Osteoarthritis of the knee is a common and frequent disease, especially in middle-aged and elderly patients. It is more common in women than in men, and the lesions are more severe in women. The pain in the affected joints is vague, aggravated by activity and exertion at first, then relieved by rest, and continues with stiffness of the joint, which improves with activity. In the later stages, the joint swelling increases, movement is limited, and deformity but no ankylosis is present.
I. Overview of osteoarthritis of the knee
(A) Definition
Osteoarthritis of the knee is a common chronic joint disease, the main lesion is degenerative changes in the articular cartilage and secondary osteophytes, and there is the formation of bony bulge at the edge of the joint. Clinical symptoms such as knee pain, limitation of movement and joint deformity can be produced.
(B) Etiology and classification
Primary osteoarthritis of the knee is usually seen in obese people over 50 years of age and refers to joint lesions not associated with other diseases due to aging; secondary osteoarthritis of the knee is often caused by congenital or acquired deformity of the joint, joint injury, inflammation, genetics and metabolic endocrine diseases.
(iii) Pathology
1. early articular cartilage becomes yellowish and loses its luster, followed by rough cartilage surface, localized softening, loss of elasticity, and degeneration of collagen fibers.
2, bone changes: the emergence of bone neoplasm at the edge of the cartilage, bone proliferation in the subchondral bone marrow, and atrophy of the subchondral bone of the articulation with cystic changes.
3, changes in the synovial membrane: exfoliated cartilage fragments and osteophytes stimulate the synovial membrane causing inflammation and promote synovial exudation, manifesting as proliferative synovitis and fibrous synovitis.
(iv) Influencing factors
1, cumulative damage caused by long-term work and social activities.
2, obesity, overweight.
3, gender: female prevalence.
4, genetic predisposition.
5, geography: people in cold and humid areas are prone.
6.Occupation: teachers and shopkeepers are the high incidence.
(E) Morbidity status
Osteoarthritis of the knee is a multiple disease, common over 50 years of age, and about 80% of people over 60 years of age are affected. There are more female patients than male, and the lesions are more severe in female patients.
(F) Characteristics of articular cartilage
1, low coefficient of friction: the coefficient of friction of water is 0.006, cartilage is 6 times lower than the coefficient of friction of water.
2, no blood vessels in the joint cavity, nutrient metabolism depends entirely on the mutual extrusion of cartilage.
3, the main nutrient is ammonia.
4, joint cartilage is not easily repaired after injury.
5.It can produce lubrication when exercising.
6, articular cartilage does not contain nerves.
(G) Pathological changes characteristics
Cartilage is prone to thinning, melting, and further formation of marginal bone spurs, which in turn narrow the joint space, surrounding ligament relaxation, and weakening of elasticity. It also causes contracture of the attached muscles and weakens muscle strength, resulting in joint instability and joint stiffness. Synovial hyperplasia produces proliferative synovitis, which can result in joint effusion. In addition, joint deformation and free bodies can be produced in the joint cavity.
A lateral view of the knee joint shows patellar tenderness, which is a sign of degenerative changes. There is severe osteophytosis of the bone margins and narrowing of the gap.
In addition, proliferative synovitis can cause fluid accumulation in the joint cavity, which is indicated by a positive floating patella test in clinical practice.
Clinical manifestations and pain analysis of osteoarthritis of the knee
(A) Clinical manifestations
The age of onset is more than 50 years old. The first manifestation is joint pain, which is mild and dull at the beginning and gradually increases later. Some patients feel pain at rest or in the morning, but it is relieved after a little activity, which is called “rest pain”, also known as glued phenomenon. It can also be manifested as joint swelling, with synovitis, fluid in the joint, positive floating patella test, and limited active or passive movement. It can also be characterized by impaired joint movement, joint stiffness, and various sounds such as creaking and rubbing when moving, resulting in joint instability. At a later stage, the joint forms a deformity, with inversion of the knee being the most common.
(B) Pain analysis
The site of pain is divided into intra-articular pain and extra-articular pain. Pain is related to activity and is aggravated after activity; it is easily aggravated during the cold season; overexertion or psychological stress may also aggravate the condition.
Intra-articular pain is mainly manifested in the joint cavity, including pain in the upper and lower bursa of the knee and patella; extra-articular pain mainly refers to pain outside the joint cavity, including pain in the inner and outer condyles of the tibia, inner and outer condyles of the femur and the posterior region of the joint.
1, intra-articular pain causes.
Inflammatory factors stimulate the release of inflammatory mediators such as IL-1IL-6 from surrounding tissues. Further cause synovial hyperplasia, hypertrophy and inflammatory response, and patellofemoral joint surface melting, bin femoral joint peri-articular synovial inflammation. In addition, it can cause meniscus degeneration, tear and dislocation. It increases the friction coefficient of the joint and increases the force on the ligament and joint capsule. Further formation of free bodies, so that the subchondral bone pressure changes, joint deformity, stress concentration. This eventually leads to joint effusion and joint capsule swelling. Make the joint movement obstacle, pain aggravated.
2. Extra-articular causes of pain.
(1) Bone – ligament junction injury. (2) Bone – joint capsule joints injury. (3) Joint loosening stimulates the ligaments and joint capsule. (4) Injury to the tendon free body. (5) Increased intraosseous pressure.
The prevalent sites of extra-articular pain include the medial tibial condyle, the lateral tibial condyle, the medial femoral condyle, the lateral femoral condyle, the medial joint space, the biceps femoris tendon, and the goose foot area.
Auxiliary examinations and diagnosis of osteoarthritis of the knee
(A) Auxiliary examinations
1, laboratory tests: generally within the normal range, joint fluid examination can be seen in the increase of white blood cells, occasionally see red blood cells.
2. X-ray examination: In the early stage of the disease, when there are only degenerative changes in the cartilage, the X-ray film shows no abnormal findings, and as the articular cartilage becomes thinner, the joint space gradually becomes narrower, and the narrowing of the space may be unevenly changed. On standard X-rays, the knee joint gap is 4mm in adults and less than 3mm is considered narrow. in normal people over 60 years of age, the joint gap is 3mm and less than 2mm is considered narrow. In severe cases, the joint space disappears. The subchondral bone plate is dense and sclerotic, like ivory. Cystic changes are seen in the weight-bearing subchondral bone. These changes are often multiple, usually less than 1 cm in diameter, and may be round, ovoid, or bean-shaped.
In the later stage, there may be bone redundancy formation at the joint edges (i.e. cartilage edges) and soft tissue stops, or intra-articular free body osteophytes, hypertrophy of bone ends, and soft tissue swelling shadows may be seen. Joint space narrowing, subchondral bone plate sclerosis and bone superfluous formation are the basic features of osteoarthritis.
(ii) Diagnosis
Most commonly seen in middle-aged and elderly people. The pain in the affected joints is vague, aggravated by activity and exertion at the beginning and relieved by rest, and then persists with joint stiffness, which improves with activity. In the later stage, swelling of the joint increases, movement is limited, and deformity but no ankylosis. Later X-rays show joint space narrowing, subchondral cystic changes and osteochondral sclerosis, and bone spur formation at the edge of the joint.
Treatment of osteoarthritis of the knee
(A) Classification and treatment
1, light: extra-articular pain is predominant, with partial melting of patellar cartilage and mild cystic swelling above and below the patella. Short history, x-ray shows normal joint space, pain is mainly in the inner tibial condyle.
Treatment: symptomatic treatment of painful injection, joint rehabilitation training.
2.Medium-sized
(1) Type A (synovitis type): persistent pain, synovial hyperplasia, fluid accumulation, joint swelling mainly in the upper and lower patellar bursa. x-ray film shows thinning of joint cartilage and bone spurs. Longer history of disease, more common in women.
Treatment: Systematic medication, arthroscopic irrigation, synovectomy, joint compression bandaging if necessary.
(2) Type B (joint abrasion type): persistent pain, obvious when walking up and down stairs, limited squatting and standing. x-ray shows narrowing of joint space and obvious bone spurs.
Treatment: joint cavity injection, joint health care.
3.Heavy: history of several decades, joint effusion, rubbing, joint deformity, function is obviously limited, X-ray film shows that the joint gap is obviously narrowed or disappeared, or even fused, the joint can appear subluxation.
Treatment: surgery, symptomatic, rehabilitation, joint health care.
(II) Treatment characteristics
1.The pain can be controlled, especially early, light and medium pain can be controlled.
2.Joint rehabilitation training treatment is the basis.
3. Individualized treatment is required for different individuals.
(C) Conservative treatment principles
1.Rest: Protect the joint, avoid excessive activity or injury, and do not overload. In severe cases, bed rest and brace fixation should be used to prevent deformation.
2, functional exercise: active non-weight-bearing activities are the main focus, first for strengthening muscle exercises, and then gradually practice to increase joint activity.
3.Physiotherapy: wet and hot compresses, ultra-short wave, microwave, iontophoresis can relieve pain and muscle spasm, help improve blood circulation and reduce swelling.
4.Manipulation therapy: mainly used to release the free body embedded between two bones when the joint is locked, in order to relieve the patient’s pain.
5.Chinese herbal medicine treatment: internal application, external application, fumigation and soaking of herbs for blood circulation.
6, the application of anti-inflammatory and analgesic drugs: such drugs are still effective in the treatment of the disease, although not to suspend the development of the disease, but can relieve symptoms and eliminate pain.
(D) Treatment methods
1.Drug treatment
(1) anti-inflammatory and analgesic drugs: commonly used are fenbid, paracetamol and tylenol. Tayloring is a combination of paracetamol and oxycodone, which has both anti-inflammatory analgesic and narcotic analgesic effects, and is a better drug for clinical efficacy. There is also a new combination of aminoglutethimide, which is a combination of tramadol and acetaminophen, and is also a drug with good efficacy.
(2) Cartilage repair: Blue Bay Aminoglycan preparation for oral administration.
(3) Chinese herbal medicine to activate blood and reduce swelling.
(4) Local application and creams can be used.
2.Physiotherapy
There are physical therapies such as Chinese medicine ion introduction, ultra-short wave, Han’s pain relief instrument, heat therapy and light therapy, all of which have good clinical effects.
3.Local treatment
(1) Joint puncture to extract joint fluid.
(2) Joint injection, which can be injected with sodium vitrate and cortisol.
(3) Joint irrigation, especially in the case of synovitis, joint cavity irrigation can be performed after joint fluid extraction.
(4) Ozone therapy, especially in the case of synovitis, has a very good effect.
4.Injection therapy
Injection therapy can eliminate the original lesion stimulation, eliminate inflammatory exudation, hyperplasia, swelling, and relieve muscle tension or spasm. Improving local blood circulation and blocking the vicious cycle of pain.
There is also chronic strain and degenerative changes in the soft tissues outside the joint capsule in osteoarthritis of the knee. Painful spots, painful tendon knots or cords can be detected by careful palpation, commonly around the patella, the inner and outer condylar margins of the femoral talus, the joint space, around the meniscus and the infrapatellar fat pad, etc. Local cortisol injection therapy is feasible.
Intra-articular injections, mainly in cases of synovitis or hyperplasia where the joint needs lubrication. General injection of sodium vitrate can increase the synovial fluid of joint cavity and play the function of lubrication.
5.Surgical treatment
Surgery is performed for those with severe symptoms. There are two kinds of surgical treatment. The first is arthroscopic surgery, bone and synovial excision, free body removal, meniscectomy, joint cleaning; the second is the joint fusion, knee artificial joint replacement surgery is feasible for serious deformation and stiffness of the joint, especially when it seriously affects the function.
V. Joint maintenance
There are two ways of joint maintenance, one is maintenance training, and the other is joint nutrition therapy.
(A) Joint injury and maintenance mechanism
1, joint injury mechanism
Due to uneven weight-bearing, insufficient joint mobility, obstructed venous return, and sometimes weakened muscle regulation, the surrounding ligaments become degenerative and less elastic. Further development is reduced joint lubrication and lack of ammonia nutrition. These can cause damage to the joints, especially the cartilage of the joints, and develop into osteoarthropathy of the knee.
2, the mechanism of joint maintenance
Promote synovial fluid secretion, promote cartilage metabolism, enhance joint lubrication; enhance muscle, joint capsule, ligament function, promote venous return; need to supplement the nutrient ammonia.
(B) Maintenance training
1.The purpose of joint maintenance training
The purpose of joint maintenance training is to relieve symptoms, promote venous reflux, enhance muscle strength, relieve muscle spasm, improve joint function, and increase cartilage nutrition and lubrication.
2.Joint maintenance training methods
Mainly active training, the formation of regular exercise and walking.
(1) Joint health exercises: do active functional exercises of the joints without weight bearing.
(2) All-round, maximum range of knee joint activities.
(3) A posture of less than 1 hour.
(4) Reduce squatting exercises: squatting is more weight-bearing on the joints and can easily damage and injure the joint surfaces and joint cartilage.
(5) Carry out coordinated exercises for different muscle groups and thoroughly relax the muscles.
In the case of non-weight-bearing joints, active exercises for joint maintenance can be performed in the prone, sitting and standing positions.
(C) Joint nutrition
1.Balanced nutrition: mainly through nutritional therapy, balanced intake of substances that are nutritious to joint cartilage.
2.Supplementation of joint nutrients aminosaccharide.