I. What is osteoarthritis?
Osteoarthritis (OA) is also known as age-related arthritis, degenerative arthritis, osteoarthropathy. The disease can be involved in most joints throughout the body, more often involving the lumbar spine, interphalangeal joints and lower limb weight-bearing joints such as the knee, hip, etc., and the highest clinical incidence of the knee, the greatest impact on the quality of life of patients. Various orthopedic books have been quite rich in the introduction of OA, this article is only the author’s clinical treatment of osteoarthritis of the knee joint as the main point of view.
OA is mostly seen in the middle-aged and elderly, the incidence of elderly people over 60 years of age up to 40% -50%, more women than men, especially in postmenopausal women. As the disease is manifested only by mild joint pain in the early stage, the patient consultation rate is not high, when the disease develops to an advanced stage of severe joint pain, joint deformity, functional limitations, and limited treatment methods, seriously affecting the quality of life of the elderly.
What is the cause?
The cause of osteoarthritis is not yet fully understood, some of the OA related to trauma, congenital deformity, infection, metabolic and neurological diseases, known as secondary OA. most OA lack of clear causes, known as primary OA, mostly related to genetics, heavy physical labor and aging. These causes can lead to disturbances in the biomechanical environment of the joint, degeneration and destruction of articular cartilage, and ultimately affect the subarticular bone with painful symptoms and joint deformity. The following causes can contribute to the development of OA:
Aging primary OA is common in the elderly, but the pathological evidence is that OA does not occur in some older people, so OA is not an inevitable result of aging, and increasing age only increases the risk of OA;
Chondrocyte and matrix anabolic balance is disrupted in articular cartilage cartilage tissue surrounded by a proteoglycan matrix, there is a continuous balance between synthesis and degradation of chondrocytes and matrix, and the metabolic balance is regulated by the growth factors and enzymes of the joint fluid. Changes in any of the above factors can cause OA.
Third, changes in joint mechanics.
1, local factors of cartilage damage are abnormal loading, including one-time overload stress and repeated multiple injury stress (such as overweight), which can cause cartilage degeneration, reduced shock absorption performance and sclerosis of the subchondral bone.
2, the loss of cartilage lubrication and shock absorption can cause local subchondral bone sclerosis and osteophytes.
3, ligament, meniscal injury and cartilage wear caused by joint instability will also accelerate the development of OA.
Fourth, how to diagnose and differential diagnosis?
Most osteoarthritis is not difficult to diagnose, mainly through symptoms, signs and imaging examinations for diagnosis. A few atypical cases need to be differentiated from rheumatoid arthritis, compulsory spondylitis and other autoimmune diseases when blood tests are required. Here is how to quickly and accurately diagnose osteoarthritis when seeing patients in the outpatient clinic.
The diagnosis of osteoarthritis should begin when the patient enters the clinic. Since the early consultation rate of osteoarthritis patients in China is not high, most of the patients who come to the hospital are late stage patients, and most of these patients have some common features: “mostly elderly women, most of them are heavier or can be seen to have a long history of physical labor, joint deformity (“O “shaped legs), limping or requiring instrumental assistance to walk.” The above characteristics will give the physician an initial impression as soon as the patient steps into the office. The following is a brief description of the diagnosis of this disease in terms of symptoms, signs and ancillary tests, using the most common clinical example of osteoarthritis of the knee.
Patients with osteoarthritis of the knee commonly complain of knee pain, mostly bilateral, with varying degrees of bilateral pain, which can be alternately aggravated, and cannot be clearly defined in terms of location and nature, and can radiate to the thighs and calves. The pain occurs after walking, and the walking distance is gradually reduced as the disease worsens. Patients may also experience morning stiffness, resting pain and nocturnal pain.
Early in the course of the disease, there may be no signs, but as the disease progresses, swelling and deformity of the knee joint may occur. Inversion and flexion deformities predominate.
The primary imaging test for knee OA is a standing front and side x-ray of the knee, which should include the femur and mid tibia. The reason for emphasizing the standing position is that when the affected knee is loaded with weight, we can clearly observe the narrowing of the joint space and changes in the force lines of the lower extremity. The normal joint space and lower extremity force lines can still be seen in the prone position, which can affect the severity of the disease.
Note that rotation and flexion of the lower extremity can affect the determination of normal lower extremity force lines during orthopantomographs. The main manifestations of knee OA on ortho-x-ray are narrowing or loss of joint space, abnormal force lines in the lower extremity, and the formation of “bone spurs” (bony redundancy) at the edges of the tibial and femoral articular surfaces. The clinical findings are mainly a reduction of the medial space and inversion deformity. Lateral X-ray can observe the narrowing of the patellofemoral joint space and the formation of “bone spur” (bone superfluous) in front and behind the joint surface.
V. Differential diagnosis
Osteoarthritis is not difficult to diagnose, in the symptoms, signs are not typical when the need and rheumatoid arthritis, compulsory spondylitis and other autoimmune diseases to distinguish, through the imaging performance and blood marker examination is not difficult to identify, not detailed here.OA treatment as follows.
1, the treatment of OA in the early stage
Early OA treatment principles are to improve the symptoms and slow down the development of the disease. Non-surgical treatment is the main focus. In patients with symptoms and articular cartilage has not yet appeared obvious lesions, the joint space has not yet become narrow when the start of preventive comprehensive treatment.
(1) Reduce the load of joint use
Reduce weight, prolonged walking, frequent stairs, climbing, and other sports that place a high load on the joints. Minimize the intensity of joint activities within the scope of normal life and work.
(2) Muscle function exercise
To maintain knee stability and reduce quadriceps atrophy, functional training of the quadriceps muscle should be performed. Static non-weight-bearing exercises such as straight leg raise and resistance knee extension training should be the main focus. Muscle controlled contraction training is recommended instead of muscle high frequency contraction and diastolic training. That is, control the quadriceps in a contracted state for a sustained period of time, then relax and rest. Repeatedly. Swimming exercise is also a good method.
(3) Drug treatment
The current treatment of OA drugs are mostly to improve the symptoms and delay the development of the disease class of drugs, the reversal of the disease itself does not have much effect.
a to improve pain symptoms can be used non-steroidal anti-inflammatory drugs (NSAIDS), selective COX-2 inhibitors such as “celecoxib” digestive system side effects are small, recommended. nSAIDS drugs with the relief of muscle tension drugs for symptom relief more effective, such drugs are mainly The main drugs in this category are “Eperisone Hydrochloride” and so on.
(4) Physiotherapy
Many physical therapy can relieve symptoms such as heat therapy, shock wave therapy, etc. can be used for OA treatment, but should avoid violent massage.
2, the treatment of advanced OA
Treatment methods for advanced OA are limited. The principle of treatment is to relieve the patient’s symptoms as much as possible, restore joint function and improve the quality of life of patients. Whether the choice of non-surgical treatment or surgical treatment are based on the above principles as the standard.
(1) non-surgical treatment
In all, early non-surgical treatment methods can be used for advanced OA treatment, but most of the treatment is not effective.
(2) Arthroscopic surgical treatment
In the author’s experience, arthroscopic surgery is only used in cases accompanied by meniscal damage or free body formation in the knee, and such cases are performed only to relieve the symptoms of joint strangulation. Arthroscopic irrigation alone is only effective for a short period of time in most patients, usually 4-6 months, and is of little significance.
(3) Osteotomy
Various types of osteotomies are performed to improve symptoms by shifting the joint load from the diseased compartment to the more normal compartment by changing the knee joint force lines. Because of its narrower indications, it has more complications. And with the maturity of knee arthroplasty, osteotomy has very few opportunities for clinical use.
(3) Arthroplasty
For advanced OA, knee arthroplasty (TKA) can effectively relieve patients’ pain, rebuild joint function, and improve patients’ quality of life. Knee arthroplasty has been in clinical use for more than 40 years and is now very mature in terms of prosthesis design, materials, surgical instruments, and surgical techniques. The life expectancy of the prosthesis has theoretically exceeded 20 years, and some scholars have performed 15-year post-operative follow-ups with a prosthesis survival rate of 94% or more. Knee replacement surgery itself is complex and will not be described in detail here. However, the author would like to emphasize two issues with regard to knee arthroplasty.
Also for some other patients, the indications for surgery should not be blindly expanded. For example, some elderly patients have a more severe x-ray presentation, but have milder self-perceived symptoms and joint function that has not yet had a major impact on their lives. Some patients even treat knee replacement as orthopedic and cosmetic surgery. Expanding the indications for surgery at this time can have adverse consequences. It should always be remembered that we treat the patient’s symptoms and not the radiographs.