The concept of osteoarthritis of the knee: including chondromalacia patellae, proliferative arthritis, and traumatic arthritis, all three are painful syndromes caused by the degeneration of joint cartilage.
Osteoarthritis (OA) latest definition: In 1995, the International Conference on Osteoarthritis proposed that osteoarthritis is the result of a combination of mechanical and biological factors that lead to an imbalance in the degradation and normal coupling of chondrocytes, extracellular matrix and subchondral bone. Xinghua, Department of Osteoarthritis, Guangzhou First People’s Hospital
Pathogenesis.
Due to the imbalance of mechanical force distribution or overload causing cartilage wear or abnormal chondrocyte metabolism, the damaged chondrocytes release enzymes such as lysosomal enzymes and collagenases, which cause the collagen network to break, the proteoglycan in the network to degrade, and its physical and chemical properties to change. During the degeneration process, the degeneration of chondrocytes leads to the inability to synthesize and secrete type II collagen fibers and proteoglycans normally, making the normal physiological function of cartilage matrix decrease, causing microfracture of cartilage and subchondral bone under the stimulation of continuous external force, followed by the mutual influence of various components in cartilage and degeneration; or under the uneven force in the growth period, leading to the stress concentration on the joint surface, causing microfracture of cartilage and microfractures of the subchondral bone, which then allows the various components in the cartilage to interact with each other and degenerate.
Etiology.
(1) injury: intra-articular fracture, meniscal injury, patellar dislocation and other causes of articular cartilage injury; (2) excessive weight bearing: excessive weight bearing on the articular surface due to obesity or internal or external knee deformity; (3) destruction of articular cartilage due to infection or inflammation; (4) subchondral bone necrosis, such as brittle osteoarthritis occurs intra-articular free bodies, causing destruction of the articular cartilage surface.
Pathology: (a) mechanical cumulative injury: wear and tear of the knee joint contents, increased pressure in the knee joint cavity
(b) Biomechanical changes of knee osteoarthritis: internal and external deformity of the knee joint, weight-bearing
(b) Biomechanical changes of knee osteoarthritis: inward and outward deformation of the knee joint, inward or outward shift of the line of force, which reduces the effective weight-bearing area of the joint and increases the pressure of the trabeculae in the unit area of the joint.
The pressure on the trabeculae in the joint unit area is increased, and microfractures of the trabeculae may occur, while bone collapse and
Subchondral bone sclerosis.
(c) autoimmune reaction caused by injury: repeated swelling of the joint, increase of monocytes, immunoglobulins and complement in the synovial fluid, congestion and monocyte infiltration in the synovial membrane, and plasma cells and lymphocytes in the subchondral bone marrow cavity.
Clinical diagnosis.
(a) Symptoms.
1. Subpatellar pain
The early symptom is a sensation of friction and pain under the patella caused by active extension and flexion of the knee joint. During movements such as going up and down stairs or standing up from a seated position, the quadriceps muscle contraction causes subpatellar pain and frictional sensation. There is no symptom when the knee is passively extended and flexed, but sometimes there is also interlocking phenomenon and subpatellar pressure pain.
2. Repeated swelling of the joint
Most of the swelling and fluid accumulation in the joint, pain, pressure pain around the joint, and muscle spasm in the knee joint are caused after less serious trauma or mild sprain. After resting for 1 to 2 months, the symptoms may subside naturally. It can be asymptomatic for a long time, but can recur due to mild trauma. Due to weakness of the quadriceps muscle or due to pain, the knee joint may appear to “flash out”.
3. Joint deformity
As the disease progresses, the knee joint becomes inversion or valgus deformity, and the bone edge of the joint increases in size. The active and passive range of motion of the joint gradually decreases, and joint pain becomes more severe, causing pain even when walking on a level path and standing. The joint ligaments become lax and the joint becomes stable. Some patients are unable to fully straighten the knee joint, and in severe cases, the knee joint is deformed in flexion and contracture. At first, the pain is worse with activity and relieved after rest, but later it may become persistent. Systemic symptoms are generally rare.
(B) Physical signs
1.Examination
Atrophy of the quadriceps may be seen, while the knee joint is coarse. Occasionally, swelling of the synovial membrane and a positive floating patella test can be palpated. Pressure pain on the deep surface of the patella and around the knee joint. Mild or moderate restriction of joint motion is seen, but fibrous or bony ankylosis is rare. In severe cases, inversion or valgus deformity of the knee is seen, and signs of ligamentous laxity of the joint are seen on lateral motion examination. Outward or inward bending of the knee joint may be observed during unipedal standing.
2. X-ray findings
Early X-rays are often negative. Occasionally, small bone spurs can be seen on the upper and lower edges of the patella in lateral views. Later, the joint space is narrowed, the subchondral bone plate is dense, the joint edge and the intercalary crest are proliferated, and the subchondral bone is sometimes small and cystic, with rounded changes and dense cystic bone.
Knee x-ray angiometry: In order to estimate the severity of knee osteoarthritis and to plan for surgery, all knee femur and tibia angiometry should be performed.
Diagnostic staging
1. Ahlback (1968) classified osteoarthritis of the knee into 5 levels according to the severity of the knee radiographs
(1) Joint space narrowing (50% articular cartilage wear)
(2) Loss of joint line
(3) Mild bone wear
(4) Moderate bone wear (0.5 to 1 cm of wear)
(5) Severe bone wear and joint subluxation
Based on the above classification and the measurement of the bone tibia angle, the treatment methods can be estimated and compared.
2.Knee osteoarthritis is clinically classified into 4 types
Type I: Synovial inflammation stage.
For the early stage, also the early stage of chondromalacia patella, walking pain, painful site in the lower edge of the patella medially. It has little effect on
The impact on joint function is not significant, and the patellar cartilage is white on X-ray, and the joint cavity is normal.
Type II: Osteomalacia stage.
Recurrent pain, difficulty in walking, atrophy of the quadriceps muscle, knee flexion disorder, activity around within
Within 120. X-rays reveal calcification of articular cartilage, high and sharp tibial ramus, and joint rats.
Type III: joint deformation stage:
History of more than one year, recurrent pain, knee valgus, quadriceps atrophy, knee flexion not up to 100.
Radiographs of the joint cavity are narrow and wide, and the articular cartilage is calcified.
Type IV: phase of joint subluxation.
Type III is aggravated, the knee joint is useless, standing is difficult, the joint cavity disappears medially on X-ray, and the femoral ankle is outwardly
Dislocation.
3.Definition and typing.
(1) Strain injury to the tendons and bones: the tendons and bones and joints are rigid and normal.
The symptoms are localized pain and weakness, atrophy and numbness, aggravated by activity, but rest
The symptoms diminish after rest. The tongue is pale, the fur is thin and white, and the pulse is sunken and thin. Shujin Bao Bao Tang or Zuo Gui Drink is recommended.
Add or subtract.
(2) Cold and dampness stagnation: due to living in wet places for a long time, wading through water and rain, the evil of cold and dampness invades, injects in the meridians and joints, causing the Qi and blood to close.
The symptoms are pain in the joints, flexion and extension, and weakness of heavy weight or
The symptoms include pain in joints, flexion and extension, weakness or swelling, numbness of the skin, white and greasy tongue coating, and slow pulse. Recipe
Select Danggui Siwei Tang or Douwuxiaosheng Tang with addition and subtraction.
(3) Deficiency of liver and kidney: Injury for a long time, dark depletion of Yin and blood, loss of essence and blood, loss of nourishment of tendons and bones, symptoms include hidden joint
The symptoms include soreness and weakness of the joints, muscle atrophy, increased walking symptoms or weakness of the limbs, dizziness and dizziness, tinnitus, insomnia, etc.
tinnitus, insomnia, etc. The formula is Liu Wei Di Huang Tang plus or minus.