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 axial compression mode, therefore its articular surfaces are subjected to constant loads and undergo degenerative changes in hyaline cartilage.

Prevalence

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

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

In terms of frequency, knee damage comes right after the hip joint, so a consistent phrase has been coined: "gonarthrosis of the knee joint. "The dependence of the frequency of the disease on age has been studied:

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

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

In the field of permanent disability, deforming arthrosis of the knee joint accounts for almost 30% of all causes of disability related to joint pathology.

Classification of gonarthrosis

For reasons of development, the disease is divided into two large groups: primary and secondary. Primary arises without obvious preconditions. The second is preceded (or accompanied by) provocative 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, disappearing endarteritis, atherosclerosis of the vessels of the lower limbs;

In medical practice, classification according to the severity of pathological changes is more useful. The assessment is made according to X-ray studies. The best known clinical and radiological classification.

I stage

The photo shows a slight narrowing of the inter-articular gap (a comparison is made with a healthy joint), the beginning of sclerosis of the pericartilaginous bone tissue. Clinically - the pain appears during walking or immediately after it, with prolonged standing. More pronounced when walking on stairs. Goes to rest. First-degree gonarthrosis does not affect joint function much.

Phase II

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

Phase III

Sclerosis of cartilaginous elements, deformation of articular surfaces. There are areas of subchondral necrosis, local osteoporosis. Cysts in adjacent bone tissue. The shared 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 deformation. Movement in the knee is sometimes impossible, contracture is formed. When moving - severe pain, lameness.

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

Mechanism of development

The pathogenesis of any arthrosis goes through three stages:

1. Damage to cartilage microstructures. 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 collagen to assemble into macromolecules is impaired. This leads to a decrease in the strength and durability of hyaline cartilage. Chondroprotectors oppose such phenomena.
2. If the provoking factor is not eliminated, the weakening of cartilage components (glycosaminoglycans, proteoglycans) continues. This leads to the activation of recovery processes. Their power reserve is not particularly large, so this stage quickly passes into the next.
3. Disruption of compensatory mechanisms leads to progressive destruction of articular cartilage, death of its cells - chondrocytes. Cartilage cracks extend into the underlying bone. The rate of detachment of cartilaginous components increases, their defibration occurs, which leads to thinning of the hyaline membrane.

From the side of the bone, with deforming arthrosis of the knee joint, thickening (sclerosis), cysts and areas with uneven bone density appear. Therefore, the deformation of the articular surfaces, the instability of the joint develops.

Diagnosing

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

Objective examination

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

At this stage, it is important to find out the condition of the second knee. If you miss bilateral gonarthrosis and focus only on the knee that bothers you the most, you can make a serious diagnostic error.

For this, functional tests must be performed on two limbs at once. Attention is drawn to the pain of active and passive movements, sensitivity to palpation, crepitus (crunching) during stretching and bending. Chronic inflammatory processes lead to the appearance of a Becker cyst - a protrusion of the articular bag in the popliteal fossa, which can also be detected by palpation.

Instrumental methods

The first is radiography. A view of the knee in two projections allows a preliminary assessment of the state of the joint and determination of the stage of the disease. The disadvantage of the method is that the radiological signs appear later than the symptoms and morphological changes accompanying knee arthrosis.

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

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 joints in the morning, which continues for at least half an hour.
• Cracking, determined by movement (active and passive).

If these symptoms are accompanied by osteophytes found on x-rays and pain, it is most likely that gonarthrosis of the knee joint occurs.

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

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

Rheumatoid arthritis	Begins at an early age, stiffness in the morning for more than 30 minutes, pain worse at rest and weaker on movement, rheumatoid nodules on the skin, accompanying lesions of the internal organs, symptoms of intoxication (fever, sweating), C-reactive protein. in blood tests.
Crystal arthritis	The pain is sharp, at night or in the morning; the skin over the diseased joint is edematous, red, hot; crystals in a microscopic examination of the synovial fluid, increased uric acid in the blood (with gout).
Spondyloarthropathies	Arthritis of other unrelated joints (intercostal, lumbar joints); inflammatory processes in tendons; damage to the cornea, skin, mucosa.

In the International Classification of Diseases of the Tenth Revision (ICD 10), all these diseases are assigned the index "M", 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 arthrosis of the knee joint. And they exist. Help can be provided in different ways.

In the first place are the achievements of traditional medicine, based on a deep study of the causes and mechanism of the disease. Medical and surgical methods are used here. Competent treatment requires the continuous and complex use of medications, 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 necessary to obtain the consent of the attending physician!

medical assistance

This type of treatment involves the use of various medications. For medicinal effects, drugs from different groups are used:

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

NSAIDs, rapid analgesics, opiates

Medicines of this group are designed to eliminate pain. The pain syndrome pretty much disrupts the life of patients with arthrosis, its removal significantly improves the quality of human life. NSAIDs, anilides, non-narcotic and narcotic analgesics are capable of this.

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

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

The main advantage of NSAIDs are the many forms for local treatment (ointment, gel). It allows you to control the manifestations of the disease at home.

Analgesics with central action are prescribed for a short period, with the ineffectiveness of the other two groups. The most popular opiate is prescribed during an exacerbation, most often with bilateral gonarthrosis. These drugs are addictive. You can't get them yourself!

Slow-acting symptomatic medications

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 for several weeks (2-8) and continues after cancellation for 2-3 months.

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

The most studied and well-known chondroprotectors (chondroitin sulfate and glycosaminoglycans) are ready-made components of articular cartilage. It is well absorbed into the blood, forming high concentrations in the joint cavity. To speed up the effect, injections can be made directly into the joint.

It has been proven that chondroitin sulfate, taken in courses for two years at a daily dose of 800 mg, has 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 decomposing enzyme), they significantly slow down the destruction of cartilage, increase the synthesis of "their" 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 condition of the knee joint.

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

Glucocorticosteroids

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

They have many side effects, so you should not abuse hormonal drugs for deforming arthrosis of the knee joint.

Group name	strengths	Shortcomings
NSAIDs, analgesics, opiates	Fast effect, multiple forms for topical application.	Side effects, unstable effect, dangerous for age-related patients, addiction appears.
Chondroprotectors	They act pathogenically, have a stable effect, are non-toxic, there are forms for external and intra-articular use.	Slow development of the effect.
Hormones	Fast effect where NSAIDs are not enough; form 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. There are many recipes, but there are some, but:

• no clinical studies have been conducted;
• it is impossible to dose the medicinal substance correctly;
• 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 proven by the fact that biologically active substances (gum, bile, infusions of medicinal plants) are used for preparation.

Moreover, competent treatment with folk remedies begins with adherence to a diet, weight loss. Only this method, aimed at reducing the load on the joint, can change osteoarthritis of the knee joint of the first degree (the condition is young age, sufficient compensatory ability). Healthy food, in itself, stimulates the regenerative abilities of the body. The diet includes: a slight feeling of hunger, vegetables, freshly squeezed juices. It is recommended to add low-fat jelly, jelly to the diet.

External tools are very different. They mainly have an irritating and warming effect. The most studied components are bile, dimethyl sulfoxide and bischofite. Bile should be used medicinally, and not independently extracted from an animal's carcass. Dimethyl sulfoxide is an analogue of a chemical warfare agent, mustard gas. Bischofite is a petroleum derivative. This is the difference in 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 features of application.

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

The last thing I want to convey is that a person has a health. You should not completely rely on the apparent simplicity and cheapness of folk remedies. If you have already decided to try them, increase your attention to the injured 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 confuse traditional medicine. Or postpone it for a grace period. Unsatisfactory treatment is an indication for complex surgical intervention.