I. Definition and pathogenesis
Age-related osteoarthritis (OA) or proliferative arthritis, degenerative arthritis, is a common and prevalent disease in the middle-aged and elderly. The incidence increases significantly with age, and he threatens the normal life and activities of about 1/3 of adults worldwide. As human beings enter an aging society, the incidence of osteoarthritis is increasing year by year, therefore, correct understanding, active prevention, exact diagnosis and reasonable treatment are very important.
The pathogenesis of osteoarthritis is not well understood. The occurrence of osteoarthritis is an active repair process after the destruction of joint cartilage due to multiple causes, and this process is very complex, involving factors such as genetics, endocrine factors, enzyme metabolism, and weight nutrition. The main factors are.
(1) Dysregulation of cartilage and matrix synthesis and catabolism.
(2) Damage to the subchondral bone plate.
(3) inflammatory response.
Second, the epidemiology of OA
The prevalence of OA is high. It has been reported that in the United States, the incidence of OA is second only to coronary heart disease, ranking second.
The epidemiological characteristics of OA.
(1) The incidence of OA is higher in women than in men, 2.59/1000 and 1.7/1000, respectively, and is especially more common in postmenopausal women.
(2) Age is closely related to OA, the higher the age, the higher the incidence. 15-44 years of age, the incidence of OA is about 5%; and over 60 years of age, 50% of the population with OA; over 75 years of age, 80% of the population with symptoms of OA. In recent years, the age of onset is gradually younger, 46-56 years of age of middle-aged and older people, the incidence is higher.
(3) race and OA also have a certain relationship, such as the Caucasian hip OA more common, while the Oriental (Asian) knee OA more common. It is also reported that the ancient people hip OA more than knee OA, and modern people knee OA is the most common OA. 16 million patients with OA in the United States, China has more than 100 million people over 60 years of age, it is estimated that OA patients are about 50 million. It is expected that the largest population of OA patients will be in China in the future.
In April 1998, Professor Lars Lidgren, Director of the Department of Orthopaedics at Lund University, Sweden, and President of the European Orthopaedic Research Society, first initiated and initiated the establishment of the period 2000-2010 as the international “Bone and Joint Decade”, with the aim of arousing the attention of governments, medical practitioners and patients to this disease. The aim was to draw the attention of governments, medical practitioners and patients to this disease, so that human, material and financial resources could be invested in multidisciplinary and multicenter collaborative research on a global scale to improve the overall prevention and treatment of this disease.
This initiative soon received positive responses and support from the United Nations, the World Health Organization, and dozens of governments. The Chinese government also attaches great importance to this initiative, and the Orthopedic Branch of the Chinese Medical Association joined the “Bone and Joint Decade” in October 2002 on behalf of China, and signed the declaration at the same time.
Third, the etiology and classification of OA
Although medical science has made a lot of significant progress in recent years, but the exact cause of OA is still little known. the most basic pathological changes in OA is the degeneration of articular cartilage damage. At present, it is believed that OA is formed by the interaction of a variety of factors, even if due to various reasons caused by articular cartilage fibrosis, cleavage, ulceration, loss of the whole joint disease, including cartilage degeneration and loss, subchondral bone sclerosis or cystic changes, the formation of bone boils at the joint edge, synovial hyperplasia, joint capsule contracture, ligament degeneration or contracture, muscle atrophy and weakness.
According to the classification of the American Rheumatism Association, OA can be divided into primary OA secondary OA. the exact cause of the former is unclear and may include age, sex, occupation, race, obesity, genetics and excessive exercise; the latter can be secondary to any joint injury or disease, such as meniscal injury, intra- or peri-articular fracture, joint ligament injury, femoral head necrosis, congenital deformity or dislocation, etc.
A recent retrospective study from Boston University reported that strain was a significant contributor to the high risk factors for knee OA. In particular, the intensity of joint loading and / or a high degree of flexion of the work or activity, for example, due to frequent stairs, the incidence of knee OA in the residents of the building is higher than the residents of the cottage.
Fourth, the clinical manifestations of OA
The most significant symptom of osteoarthrosis is pain, usually symptoms and signs are limited to local
1, pain Patients initially feel mild joint inconvenience, up and down the stairs, on the bus when feeling painful strain, the need to grab the handrail to assist. When changing from one posture to another (e.g., from sitting to standing up and walking), the patient feels pain and difficulty in moving at first, but after a period of activity, the pain is relieved and the joint feels comfortable. Excessive exercise, such as walking long distances, can cause joint pain and limited movement, which can be relieved after rest. In the late stage of the disease, the pain and muscle spasm increase and are persistent and cannot be relieved quickly after rest. Pain at night is common in this stage. Since cartilage is not innervated and insensitive to pain, the patient’s pain originates from intra-articular and peri-articular structures. As the cartilage is damaged, the villi proliferate, causing joint adhesions, synovial congestion, thickening of the joint capsule, fibrosis and shortening of the joint capsule, which can cause pain due to nerve irritation in the capsule when the joint is moved.
2, friction sensation A mild friction sensation can be palpated during joint movement in the early stage, but in the late stage, a significant sand-like friction sensation can be palpated and the patient has significant pain.
3, joint effusion secondary to synovitis may occur in the joint moderate effusion.
4.Mobility restriction In the late stage of the disease, joint movement is restricted to varying degrees as the pain increases.
5.Joint deformity Knee flexion or inversion deformity may occur, especially inversion deformity is common.
6. Intra-articular free body Intra-articular free body can come from the synovial mold or cartilage lesions, also known as joint rats, which can move within the joint and cause damage to the articular cartilage. Joint activity can occur due to the interlocking phenomenon of intra-articular free body, especially in the knee joint, which requires removal of the free body when it occurs.
Five, OA x-ray performance
1, early articular cartilage only mild degenerative changes, X-ray film no significant changes.
2, progressive articular cartilage further wear, irregular cartilage performance, joint space narrowing or obvious narrowing, lip-like osteophytes at the edge of the joint, osteochondral sclerosis on the surface of the joint, the appearance of degenerative cystic changes in the weight-bearing area translucent area.
3. In the late stage, the bone redundancy increases, the cartilage destruction intensifies, the joint space is obviously narrowed or disappears, and the osteosclerosis of the joint edge increases, especially in the weight-bearing area. The joint is unstable and may have a tendency of subluxation. Free body can be seen in the joint.
Sixth, the prevention of OA
Prevention of osteoarthritis first of all to develop good habits, develop good habits for osteoarthritis patients is the best potent medicine, we suggest that we pay attention to the following points.
1, obese people should pay attention to weight loss.
2, car for people to walk to appropriate activities.
3, crutches to reduce the weight of the joint.
4, the elderly do not do a lot of strenuous exercise.
5, women entering menopause should ask the doctor to help regulate endocrine function.
6, choose a reasonable exercise to exercise the muscles to enhance joint stability.
7, diet less high-fat food, less caffeine-containing beverages, such as cola.
Prevention of osteoarthritis is mainly to reduce the burden on the joints and reasonable functional exercise. To protect the joints, especially the weight-bearing joints, do not make the joints overactive and reduce the pressure on the joint surfaces. When people walk, gravity is transferred to both lower limbs, which increases the weight on both lower limbs by 3 to 4 times. Using a cane or crutches can reduce the weight bearing on the joints by 50%, so it is better for the elderly to use a cane to protect the joints. For obese people, weight should be reduced to reduce the pressure on weight-bearing joints in order to protect the joints and prolong the life of the joints. Patients with osteoarthrosis of the hip or knee should avoid long or frequent trips up and down stairs. Patients with osteoarthritis are not prohibited from necessary daily activities, especially non-weight-bearing exercise is essential.
Such exercises are beneficial in maintaining function and strength and maintaining joint mobility to keep the joint in a normal uncoupled position. Functional exercises can be performed with isometric contraction, isotonic contraction, range of motion exercises and extension functional exercises. Isometric contraction, muscle contraction against a fixed object (such as the backbone) without joint mobility, mainly increases muscle strength without increasing the volume of the muscle isotonic contraction. Contraction of the muscle is accompanied by lengthening of the muscle or shortening of the joint in its range of motion, which increases the strength and volume of the muscle to resist muscle atrophy. Both types of exercise increase local muscle tolerance. Range-of-motion exercises include active and passive exercises. Active activities involve the patient moving the joint within the achievable range of motion, while passive activities involve someone else or the doctor helping to move the joint. Extension exercises are performed by the physician and others to move the patient’s joints within the reachable range of motion, providing an extended pull at the end of the range of motion.
VII. Treatment of OA
OA treatment is mainly aimed at reducing pain, improving function, slowing down the progress of the disease, and improving quality of life.
1, physical therapy
①, heat therapy, deep heat therapy, including heat transmission and microwave therapy, shallow heat therapy, including infrared, warm water baths, hot water bags, etc.
② Electrotherapy, electrotherapy including transcutaneous electrical nerve stimulation, pulsed electromagnetic field, laser, one-way electrical stimulation, etc.
③ Chinese medicine, including Chinese herbal fumigation, acupuncture, plasters, etc.
2.Drug treatment
The NSAIDs are divided into COX-1 specific inhibitors, small doses of aspirin belong to this category; COX non-specific inhibitors. Indomethacin, ibuprofen, naproxen and diclofenac belong to this category; COX-2 propensity inhibitors, also known as selective inhibitors, nabumetone (Relifen), meloxicam and etodolac belong to this category; COX-2 specific inhibitors, celecoxib and rofecoxib belong to this category.
Ralifene, meloxicam and etodolac are comparable to diclofenac, inflamoxicam and indomethacin in terms of efficacy in diseases such as osteoarthritis, but have significantly lower gastrointestinal adverse effects than the latter category. Relifen is easy to diffuse into the synovial fluid and mechanical tissues, so it is suitable for the elderly.
②Central analgesic drugs, such as tramadol hydrochloride, etc.
③Glucosamine and chondroitin sulfate. Glucosamine is a monosaccharide amino acid, consisting of glucose-binding amino acids, and is found in cartilage tissues. The mechanism for treating OA may be due to its ability to stimulate the synthesis of aminoglucan and proteoglycan in cartilage, or to increase the production of hyaluronic acid in synovial fluid which may reduce cartilage wear. Chondroitin sulfate, a molecule composed of repeating aminoglucan-binding sugars, promotes cartilage repair and maintains synovial fluid viscosity. However, these drugs are slow to show effects and lack sound clinical data and evidence. Commonly used are glucosamine sulfate (GS) and others.
④ Chinese herbs and proprietary Chinese medicines can achieve the purpose of relieving pain, delaying joint aging and improving function.
3.Injection therapy Intra-articular injection therapy is also a treatment method that can relieve joint symptoms, and commonly used drugs include glucocorticoids and hyaluronic acid preparations (sodium vitrate). Glucocorticosteroid pain relief effect appears quickly, but long-term, large amounts of steroid injections may cause medical inflammation in the joint cavity, and significant side effects limit its application. The mechanism of action of intra-articular sodium hyaluronate injections is.
①Supplement the deficiency of endogenous hyaluronic acid and promote the secretion of endogenous hyaluronic acid;
②Protect joint tissues and eliminate pain-causing substances to relieve pain;
③Lubricate joints, reduce friction, and improve joint mobility;
④Inhibit inflammation and reduce exudation;
⑤ Protect cartilage and promote repair. Intra-articular injection of hyaluronic acid has become a valuable treatment for osteoarthritis as a new method of clinical treatment. However, intra-articular injection therapy is after all an invasive operation, and special attention should be paid to aseptic operation to avoid medically-derived intra-articular infection. The following are commonly used clinically: Spironolactone and Argi. Generally, one injection is given once a week, and every five weeks is a course of treatment.
4.Surgical treatment
In early stage patients, if the joint space is narrowed and widened, high tibial osteotomy is often used to correct the deformity, change the force line and reduce the pain.
For patients in the middle stage, the synovial membrane is thickened and free bodies are formed in the joint, arthroscopic cleaning can also be used to relieve pain and improve function.
③In late stage patients, the joint surface is severely damaged, joint mobility is lost, and joint deformity is deformed. In recent years, artificial joint replacement has been widely used for treatment, and satisfactory results have been achieved.