factor (RF) is positive. x-ray is dominated by erosive joint changes.
(2) Ankylosing spondylitis (AS): This disease is most likely to occur in young men. The main invasion of the sacroiliac joint and spine. It also involves the knee, manic, hip joints, often accompanied by tendonitis. The patient often has inflammatory lower back pain at the same time, and radiological examination of the rubella shows sacroiliac arthritis, often with human leukocyte antigen (HLA) a B27 (+).
(3) psoriatic arthritis: the disease is most common in middle-aged people, with a slow onset, mainly involving the distal interphalangeal joints, metacarpophalangeal joints, metatarsal joints, knee and wrist joints and other extremity joints, the joint lesions are often asymmetrical, and there may be joint deformities. The skin and finger (toe) nail changes of psoriasis may appear during the course of the disease.
(4) Gouty arthritis: This disease occurs mostly in middle-aged men and above, often manifesting as recurrent acute arthritis, most often involving the first metatarsophalangeal joint and tarsal joint, but also invading the knee, ankle, elbow, wrist and hand joints, manifesting as joint redness, swelling, heat and severe pain, with elevated blood uric acid levels and urate crystals detected in synovial fluid. In chronic cases, kidney damage may occur, and gout stones may appear around the joints and in the auricle and other areas.
III. Treatment
The purpose of treatment is to relieve pain, stop and delay the progression of the disease, protect joint function and improve the quality of life. The treatment plan should be individualized. The treatment plan should be individualized, taking into account the patient’s risk factors, the location of the affected joints, structural changes in the joints, inflammation, pain, co-morbidities and other specific conditions. The principle of treatment should be non-pharmacological treatment combined with pharmacological treatment, and if necessary, surgery.
1.Non-pharmacological treatment
Non-pharmacological treatment has a very important role in the treatment of OA. Including patient education, exercise, life guidance and physical therapy.
(1) patient education
(1) patient education ① to make patients understand that the majority of the disease has a good prognosis, to eliminate the burden on their minds.
(2) Advise patients to avoid various factors that are unfavorable to the treatment of the disease and establish a reasonable lifestyle. Such as protecting the affected joints, avoiding prolonged standing, kneeling and squatting, climbing stairs, poor posture, etc.
③Regulate the use of medication under the guidance of physicians and understand the usage and adverse effects of the drugs used.
(4) Family and social support and help play a positive role in the treatment of patients.
(2) Exercise and life guidance
(1) Reasonable joint and muscle exercises: the joints are moved under non-weight-bearing condition to maintain joint mobility; exercises of relevant muscles or muscle groups are carried out to enhance muscle strength and increase joint stability.
②Different exercises for different affected joints, such as grasping and gripping exercises for hand joints, flexion and extension activities for knee joints under non-weight-bearing conditions, and gentle activities in different directions for cervical and lumbar joints.
③ Aerobic exercise: walking, swimming, cycling, etc. can help maintain joint function.
(iv) Obese people should reduce body mass: being overweight increases the burden on the joints and standard body mass should be maintained.
⑤ Reduce the load on the involved joints: canes, walkers, etc. can be used to assist with activities.
⑥Protect the joint: wear an elastic sleeve to protect the joint, such as a knee brace; use medial patellar ligature treatment for patellofemoral joint OA to significantly reduce pain; avoid wearing high heels. Wear soft, flexible “sports shoes”, use suitable insoles, and use wedge-shaped insoles to assist in the treatment of medial compartment OA of the knee joint.
(3) Physiotherapy
The main purpose of physiotherapy in the acute phase is to relieve pain, reduce swelling and improve joint function; the purpose of physiotherapy in the chronic phase is to enhance local blood circulation and improve joint function. Physiotherapy can reduce pain symptoms and relieve joint stiffness, including acupuncture, massage, tui-na, heat therapy, hydrotherapy, etc.
2.Medication
Mainly divided into symptom control drugs, drugs to improve the condition and cartilage protection agents.
(1) Symptom control drugs
According to the route of administration, they are divided into several doses, injections and local topical drugs.
Oral drugs.
① Acetaminophen: Because the elderly are prone to adverse reactions to non-steroidal anti-inflammatory drugs (NSAIDs), and synovitis in OA is not a major factor in the early stages of the disease. Therefore, mild cases can be short-term use of general analgesics as the drug of choice, such as acetaminophen, 0.3 plus 6 g each time. 2-3 times a day orally, the daily dose does not exceed 4 go main adverse effects are gastrointestinal symptoms and hepatotoxicity.
②NSAIDs: NSAIDs have both analgesic and anti-inflammatory effects, and are the most commonly used class of drugs to control the symptoms of OA. Mainly through the inhibition of cyclooxygenase activity, reduce prostaglandin synthesis, play a role in reducing pain and swelling caused by joint inflammation, improve joint movement. The main adverse effects include gastrointestinal symptoms, renal or hepatic impairment, impact on platelet function, and increased risk of cardiovascular adverse events.NSAIDs should be used at the lowest effective dose for a short course of treatment; selective cyclooxygenase (COX)-2 inhibitors or non-selective NSAID misoprostol or proton pump inhibitors should be used for those with gastrointestinal risk factors. In conclusion, the choice of drug class and dose should be individualized, taking into account the individual patient’s underlying conditions, and attention should be paid to both cardiovascular and gastrointestinal risks in elderly patients. See the RA chapter for specific drug applications.
(③) Opioids: For patients with acute pain episodes, when acetaminophen and NSAIDs do not provide adequate pain relief or are contraindicated, weak opioids can be considered, which are better tolerated and less addictive. For example, oral codeine or tramadol have no significant adverse effects on the gastric mucosa because tramadol does not inhibit prostaglandin synthesis. This class of preparations should be started at low doses and slowly increased every few days to reduce adverse effects.
Injectable drugs.
①Glucocorticoids: Long-acting glucocorticoids injected into the joint cavity can relieve pain and reduce exudation. The effect lasts for several weeks to months, but the injection should not be repeated in the same joint, and the interval between injections should not be shorter than 4 coincidental months.
Hyaluronic acid (vitreous acid): non-pharmacologic therapy and simple pain relief stab is not effective in knee OA can be treated with intra-articular crutches hyaluronic acid (vitreous acid) type of preparation. To reduce joint pain, increase joint mobility, protection of cartilage are effective, the treatment effect can last for several months. It has good efficacy in mild to moderate OA. Intra-articular knee injections are given once a week for 4 to 6 weeks. The frequency of injections can be adjusted according to the patient’s symptoms. (③) NSAIDs: Intramuscular injection has a rapid onset of action, and gastrointestinal reactions are not obvious.
Topical topical drugs.
①NSAIDs: topical topical NSAIDs system to reduce joint pain. Small adverse reactions.
②Capsaicin: Capsaicin emulsion can consume substance P of local sensory nerve endings. It can reduce joint pain and pressure pain.
(2) slow-acting osteoarthritis drugs (DMOAD) and chondroprotective agents such drugs generally have a slow onset of action. It takes several weeks of treatment to see results. Therefore, it is called osteoarthritis slow-acting drugs. It has the effect of reducing the activity of matrix metalloproteinases, collagenases, etc., both town anti-inflammatory, analgesic, and can protect joint cartilage, and has the effect of delaying the development of OA. However, there is no recognized ideal drug, commonly used drugs glucosamine, diacetin, chondroitin sulfate, etc. may have some effect.
Glucosamine: Amino pavement glucose is a natural amino monosaccharide, which is an important component necessary for the synthesis of proteoglycans in the matrix of human articular cartilage. It can improve the metabolism of articular cartilage and enhance the repair ability of articular cartilage. It protects the damaged articular cartilage, relieves the pain symptoms of OA, improves joint function, and delays the pathological process and disease process of OA. Thus, it has both symptom modulating and structural modulating effects. Glucosamine house to have glucosamine sulfate and glucosamine hydrochloride, the two glucosamine content differences, but the biological effects are similar. The usual dose should not be <1500 mg/d, otherwise the efficacy is poor. It should be divided into 2-3 doses and last for more than 8 weeks to show efficacy, and the efficacy is more stable if used for more than 1 year, and can be used in combination with NSAIDs.
Chondroitin sulfate: By competitively inhibiting the activity of degradative enzymes. Reduce the destruction of cartilage matrix and synovial fluid components; by reducing the formation of fibrin thrombus. Improves blood circulation in synovial membrane and subchondral bone. Effective in reducing the symptoms of OA, alleviating pain, improving joint function and reducing the dosage of NSAIDs or other pain medications. Adults take 1200mg orally daily.
Glucosamine acts synergistically in combination with chondroitin sulfate. Glucosamine stimulates the synthesis of cartilage matrix, while chondroitin sulfate inhibits its degradation. The combination of the two can increase the content of cartilage matrix, which can more effectively protect articular cartilage, reverse damage and promote damage repair. Therefore, it can slow down the development of OA and reduce the symptoms.
Diacerein: Diacerein is an inhibitor of endocytosis (IL). It can inhibit cartilage degradation, promote cartilage synthesis and inhibit synovial inflammation. It can not only effectively improve the symptoms of osteoarthritis. It reduces pain and improves joint function. And has a follow-up effect, after 3 months of continuous treatment, the effect can last at least 1 month; it can also delay the progress of OA disease, with structural regulation. The drug does not inhibit the synthesis of prostaglandin. Adult dosage: 50 mg twice daily with meals, usually taken for at least 3 months.
Doxycycline: It has the effect of inhibiting matrix metalloproteinase, which can exert anti-inflammatory effect, inhibit the production of nitric oxide and reduce the effect of bone resorption. It may reduce cartilage destruction in OA. 100 mg per dose, orally 1-2 times daily.
Bisphosphonates: The main mechanism of action in OA treatment is to inhibit the dissolution of minerals by osteoblasts while preventing the efflux of minerals. It also inhibits collagenase and prostaglandin E,, thus reducing bone flab formation.
Vitamins A, C, E, D: Cartilage damage in OA may be related to the action of oxygen free radicals, and recent studies have found that vitamins A, C, and E may be beneficial in the treatment of OA mainly through their antioxidant mechanisms. Vitamin D plays a role in the treatment of OA through its effect on bone mineralization and cell differentiation.
3.Surgical treatment and other treatments
For patients who have no obvious effect by medical treatment, serious lesions and obvious joint dysfunction can consider surgical treatment to correct deformity and improve joint function. The main way of surgical treatment is through arthroscopic surgery and open surgery.
(1) Arthroscopic surgery
If medical treatment is not effective, intra-articular lavage can be performed to remove fibrin, cartilage debris and other impurities, which is called joint debridement; or arthroscopic removal of cartilage fragments to reduce symptoms, which is called free body removal.
(2) Surgical treatment
(1) Osteotomy: It can improve the balance of joint force lines and effectively relieve the patient’s hip or knee pain.
(2) Human T arthroplasty: for patients over 60 years old with progressive OA who do not respond well to regular drug treatment, joint replacement can be performed, which can significantly reduce pain symptoms and improve joint function.
(iii) Joint fusion.