【Overview】.
Osteoarthritis is a chronic joint disease characterized by degeneration and destruction of joint cartilage and osteophytes. The disease is more prevalent after middle age. Preliminary domestic surveys show that the overall prevalence of osteoarthritis is about 15%, with a prevalence of 10%-17% in people aged 40 years and 50% in people aged 60 years or older. Among people over the age of 75, 80% suffer from osteoarthritis. The ultimate disability rate of the disease is 53%. Clinically, swollen and painful joints, osteophytes, and limited motion are most common. There are no geographical or racial differences in the development of osteoarthritis. Age, obesity, inflammation, trauma, and genetic factors may be associated with the development of this disease.
Clinical manifestations
1.Symptoms and signs
Osteoarthritis mainly manifests as pain, swelling, morning stiffness, joint effusion and bony hypertrophy of the affected joints, which may be accompanied by bone rubbing sound, dysfunction or deformity during activities.
(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. It is usually mild or moderate intermittent pain in the early stage, which improves with rest and worsens with activity. There may be localized pressure pain in the joints, which is especially obvious when there is joint swelling.
(2) Joint swelling 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, bony swelling around the joint may be detected.
(3) Morning stiffness Patients may experience stiffness and a feeling of adhesion in the morning, which may be relieved by activity. The duration of morning stiffness is relatively short, usually a few minutes to ten minutes, and rarely exceeds half an hour.
(4) Joint friction sounds are mainly seen in osteoarthritis of the knee joint. Due to the destruction of cartilage, the joint surface is rough and there is a bone rubbing sound (sensation) and twisting sensation when the joint is moved, or there is local pain in the joint.
2.Osteoarthritis of different parts
(1) Hand
The distal interphalangeal joint is most commonly involved, showing bony enlargement on both sides of the extensor side of the joint, called Heberden’s node. The proximal interphalangeal joint is called Bouchard’s node. It may be accompanied by mild localized redness, swelling, pain, and tenderness of the nodule. 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 joint
Knee joint involvement 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 and relieved by rest. Severe cases may present with inversion or valgus deformity of the knee.
(3) Hip joint
The involvement of the hip joint is mostly characterized by localized intermittent dull pain, which may become persistent with the development of the disease. In some patients, the pain may radiate to the groin, inner thighs and buttocks. The hip joint movement is mostly limited by internal rotation and external rotation, followed by internal retraction, external rotation and extension.
(4) Spine
Involvement of the cervical spine is more common. There may be hyperplasia and osteophytes of the vertebral body, intervertebral disc and posterior synovial joint, causing local pain and stiffness, and corresponding radiological pain and neurological symptoms when local blood vessels and nerves are compressed. Involvement of the cervical spine compresses the vertebrobasilar artery, causing symptoms of inadequate blood supply to the brain. Intermittent claudication and cauda equina syndrome may occur when lumbar spine osteophytes lead to spinal stenosis.
(5) Foot
The metatarsophalangeal joint is often involved, and in addition to local pain, pressure pain and bony hypertrophy, deformities such as bunions can occur.
3.Special types of osteoarthritis
(1) Primary generalized osteoarthritis The distal interphalangeal joint, proximal interphalangeal joint and the first carpometacarpal joint are the preferred sites. Knee, hip, metatarsophalangeal joints and spine may also be involved. Symptoms are episodic and may include effusion and fever in the affected joints. They can be classified into two categories based on clinical and epidemiological findings.
(1) The nodular type mainly involves the distal interphalangeal joints and is more common in women, with family clustering.
The non-nodular type is predominantly involving the proximal interphalangeal joints and is not characterized by gender or family clustering, but often has recurrent peripheral arthritis. Severe patients may have increased sedimentation and increased C-reactive protein.
(2) Erosive inflammatory osteoarthritis is common in postmenopausal women, mainly involving the distal and proximal interphalangeal joints and carpometacarpal joints. There is a familial tendency and recurrent acute attacks. The affected joints are painful and tenderness, eventually leading to deformity and ankylosis. The patient’s synovial examination reveals marked proliferative synovitis with immune complex deposition and vascular opacification. x-rays show marked osteophytes and subchondral osteosclerosis, and in advanced stages, marked bone erosion and bony ankylosis of the joint.
(3) Diffuse idiopathic skeletal hyperostosis (DISH) occurs in middle-aged and elderly men. The lesion involves the entire spine with diffuse osteophytes and extensive hyperostosis of the spinal ligaments and their adjacent bony cortical hyperplasia. However, the small vertebral joints and intervertebral discs remain intact. X-rays show characteristic calcification of the anterior and posterior longitudinal ligaments of the vertebral body, mainly in the lower thoracic segment, usually with 4 or more consecutive vertebrae, and may be accompanied by extensive osteophytes.
4.Laboratory tests
The indicators of blood routine, protein electrophoresis, immune complexes and serum complement are generally within normal range. Patients with synovitis may have mildly elevated C-reactive protein and blood sedimentation. Rheumatoid factor and antinuclear antibodies are negative. Patients with secondary osteoarthritis may present with abnormal laboratory tests of the primary disease. Those presenting with synovitis may have joint effusion; however, the joint fluid is usually clear, yellowish, and of normal or slightly reduced viscosity, but the mucin is well coagulated.
5.X-ray examination
The X-ray features of osteoarthritis are: asymmetric joint space narrowing; subchondral bone sclerosis and cystic changes; osteophytes and bone redundancy formation at the joint edges; intra-articular free bodies; joint deformation and subluxation. These changes are an important basis for the diagnosis of osteoarthritis.
Diagnostic points】
The diagnosis of osteoarthritis is not difficult according to the clinical manifestations, signs and imaging and other auxiliary examinations of the patient. At present, most domestic use the American College of Rheumatology 1995 diagnostic criteria.
Treatment】
The purpose of treatment is to relieve pain, stop and delay the progression of the disease, and protect joint function. The treatment plan should be based on the condition of each patient.
1.General treatment
(1) Patient education Make patients understand the principles of treatment, exercise methods, as well as the use of drugs and adverse effects of the disease.
(2) Physical therapy including heat therapy, hydrotherapy, transcutaneous electrical nerve stimulation therapy, acupuncture, massage and tui-na, traction, etc., all help to reduce pain and relieve joint stiffness.
(3) Reduce joint load and protect joint function Patients with knee or hip joint involvement should avoid excessive load, and avoid prolonged standing, kneeling and squatting. Patients with knee or hip involvement should avoid prolonged standing, kneeling and squatting. Canes and walkers can be used to assist activities, and obese patients should reduce their body weight. Coordinated muscle movement and muscle strength can reduce the painful symptoms of the joint. Therefore, patients should pay attention to strengthen the strength exercise of the muscles around the joint and design exercise programs to maintain the range of motion of the joint.
2.Medication
Mainly can be divided into symptom control drugs, drugs to improve the condition and cartilage protection agents.
(1) Symptom control drugs
(1) Non-steroidal anti-inflammatory drugs (NSAIDs) NSAIDs are the most commonly used drugs for osteoarthritis treatment, and their function is to reduce pain and swelling and improve joint movement. The main drugs include diclofenac, etc. Selective cyclooxygenase-2 inhibitors such as rofecoxib, celecoxib and meloxicam are more appropriate if the patient is at a higher risk of NSAID-related gastrointestinal disease. Drug doses should be individualized, with attention to the effects on other comorbid diseases in elderly patients.
② Other analgesics Acetaminophen has good analgesic effect on osteoarthritis with low cost and is still widely used abroad, while its application in China is relatively small. If the above methods are not effective in relieving symptoms, tramadol may be used. The drug is a weak opioid, well tolerated and less addictive, with an average daily dose of 200-300mg, but attention should be paid to adverse reactions.
Local treatment includes topical NSAIDs and intra-articular injections. Glucocorticoids can relieve pain and reduce exudation, and the effect can last for several weeks to months, but they are only suitable for joint cavity injection treatment, and should not be repeatedly injected in the same joint, and the number of injections should be less than 4 times in a year.
Intra-articular injections of hyaluronic acid preparations (Shinvic, Qisheng, and Spironol) are effective in reducing joint pain, increasing joint mobility, and protecting cartilage, and the therapeutic effect can last for several months.
(2) Improving drugs and chondroprotective agents.
These drugs have the effect of reducing the activity of matrix metalloproteinases, collagenases, etc., which can be anti-inflammatory, analgesic, and protect joint cartilage, and have the effect of delaying the development of osteoarthritis. The onset of action is generally slow. The main drugs include glucosamine sulfate, glucosaminoglycan, S-adenosylmethionine and doxycycline. Diacerein may also significantly improve patient symptoms, protect cartilage, and improve the course of the disease.
Cartilage damage in osteoarthritis may be related to the action of oxygen free radicals. Studies in recent years have found that vitamins C, D and E may be beneficial in the treatment of osteoarthritis mainly through their antioxidant mechanism.
3.Surgical treatment
Surgical treatment can be considered for patients with severe lesions and significant joint dysfunction who have not been treated with medical therapy.
(1) Arthroscopic surgery For patients with significant joint pain and unsatisfactory results of painkillers and intra-articular glucocorticoid injections, intra-articular lavage can be used to remove fibrin, cartilage debris and other impurities, which can reduce the patient’s symptoms. Cartilage fragments can also be removed arthroscopically.
(2) Orthopedic surgery Osteotomy can improve the balance of joint force lines and effectively relieve hip or knee pain. Patients over 60 years of age with progressive osteoarthritis who do not respond well to regular medication may be offered joint replacement, which can significantly reduce pain symptoms and improve joint function.
In addition, new treatments such as cartilage transplantation and autologous chondrocyte transplantation may be used in the treatment of osteoarthritis, but further clinical studies are needed.