What is osteoarthritis?
Osteoarthritis (OA) is also known as age-related arthritis, degenerative arthritis, and osteoarthropathy. The disease can involve most joints in the body, more often involving the lumbar spine, interphalangeal joints and lower limb weight-bearing joints such as the knee, hip, etc., and the clinical incidence of the knee is the highest, the greatest impact on the quality of life of patients. Various orthopedic books have been quite rich in the introduction of OA, this article is only the author’s clinical treatment of osteoarthritis of the main knee joint, a little bit of light opinion for your reference. Beijing 301 Hospital Orthopedics Cai OA is mostly seen in the elderly, the incidence of elderly people over 60 years of age up to 40% -50%, more women than men, especially in postmenopausal women. Because the disease in the early stage of only mild joint pain as a manifestation, patients do not have a high rate of consultation, when the disease develops to an advanced stage of severe joint pain, joint deformity, functional limitations, limited treatment methods, seriously affecting the quality of life of the elderly.
What are the causes?
The cause of osteoarthritis is not yet fully understood, some OA related to trauma, congenital deformity, infection, metabolic and neurological diseases, called secondary OA. most OA lacks a clear cause, called primary OA, mostly related to genetics, heavy physical labor and aging. These causes can lead to disturbances in the biomechanical environment of the joint, degeneration and destruction of articular cartilage, and ultimately affect the subarticular bone with painful symptoms and joint deformity. The following causes can contribute to the development of OA.
Aging primary OA is common in the elderly, but the disease test evidence that OA does not occur in some elderly people, so OA is not the inevitable result of aging, age increases only increases the risk of OA occurrence chondrocyte and matrix anabolic balance is disrupted in the articular cartilage cartilage in the cartilage tissue surrounded by a proteoglycan matrix, there is a continuous balance between synthesis and degradation of chondrocytes and matrix, and the metabolic balance is affected by The metabolic balance is regulated by joint fluid growth factors and enzymes. Alterations in any of these factors can cause OA.
Altered joint mechanics
1, local factors of cartilage damage are abnormal loading, including one-time overload stress and repeated multiple injury stress (such as overweight), which can cause cartilage degeneration, reduced shock absorption performance and sclerosis of subchondral bone.
2, the loss of cartilage lubrication and shock absorption will cause local subchondral bone sclerosis and osteophytes.
3, ligament, meniscal damage and cartilage wear caused by joint instability will also accelerate the development of OA how to diagnose and differential diagnosis?
The diagnosis of most osteoarthritis is not difficult and is made mainly through symptoms, signs and imaging examinations. In a few atypical cases, blood tests are required to differentiate the disease from rheumatoid arthritis, spondylitis and other autoimmune diseases. Here is how to quickly and accurately diagnose osteoarthritis when seeing patients in the outpatient clinic.
Diagnosis of osteoarthritis should begin when the patient enters the clinic. Because of the low rate of early consultation of patients with osteoarthritis in China, most of the patients who come to the hospital are late stage patients, and most of these patients have some common features: “mostly elderly women, most are heavier or can be seen to have a long history of physical labor, joint deformity (“O “shaped legs), limping or requiring instrumental assistance to walk.” The above characteristics will give the physician an initial impression as soon as the patient steps into the office. The following is a brief description of the diagnostic symptoms of osteoarthritis of the knee in terms of symptoms, signs, and ancillary tests. Patients with osteoarthritis of the knee commonly complain of pain in the knee, mostly bilateral, with varying degrees of bilateral pain, which can be alternately worse and cannot be specified in terms of location and nature. The pain occurs after walking, and the walking distance is gradually reduced as the disease worsens. Patients may also experience morning stiffness, resting pain and nocturnal pain.
Early in the course of the disease, there may be no signs, but as the disease progresses, swelling and deformity of the knee joint may occur. Inversion and flexion deformities predominate.
The primary imaging test for knee OA is a standing front and side x-ray of the knee, which should include the femur and mid tibia. The reason for emphasizing the standing position is that when the affected knee is loaded with weight, we can clearly observe the narrowing of the joint space and changes in the force lines of the lower extremity. The normal joint space and lower extremity force lines can still be seen in the prone position, which can affect the severity of the disease. Note that rotation and flexion of the lower extremity can affect the determination of normal lower extremity force lines during orthopantomographs. The main manifestations of knee OA on orthopantomographs are narrowing or loss of joint space, abnormal lower extremity force lines, and the formation of “bone spurs” (bony redundancies) on the edges of the tibial and femoral articular surfaces. Clinical findings include reduced medial space and inversion deformity. Lateral X-ray can observe the narrowing of the patellofemoral joint space and the formation of “bone spur” (bone superfluous) in front and behind the joint surface.
Differential diagnosis of osteoarthritis is not difficult, but when symptoms and signs are atypical, it needs to be differentiated from rheumatoid arthritis, compulsory spondylitis and other autoimmune diseases, which are not difficult to differentiate by imaging and blood markers, and are not detailed here.
Treatment of OA
1, in the early treatment of OA, early OA treatment principles are to improve the symptoms and slow down the development of the disease. Non-surgical treatment is the main focus. In patients with symptoms and articular cartilage has not yet appeared obvious lesions, the joint space has not yet become narrow when the start of preventive comprehensive treatment.
(1) Reduce the load of joint use. Reduce weight, prolonged walking, frequent stair climbing, mountain climbing, and other sports that place a high load on the joints. Minimize the intensity of joint activities within the scope of normal life and work.
(2) Muscle function exercise. To maintain knee stability and reduce quadriceps atrophy, functional training of the quadriceps muscle should be performed. Static non-weight-bearing exercises such as straight leg raises and resistance knee extension training should be the main focus. Muscle controlled contraction training is recommended instead of muscle high frequency contraction and diastolic training. That is, control the quadriceps in a contracted state for a sustained period of time, then relax and rest. Repeatedly. Swimming exercise is also a good method.
(3) Drug therapy. The current treatment of OA drugs are mostly to improve the symptoms and delay the development of the disease class of drugs, the reversal of the disease itself does not play a large role.
① improve pain symptoms can be used non-steroidal anti-inflammatory drugs (NSAIDS), selective COX-2 inhibitors such as “Celecoxib” digestive side effects are small, recommended. nSAIDS drugs with the relief of muscle tension drugs for symptom relief more effective, such drugs are The main drugs in this category are “Eperisone Hydrochloride” and others.
②Glucosamine sulfate acts to nourish cartilage, improve cartilage metabolism and slow down the development of the disease.
③The joint cavity injection of sodium vitrate can increase joint lubrication and reduce symptoms. However, skilled joint puncture technique and aseptic concept are required.
(4) Physiotherapy. Many physical therapy can relieve symptoms such as heat therapy, shock wave therapy, etc. can be used for OA treatment, but should avoid violent massage.
2, the treatment of advanced OA late OA treatment methods are limited. The principle of treatment is to alleviate the symptoms of patients as far as possible, restore joint function and improve the quality of life of patients. Whether it is the choice of non-surgical treatment or surgical treatment are based on the above principles as the standard.
(1) Non-surgical treatment. In all, early non-surgical treatment methods can be used for advanced OA treatment, but most of the treatment is not effective.
(2) arthroscopic surgical treatment. In the author’s experience, arthroscopic surgery is only used in cases accompanied by meniscal injury or free body formation in the knee, and such cases are performed arthroscopically only to relieve the symptoms of joint strangulation. Arthroscopic irrigation alone is only effective in most patients for a short period of time, usually 4-6 months, and is not very meaningful.
(3) Osteotomy. Various types of osteotomies are performed to improve symptoms by changing the knee joint force lines and shifting the joint load from the diseased compartment to a more normal compartment. Because of its narrower indications, it has more complications. With the maturation of knee arthroplasty, the use of osteotomy in clinical practice is extremely rare.
(4) Arthroplasty. For advanced OA, knee arthroplasty (TKA) can effectively relieve patients’ pain, reconstruct joint function and improve patients’ quality of life. Knee arthroplasty has been in clinical use for more than 40 years, and now both the prosthesis design, materials, surgical instruments, and surgical techniques have become very mature. The life expectancy of the prosthesis has theoretically exceeded 20 years, and some scholars have performed 15-year post-operative follow-ups with a prosthesis survival rate of 94% or more. Knee replacement surgery itself is complex and will not be described in detail here. However, the author would like to emphasize two issues for knee arthroplasty.
① Those patients are suitable for TKA my opinion is that the purpose of the surgery everything to improve symptoms, reconstruct joint function and improve the patient’s quality of life needs as a starting point. Some young patients with OA due to congenital development and other diseases have severe symptoms and joint function deficits that have seriously affected their lives. The indications for surgery cannot be narrowed because of the younger age of the patient. At the same time, for some other patients, the indications for surgery should not be expanded blindly. For example, some elderly patients already have a more severe x-ray presentation, but have milder self-perceived symptoms and joint function that has not yet had a major impact on their lives. Some patients even treat knee replacement as orthopedic and cosmetic surgery. Expanding the indications for surgery at this time can have adverse consequences. It should always be remembered that we are treating the patient’s symptoms and not the x-rays.
② Post-operative knee replacement rehabilitation is very important for improving knee function in advanced OA, where only 50% of the work has been successfully completed, and post-operative rehabilitation is very important for TKA surgery. Rehabilitation after artificial knee arthroplasty has become an integral part of the procedure. Continuous passive motion exercises (CPM), joint mobility exercises, walking exercises, physiotherapy, and quadriceps muscle training in the early postoperative period, as well as quadriceps muscle training in the late postoperative period, have been used to prevent postoperative complications, improve knee range of motion, and restore walking ability, allowing for a high level of final efficacy of the surgery. It is also important to note that rehabilitation after knee arthroplasty is painful and patients may have an avoidance mentality. In the 3 months after surgery, some patients are satisfied with the gradual recovery of joint function, pain reduction, and feeling much better than before surgery, and if they stop training at this time, the final outcome of the surgery will be greatly reduced. Therefore, we emphasize that postoperative rehabilitation training needs to be carried out under good analgesic treatment, and should be continued within 3 months after surgery, with regular follow-up reviews, and physicians should supervise and guide patients to complete all rehabilitation treatments, so as to finally obtain perfect surgical results.
TKA surgery is a systematic project in terms of indication selection, preoperative planning, surgical technique and postoperative rehabilitation, and neglecting any aspect of it will bring adverse consequences.