(I) Etiology and pathology
[Typhoid/cold/fat/old].
Osteoarthritis of the knee joint mostly originates from injury/cold/fat/old/. Knee osteoarthritis is divided into primary and secondary, primary osteoarthritis for the elderly knee joint long-term activities, often rotate each other wear and tear, so that the bone and cartilage degeneration, aging, exfoliation, bone exposed (with nerve tissue), and gradually formed bone spur-like hyperplasia and deformity. Secondary osteoarthritis is the result of trauma, fracture, dislocation, and other diseases of the knee joint, resulting in osteophytes in the bone and cartilage, and changes in the physiological function of the knee joint. Overweight, improper walking and working posture are often the causes of this disease.
(II) Symptoms
[Osteoarthritis + synovitis].
The pain is often accompanied by changes in posture in daily life, such as when squatting, when turning, when standing up after sitting for a long time, and when going up and down stairs, but the pain is not obvious at other times. After a few moments of activity, the stiffness and pain are relieved, but when the activity is intense, the leg feels uncomfortable again, and there is a popping sound and a rough rubbing sensation, rubbing sound (synovial hypertrophy). When the disease continues to develop until the joint cartilage disappears and the subchondral bone is exposed, the pain becomes continuous, and the pain is felt even when walking on a flat surface, and when sleeping at night, the leg feels inappropriate wherever it is placed, and sometimes wakes up with pain after sleeping, with redness and swelling of the knee joint and fluctuating sensations, and with the appearance of joint effusion. At this point, the condition is more serious. In short, the symptoms of osteoarthritis of the knee: osteoarthritis + acute and chronic synovitis (with abundant blood vessels, lymphatic and nerve tissues).
(C) Conservative treatment of osteoarthritis.
The current treatment of osteoarthritis of the knee aims to relieve symptoms, improve joint function, avoid or reduce deformity, reduce the risk of progression and facilitate the repair of damaged joints.
1. Self-adjustment exercises and weight loss.
For those whose symptoms are not severe can be addressed through physical therapy (light, heat, electricity), physical exercise (walking, swimming, cycling), crutches, and self-regulation. Remember not to fatigue, do not weight, do not climb (stairs), do not treadmill, and obesity is the only expected factor affecting osteoarthritis after, weight loss is a wise move.
2. Symptom control drugs.
These drugs can stop pain and improve symptoms more quickly, but they do not affect the basic lesions of osteoarthritis.
① Analgesics: Since the majority of patients with osteoarthritis are elderly, and the elderly are prone to side effects of non-steroidal anti-inflammatory drugs, and synovial inflammation in osteoarthritis, especially in the early stages, is not the main factor, and pain is not always caused by synovitis, so general analgesics can be used. It has been studied that there is no significant difference in the analgesic effect of analgesics and NSAIDs, and the gastrointestinal adverse effects of analgesics are less. For example, acetaminophen (i.e. paracetamol) is generally taken 0.3-0.6 grams, 2-3 times a day. Analgesics can be taken frequently, or only when in pain or when performing certain activities.
②Non-steroidal anti-inflammatory drugs: They have a good therapeutic effect on the inflammatory manifestations of osteoarthritis patients such as joint swelling, pain, fluid accumulation and limitation of activities. However, some non-steroidal anti-inflammatory drugs such as aspirin and anti-inflammatory pain inhibit the synthesis of cartilage matrix, and although long-term application improves joint pain, the basic lesion of osteoarthritis will be aggravated. In the study, it was found that, for example, diclofenac sodium (including Fotarine, Daphne, Intacrine, Diclofenac pain, Oxycodone), Chironolactone, Euthyrox, Nordren, Cilobal, Wanluo, etc. have no effect on joint cartilage and are more suitable for application in osteoarthritis.
Non-steroidal anti-inflammatory drugs are mainly used to inhibit inflammation and thus reduce pain. Their anti-inflammatory effects often take a few hours, a day or two, or even two or three weeks after the start of the drug before they start to play, so it is best to say whether a certain non-steroidal anti-inflammatory drug has any effect after taking it for a while.
(3) Adrenocorticotropic hormone: Although beneficial to chondrocytes has been reported, systemic application is not necessary and is only indicated for the development of synovitis and joint cavity effusion.
The duration of relief is highly variable between the two diseases, with most lasting more than four weeks. Repeated intra-articular injections in joints with osteoarthritis can increase joint damage, and direct injection of glucocorticoids into tendons can cause delayed tendon rupture and should therefore be avoided. Patients whose symptoms improve after intra-articular glucocorticoid injections should be careful to avoid overuse of the improving joint.) , limetasone, etc. The same joint medication should not be used more than four times a year, and the interval between two times should not be shorter than two months.
3, change of condition drugs.
That is, what used to be called chondroprotective agents. The effect of this type of drugs is slow, generally need to treat a few weeks before the effect, but after the drug is discontinued, the effect still lasts for a certain period of time, and at the same time can slow down, stabilize or even reverse the process of osteoarthritis cartilage degradation.
① Hyaluronic acid: In the 1930s, scientists successfully extracted it from the vitreous humor of bovine eyeballs, and it was named vitreous acid, also known as hyaluronic acid. It began to be used for the treatment of arthritis in racehorses. Since 1974, intra-articular injection was first used to treat osteoarthritis and achieved good results. Hyaluronic acid is the main component of joint fluid and is also found in cartilage.
The preparation used clinically is extracted and purified from cockle. At present, domestic hyaluronic acid products include sodium vitreous acid injection (trade name Schippers), 2 ml intra-articular injection, once a week for 5 times, and the efficacy can last for about half a year. Imported products include Xinvicor, 2 ml of intra-articular injection, once a week, 3 times a course, the effect can be maintained for about 1 year.
②Peroxide dismutase (SOD): It can remove the by-products produced in the process of oxygen metabolism, thus reducing the damage to joint cartilage. It has a slow onset of action and the efficacy can last up to 18 months. It has been used clinically in Europe and the United States.
(③) D-glucosamine: The first to be used in China was an oral sulfate called glucosamine, with the trade name of Vibramix. The recommended usage is 314-628 mg, 3 times a day, with meals and swallowed at the same time, for 8 weeks, and a course of treatment can be repeated every six months or so. It has few side effects, mainly mild nausea, constipation and drowsiness.
Glucosamine: Glucosamine is the most important monosaccharide that constitutes polyglucosamine (GS) and proteoglycans in the cartilage matrix of joints. Normal people can synthesize GS through the amination of glucose, but in osteoarthritis, the synthesis of GS in chondrocytes is blocked or insufficient, resulting in softening and loss of elasticity of cartilage matrix, destruction of collagen fiber structure, and increase of cartilage surface lumen to make bones worn and destroyed.
Glucosamine can block the pathogenesis of osteoarthritis, promote the synthesis of proteoglycans with normal structure in chondrocytes, and inhibit the production of enzymes (such as collagenase and phospholipase A2) that damage tissue and cartilage, reduce damage to chondrocytes, improve joint movement, relieve joint pain, and delay the course of osteoarthritis. It is best taken orally 250-500mg once, 3 times a day, with meals.
Available for diabetic patients: In addition, glucosamine is synthesized by human cells as a large mucopolysaccharide, rather than being used to synthesize carbohydrates for use as energy. Therefore, glucosamine can be used by diabetic patients within the therapeutic dose.
4, osteoporosis medicine.
【Osteoporosis → osteoarthritis → osteoporosis】 Osteoporosis and the onset and accelerated development of osteoarthritis have a certain connection, and therefore the treatment of osteoarthritis, starting from the prevention and treatment of osteoporosis. Calcitonin and active vitamin D3 can not only treat osteoporosis, but also have a good promotion effect on cartilage damage repair, while diphosphonates can both treat osteoporosis and inhibit excessive osteophytes, so calcitonin, active vitamin D3 and diphosphonates are the choices for clinical treatment of osteoporosis with osteoarthritis.
5.Other.
In addition, there are tetracycline antibiotics (such as doxycycline), glucosaminoglycans, S-adenosylmethionine, bone resorption agents (including etidronate, clodronate, pamidronate, alendronate, etc.), synthetic matrix metalloproteinase inhibitors, cytokines to promote cartilage repair, etc. Currently, some of these agents have seen results, and some are still in the exploratory research Some of these agents have shown results, while others are still in the exploratory stage. They should not be recommended at all.
6. Principles of Chinese medicine.
Tonic/Qi/Blood/Liver/Spleen/Kidney (support the righteous) + remove wind/cold/damp (dispel evil) + activate blood to dispel blood stasis (treat wind first, blood flow wind extinguishes itself).
(D) surgical treatment of osteoarthritis.
1 , when drugs and other methods can not play a role in the relief of the bone and joint, you can resort to arthroscopic cleaning or lavage, and can further understand the extent and scope of osteoarthritis lesions. Common surgical procedures for osteoarthritis include: osteotomy, joint cleaning, osteoarticular fusion and artificial joint replacement.
In advanced stages of osteoarthritis, severe metamorphosis of the articular cartilage, deformity of the joints, restricted movement, and serious impact on daily life, joint replacement can be used if the general treatment is not effective.
Joint replacement is a way to extend the life of elderly patients while improving their quality of life, while for younger patients, joint replacement allows them to actively participate in social life and work. The age range of artificial joints (total hip/total knee replacement) has widened compared to the past, and frailty is a characteristic of elderly patients. Moreover, the greater the functional limitation, the better the postoperative improvement. The surgical outcome is significantly better than that of arthrofusion or osteotomy.
Artificial joints are very effective for both pain and disability, and their cost is very worthwhile and effective compared to most other chronic conditions. The incidence of artificial joint replacement surgery, deep vein embolism is very low, and the incidence of joint dislocation has decreased from 7% to about 3%.
(v) Prevention of osteoarthritis.
Osteoarthrosis is a degenerative disease that occurs mainly in the cartilage. During a person’s lifetime, bone mass reaches a peak at age 30 and begins to decline gradually thereafter. The increase and maintenance of peak bone mass helps to prevent the occurrence of osteoporosis, which is associated with the onset and accelerated development of osteoarthritis, and thus prevention of osteoarthritis should begin in middle age or even in adolescence (osteoporosis). For details, please refer to the article “Osteoporosis” on this website.
For acute synovitis of the knee, please read the article “Notes on Synovitis of the Knee” on this website.
Appendix-1: The classification criteria for osteoarthritis in the United States (ACR) are as follows;
(a) Hand joint criteria established in the United States: Those who have hand joint pain or stiffness with at least three of the following four conditions
1.The distal and proximal phalanges of the 2nd and 3rd fingers of both hands and the first carpometacarpal joint, 2 or more of these 103 joints show hypertrophy of the hard tissue.
2. At least 2 distal phalanges have hypertrophy.
3. Less than 3 metacarpophalangeal joints are involved (swollen).
4.At least 1 of the above 10 joints is deformed.
(B) Knee joint criteria Knee pain and X-rays of the knee show bone arthrosis, which is accompanied by any of the following.
1. Age >50 years.
2. Stiffness of the affected knee <30 min.
3. There is bone friction sound.
(C) Hip joint criteria Hip pain with at least two of the following three conditions
1.Blood sedimentation <20mm/1sth
2.X-ray shows bone artifact in the femur or femoral head
3.X-ray shows at least symptoms of osteochondritis