Treatment of grade 3 knee joint gonarthrosis in Moscow

Osteoarthritis deformans is a chronic degenerative joint disease. It is based on primary degeneration of articular cartilage with subsequent changes in bone articular surfaces and the development of marginal osteophytes, which entails joint deformation. 10-12% of the Russian population suffers from deforming osteoarthritis. For the treatment of deforming osteoarthritis, all conditions have been created at the Yusupov Hospital:

• Chambers with a European level of comfort;
• Equipment from leading global manufacturers;
• Individual approach to the treatment of each patient;
• Use of modern medications and innovative surgical technologies.

At a young age, deforming osteoarthritis (ICD10 code from M15 to M19) more often develops in men who have sustained injuries to the musculoskeletal system. In old age, the disease mainly affects women. With deforming osteoarthritis, the knee and hip joints are primarily affected. The degree of deforming arthrosis increases depending on the severity of joint deformation.

Main characteristics

Most often, this disease appears in people after the age of 45, since it is during this period that age-related changes occur in the body. The tissues begin to thin out and become vulnerable to injury and damage. In younger people, such negative changes occur as a result of active participation in professional sports.

Treatment of the disease in the initial stages of development involves the use of conservative methods. Men over 45 years of age, as well as women over 55 years of age are at risk. Also, the risk of developing gonarthrosis is present in people who have a genetic predisposition to diseases of the musculoskeletal system.

Osteoarthritis of the knee joint is a non-inflammatory disease; it progresses slowly. As it develops, the quality and quantity of cartilage tissue changes. The main symptoms include pain. Most often they appear in the following cases:

• during joint flexion;
• when climbing stairs;
• after prolonged sitting.

In the initial stages of development, stiffness and pain occur in the morning after waking up. After some time, these symptoms go away on their own. As the disease progresses, the duration of unpleasant symptoms increases.

If irreversible changes occur in the cartilage tissue, inflammatory processes may develop in the joint. In this case, the disease, which is initially non-inflammatory in nature, is complemented by an inflammatory process. The main goal of therapy is to reduce the frequency and duration of the period of inflammation.

Articular cartilage gradually wears out, and its amount between the rubbing surfaces of the bones decreases. Gonarthrosis is one of the most common diseases in the world among older people. Age is considered a significant risk factor.

Disability

In order to determine whether a person needs to be given a disability, one must first diagnose what stage the disease is at.

A person is recognized as able to work in the following cases:

• if the changes are minor or moderate;
• the disease is accompanied by various disorders of static-dynamic functions, but the course of gonarthrosis is slowly progressive.

Disability of the third group is given to people in the following cases:

• if a moderate impairment of motor function is diagnosed;
• if a person performs work that involves significant physical activity;
• if a person is forced to constantly be on his feet;
• if there is a pronounced violation of the static-dynamic function.

There are certain situations in which patients with gonarthrosis will be sent to undergo a disability commission:

• if the progression of the disease lasts for three years or longer, with exacerbations occurring at least three times during the year;
• if the patient underwent surgery to treat arthrosis of the knee joint, as a result this significantly affected his ability to work;
• in case of violation of the musculoskeletal function of a limb, if this process is pronounced.

During the commission, the patient's medical history is studied. The person’s complaints must be taken into account and the clinical picture is assessed. The patient must show how able he is to work. Disability of the second and third groups is confirmed once a year, and the first group must be confirmed once every two years.

Degrees of functional joint insufficiency

(Astapenko M.G., 1956)

FNS - I - there is only a slight limitation of movements, allowing the patient to engage in normal work, i.e. not depriving him of his professional ability to work.

FNS – II - restriction of movements is so pronounced that it deprives the patient of professional ability to work; At the same time, the patient’s ability to self-care is significantly limited. Such a patient usually requires inpatient treatment.

FNS - III - a very sharp limitation or complete loss of joint mobility, when even self-care is impossible.

X-ray stages of RA (according to Steinbrocker):

I – periarticular osteoporosis;

II - narrowing of joint spaces + a few bone erosions (more than 5);

III – stage IIb + multiple (more than 5) bone erosions, subluxations in the joints;

IY – stage III + bone ankylosis.

Indicators of the degree of activity of rheumatoid arthritis

(V.A. Nasonova, M.G. Astapenko)

* The degree of activity of the process is determined by the number of points: 1st – 8 points; 2nd – 9-16 points; 3rd – 17-24 points.

Diagnostics

To diagnose RA, the criteria of the American College of Rheumatology (1987) are used.

1. Morning stiffness – stiffness in the morning in the joints or periarticular tissues, lasting for at least 1 hour.

2. Arthritis of 3 or more joints - swelling or effusion diagnosed by a doctor in at least 3 joints. Possible damage to 14 joints (on 2 sides): metacarpophalangeal, proximal interphalangeal, wrist, elbow, ankle joints.

3. Arthritis of the joints of the hands - swelling of at least one of the following groups of joints: wrist, metacarpophalangeal and proximal interphalangeal.

4. Symmetrical arthritis - similar, but without absolute symmetry, bilateral damage to the joints (metacarpophalangeal, proximal interphalangeal, metatarsophalangeal).

5. Rheumatoid nodules - subcutaneous nodules (diagnosed by a doctor), localized mainly on protruding areas of the body, extensor surfaces or in periarticular areas.

6. RF – detection of elevated titers in blood serum by any standardized method.

7. X-ray changes typical of RA: erosions or periarticular osteoporosis, localized in the joints of the hands and feet and most pronounced in the clinically affected joints.

RA is diagnosed when at least 4 of 7 criteria are met, with criteria 1 through 4 being present for at least 6 weeks. With “reliable” RA, the “sensitivity” of the criteria is 91-94%, specificity – 89%. In “early” RA (less than 12 weeks), the specificity of the criteria is high (78-87%), but the “sensitivity” (26-47%) is low.

Examples of diagnosis formulation:

1. Rheumatoid polyarthritis (with damage to the joints of the hands, feet, knee joints), seronegative, activity level 2, stage IIc, FNS II.

Complications: reactive amyloidosis, nephrotic syndrome, CKD stage 1.

2. Rheumatoid arthritis (with damage to small joints of the hands, feet, hip joints) with extra-articular manifestations (hypotrophy of the interosseous muscles, anemia, rheumatoid nodules), seropositive, activity III, stage III, FNS III.

Complication: aseptic necrosis of the femoral head on the left.

OSTEOARTHROSIS (OA)

Osteoarthritis is a heterogeneous group of diseases of various etiologies with similar biological, morphological, clinical manifestations and outcome, which are based on damage to all components of the joint, primarily cartilage, as well as subchondral bone, synovium, ligaments, capsule, and periarticular muscles.

Clinical classification of osteoarthritis (according to VNOR, 1990)

Causes of pathology

Experts identify certain provoking factors for gonarthrosis:

• previous injuries and injuries to the knee joints;
• if there is instability of the joint due to damage to the ligamentous apparatus;
• if you have previously suffered a meniscus tear;
• in the presence of direct injuries to cartilage tissue;
• if the person is over 45 years old;
• if a person systematically experiences high physical activity, with regular lifting and carrying heavy objects;
• if you are overweight;
• with frequent emotional stress;
• if there is a genetic predisposition to diseases of the joint and musculoskeletal system;
• if there is a lack of physical activity;
• in the presence of disturbances in metabolic processes.

It is impossible to determine the reliable cause of the development of the pathological process. Gonarthrosis in most cases is primary; changes in the joint are caused by wear and tear of the cartilage tissue. Secondary gonarthrosis is also diagnosed, which develops against the background of other degenerative changes in the body. For example, secondary gonarthrosis is often present in people suffering from clubfoot.

The key clinical manifestations of the disease are:

• painful sensations in the joint, which manifest themselves when going up or down stairs, when bending or straightening the joint;
• pain syndrome, a feeling of stiffness in the joint after a long rest. As the person moves, the pain decreases;
• the pain syndrome becomes intense after undergoing heavy stress - physical or sports;
• swelling in the joint, knee deformity;
• crunching in the joint when moving, flexing or extending;
• increased pain due to rainy or cold weather.

As the disease progresses, symptoms become more pronounced. The pain does not disappear even with rest. In this case, the pathological process is complemented by a decrease in the range of motion in the joint. Most often, such changes are present at the third stage of development of gonarthrosis. If unpleasant symptoms appear, it is important to visit a traumatologist, orthopedist or rheumatologist as soon as possible. After a while, the pain syndrome can no longer be relieved with painkillers. The person will develop lameness and will be forced to walk with the help of a cane.

Reasons for development

Chronic heart failure occurs against the background of other diseases that affect the myocardium and blood vessels. Therefore, it is always necessary to treat or keep primary diseases under medical supervision, as well as monitor the condition of your circulatory system.

Factors in the development of CHF

• Arterial hypertension (AH) is the main cause of chronic heart failure.
• Coronary heart disease (CHD) is in second place among the provoking factors.
• Cardiomyopathies (including those provoked by infectious diseases, diabetes mellitus, hypokalemia, etc.).
• Valvular (mitral, aortic, tricuspid, pulmonary) and congenital heart defects.
• Arrhythmias (tachyarrhythmias, bradyarrhythmias).
• Diseases of the pericardium and endocardium.
• Conduction disturbances (antrioventricular block).
• High load (for example, with anemia).
• Volume overload (eg, renal failure).

The course of any disease from the list above should be monitored by the attending physician

Diagnostic methods

The key methods for diagnosing diseases of the articular apparatus are:

• radiography of the knee joints. In this case, it is necessary to determine at what stage the disease is. X-rays of both extremities usually need to be taken;
• computed tomography - allows you to determine how worn out the cartilage tissue is, how pronounced the changes in the joint structures are. The diagnosis also determines whether there are ligament injuries and whether there are other pathologies, for example, a Baker’s cyst;
• magnetic resonance imaging of the knee joints - with this procedure you can determine the severity of changes in the tissues. MRI helps to assess the condition of vascular structures and determine how much blood circulation has worsened;
• sometimes doctors prescribe a procedure such as a topogram;
• The collection of anamnestic data is mandatory. The doctor evaluates the patient’s complaints, clinical manifestations of the disease;
• Using ultrasound examination of joint tissues, you can determine how worn out the cartilage tissue is. You can find out whether pathological processes are present in the ligamentous, muscular apparatus, in the periarticular space, whether there are changes in the meniscus;
• Joint arthroscopy is a diagnostic puncture. After the procedure, the resulting material is sent to the laboratory for further research.

Diagnosis of osteoarthritis

The diagnosis of “deforming osteoarthritis” is made by doctors at the Yusupov Hospital based on the patient’s complaints and anamnestic data, clinical and instrumental research, and the exclusion of other diseases. An important diagnostic factor is a thorough analysis of the history of the development of the disease, which allows us to identify risk factors for the development of osteoarthritis.

There are no laboratory signs specific to osteoarthritis. Laboratory studies are carried out for the following purposes:

• Differential diagnosis;
• Before starting treatment, to identify possible contraindications for prescribing medications;
• To detect inflammation (the erythrocyte sedimentation rate and reactive protein are examined).

Synovial fluid examination is carried out only in the presence of synovitis for the purpose of differential diagnosis. In osteoarthritis, synovial fluid is non-inflammatory. It is slightly cloudy or transparent, viscous, with a concentration of leukocytes less than 2000 per 1mm3.

The most reliable method for diagnosing osteoarthritis is x-ray examination. It reveals narrowing of the joint space, marginal osteophytes, and subchondral sclerosis. If osteoarthritis of the knee joints is suspected, an x-ray is taken in anteroposterior and lateral projections in a standing position. If osteoarthritis of the hip joint is suspected, an X-ray examination of the pelvic bones is performed, including both hip joints.

Drug therapy

Conservative therapy is effective if gonarthrosis is in the early stages of development. If the disease is detected at the second or third stage, with the help of medications it is possible to only slightly relieve the inflammatory process and pain.

With the help of drugs you can achieve the following results:

• stop the inflammatory process;
• pain syndrome, a feeling of stiffness in the joint after a long rest. As the person moves, the pain decreases;
• accelerate the regeneration of cartilage tissue;
• get rid of severe painful sensations;
• restore joint function.

In parallel with the use of medications, it is important to limit the load on the affected limb during treatment. As part of conservative therapy, the following drugs are prescribed:

• analgesics, non-steroidal anti-inflammatory drugs, chondroprotectors;
• local application of ointments, gels, creams;
• Intra-articular injections of drugs are administered. Most often these are hormonal drugs that help get rid of the inflammatory syndrome within a short period of time. They also replenish synovial fluid and promote the restoration of cartilage tissue;
• intra-articular injections of the patient's processed plasma are administered;
• Regenerative medicine is used - this is the introduction of intra-articular injections of autologous cartilage tissue cells, which are obtained from the lipid structures of the patient’s body.

Auxiliary treatment

• Physiotherapy. Special therapeutic exercises are mandatory for those people who strive to maintain motor function of the joints for as long as possible. With the help of therapeutic exercises, muscle strength and endurance increase, and coordination improves. With regular exercise, synovial fluid is actively produced, which is a natural lubricant between the joint. Thanks to it, joint friction is reduced.
• Special food. This is a must for those people who are obese. If you are overweight, your knee joints experience regular heavy loads. Therefore, doctors strongly recommend monitoring your diet in order to reduce body weight and reduce stress.

Additional methods also include physiotherapeutic procedures:

• UHF;
• magnetic therapy;
• massage
• balneotherapy
• cryotherapy
• electrophoresis
• current therapy;
• manual therapy;
• acupuncture
• hirudotherapy
• mud baths;
• ozone therapy
• galvanotherapy

If the listed methods for treating grade 3 gonarthrosis are ineffective, the doctor prescribes the following procedures:

• Arthroscopy is not only a diagnostic procedure. With the help of arthroscopy, surgery is performed on the meniscus, cartilage tissue, joint effusions and fluid accumulation in the joint are removed;;
• endoprosthetics - this procedure is prescribed for complete destruction of cartilaginous structures. It involves replacing a joint or one of its parts with an implant that is not rejected by the body;;
• osteotomy – involves surgery on the bone. The main task is to restore the integrity of bones, as a result of which the destruction of cartilage tissue slows down.

Doctors also recommend wearing special orthoses. With their help you can reduce the load on the joint. Orthoses and bandages will be especially useful for those people who play professional sports or for patients who regularly exercise their joints.