With the development of an aging population, osteoarthritis (OA) has become a major disease that endangers the physical and mental health of the elderly, and the knee joint is one of the most vulnerable joints. Osteoarthritis is a chronic degenerative disease that is characterized by recurrent joint pain and gradual impairment of joint movement. The main pathological changes are progressive destruction of the affected articular cartilage, cartilage degeneration and subchondral bone sclerosis, and the essence of the disease is the imbalance between the catabolism and anabolism of the articular cartilage matrix. There are many treatment methods, including non-surgical treatment, surgical treatment, clinical non-surgical treatment is the main, if not effective, consider surgical treatment.
1, knee osteoarthritis (KOA) risk factors for the occurrence of
(1) Injury: intra-articular fracture, meniscal injury, patellar dislocation and other causes of articular cartilage damage;
(2) Excessive weight-bearing: excessive weight-bearing on the joint surface due to obesity or internal or external deformity of the knee joint, and the knee joint of obese and overweight elderly people is susceptible to this disease;
(3) Infection or inflammation causing destruction of articular cartilage;
(4) subchondral bone necrosis, such as dry brittle osteitis occurs intra-articular free bodies, resulting in damage to the articular cartilage surface.
2.Treatment
2.1 Non-surgical treatment should be tailored and individualized according to the patient’s age, occupation, and degree of joint damage. An appropriate treatment plan that helps to relieve joint pain and stiffness, improve joint mobility, and improve the patient’s quality of life includes physical therapy and/or specialized therapy, exercise, weight control, patient education, and pharmacotherapy.
2.2 Medication Medication plays an important role in the treatment of osteoarthritis of the knee, but the complex mechanism of knee osteoarthritis pain, joint swelling, pain, and increased synovial fluid are not absolute indications for the use of anti-inflammatory and analgesic drugs. When sports exercise, physical therapy and other therapeutic measures are ineffective, non-steroidal anti-inflammatory drugs (NSAIDS) can be added. The dose and interval of administration can be determined according to the in vivo metabolic characteristics of the drugs and the patient’s response to the drugs, and the dose can be adjusted in the course of treatment. Commonly used drugs are.
(1) Analgesics;
(2) non-steroidal anti-inflammatory drugs;
(3) cartilage nutrition drugs;
(4) steroidal anti-inflammatory drugs;
(5) Hyaluronic acid. The routes of administration are oral, topical and joint lavage.
2.2.1 Analgesics The most commonly used analgesic is paracetamol (acetaminophen), which was recommended as the first-line drug for knee osteoarthritis by the European Rheumatism Association in 2000, and is safe and effective, well tolerated, and can relieve knee pain below moderate level, but for more severe pain, the effect is not good, and there is a risk of upper gastrointestinal bleeding if the dosage is more than 2g/d.
2.2.2 Non-steroidal anti-inflammatory drugs (NSAIDs) are traditionally used in the treatment of osteoarthritis, and the mechanism of action is to prevent the synthesis of prostaglandins to play a pain-relieving and anti-inflammatory role, but also reduces the role of prostaglandins in protecting the gastric mucosa, which can lead to gastric discomfort, and in serious cases lead to gastric ulcers or bleeding and other side effects. toheed et al. considered etodolac (600 ml/d) to be the most effective, while anti-inflammatory pain Perkins found that anti-inflammatory pain increased the rate of joint degeneration. For the consideration of reducing the side effects of NSAIDs, they are made into emulsions for topical application, such as Fotarine emulsion, which are applied topically to relieve joint pain, but there are inconveniences such as contamination of clothing.
2.2.3 Chondrotropic drugs are being used more and more widely, such as glucosamine sulfate, chondroitin sulfate and so on. The effect of these drugs is better than non-steroidal anti-inflammatory drugs, and the drug is slow to take effect, mostly after 4-6 weeks, and the effect lasts 4-8 weeks after stopping. Chondroitin sulfate is a physiological substance necessary for the synthesis of proteoglycan and hyaluronic acid by chondrocytes, which can block the pathological process of osteoarthritis and inhibit enzymes that can damage cartilage, but does not inhibit the synthesis of prostaglandins, and has a mild anti-inflammatory effect. Chondroitin sulfate is well absorbed orally, inhibits proteoglycan and collagen catabolism, stimulates the synthesis of cartilage layer structure, has no effect on normal cartilage, only on diseased articular cartilage, and has a general pain-relieving effect, but can significantly improve joint function.
2.2.4 Hyaluronic acid (HA) Discovered in 1936 by Meyer et al. from the vitreous humor of bull’s eye, sodium hyaluronate (SA) is a derivative of hyaluronic acid with a larger molecular weight and better viscoelasticity. In patients with osteoarthritis of the knee joint, the lubrication and shock absorption capacity of the synovial fluid is reduced, and the content of hyaluronic acid molecules is decreased. Hyaluronic acid is a long-chain macromolecular substance abundant in the synovial fluid, and under normal conditions, it is entangled with each other to form a net-like structure, which maintains the rheological properties of normal synovial fluid. Recently, hyaluronic acid is not only the main component of synovial fluid, but also the surface component of articular cartilage. It can be dissolved in synovial fluid, reduce friction during low-speed movement, absorb shock during high-speed movement, have a strong inhibitory effect on the excitability of synovial membrane and its underlying nociceptive receptors and sensory fibers, relieve joint pain, and have a barrier effect and anti-inflammatory effect. Injecting hyaluronic acid or its derivatives into the joint cavity is a means of treatment. Wang Yubin et al. treated osteoarthritis of the knee joint with Spektor injection, and the total effective rate was 96.3% after 5 weeks, with no obvious toxic side effects. 16 months after stopping the drug, 74% of patients had no recurrence. However, this method also has side effects such as septic infection of the joint and aseptic acute arthritis.
2.2.5 Intra-articular injection of glucocorticoids It can stabilize the damaged lysosomal membrane, prevent the release of proteolytic enzymes, inhibit the activity of released enzymes, also inhibit mast cell and histamine activity, and reduce the synthesis of prostaglandins by inhibiting the synthesis of arachidonic acid from cellular phospholipids, thus reducing inflammation and immune response, but it can inhibit the synthesis of proteoglycan and collagen, and the damage to cartilage increases with The damage to cartilage increases with the injection of hormones and should not be used in general.
2.3 Exercise Slow, gentle extension activities will help prevent joint stiffness, such as yoga and tai chi; aerobic exercises that are both therapeutic and recreational, such as walking and swimming. Exercise can strengthen the quadriceps, enhance joint stability, and strengthen the soft tissue toughness of the knee, while mechanical stress regulates the synthesis and degeneration of the cartilage layer. Exercise can also lose weight, reduce weight pressure on weight-bearing joints, reduce the risk factors for osteoarthritis, reduce joint damage, and improve joint function. It is easy to implement and less costly. Doctors can develop an exercise program suitable for individual patients according to their different conditions and carry out the program in a step-by-step manner, which can effectively reduce the pain of the disease.
2.4 Health education and lifestyle changes for patients Some scholars believe that the application of large amounts of antioxidant micronutrients, especially vitamin C, can reduce the risk of cartilage loss in the knee joint and slow down the development of osteoarthritic lesions. As people become more health-conscious, good lifestyle practices such as diet and nutrition and weight loss are receiving more attention in the treatment of osteoarthritis, and guidelines for exercise and weight loss are being given more priority than pharmacotherapy.
2.5 Physical and professional treatment correctly uses hot and cold therapy with the aid of assistive devices such as crutches, slings or shoe inserts, installation of necessary splints and supports, and guidance on the correct use of joints. Mineral bath, sand therapy, infrared physiotherapy, low-energy laser, magnetic therapy, external application of herbs for blood circulation and blood stasis, fumigation, immersion, acupuncture, etc., can be applied as adjuvant therapy to receive better results, relieve pain, delay the course of the disease, and significantly reduce the dosage of non-steroidal anti-inflammatory drugs.
3.Surgical treatment
3.1 incision under direct vision cleanup Maghuson (1941) first advocated, the excellent rate of 65% to 75%. It is suitable for obese women over 40 years old with swollen and painful joints, obvious bony bulge at the edge of the joint, free bodies in the joint, weight-bearing joints are relatively intact, and the effect of conservative therapy is not effective.
3.2 Arthroscopic cleanup Less damage and faster postoperative recovery, poor results for those with obvious damage to the knee joint and existing deformity of internal and external rotation angle, H-Shahriaree reported an excellent rate of 76%.
3.3 Tibial high osteotomy For young patients and those with mild joint wear and bone collapse of the tibial plateau, not exceeding 0.5 cm.
3.4 Knee fusion For young patients with solitary severe osteoarthritis of the knee engaged in physical activity.
3.5 Artificial joint replacement For elderly patients with more bone and joint destruction and severe pain.