Osteoarthritis of the knee joint (gonarthrosis): diagnosis and treatment

Up to 20% of all people over the age of 25 are at risk of developing deforming osteoarthritis of the knee. The knee joint works in the axial compression mode, therefore its articular surfaces are subjected to constant loads and are subject to degenerative changes in the hyaline cartilage.

Predominance

Articular cartilage pathology of a degenerative-dystrophic nature with the participation of bone tissue, articular bag, ligaments and muscles in the process is called deforming arthrosis. In terminology there are synonyms:

• osteoarthritis;
• osteoarthritis;
• degenerative arthritis;
• osteoarthritis;
• hypertrophic arthritis;

In terms of frequency, damage to the knee comes immediately after the hip joint, which is why a stable phrase has formed - "gonarthrosis of the knee joint. "The dependence of the frequency of the disease on age was studied:

26 - 44 years	5% of adults
45 - 59 years	16, 70%
60 - 69 years	12, 10%
70 years and older	eleven%

In all age groups, representatives of the fair sex quantitatively predominate. In them, osteoarthritis of the knee occurs 1. 2-1. 4 times more than in men.

In the field of persistent disability, deforming osteoarthritis of the knee joint represents almost 30% of all causes of disability associated with joint pathology.

Gonarthrosis classification

For developmental reasons, the disease is divided into two large groups: primary and secondary. The primary arises without visible prerequisites. The secondary is preceded (or accompanied by) provoking factors:

1. biomechanical disorders: injuries, excessive loads, developmental abnormalities (dysplasia), skeletal pathology (scoliosis, flat feet), obesity;
2. inflammatory processes: aseptic or infectious arthritis, frequent hemarthrosis in hemophilia;
3. metabolic diseases: gout, hemochromatosis, Paget's disease;
4. endocrine gland disorders: acromegaly, diabetes mellitus, parathyroid gland disorders;
5. violations of adequate blood supply: varicose veins and post-thrombophlebitic syndrome, endarteritis obliterans, atherosclerosis of the vessels of the lower extremity;

In medical practice, classification according to the severity of pathological changes is more useful. The assessment is made according to radiographic studies. The most popular clinical and radiological classification.

I stage

The picture shows a slight narrowing of the inter-articular space (comparison with a healthy joint is made), the beginning of sclerosis of the pericartilaginous bone tissue. Clinically, the pain occurs when walking or immediately after, with a prolonged position. More pronounced when climbing stairs. It happens at rest. Gonarthrosis of the first degree does not greatly affect the function of the joint.

II stage

The joint space is 2-3 times narrower than normal. Sclerosis is more pronounced, osteophytes are found (pointed growths of bone tissue along the edges of the joint space and condyles). The pain is moderate, there are signs of muscle hypotrophy, lameness. Deformation of the knee in the frontal axis is appreciated. Second degree gonarthrosis leads to a noticeable limitation of joint mobility.

III stage

Sclerosis of cartilaginous elements, deformation of articular surfaces. There are areas of subchondral necrosis, local osteoporosis. Cysts in adjacent bone tissue. The joint space is critically narrowed, sometimes not defined. Osteophytes of considerable size. Atrophy of the muscles of the thigh and lower leg, the joint is unstable, there is a pronounced deformity. Movement in the knee is sometimes impossible, a contracture forms. When moving: severe pain, limp.

This classification approach is convenient because it allows evaluation of clinical manifestations in relation to organic changes. It gives the opportunity to choose a more effective treatment based on a comprehensive evaluation of the state of the joint.

development mechanism

The pathogenesis of any osteoarthritis goes through three stages:

1. Damage to the microstructures of the cartilage. Under the influence of any of the damaging factors, high molecular weight compounds lose their strength and become enriched with water molecules. The ability of low molecular weight collagens to assemble into macromolecules is impaired. This leads to a decrease in the strength and durability of the hyaline cartilage. Chondroprotectors counteract such phenomena.
2. If the provoking factor is not removed, the weakening of cartilage components (glycosaminoglycans, proteoglycans) continues. This leads to the activation of recovery processes. His energy reserve is not particularly large, so this stage quickly goes to the next.
3. Disruption of compensatory mechanisms leads to the progressive destruction of articular cartilage, the death of its cells - chondrocytes. Cracks in the cartilage extend into the underlying bone. The degree of detachment of cartilaginous components increases, their defibration occurs, which leads to thinning of the hyaline membrane.

On the part of the bone, with deforming arthrosis of the knee joint, thickening (sclerosis) occurs, cysts and areas with uneven bone density appear. Thus, deformation of the articular surfaces develops, joint instability.

Diagnostics

The diagnosis is based on a set of data obtained as a result of a survey (anamnesis), a medical examination and instrumental research methods. The latter include radiographic examinations (CT, MRI), radioisotope (scintigraphy), arthroscopy.

objective exam

It includes clarification of the patient's life history, the circumstances preceding the development of gonarthrosis of the knee joint, the collection of complaints and examination. In the process, the presence of provoking factors and the degree of their influence on the development of the disease are clarified.

At this stage, it is important to find out the condition of the second knee. If you miss bilateral knee osteoarthritis and focus only on the knee you are most concerned about, you may be making a serious diagnostic error.

To do this, functional tests must be performed on two limbs at the same time. Attention is drawn to the pain of active and passive movements, tenderness on palpation, crepitus (crunching) during extension and flexion. Chronic inflammatory processes lead to the appearance of a Becker's cyst - a protrusion of the articular bag in the popliteal fossa, which can also be detected by palpation.

instrumental methods

The first is the x-ray. An image of the knee in two projections allows a preliminary evaluation of the state of the joint and determine the stage of the disease. The disadvantage of the method is that the radiological signs occur later than the symptoms and morphological changes that accompany osteoarthritis of the knee joint.

In such cases, MRI (magnetic resonance imaging) helps. It is possible to determine the initial stages of degenerative changes in cartilage and bone structures, it is possible to assess the state of intra-articular ligaments, menisci. Scintigraphy for gonarthrosis of the knee joint provides data on the functional status.

Direct examination of the joint cavity is possible with arthroscopy.

For the unification of diagnostic data, the American College of Rheumatology proposed the following criteria:

• Age over 50 years.
• Stiffness in the joint in the morning, which persists for at least half an hour.
• Cracking, determined by movement (active and passive).

If these symptoms are accompanied by osteophytes on the X-ray and pain, gonarthrosis of the knee joint is most likely occurring.

The initial stages of the disease may not be pronounced, therefore it is necessary to carry out differential diagnosis with other joint pathologies, in which pathogenic drugs for osteoarthritis (chondroprotectors) will be ineffective.

All possible measures should be taken so as not to confuse gonarthrosis with the following conditions:

Rheumatoid arthritis	Early age onset, morning stiffness lasting more than 30 minutes, pain worse at rest and weaker with movement, rheumatoid skin nodules, concomitant internal organ lesions, symptoms of intoxication (fever, sweating), C-reactive protein on test of blood.
crystalline arthritis	The pain is sharp, at night or in the morning; the skin over the diseased joint is edematous, red, hot; crystals on a microscopic examination of the synovial fluid, an increase in uric acid in the blood (with gout).
spondyloarthropathies	Arthritis of other unrelated joints (intercostal joint, lumbar); inflammatory processes in the tendons; damage to the cornea, skin, mucous membranes.

In the International Classification of Diseases of the Tenth Revision (ICD 10), all of these diseases are assigned the "M" index, but a different numerical code.

These are fundamentally different pathological processes that require a professional approach to diagnosis and qualified treatment.

therapeutic measures

If there is a disease, there must be ways to cure osteoarthritis of the knee joint. And they exist. Help can be provided in a number of ways.

In the first place are the achievements of traditional medicine, based on a deep study of the causes and mechanism of disease. Here medical and surgical methods are used. Competent treatment requires the constant and complex use of drugs, physiotherapy methods and rehabilitation measures.

The second way is treatment with folk remedies. The effectiveness of these methods, to put it mildly, is questionable. But they are used because it is possible to reduce the manifestations of the disease at home. Folk remedies can only be used as an adjunct to drug treatment or as part of complex therapy, it is imperative to obtain the consent of the attending physician!

medicinal help

This type of treatment includes the use of various medications. For medicinal purposes, drugs of different groups are used:

1. non-steroidal anti-inflammatory drugs, analgesics, opioids;
2. slow-acting symptomatic drugs (chondroprotectors);
3. glucocorticoid hormones;

NSAIDs, rapid pain relievers, opioids

Drugs from this group are designed to eliminate pain. Pain syndrome quite spoils the life of patients with arthrosis, its elimination significantly improves the quality of human life. NSAIDs, anilides, non-narcotic and narcotic pain relievers are capable of doing this.

A common drawback is side effects. These drugs adversely affect the kidneys, the protective mechanisms of the gastrointestinal tract. An alternative that can reduce harmful manifestations are injections. Intramuscular administration causes less damage to the stomach and accelerates the effect.

Due to side effects, drugs from this group are prescribed during exacerbations, careful selection of the dose is required.

The main advantage of NSAIDs is the many forms of local treatment (ointments, gels). It allows you to control the manifestations of the disease at home.

Centrally acting analgesics are prescribed for a short period, with the other two groups being ineffective. The most popular opioid is prescribed during an exacerbation, more often with bilateral gonarthrosis. These drugs are addictive. You can't take them on your own!

Slow-Acting Symptomatic Drugs

The action of these substances is twofold: they have the ability to reduce pain (like NSAIDs) and contribute to the restoration of hyaline cartilage. They are often called chondroprotectors.

The effect develops over several weeks (2-8) and persists after cancellation for 2-3 months.

In addition to chondroitin sulfate and glycosaminoglycans, this group includes preparations based on hyaluronic acid, compounds derived from avocado and soy.

The most studied and popular chondroprotectors (chondroitin sulfate and glycosaminoglycans) are ready-to-use components of articular cartilage. Well absorbed into the blood, it forms high concentrations in the joint cavity. To speed up the effect, injections can be done directly into the joint.

Chondroitin sulfate, taken in courses for two years at a daily dose of 800 mg, has been shown to have a stabilizing effect on the joint space in gonarthrosis of the knee joint of the second degree.

Avocado/soy compounds have anti-inflammatory effects. Due to the inhibition of collagenase (a breakdown enzyme), they significantly slow down the destruction of cartilage and increase the synthesis of "their own" collagen. They are also very well tolerated.

Hyaluronic acid derivatives are used in the form of intra-articular injections. These funds, like chondroprotectors, improve the functional state of the knee joint.

The mechanism of action of various slow-acting symptomatic drugs is somewhat different, so their combined use is recommended. A high level of safety allows you to take chondroprotectors for a long period without tangible harm to the body.

Glucocorticosteroids

The main action is anti-inflammatory. These funds are prescribed when NSAIDs are ineffective. The tablets also damage the stomach lining. There are forms for intra-articular injections.

They have numerous side reactions, so you should not abuse hormonal drugs to deform arthrosis of the knee joint.

Group name	Advantage	Defects
NSAIDs, pain relievers, opioids	Quick effect, many forms for topical application.	Side effects, unstable effect, dangerous for age-related patients, addiction occurs.
Chondroprotectors	They act pathogenetically, have a long-lasting effect, are not toxic, there are forms for external and intra-articular use.	Slow development of effect.
hormones	Quick effect where NSAIDs are not enough; Forms for intra-articular administration.	Side effects, unstable effect, long-term use is impossible.

ethnoscience

At home, you can reduce the manifestations of the disease with folk remedies. Recipes there are many, but there are few but:

• no clinical studies have been conducted;
• it is impossible to accurately dose the medicinal substance;
• the indications are not clearly defined;
• individual tolerance of folk remedies is not taken into account;

The advantages include a wide therapeutic range, a large selection for external use. Homemade compresses and tinctures, ointments are popular.

The effectiveness of home treatment can be proved by the fact that biologically active substances (gum, bile, infusions of medicinal plants) are used for the preparation.

Also, competent treatment with folk remedies begins with compliance with a diet, weight loss. This method alone, aimed at reducing the load on the joint, can reverse osteoarthritis of the knee joint of the first degree (the condition is a young age, sufficient compensatory abilities). A healthy diet, in itself, stimulates the regenerative capacities of the body. The diet includes: a slight feeling of hunger, vegetables, freshly squeezed juices. It is advisable to add low-fat jellies, jellies to the diet.

External means are very diverse. They mainly have an irritant and warming effect. The most studied components are bile, dimethylsulfoxide and bischofite. The bile is to be used medically and not independently extracted from an animal carcass. Dimethyl sulfoxide is an analogue of a chemical warfare agent, mustard gas. The bischofita is a petroleum derivative. That is the difference of origin.

All three drugs have an anti-inflammatory effect, however, at home they should be used only after consulting a doctor. These substances also have contraindications and application features.

We must not forget the placebo effect in the treatment of home remedies.

The last thing I want to convey is that a person has only one health. You should not completely trust the seeming simplicity and low cost of folk remedies. If you have already decided to try them, increase your attention to the sore joint. The progression of the disease against the background of treatment with folk remedies is a reason to reconsider the approach to therapy.

If osteoarthritis of the knee joint of grade 2 or higher is diagnosed, it is better not to mess with traditional medicine. Or postpone it for a remission period. Unsatisfactory treatment is an indication for complex surgical intervention.