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 functions in axial compression mode, therefore its articular surfaces are exposed to constant loads and degenerative changes in the hyaline cartilage.

Prevalence

Pathology of the articular cartilage of a degenerative-dystrophic nature with involvement of bone tissue, joint sac, ligaments and muscles in the process is called deforming arthrosis. There are synonyms in terminology:

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

In terms of frequency, damage to the knee occurs immediately after the hip joint, so a stable phrase was formed: "gonarthrosis of the knee joint". The dependence of the frequency of the disease on age was studied:

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

In all age groups, representatives of the fairer 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 associated with joint pathology.

Classification of gonarthrosis

Due to the reasons of development, the disease is divided into two large groups: primary and secondary. It primarily arises without visible preconditions. Secondary is preceded (or followed) by provoking factors:

1. biomechanical disorders: injuries, excessive loads, developmental anomalies (dysplasia), skeletal pathology (scoliosis, flat feet), obesity;
2. inflammatory processes: aseptic or infectious arthritis, frequent hemarthroses 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, obliterating endarteritis, atherosclerosis of blood vessels of the lower extremities;

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

I stage

The picture shows a slight narrowing of the inter-articular gap (comparison is with a healthy joint), the beginning of sclerosis of the pericartilaginous bone tissue. Clinical - pain occurs during walking or immediately after it, with prolonged standing. More pronounced when climbing stairs. Passes at rest. 1st degree gonarthrosis does not significantly affect joint function.

II phase

The joint space is 2-3 times narrower than normal. Sclerosis is more pronounced, there are osteophytes (pointy outgrowths of bone tissue along the edges of the joint space and condyles). The pain is moderate, there are signs of muscle hypotrophy, lameness. The deformation of the knee in the front axis is visible. Gonarthrosis of the 2nd degree leads to a significant limitation of joint mobility.

III phase

Sclerosis of cartilaginous elements, deformation of joint surfaces. There are areas of subchondral necrosis, local osteoporosis. Cysts in adjacent bone tissue. The joint space is critically narrowed, sometimes not defined. Osteophytes of significant size. Atrophy of the upper leg and lower leg muscles, the joint is unstable, there is pronounced deformation. Movement in the knee is sometimes impossible, a contracture is created. 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 possibility of choosing a more effective treatment based on a comprehensive assessment of the condition of the joint.

Development mechanism

The pathogenesis of any arthrosis goes through three stages:

1. Damage to cartilage microstructures. Under the influence of some of the harmful factors, high-molecular 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 the hyaline cartilage. Chondroprotectors suppress such phenomena.
2. If the provoking factor is not eliminated, the weakening of cartilage components (glycosaminoglycans, proteoglycans) continues. This leads to the activation of the recovery process. Their power reserve is not particularly large, so this phase quickly transitions to the next.
3. Disruption of compensatory mechanisms leads to progressive destruction of articular cartilage, death of its cells - chondrocytes. Cartilage cracks extend to the lower bone. The degree of separation of cartilaginous components increases, their defibration occurs, which leads to thinning of the hyaline membrane.

In deforming arthrosis of the knee joint, thickening (sclerosis) occurs on the part of the bone, cysts and areas of uneven bone density appear. Therefore, deformation of joint surfaces, joint instability develops.

Diagnostics

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 review

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

At this stage, it is important to find out the condition of the other knee. If you miss bilateral gonarthrosis and focus only on the knee that worries you more, you can make a big diagnostic mistake.

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

Instrumental methods

The first is radiography. The image of the knee in two projections enables a preliminary assessment of the condition of the joint and determination of the stage of the disease. The drawback of the method is that the radiological signs appear later than the symptoms and morphological changes that accompany arthrosis of the knee joint.

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

Direct inspection of the joint cavity is possible with arthroscopy.

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

• Age over 50 years.
• Stiffness in the wrist in the morning, lasting at least half an hour.
• Shooting, determined by movement (active and passive).

If these symptoms are accompanied by osteophytes found on X-ray and pain, there is a high probability of gonarthrosis of the knee joint.

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

All possible measures should be taken so that gonarthrosis is not confused with the following conditions:

Rheumatoid arthritis	Onset at an early age, stiffness in the morning for more than 30 minutes, pain stronger at rest and weaker when moving, rheumatoid nodules on the skin, accompanying lesions of 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 above the affected joint is edematous, red, hot; crystals on microscopic examination of synovial fluid, increase of uric acid in the blood (in gout).
Spondyloarthropathies	Arthritis of other, unrelated joints (intercostal, lumbar joint); inflammatory processes in tendons; damage to the cornea, skin, mucous membrane.

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 osteoarthritis of the knee joint. And they exist. Help can be provided in a variety of ways.

In the first place are the achievements of traditional medicine, based on a deep study of the causes and mechanisms of diseases. Medical and surgical methods are used here. Competent treatment requires consistent and complex application of drugs, physiotherapy methods and rehabilitation measures.

Another way is treatment with folk remedies. The effectiveness of these methods is questionable, to say the least. 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 doctor's consent!

medical assistance

This type of treatment involves the use of various drugs. Medicines from different groups are used for medicinal effects:

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 relieve pain. Pain syndrome pretty much spoils 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 have a negative effect on the kidneys, protective 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 dose selection is required.

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

Centrally acting analgesics are prescribed for a short time, with the ineffectiveness of the other two groups. The most popular opiate is prescribed during an exacerbation, more often with bilateral gonarthrosis. These drugs are addictive. You can't take them yourself!

Slow-acting symptomatic drugs

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

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

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

The most studied and popular chondroprotectors (chondroitin sulfate and glycosaminoglycans) are finished components of articular cartilage. They are 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.

Chondroitin sulfate, taken in courses for two years in a daily dose of 800 mg, has been proven to have a stabilizing effect on the joint space in 2nd degree gonarthrosis of the knee joint.

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

Hyaluronic acid derivatives are used in the form of intra-articular injections. These agents, like chondroprotectors, improve the functional state 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 time without tangible harm to the body.

Glucocorticosteroids

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

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

Group name	Advantages	Disadvantages
NSAIDs, analgesics, opiates	Fast action, many forms for local application.	Side effects, unstable effect, dangerous for age-related patients, addiction occurs.
Chondroprotectors	They act pathogenetically, have a lasting effect, are non-toxic, there are forms for external and intra-articular application.	Slow development of the effect.
Hormones	Fast effect where NSAIDs are not enough; forms for intra-articular administration.	Side effects, unstable effect, long-term use is impossible.

ethnoscience

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

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

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 confirmed by the fact that biologically active substances (gum, bile, herbal infusions) are used for the preparation.

In addition, competent treatment with folk remedies begins with adherence to diet, weight loss. This method alone, aimed at reducing the load on the joint, can reverse osteoarthritis of the knee joint of the 1st degree (the condition is young age, sufficient compensatory abilities). A healthy diet, in itself, stimulates the body's regenerative abilities. The diet includes: mild hunger, vegetables, freshly squeezed juices. It is recommended to add low-fat jelly, jelly to the diet.

External resources are very diverse. They mostly have an irritating and warming effect. The most studied components are bile, dimethyl sulfoxide and bischofite. Bile should be used medicinally, and not extracted independently from the animal's corpse. Dimethyl sulfoxide is an analogue of the chemical warfare agent, mustard gas. Bischofite is an oil derivative. It is a difference in origin.

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

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

The last thing I want to say is that man has one health. You should not completely rely on the apparent simplicity and cheapness of folk remedies. If you have already decided to try them, pay more attention to the painful 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 2 or more degrees is diagnosed, it is better not to mess with traditional medicine. Or postpone it for a period of remission. Unsatisfactory treatment is an indication for complex surgical intervention.