Treatment of arthrosis of the acromioclavicular joint: medications and physiotherapy

Introduction

Infectious arthritis of the sternoclavicular joint (SJJ) is a rare surgical disease. Its frequency among arthritis of other localizations is less than 1% [1, 2, 10, 16]. Features of the anatomical structure of this area, polymorphism of clinical manifestations, due to the variety of options for the course of the pathological process, often become the cause of diagnostic errors [2, 5, 7, 16]. Another reason for frequent diagnostic difficulties is the lack of awareness of surgeons about this disease and the peculiarities of its course [23, 28]. When a patient first seeks medical help, especially in the subacute course of the process, the differential diagnostic list most often includes non-surgical diseases, such as Tietze syndrome (a disease from the group of chondropathy, accompanied by aseptic inflammation of the upper costal cartilages), rheumatoid arthritis, osteoarthritis, metastatic tumor lesion of the joint [1, 2, 7, 18]. Among the surgical diseases under the guise of which infectious arthritis of the GCS can occur, the most common are cervical or supraclavicular lymphadenitis, phlegmon or neck cyst [1, 2, 27]. Delayed diagnosis can lead to progression of the disease with involvement in the pathological process of the first costosternal joint, mediastinum, and cellular spaces of the neck [1, 17, 23].

Infection of GCS most often occurs hematogenously, and GCS arthritis is often observed in patients with transient or permanent immunodeficiency, for example due to cancer, diabetes mellitus, long-term use of corticosteroids, HIV infection [6, 11, 13, 15]. In some cases, the development of the inflammatory process is preceded by minor trauma, hypothermia, catheterization of the subclavian vein, and the injection of narcotic drugs into the veins of the upper limb by drug addicts [4, 12, 20, 21]. Quite rarely, the cause of the inflammatory process in the GCS is specific infections: syphilis, tuberculosis, salmonellosis, brucellosis [2, 6, 9, 19]. Purulent inflammation of the GCS can occur during sepsis [6, 23]. Isolated observations of the development of GCS arthritis are also described in chronic autoimmune diseases with skin lesions [4, 26]. Sometimes the disease develops spontaneously against the background of complete well-being [10, 11, 16, 22].

GCS is characterized by a number of anatomical features that largely determine the clinical course of the disease. The articular cavity of the GJ is quite small and surrounded by dense ligaments; the joint capsule has little ability to stretch [1, 14]. All this contributes to the relatively rapid spread of infection beyond the joint, leading to the formation of periarticular phlegmon and involvement in the pathological process of the sternum, the first sternocostal joint, and the mediastinum, located in close proximity to the primary focus of infection [1, 2, 14, 25].

As a rule, damage to the RGC is a unilateral process, but in 2-5% of cases bilateral damage occurs [8, 21, 24].

Both gram-positive and gram-negative flora can be involved in the development of infectious arthritis of the GCS; Staphylococcus aureus is the most common [3, 6, 20, 24].

Difficulties in diagnosis

With typical symptoms, it is not too difficult to suspect a problem; it is more difficult to act from the standpoint of evidence-based medicine, that is, to identify the anatomical substrate of the disease. The bone fragments of the acromion and clavicle are directly affected in the most advanced stages, when treatment is aimed at relieving symptoms. Initially, the changes concern cartilage tissue and the appearance of small osteophytes. Therefore, the full range of diagnostic measures should include:

• blood test to exclude a systemic process;
• x-ray of the shoulder - an experienced doctor will be able to notice a decrease in the distance between the distal end of the scapula and the collarbone;
• computed tomography – all the subtleties of changes in bone tissue are visible;
• MRI – makes it possible to evaluate the pathology of tendons, cartilage and bones;
• densitometry – to identify age-related osteoporosis.

All questions can be resolved only by magnetic resonance examination. The destruction of the articular capsule, a decrease in the amount of cartilage tissue in the articulation cavity, and marginal bone growths are clearly visible.

For differential diagnosis, the involvement of doctors of the following specialties is indicated:

• therapist - primary care, organization of the diagnostic process;
• rheumatologist - exclusion of systemic nature of the lesion;
• neurologist – assessing the condition of the upper limb and prescribing conservative treatment;
• traumatologist – determining indications for surgical correction and performing surgical procedures;
• physical therapy doctor (instructor) – development of individual exercises to activate recovery processes in the joint.

Only the joint work of specialists will allow us to establish effective activities for the full diagnosis and treatment of arthrosis of the acromioclavicular joint. In some cases, there is an underestimation of the significance of damage in this joint, which leads to delayed diagnosis and a protracted period of painful symptoms for the patient.

Material and methods

Over a 7-year period (2008–2014), 18 patients aged from 27 to 88 years with infectious arthritis of the GCS were treated in the clinic. Men predominated - 11 patients. The average age of patients is about 50 years. A number of factors contributing to the occurrence of the inflammatory process were identified: hypothermia (5 patients), physical activity combined with blunt trauma (4), radiation therapy for nevus (1), drug addiction (1). In 2 patients, the lesion of the GCS was a manifestation of sepsis with multiple purulent foci. Two patients with GCS arthritis suffered from severe diabetes mellitus. However, in the majority of patients (6) we were unable to identify significant risk factors for the occurrence of the disease. They were hospitalized with a picture of a first-time acute inflammatory process in the area of ​​the GCS. The remaining patients had a history of the disease from 2 months to several years and were hospitalized with a picture of chronic inflammation, including the formation of purulent fistulas. One patient had bilateral lesions.

The clinical picture of GCS arthritis consists of local and general signs of inflammation. Among the local symptoms, the most persistent are pain and swelling of the soft tissues, often extending to the neck and anterior chest wall, which can make diagnosis difficult. Skin hyperemia is a late symptom and usually indicates the transition of purulent inflammation beyond the GCS with the formation of phlegmon. General signs of inflammation can range from minimal to severe systemic inflammatory response.

The picture of acute serous arthritis was observed in 2 patients. In 10 cases, panarthritis with the formation of periarticular phlegmon was detected. 6 patients had osteoarthritis with purulent periarticular complications, the most severe of which was anterosuperior mediastinitis. The last 6 patients were treated for a long time independently or on an outpatient basis and at the time of hospitalization were in serious condition with a pronounced picture of a purulent-inflammatory process in the area of ​​the GCS and multiple leaks.

Clinical diagnosis of the disease in all observations was supplemented by instrumental diagnostics. The information content of traditionally used plain radiography is low not only at the initial stage, but also during developing bone-destructive changes. The value of radioisotope scintigraphy is maximum in the first days of the disease, when there is not only no destruction of bone structures, but also no spread of the inflammatory process to the surrounding soft tissue. Magnetic resonance imaging (MRI) allows you to diagnose periarticular tissue edema, as well as developing purulent leaks (in the mediastinum, on the neck, chest wall). The information value of computed tomography (CT) is associated with the possibility of detailed diagnosis of osteodestruction, which is extremely important when determining the extent of surgical intervention. Joint puncture is not always informative due to the small size of its cavity.

Treatment of patients with infectious arthritis of GCS was carried out in accordance with the general principles of treatment of surgical infection depending on the stage of the disease. For serous arthritis, treatment was conservative and included antibacterial therapy and physiotherapeutic procedures. When periarticular phlegmon formed, patients were operated on as an emergency. The phlegmon was opened, necrectomy, and wound drainage were performed. Purulent leaks into the mediastinum, neck, and chest wall determined the need to expand the scope of surgical intervention. Bone sequestra also had to be removed. The wounds were drained with swabs containing antiseptics or polyethylene oxide-based ointments. GCS resection was performed in patients with osteoarthritis 2-3 months after acute inflammatory phenomena subsided. In a similar manner, 4 patients hospitalized with a picture of an acute inflammatory process were operated on as planned.

Symptoms of arthrosis of the shoulder joint

Symptoms and treatment of arthrosis of the shoulder joint

will change depending on the stage of the disease. There are 3 stages, for which the following symptoms are specific:

• 1st stage. Pain with arthrosis of the shoulder joint
  in the initial stage is localized directly in the joint itself, but can also radiate to the scapula. The nature of the pain is predominantly aching or dull, with a tendency to intensify after exercise or during the working day. There are no acute pains or pains at rest. X-ray examination can reveal a slight reduction in the lumen of the joint space and rare osteophytes (bone outgrowths in the form of spines, tubercles, hooks, “visors”). At this stage, the disease is most responsive to treatment and is considered conditionally reversible.
• 2nd stage. The pain intensifies and persists during rest, bothering the patient at night. A dry, rough crunch appears in the shoulder
  and difficulty moving (as if sand had been poured into the joint). Arthrosis of the shoulder of the 2nd degree is characterized by severe swelling, increased temperature of the soft tissues and other symptoms of inflammation, which impose restrictions on the patient’s usual daily activity. Gradual muscle atrophy begins, which is expressed in the “shrinking” of muscle tissue. Some patients also note spastic muscle tension and an inability to perform certain movements (usually in the extreme position of the humerus).
• 3rd stage. Constraining pain due to arthrosis of the shoulder joint
  of the 3rd stage interferes with the performance of work duties and healthy sleep. There is a pronounced limitation of mobility in the joint, stiffness of the arms and back. The hallmark of this stage can be considered deformation of the shoulder joint, which becomes noticeable even to the naked eye.

Pain

Pain is the most noticeable symptom of shoulder arthrosis

.
Its cause is the appearance of erosions and abrasions on the surface of the synovial cartilage. They make the articular surfaces rough, create friction and prevent healthy sliding of the articular elements. Subsequently, osteophytes, which injure the periarticular tissues, contribute to the increased pain syndrome. Typically, pain occurs at the end of a working day or after heavy exertion (for example, working out in the gym). At first, pain from arthrosis of the shoulder joint
subsides after rest, which is why it is mistakenly attributed to overwork or overload. However, the patient soon notices a strong and progressive decrease in endurance.

Later, without treatment of arthrosis of the shoulder joint

, the pain changes from dull to acute, localized in the region of the clavicular-scapular triangle.
Sharp pain during physical activity can be almost unbearable. Subsequently, severe aching pain bothers patients even at night. It is typical that pain with arthrosis of the shoulder joint
intensifies when you try to raise your arms up or put them behind your back. Often moving your hands to this position is accompanied by dull clicks, crunching sounds, and crackling sounds.

Crunch in the shoulder

Crunch in the shoulder

- This is
a symptom of arthrosis of the shoulder joint
, which intensifies as the articular surfaces wear out. It is important to know that a crunch in the shoulder joint is considered a physiological norm, and ringing clicks can often be heard even in healthy people. Such harmless clicks usually occur due to air bubbles bursting during compression in the joint fluid.

We can talk about arthrosis of the shoulder joint based on a crunch only if it is accompanied by pain and limited mobility. Also causing concern is a dull, “heavy” crunching sound (as if the bones are rubbing, “clinging” to each other).

Impaired mobility in the shoulder joint

The amplitude of voluntary movements is reduced due to the narrowing of the joint space. The lumen of the joint space may shrink due to thinning of the cartilage and the proliferation of osteophytes. Inflammatory swelling can also partially block the shoulder. In the later stages of the disease, contractures (persistent limitations of mobility) and even ankylosis (complete fusion of bones) occur.

Impaired mobility as a symptom of arthrosis of the shoulder joint is usually accompanied by nagging, aching or sharp pain when trying to tie an apron, hang up laundry, turn the steering wheel or perform other household activities. In the morning, patients are bothered by stiffness, which first goes away after normal morning activity, and then can continue throughout the day. Typically, stiffness is accompanied by periodic muscle spasms due to constant tension.

Shoulder deformity

Shoulder deformity becomes noticeable already at the 3rd stage of arthrosis, when the only treatment option may be surgery. As articular cartilage is depleted, compensatory replacement mechanisms are launched: bone tissue grows in place of cartilage in order to maintain the stability of the musculoskeletal system. Due to the proliferation of osteophytes and changes in the structure of the cartilage, deformation of the bone tissue begins, which also undergoes wear.

The external contours of the joint also change due to edema, which occurs due to overproduction of synovial fluid and disruption of metabolic processes in the source of inflammation.

Shoulder deformation indicates that the cartilage is completely destroyed, and the degenerative process has spread to the heads of the bones. The natural result of this, in addition to deformation and disruption of congruence (coincidence) of articular surfaces, is shortening of ligaments and muscle dystrophy.

Results and discussion

Analysis of case histories of patients with purulent arthritis of GCS indicates significant diagnostic difficulties, not only at the early stage of the disease, but also when the inflammatory process spreads to surrounding tissues. The difficulty of diagnosing the disease was determined by two main reasons: the rarity of the disease and the lack of familiarity of specialists with it. In most cases, it was possible to suspect a pathological process in the GCS even during a clinical examination of the patient, and instrumental diagnostic methods such as CT, MRI and osteoscintigraphy make it possible to establish the stage of the disease and the extent of the pathological process to surrounding tissues (Fig. 1). An examination of hospitalized patients showed that such a traditional method of diagnosing diseases of bones and joints as plain radiography is of little information. The method of choice for instrumental diagnosis of RGC lesions was multislice CT with multiplanar and three-dimensional image reconstructions (Fig. 2 , 3)

. The study should be performed immediately upon hospitalization of such patients in the department of purulent surgery. MRI is highly informative in diagnosing this disease.

Rice. 1. Computer tomogram with multiplanar image reconstruction.

Rice. 2. Computer tomogram with multiplanar image reconstruction.

Rice.
3. Computer tomogram with 3D image reconstruction. The inflammatory process in the area of ​​the GCS can go through several stages in its development: serous arthritis, purulent arthritis (often with the formation of periarticular phlegmon), osteoarthritis (with destructive changes in the area of ​​the clavicle and sternum) (Fig. 4).

Rice. 4. Computer tomogram.

The effectiveness of conservative treatment in the form of antibacterial therapy is observed only in the early stages of the disease (serous arthritis). Acute purulent arthritis, which, due to the peculiarities of the anatomical structure of the GCS, is accompanied by a rapid transition of the purulent-inflammatory process to the surrounding tissues, requires emergency surgical intervention. The operation, as a rule, consists of opening and draining paraarticular phlegmon and purulent leaks. Resection of the GCS in the presence of bone-destructive changes in the latter is performed in the second stage after 2-3 months. Patients hospitalized with a picture of chronic osteoarthritis underwent planned resection of the GCS.

Analysis of the bacterial flora most often indicated the presence of Staphylococcus aureus (38.8%), including polyantibiotic-resistant - 16.6% (among all microorganisms of this species). Streptococcus
pneumonia
was identified in 1 (5.5%) patient ; in the remaining cases (38.8%), it was not possible to identify the microflora from the foci of purulent inflammation.

Long-term results of treatment of infectious arthritis with GCS were monitored in 10 patients for up to 6 years. In one patient who had serous inflammation, no relapse of the disease was noted after conservative treatment. In 3 out of 5 patients operated on for panarthritis with periarticular phlegmon, the surgical wound healed by secondary intention, and they had no subsequent complaints. The remaining 2 patients developed purulent fistulas in the paraarticular area, but they decided to refrain from further examination and treatment. In 4 radically operated patients who underwent GCS resection for osteoarthritis, no relapse of the disease was observed. In 2 of them, in the long-term period, there was a restriction of movements of the upper limb on the side of the operation, especially during its abduction.

Thus, infectious arthritis of the sternoclavicular joint is a rare surgical disease characterized by hematogenous infection of the joint predominantly by Staphylococcus aureus. The methods of choice for instrumental diagnostics are CT and MRI. Early diagnosis of the disease at the stage of serous inflammation allows for antibiotic therapy with good results. Given the rather high probability of the presence of multidrug-resistant Staphylococcus aureus, the use of appropriate antibiotics is preferable. With the development of purulent arthritis with the formation of periarticular phlegmon, emergency surgery is required to open and drain the abscess. Resection of the sternoclavicular joint is indicated for the development of osteoarthritis and is performed outside the period of acute inflammation.

Causes, anatomy and biomechanics of the problem

Movements associated with lifting the upper limbs are carried out by the shoulder joint, scapula and collarbone. These bone formations form joints with different levels of activity. Just above the humerus is the acromion, a semicircular process of the scapula. Its distal end is connected to the proximal part of the clavicle. This place is usually called the acromioclavicular joint. In addition to bone structures, ligaments and cartilage tissue are present in the junction area. The latter forms a capsule around the joint, but inside there is practically no synovial fluid, since the range of movements of the joint is limited.

For the joint to function fully, it is sufficient to contain fairly dense cartilage tissue inside the cavity. However, for various reasons, bone structures grow, growths (osteophytes) appear, which leads to the appearance of clinical symptoms of the disease. The exact factor that leads to arthrosis of the acromioclavicular joint has not been identified, but there are situations that provoke the appearance of the disease. These include:

• lifting weights;
• prolonged work with arms raised;
• hereditary characteristics of the osteochondral junction (weakness of the ligamentous apparatus, underdevelopment of chondrocytes);
• injuries of the acromioclavicular region;
• systemic connective tissue diseases (lupus, rheumatoid arthritis);
• previous operations in the same area;
• habit of sleeping with a bent arm under your head.

The greatest importance in the development of arthrosis of the acromioclavicular joint is the professional high load on the shoulder region. Therefore, the disease mainly affects people over 35 years of age who have been employed for a long period in the following professions:

• weightlifters;
• bodybuilders;
• welders;
• track and field athletes training with parallel bars or horizontal bars;
• miners;
• other professions in which the arms are subject to maximum load when raised (electricians, trainers, boxers, etc.).

The main immediate cause of the appearance of clinical symptoms is the replacement of cartilaginous mobile tissue with bone static structures. Osteophytes appear, which limit the already meager activity of the joint. Acromioclavicular arthrosis develops over a long period, so when painful sensations begin, the pathology is already far advanced.

Treatment and rehabilitation

It is impossible to completely cure the disease with conservative methods of therapy. However, this method of helping the patient is effective in terms of controlling the symptoms of the disease. It is possible to relieve the manifestations of acromioclavicular arthrosis and stabilize the progression of osteochondral changes. The basic principles of treatment can be presented as follows:

• effective pain relief - NSAIDs and simple analgesics, intra-articular blockades are used;
• improving blood flow in the joint area - peripheral vasodilators are used;
• anti-inflammatory treatment - hormones are used parenterally for a short course and intra-articular administration;
• chondroprotector therapy – restoration of cartilage tissue;
• preparations for external use – enhance the effectiveness of systemic agents;
• Exercise therapy, massage, acupuncture.

If the entire complex of conservative methods is ineffective and clinical symptoms increase, surgical correction of arthrosis is performed.

The table below presents the main drugs, course of treatment and main dosages for various types of drug delivery to the affected area.

In clinical practice, several drugs from different groups are usually combined with different routes of administration. Intra-articular agents are actively used together with oral medications. Chondroprotectors are often prescribed for arthrosis of the acromioclavicular joint. However, no studies have been conducted to prove the effectiveness of drugs from the chondroitin and glucosamine group for diseases of this joint.

Surgical correction is indicated in the presence of large numbers of osteophytes and destruction of bone tissue at the distal end of the acromion and the proximal portion of the clavicle. Usually, grinding of the bone structures is performed to increase the distance between them. A false joint filled with connective tissue is formed. Its function is sufficient for shoulder movements without pain. The operation is performed both openly and using endoscopic techniques.