Osteochondropathy of the patella: causes, diagnosis, treatment

Osteochondropathy of the patella refers to a group of diseases in which aseptic necrosis of bone tissue occurs. Destructive processes most often occur due to mechanical damage. The disease is quite rare and occurs in 3% of patients visiting orthopedic doctors. The pathology affects children, adolescents and men under 30 years of age. With timely treatment, the disease goes away without a trace, but can still lead to serious complications and even disability for the patient. Below we will take a closer look at the symptoms, treatment and causes of osteochondropathy of the patella.

What it is?

Osteochondropathy refers to several ailments that occur in the knee area. All diseases differ in location in the knee joint and symptoms. These include:

• Koenig's disease. Characterized by inflammation of cartilage tissue. Damaged pieces of cartilage separate or peel away from the bone. Their erratic movement along the joint capsule disrupts the movement of the joint itself. The inflammatory process occurs in cartilage tissue. In neglected form, its deeper parts die off. The pathology is common between the ages of 10 and 20 years. Moreover, it occurs 3 times more often in boys than in girls.
• Larsen-Johansson disease (osteochondropathy of the patella). With this disease, an improperly ossified patella causes pain, causes swelling, leads to hydroarthrosis, and limits mobility. The affected area is fragmentation of the patella. The risk group includes teenagers involved in sports between the ages of 10 and 15 years.
• Osgood-Schlatter disease. Characterized by pathological changes in the tibia. A growth appears in the tuberosity, which causes pain in the area of ​​the kneecap. The disease causes microtrauma to the bones. It occurs in children and adolescents aged 8 to 16 years. Like Larsen's disease (osteochondropathy of the patella), it most often affects boys.
• Leuven's disease. Causes negative changes in the knee joint. Over time, the disease develops into intractable synovitis. In the early stages it is characterized by intermittent pain of moderate strength. Movements in the joint are preserved in full, but they are painless. Usually the process is one-way. Leuven's disease (osteochondropathy of the patella) develops between the ages of 12 and 14 years.

Joint pain in children

There is an opinion that normally children’s joints do not hurt, and arthralgia is a manifestation of joint diseases, the cause of which is always visible on magnetic resonance imaging (MRI). In this case, how can we explain from an instrumental point of view the presence of arthralgia against the background of hypermobility and carriage of a chronic nasopharyngeal infection or the post-exertional nature of pain? But what if the experts’ versions of the cause of joint pain in a child do not coincide? How not to miss the onset of juvenile arthritis in a child with joint pain syndrome? And can everything really be explained using MRI?

It is known that joint pain in children is a common problem for a growing body. The relevance of the problem of arthralgia in childhood is due to the high frequency of occurrence, polymorphic genesis, diffuse nature of complaints and anxiety of parents [1, 2]. Often, parents independently describe or present their own joint complaints as complaints of their child, which often complicates the timely diagnosis of arthropathy. It is believed that a child with complaints of joint pain should be comprehensively examined, since the nature of arthralgia can be identical both in the presence and absence of an anatomical “substrate” [3]. Looking ahead, I would like to note that there is no causeless pain in the joints in children.

The child's body is exposed to numerous external and internal aggressive factors. Nature, verticalizing the child, took care of a mechanism that gradually proportionally distributes the load, does not inhibit its growth activity and protects the baby from banal traumatic injuries. We are talking about age-related anatomical features of the osteoarticular system, which in young children are characterized by hypermobility, immaturity of the sensory innervation of the capsular-ligamentous apparatus and imbalance of the muscles of the lower extremities [4]. With age, strengthening of the capsular-ligamentous apparatus, perfection of sensory and proprioceptive sensitivity contribute to the balanced function of the muscles of the lower extremities and uniform distribution of the load [5].

There are “harmless” and “pathological” arthralgias of childhood. The nature of “harmless” pain (not causing harm) may be associated with the physiological characteristics of childhood. Arthralgia acquires a pathological connotation in the case of hyperreactivity or insufficiency of the immune system (immunodeficiency state), the presence of an arthrotropic infection, imperfect interaction between the central and peripheral nervous systems, irrational or unadapted loads, as well as genetically determined diseases of the osteoarticular system. It is known that joint pain can be acute and chronic, short-term and long-term and, depending on the time of day, its occurrence is classified into morning, morning and afternoon, day and evening, evening and night, scattered throughout the day or “constant”. Depending on the influence of the causative factor (stress, infection, etc.), arthralgia can be linked or unmotivated. Detailing pain sensations allows us to determine their degree of intensity, localization, fixity, as well as the presence of signs characteristic of inflammation. Instrumental diagnostics makes it possible to confirm the presence or absence of an anatomical “substrate” for arthralgia. The final verification of the cause of arthralgia should be based on a combination of clinical, anamnestic, instrumental and laboratory data.

When starting to diagnose arthralgia in childhood, it is necessary to keep in mind that the innervation of the joint is carried out through sympathetic and sensory nerve fibers. Sensory receptors (nociceptors and mechanoreceptors) permeate all joint structures, with the exception of cartilage tissue. Normally, in children and adults (in the absence of signs of inflammation or arthrosis), everyday movements are not accompanied by pain, despite irritation of joint receptors. This occurs due to the natural decoding of the afferent fiber signal into the central nervous system (CNS). However, if the frequency of impulse generation in the afferent nerve fiber increases (potentially dangerous movements, trauma, inflammation), the central nervous system interprets the increased nociceptive activity as pain. It is believed that in children two main types of pain can be distinguished: nociceptive, due to irritation of receptors, and neuropathic, as damage to the nerve fiber [6].

Diagnosis of arthralgia in childhood should be based on the study and assessment of the onset, dynamics of the articular syndrome, instrumental data, and the conclusions of other specialists [7]. In addition to the anatomical and physiological characteristics of the osteoarticular system of childhood, the diagnosis of arthralgia should take into account gender and age characteristics, as well as the psycho-emotional status of the child. The questions that the doctor should always answer are usually the same - these are pathological or causeless pain, inflammatory or non-inflammatory in nature, requiring treatment or requiring only dynamic observation. The characteristics of pain in children with “harmless” and pathological pain are clearly presented in Table.

Non-arthritic pain in children

Meniscal pain - as a rule, pain is always of one joint with a previous fact of injury. Children over 10–12 years of age are most often affected. Painful sensations are strictly load-bearing, detailed in nature and are localized in the projection of the joint space of the damaged meniscus. Blocks in the joint are possible. In most cases, there is a positive clinical test for damage to the lateral or medial meniscus [8]. Signs of the inflammatory process, as a rule, appear at the time of acute injury and are short-term in nature. The reliability of MRI (more than 1.5 T) in diagnosing damage or malformation of the meniscus (atypical discoid form) is more than 90–95%. Damage to the posterior horn of the medial meniscus is considered an MRI finding and cannot be a source of pain [9].

Osteochondral pain is usually pain in one joint, usually the lower limb, and occurs in children over 8–10 years of age. Previous irrational physical activity can serve as a trigger mechanism for the formation of osteochondropathy, but often the cause remains unclear. Pain sensations are stressful, detailed and limited to the joint area. This is typical both in the case of damage to the epiphysis and in the case of damage to the apophysis (tuberosity of the calcaneus, tuberosity of the tibia). The true focus of aseptic necrosis is always located within the loaded joint-forming zone of the bone (Fig. 1). Cases of detection of such a focus of non-loaded zones of the epiphyses indicate its dystrophic nature or are even a feature of ossification (Fig. 2). Often there is a reaction of the synovial membrane to the phenomena of osteonecrosis (first stage) or fragmentation of the epiphysis (second stage) in the form of a mild exudative component (Fig. 3). Synovitis itself can contribute to increased pain or transformation of pain with the appearance of morning stiffness. In the case of “unlacing” of the osteochondral fragment from the focus of necrosis, sensations of a free intra-articular body may appear. In children with osteochondropathy of the femoral head, symptoms of synovitis can often be protracted and persistent, requiring a long continuous course of anti-inflammatory therapy. The reliability of MRI (more than 1.5 T) and radiography in the diagnosis of osteochondritis (apophysitis), osteochondropathy is 100% [10].

Pain in the projection of the patellas, except in cases of osteochondropathy (apophysitis, osteochondropathy of the tibial tuberosity) and pathological dislocations, can occur with chondromalacia, high standing patellas and mediopatellar fold syndrome. Among orthopedic pathologies, the source of stress-related foot pain, with the exception of cases of osteochondropathy, can be a number of bone coalitions (talocalcaneal, talonavicular) and congenital malformations of the feet. In addition, systemic skeletal diseases, clinically manifested by joint stiffness syndrome, can also have manifestations such as arthralgia.

Enthesitic and tendon-muscular pain can occur in children as an acute (transient, episodic, post-traumatic) or chronic pathology. Primary chronic enthesopathy is a manifestation of SEA syndrome (seronegative enthesoarthropathy) or juvenile arthritis. Secondary chronic enthesopathy, as a rule, is concomitant or secondary-reactive in nature against the background of the underlying orthopedic pathology [11].

The following predisposing factors are identified:

• nonphysiological hypermobility or stiffness of joints;
• excess body weight;
• puberty (period of rapid extension);
• irrational or unadapted physical activity, chronic trauma;
• frequent acute respiratory diseases, persistence of chronic foci of nasopharyngeal infection;
• presence of the HLAB27 gene.

Clinical variations of the joint syndrome, as well as the severity of pain, may vary. The knee, ankle, and hip joints are most often affected, and less commonly, the shoulder and elbow joints. Painful joint syndrome is limited in nature and is localized in the projection of the tendon-muscular bundle or the area of ​​attachment of the tendon to the bone tissue (enthesis), with clinical signs of local inflammation. However, due to the anatomical and physiological characteristics of childhood, pain can often have a diffuse, non-detailed nature. More typical is the presence of starting pain, which intensifies against the background of physical activity, and less commonly, with everyday movements. The instrumental picture is characterized by inflammatory changes in the area of ​​attachment of tendons to bone tissue, tendonitis/tenosynovitis, less often with the development of osteophytes, erosions, usually with mild symptoms of synovitis. However, this type of change is visualized exclusively in adults. In children, the diagnosis of enthesopathy is based on clinical symptoms [12]. Perhaps, only against the background of the phenomena of Achilles bursitis in the structure of juvenile arthritis can erosive-dystrophic changes in the heel bone occur. The prevalence of the enthesitic nature of the articular lesion determines a relatively “favorable” variant of the course of the disease, provided there is low laboratory activity, the absence of an erosive articular component, signs of sacroiliitis and carriage of the HLAB27 gene.

Pain due to hypermobility in children of preschool and primary school age is often diffuse, symmetrical in nature and localized exclusively along the anterior surface of the legs, less often involving the knee and ankle joints or feet. The pain is usually of varying intensity, post-exertional, often in the evening and at night. Synovitis and signs of laboratory activity are always absent. Pain is relieved by intense stroking and the use of local or oral non-steroidal anti-inflammatory drugs (NSAIDs). The pain component is associated with the phenomena of myalgia due to overstrain of the leg muscles (anterior portion of the muscles) against the background of physiological weakness of the capsular-ligamentous apparatus. This type of pain is described in many literature sources as growing pains [13].

N.B. True arthralgia in children of this age is always pathological in nature.

N.B. Night pain requires special attention if it occurs exclusively in one segment of the limb (tumor formation of the bone, Fig. 4) or occurs in the form of ossalgia with fever and profuse sweating (oncohematological syndrome).

Pain due to hypermobility in older children is more often diffuse, non-detailed, exclusively in the joints of the lower extremities. Pain affects one or more joints. Pain of varying intensity associated with physical activity can be presented as stress or post-exert (daytime and evening). According to MRI, signs of mild exudative synovitis can be detected, often of a protracted nature, without signs of proliferation of the synovium. Pain is always relieved by reducing the intensity of physical activity, and children rarely need long-term use of NSAIDs. Positive tests for joint hypermobility are clinically mandatory. The absence of signs of inflammatory laboratory activity confirms the benign form of arthropathy. The mechanism of formation of the pain component and transient symptoms of synovitis is associated with microtraumatization of intra-articular structures, stretching of the capsular-ligamentous apparatus and overstrain of the patellofemoral joint. In addition, decreased proprioceptive sensitivity of the knee joints and imbalanced calf muscles also further contribute to exercise tolerance. Overstrain of the patellofemoral joint is characterized by the presence of localized pain in the retropatellar region, often of a unilateral nature [14].

Some children with joint hypermobility, in addition to symptoms of vegetative-vascular dystonia, have the so-called increased anxiety syndrome. This syndrome, according to some researchers, may be associated with interstitial duplication on chromosome 15 (Gratacos et al., 2001, duplication of 15q24-q26, called DUP 25). Accentuation of pain, the associative way of thinking of a “sick child” and stereotypical behavior are more common in girls of puberty. With this syndrome, a “colorful” picture of pain is often described, hysteria and crying are noted during the examination. Pain sensations can vary depending on the weather, time of day and the mood of the young lady herself. Arthralgia is often accompanied by episodes of false blockade of the joint, cases of pseudoluxations of the patella or instability of the entire limb; Sometimes there is an inability to fully support the foot. Clinically, imaginary pain is detected upon palpation of the joint area, a “grimace of pain” is present during examination, false contracture, stiffness of the joint or, less often, stiffness without anatomical prerequisites is possible. During the examination, as a rule, a discrepancy between the clinical and instrumental picture is revealed, there are always no signs of laboratory inflammatory activity, and the presence of neuropathy is possible. The presence of local neurological symptoms, impaired sensitivity and motor function of the limb, signs of hyperalgesia requires the exclusion of complex regional pain syndrome, as well as tumor processes in the lumbosacral spine [15].

Diagnosis of non-arthritic arthropathy consists of deciphering the etiological factor of arthralgia. Despite the apparent similarity of pain, the described variants of arthropathy have some characteristic distinctive features that allow them to be differentiated. However, true difficulties always arise with a mixed version of articular pathology, namely in the case of enthesopathy in a child with a syndrome of increased anxiety or hypermobility. As is known, the main treatment of aggressive enthesopathy is the prescription of NSAIDs, in contrast to the benign form of hypermobility or arthralgia due to the syndrome of increased anxiety. In the latter types of arthropathy, the emphasis is on restoring impaired function of a limb or joint and gradually increasing physical exercise, overcoming habitual stereotypes of “catastrophic thinking” regarding possible damage and pain, creating a positive attitude and increasing self-esteem, and to a lesser extent, emphasis is placed on drug treatment of NSAIDs .

Arthritic pain in children

• Infectious arthritis:

- bacterial (septic); - viral; - specific (tuberculosis); — Lyme arthropathy.

• Post-infectious arthritis:

- infectious-allergic, infectious-toxic; - reactive arthritis, Reiter's syndrome.

• Chronic arthritis:

- primary; - secondary.

Arthralgia due to a viral infection, as a rule, develops in children in the prodrome or during the height of the disease and coincides with the period of skin exanthema. Joint pain lasting from several hours to 1–2 weeks can less often be accompanied by symptoms of synovitis, which disappears without a trace. Viral arthritis or arthralgia can occur against the background of current hepatitis B, rubella, chickenpox, parvovirus B19 infection, entero- and adenovirus and some other viral diseases. The tropism of the group of herpes viruses to joint tissues is minimal. Children usually require a short course of NSAIDs [16].

Arthralgia of the hip joint in the post-infectious period is interpreted as infectious-toxic (infectious-allergic, post-infectious) coxitis or transient coxopathy. Sudden onset, pain and inability to support the lower limb, lameness, as a rule, colorfully characterize this pathology. Reversibility of symptoms occurs 2–3 days from the onset of the disease. Less common is recurrent (more than 3-4 episodes) or protracted arthropathy (more than 2 weeks) with the formation of osteoporosis and reversible neurodystrophic changes in the femoral head. True short-term coxitis or arthralgia of the hip joint disappears without a trace [17]. Irradiation of pain to the anterior surface of the thigh and to the knee joint in the acute period of coxitis is associated with transient neuropathy of the obturator nerve. Children aged 2 to 8 years are most often affected; the onset of the disease is often preceded by a nasopharyngeal infection, sometimes the causative factor remains unclear. In addition to the clinical picture, imaging methods (radiography, ultrasound, MRI) are of diagnostic importance.

N.B. Osteomyelitis can occur under the mask of acute coxitis, and osteochondropathy of the femoral head can occur under the mask of a protracted course of acute coxitis (Fig. 5).

Arthropathy of post-streptococcal etiology in children can occur in the form of arthralgia or acute arthritis. Joint syndrome occurs after a nasopharyngeal infection caused by group A β-hemolytic streptococcus (clinically proven episode). The duration of arthralgia is 2–4 weeks, the course of arthropathy is non-aggressive and does not cause permanent joint deformities in children. The ASL-O level (the total amount of IgA, M, G for streptococcal toxin) does not always play a decisive role in the diagnosis of arthropathy and the choice of treatment tactics, in contrast to the isolation of group A β-hemolytic streptococcus [18].

N.B. The course of acute arthritis must be differentiated from rheumatic arthritis.

Arthralgia of post-staphylococcal etiology in children, as a rule, is of a mild nature and is often characterized by the phenomena of sluggish synovitis or enthesopathy. Clinically, this may manifest itself as a slight decrease in the child’s motor activity, evening or night pain. The presence of a focus of chronic nasopharyngeal infection in the oral or nasopharyngeal area is of decisive importance in diagnosis. Sanitation of the source of infection, as a rule, relieves the child of joint pain.

In most children, articular syndrome with reactive arthritis (ReA) occurs within 1–4 weeks after a urogenital (Chlamydia trachomatis) or intestinal infection (Enterobacteriaceae family). It is believed that this is an acute non-purulent inflammation of the joints, in which the infectious agent or its antigens are not detected in the joint cavity, and the articular syndrome is associated with a number of immune disorders. However, the identification of pathogen DNA by the polymerase chain reaction method made it possible to somewhat transform this theory. Children who carry the HLAB27 gene and some other cross genes (B7, B13, B40) are at high risk for ReA. CD8+ HLAB27+ T cells are now thought to have a more robust immune response with overexcretion of TNF-α. In particular, chlamydia contributes to the chronicity of infection due to inhibition of the expression of HLA antigens on the surface of infected cells, reducing the potential for apoptosis of T cells with stimulation of local synthesis of TNF-α. And the lipopolysaccharide layer of gram-negative microorganisms is a powerful activator of tissue macrophages, synovial fibroblasts and osteoclasts, and CD8+ HLAB27+ T cells are less effective in eliminating the pathogen. The course of arthropathy is possible against the background of episodes of fever without systemic manifestations. As a rule, monoarthritis of a large joint or asymmetric oligoarthritis of the joints of the lower extremities (knee, ankle) is characteristic, sometimes in combination with the phenomena of dactylitis. Less commonly, articular syndrome can be represented by polyarthralgia. The duration of ReA can range from 1 to 3 months; the course of arthropathy is mainly acute, which dictates the need for long-term antibacterial and anti-inflammatory therapy [19].

Juvenile arthritis (JA) is a chronic inflammatory disease with more complex pathogenetic mechanisms, which usually leads to joint deformation and rarely goes away without a trace. Currently, several heterogeneous forms of arthropathy in the structure of JA are distinguished [20]. Chronic progressive inflammation of the inner lining of the joint capsule (synovial tissue), which has a high degree of aggressiveness and a tendency to spread to all structures of the joint, including the capsular-ligamentous apparatus [21]. Painful joint syndrome is multicomponent and has its own peculiarity, namely, it occurs exclusively during passive or active movements in the joints; at rest, children do not complain of pain in the joints. A characteristic feature of JA is morning stiffness, defined as short-term lameness accompanied by sensations of numbness and tenderness in one or more joints. Painful sensations that appear in the morning subside only in the evening as the intensity of the load decreases. The child spares the limb, protects the joint or joints subject to chronic inflammation from excessive physical exertion and injury. The severity of the pain syndrome depends on the aggressiveness of the disease, the type of joint involved, the amount of intra-articular fluid, as well as the reaction of the periarticular soft tissues and tendon-ligamentous apparatus. There is no point of maximum pain, and pain occurs both during palpation in the area of ​​​​the projection of the joint space and in the area of ​​​​the hypertrophied, inflamed synovium. Often, young children are not able to localize pain in the joint; swelling of the joint area may be poorly visualized against the background of a physiologically excess subcutaneous fat layer, and the first signs of an inflammatory process in the joint may be limited movement or lameness. It is known that any joint can be a target of arthritis. Rapid reversibility of inflammatory changes and resolution of contracture indicate the acute nature of arthritis [22].

This review was devoted to one of the current problems in pediatrics, namely joint pain in children. The most common forms of childhood arthropathy were presented, the leading symptom of which may be joint pain. Of course, any researcher or practitioner who sometimes faces similar problems will be able to name at least a dozen more nosological forms in which joint pain is not uncommon. However, this article is devoted to the most common forms of joint pathology in children in pediatric practice.

And in conclusion, I would like to say that joint pain is just a symptom, not a disease. A child with complaints of joint pain should be comprehensively examined. Joint pain does not lead to joint deformation and the formation of arthrosis. And “harmless” pain in the joints of childhood should remain in childhood.

Literature

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A. N. Kozhevnikov*, 1, Candidate of Medical Sciences N. A. Pozdeeva*, Candidate of Medical Sciences M. A. Konev* M. S. Nikitin* A. I. Bryanskaya*, Candidate of Medical Sciences E. V. Prokopovich* , Candidate of Medical Sciences K. A. Afonichev**, Doctor of Medical Sciences G. A. Novik**, Doctor of Medical Sciences, Professor

* Federal State Budgetary Institution Scientific Research Institute for Children's Orthopedics named after. G. I. Turner, Ministry of Health of the Russian Federation, St. Petersburg ** Federal State Budgetary Educational Institution of Higher Education, St. Petersburg State Pediatric Medical University, Ministry of Health of the Russian Federation, St. Petersburg

1 Contact information

Joint pain in children / A. N. Kozhevnikov, N. A. Pozdeeva, M. A. Konev, M. S. Nikitin, A. I. Bryanskaya, E. V. Prokopovich, K. A. Afonichev, G. A. Novik

For citation: Attending physician No. 4/2018; Issue page numbers: 50-55

Tags: children, joints, pain, diagnosis

Causes

The most common causes of knee pain are overuse and knee injuries. That is why active children and adolescents most often suffer from ACP. In addition, this pathology can occur in men under 30 years of age. ACP is much less common in older people. Symptoms of patellar osteochondropathy may also occur for other reasons:

• Flat feet.
• Scoliosis and other forms of spinal curvature.
• Hereditary predisposition.
• Improper metabolism.
• Obesity.
• Poor circulation in the legs.

Classification

Research by American rheumatologists has made it possible to develop a classification of existing types of lesions, which takes into account not only the causes of the pathology, but also the features of its localization.

1. Primary/idiopathic

• local;
• generalized (involving several areas of the musculoskeletal system).

2. Secondary knee

Because of:

• post-traumatic;
• congenital;
• caused by damage to the bone tissue system.

By localization:

• local;
• generalized.

3. Tertiary

• caused by endocrine pathologies;
• caused by neurogenic arthropathy.

It is important to note that the variability of forms and the similarity of the clinical picture necessitate a diagnostic consultation with several specialists, including: a rheumatologist, a traumatologist, and an orthopedist.

Symptoms

Usually at the very beginning of the disease there are no obvious signs. The first sign is the appearance of short-term painful sensations during physical activity. In a calm state, the patient, as a rule, does not experience any discomfort. After some time, the pain intensifies and a focus appears.

Painful sensations in the kneecap may indicate that the patient suffers from Larsen-Johansson disease. If the lesion is in the area of ​​the medial condyle, then it is osteochondritis dissecans of the patella.

Pathology appears more often in children than in adults. In the first and second stages of the disease, the patient experiences a dull aching pain in the knee. This period is characterized by the destruction of articular cartilage. It becomes difficult to bend and straighten it, and discomfort arises. The muscle corset becomes weak, swelling appears.

Over time, osteochondropathy of the lower pole of the patella, as well as the upper one, causes a peculiar crunch and the person begins to limp. At the third stage, the course of the disease worsens: bone and cartilage tissues are destroyed, pain becomes very strong, the joint becomes inflamed and deformed, swelling of the knee can be seen with the naked eye, muscle tissue atrophies.

While walking, the patient limps very strongly, and a constant crunching sound is heard when bending the knee.

Degree of development of pathology

The intensity of the lesion is determined by three degrees of osteochondrosis of the knee joint, each of which is characterized by a specific set of symptoms.

Osteochondrosis of the knee joint 1st degree

The initial stage of development of the disease. Symptoms at this stage are practically absent.

Physical activity provokes minor painful sensations.

Due to the fact that the tissues are just beginning to deform, it is quite difficult to visually identify abnormalities on an x-ray image.

Osteochondrosis of the knee joint 2nd degree

Due to the progression of tissue destruction, pain intensifies, muscles weaken, and spasms occur.

When the deformation becomes visually noticeable, the patient experiences quite severe pain and crunching when walking.

Osteochondrosis of the knee joint 3rd degree

Pathological processes progress, accompanied by pronounced pain, which is caused by the almost complete destruction of cartilage tissue and exposure of bone.

The progress of the pathology forces the patient to place the lower limb in a certain way, which impairs motor activity.

Painful sensations do not leave the patient even at rest.

Diagnostics

You cannot make a diagnosis yourself. Only an experienced doctor, depending on the symptoms and severity of the disease, can select the appropriate type of diagnosis. The five most commonly used methods are:

• Ultrasonography. It can only be done by a highly qualified specialist. He is able to see a reliable clinical picture of the disease. Ultrasound accurately determines the diagnosis and stage of the disease.
• Scintigraphy. Another highly effective method. Unfortunately, it only applies to children. Osteochondropathy of the patella using this method is determined at any stage.
• Magnetic resonance imaging helps to clearly examine the joint affected by Koenig's disease. With the help of MRI, pathology is determined even at the initial stage. An objective assessment of the state of the affected area at a given time is given. ACON is diagnosed by magnetic resonance imaging in all four types of the disease.
• In the early stages, differential diagnosis is relevant.
• Arthroscopy. Mainly used to recognize Koenig's disease. It is effective at all stages of the disease and helps to make a diagnosis with high accuracy, as well as choose an effective method of treatment in the future.

In some cases, pathology is determined using x-rays. Osteochondropathy of the patella is diagnosed using the method that the doctor considers most suitable for each individual patient.

Conservative treatment

Treatment of osteochondropathy of the patella is carried out according to one principle and generally gives a positive result with drug therapy. To relieve swelling and pain, ointments and analgesics with anti-inflammatory effects are prescribed: Ibuprofen, Diclofenac. In this case, the patient is recommended to reduce the load on the sore knee as much as possible and eliminate any movements in the joint.

A cast may be applied for up to two months. To activate the processes of restoration of cartilage tissue, chondroprotective drugs are used. You can find many ointments with glucosamine and chondroitin on the open market: “Chondroitin sulfate”, “Glucosamine Maximum” and others. During treatment, physiotherapy is also carried out - electrophoresis, paraffin applications. In addition, Neuromultivit vitamins are prescribed. If all recommendations are followed, OCP can be cured within one year. If there are no positive results after three months from the start of therapy, the issue of surgical intervention is discussed.

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Samilenko Igor Grigorievich

Traumatologist - orthopedist, doctor of the highest category

24 years of experience

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Zubikov Vladimir Sergeevich

Traumatologist-orthopedist, Doctor of Medical Sciences, doctor of the highest category, professor

44 years of experience

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Marina Vitaly Semenovich

Traumatologist-orthopedist, head of the minimally invasive traumatology and orthopedics service

Experience 36 years

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Poltavsky Dmitry Ilyich

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Experience 28 years

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Surgical method

Surgical treatment involves the use of arthroscopic equipment to surgically restore the joint. During the operation, the cartilage formation is removed and new cartilage is grafted. The reason for surgery may be a recurrence of the disease. In some cases, surgery may be performed to remove the broken joint elements. Often, such treatment is the only way to maintain the shape of the knee and its full functioning.

After the operation, you must remain calm and avoid any physical activity. Violation of the doctor’s recommendations can lead to joint deformation and complications in the form of secondary osteochondrosis of the patella.

Exercise therapy for osteochondropathy of the patella

Physical therapy is indicated during the period of immobilization. While the affected limb is fixed in a splint, the patient should use general developmental exercises. It can be:

• dynamic movements (extensor, flexion, rotation) of a healthy limb;
• rhythmic contraction of the muscles of the injured leg;
• holding the leg with the cast suspended;
• ideomotor exercises – visualization of movement in a joint.

It is necessary to start exercises a few days after surgery and plaster application, but only with the permission of the doctor. Use your healthy leg to perform any movements - move it to the side, lift it, do circular rotations, swings, statically tense the muscles.

The load on the torso muscles is also performed - the shoulders and head are raised, the position is fixed for several seconds. A few days after the operation, the patient is recommended to briefly lower the sore leg from the bed, and then raise it above the body. Walking around the ward is allowed on crutches, without support on the operated leg.

Complications

As mentioned above, most often children and adolescents are exposed to ACN, who are characterized by increased load on the legs and knee injuries. Treatment of this disease takes a long time. Sometimes it lasts for more than one year. Most often, the disease resolves without any complications for patients. Children's cartilage and bones are quickly renewed and restored. In older people, osteochondropathy is more difficult to treat and takes longer. In advanced cases, the following complications may occur:

• Arthrosis of the knee joint.
• One leg may become shorter than the other by a couple of centimeters.
• Due to the difference in the length of the limbs, the spine can be deformed and scoliosis can develop.

Without surgical intervention, lameness may remain for the rest of your life. If a child, after a bruise or other joint injury, remains at rest and does not load the joint, osteochondropathy of the patella may go away on its own. But this happens very rarely.

Prevention

It is impossible to prevent knee injury, but you can reduce the risk of developing pathological processes. It is necessary to follow simple rules in relation to all family members:

• If you have knee pain, be sure to visit an orthopedic surgeon.
• The child must know the safety rules and the dangers of severe bruises and falls.
• To identify the disease at an early stage, you should undergo regular medical examinations.
• Excessive physical activity should be avoided.

In addition, preventive measures that prevent the occurrence of osteochondropathy are exercises in the pool and therapeutic massage. To avoid Osgood-Schlatter disease, athletes are recommended to use knee pads with soft inserts during training, or sew foam pads onto sportswear.

Treatment of osteochondrosis of the knee joint

Regardless of the degree of the disease, measures to eradicate pathological processes must be comprehensive.

Only a specialist can determine the optimal treatment plan, taking into account the patient’s medical history and the characteristics of the pathological processes.

IMPORTANT! Self-medication can cause the situation to worsen and lead to irreversible consequences.

Drug therapy in the treatment of osteochondrosis of the knee joint

Treatment of osteochondrosis of the knee joint

determined taking into account an individual plan developed by a specialist.

NSAIDs (non-steroidal anti-inflammatory drugs), including the drug Artradol, are considered to be particularly important and effective in drug therapy.

In addition, the following drugs may be prescribed in combination:

• analgesics;
• chondroprotectors;
• muscle relaxants.

Physical therapy (physical therapy) as a method of complex treatment of osteochondrosis of the knee joint

Physical education classes occupy a special place in complex therapy.

The use of gymnastic exercises helps improve blood circulation and activate metabolic processes, relieving spasms and strengthening the ligamentous and muscular apparatus.

Physiotherapy

It comes in handy in the subacute period, when pain subsides.

An important point in the use of physical therapy is strict adherence to the recommendations of the attending physician and limitation of sudden movements, as well as monotonous loads.

Physiotherapy in the treatment of osteochondrosis of the knee joint

Physiotherapy helps relieve pain and also improves blood circulation.

Among the most effective physiotherapeutic procedures, it is customary to highlight the following:

• electrotherapy

  – electric shock, which provides a warming effect and improves blood flow;

• shock wave therapy

  – targeted impact with acoustic waves, which helps to activate metabolic processes and reduce swelling;

• vibration therapy

  – exposure to vibration on affected tissues, the use of which is possible only for grades 1 and 2 osteochondrosis of the knee joint;

• laser exposure

  – improves blood flow, relieving inflammatory processes.

It is important to note that physiotherapeutic procedures are only an integral part of complex treatment, and also help speed up the healing process and shorten the period of drug exposure.

Surgical treatment of osteochondrosis of the knee joint

Can the last degree of osteochondrosis of the knee joint be corrected? Definitely.

In a situation where conservative methods do not give the desired results, surgical intervention comes to the rescue, the key task of which is to preserve functionality.

The choice of surgical technique is based on the degree of development of pathological processes and is determined taking into account the individual characteristics of a specific clinical picture:

1. Drilling out affected tissues

   – used in the absence of inflammatory processes. The method has a particularly high percentage of efficiency.

2. Fixation of bone tissue with screws

   – is implemented in the presence of semi-mobile fragments, however, it has a fairly high risk of complications.

3. Securing large pieces using accessible methods

   – tissue plastic surgery, using your own cartilage tissue, which allows you to restore the functionality of the limb.