Osteoarthritis, part II: laboratory, morphology, X-ray
Now laboratory tests, patognomonichny for OA, recommended for daily application, no. An indirect sign of activity of an inflammation is increase concentration of SRB. The main indications to carrying out laboratory researches are:
1. Differential diagnostics
It is carried out with infectious, specific (including tubercular), paraneoplastic, microcrystalline arthritises, revmatoidny arthritis. Frequency of detection of a low caption of the Russian Federation at patients, advanced age according to populyatsionny researches, varies within 5-15 %. Identification of the Russian Federation demands carrying out complete inspection of RA directed on identification from the elderly patient, considering that the 2nd peak of incidence of RA is the share of aged people of 62-65 years.
2. Identification of possible contra-indications to purpose of HP
The necessary minimum of laboratory analyses includes: clinical analysis of blood, urine, blood biochemistry: general protein, urea, Creatinine, nuclear heating plant, ALT.
3. Research of sinovialny liquid
It is carried out only in the presence of secondary синовита. At suspicion on infectious генез arthritis, absolute contra-indications to carrying out артроцентеза are not present.
Osteoarthritis, part I: risk factors, classification, clinic>>>
Relative contra-indications: a hemorrhagic syndrome (hemophilias, thrombocytopenia, etc.), reception of anticoagulants, area cellulitis over an edematous joint.
For OA not inflammatory sterile character of sinovialny liquid (transparent, leukocytes 0-200 mm3 polymorphic and nuclear cages is characteristic – < 10%). Morphological changes at OA
From the morphological point of view the OA macroscopical picture is characterized by a combination of gradual and steady loss of an articulate cartilage to a thickening of a subkhondralny bone, formation regional остеофитов, and also a moderate nonspecific inflammation of a sinoviya. Morphogenetic allocate three stages:
- Normal cartilage
- Senile changes
- Changes, characteristic for OA
Accurately to outline border between "physiological" aging of a cartilage and its change at OA it is not always possible.
Consists of two main components. The first is presented extracellular matriksy, rich with different types of collagen (generally – II, IX, XI types), протеогликанами (90 % – аггрекан). Aggrekan consists of an albuminous kernel to which are attached кератан sulfate, хондроитин sulfate and hyaluronic acid. The structure of this molecule ideally counteracts load of a joint at the expense of a combination of high water repellency and low viscosity. The second component of a cartilage is presented хондроцитами, covering матрикс.
Aging is accompanied by the structural changes mentioning not collagenic components матрикса, bringing to violation of biochemical properties of a cartilage: to shortening гликозаминогликанов, to concentration increase 6-кератан sulfate. It leads to decrease in ability of a hryashchevy fabric to hold water and to emergence of microcracks.
Changes, characteristic for OA
The above described macroscopical picture grows out of the histologic phases which are consistently replacing each other:
- Phase of hypostasis and formation of microcracks. Hypostasis extracellular матрикса, mainly intermedialny layer is the first sign of OA. Formation of microcracks occurs owing to local death хондроцитов, alternating with their proliferatsiya.
- Phase of formation of cracks and poles. It is formed thanks to deepening of microcracks perpendicular to pressure. In a subkhondralny bone the vertical crevices surrounded with groups хондроцитов are formed.
- Erozirovaniye phase. Further progressing of process conducts fragmentations of cracks that is one of the reasons of formation of the inflammatory cascade; to an ogoleniye of a subkhondralny bone, formation of subkhondralny cysts. Inflammatory process at OA, unlike RA, always has more local character. The histologic picture синовита at OA is characterized by a moderate nonspecific limfoplazmotsitarny and gistiotsitarny infiltratsiya.
Arthroscopic classification of defeat of a cartilage (Beguin. J. - Locker B., 1983 g)
0 Art. Normal cartilage
1 Art. Hypostasis and/or cartilage softening
2 Art. Superficial razvolokneniye hryashchevy матрикса
3 Art. The expressed razvolokneniye
Ogoleniye’s 4 Art. of a subkhondralny bone
Radiological changes at OA
Rentgenografiya remains the simplest and public method of research of joints for an assessment of existence and expressiveness of anatomic changes of bones and a hryashchevy fabric at OA. For an adequate assessment of the articulate status it is necessary to remove not only a joint (a brush, foot) which defeat has clinical manifestations, but also contralateral departments that is especially important for OA of a knee joint. Radiological changes at OA it develops of a number of signs: dystrophic changes of an articulate cartilage – narrowing of an articulate crack; a bone fabric – cysts, an uploshcheniye and deformation of articulate surfaces; instability of joints – incomplete dislocations, violations of a physiological axis; development of kompensatorno-adaptive processes – formation остеофитов, a subkhondralny osteosclerosis. Radiological signs of OA at patients are more senior than 65 years come to light in 50-80 % of cases. Radiological signs of OA of a knee joint in the general population of people of the USA and Europe (?45 years) are noted at 14,1 % of men and 22,8 % of women. OA of a coxofemoral joint meets essentially less often – at 1,9 % of men and 2,3 % of women 45 years are more senior. Hondrokaltsinoz who is often revealed on survey roentgenograms at elderly patients, seldom has independent clinical value.
Coxofemoral joint – on roentgenograms in an early stage of an illness narrowing of medial department of an articulate crack, a point of edges of a pole of a head of a hip in the field of an attachment of a round sheaf, and also the upper edge of a vertluzhny hollow, an osteosclerosis of its articulate surface come to light. Further are observed progressing narrowing of an articulate crack, остеофиты in the field of external, then internal edge of a vertluzhny hollow, kistovidny enlightenments of a head of a femur. Its fungoid deformation, a protruziya in a basin cavity, shortening of a neck of a hip (coxa vara) are possible. Sometimes in an average part of a vertluzhny hollow it is formed wedge-shaped остеофит, causing lateral shift of a head of a hip up to incomplete dislocation formation. Free intra articulate bodies at коксартрозе come to light seldom.
Knee joint - initial changes are characterized by emergence of a point of intercondyloid eminences, non-uniform narrowing of an articulate crack (an internal half), a point of contours эпифизов femoral and bolshebertsovy bones, edges of a nadkolennik. Further narrowing of an articulate crack of a jo
int accrues, there is an osteosclerosis, kistovidny enlightenments of a bone fabric, остеофиты internal and external condyles of jointing bones, art roses of a nadkolenno-femoral joint. At varusny deformation formation of an osteonecrosis of an internal condyle of a hip is possible.
Brushes – radiological signs of OA of joints of brushes meet in 22,1-32,7 % of cases while clinical manifestations are observed essentially less often – in 1,8-5,5 %. There is an authentic communication between extent of radiological progressing of OA and intensity of a pain syndrome. Communication of radiological changes with functional insufficiency of joints appeared doubtful. Moderate narrowing of articulate cracks, formation of okolosustavny cysts, periartikulyarny остеофиты is noted. Identification of erosion possibly only in case of development of erozivny OA (Crane’s illness). The distalny and proksimalny interphalanx joints, the first carpal пястные joints of a brush and the first plusnefalangovy joints of foot are surprised. Unlike revmatoidny arthritis, pyastnofalangovy, luchezapyastny, 2-5 plusnefalangovy joints are not involved in process. A characteristic symptom of a disease – the central "erosion" forming a patognomonichny symptom of «wings of a seagull». The true erosion arising in sites, deprived the sinovialny cover, does not happen.
Feet - at initial stages of OA of the first plusnefalangovy joint narrowing of an articulate crack with formation of small cysts, an osteosclerosis is noted. Further appear dorsalny остеофиты, then an incomplete dislocation and, at last, a complete dislocation of a head of a plusnevy bone. (see kliniko-radiological classification of Hallux Valgus).
For a long time in Russia the radiological classification of OA offered by N of Page Kosinsky (1961), which now was used lost the value. We bring her only for possibility of comparison to the classification of J accepted now around the world. N of Kellgren, J. S. Lawrence (1957). This classification is recommended for use in practical work as Plenum of rheumatologists and orthopedists of Russia.
Radiological classification of OA by N.S.Kosinskaya (1961)
The I Art. – bone growths at insignificant narrowing of an articulate crack;
The II Art. – appears a subkhondralny osteosclerosis. Narrowing of an articulate crack is more distinct;
The III Art. – sharp narrowing of an articulate crack is combined with an uploshcheniye of articulate surfaces and kistovidny educations.
Radiological classification of OA by Kellgren – J. S. Lawrence (1957)
0 Art. – Changes are absent
The I Art. – Doubtful radiological signs
The II Art. – the Minimum changes (small narrowing of an articulate crack, individual остеофиты).
The Art. Sh – Moderate manifestations (moderate narrowing of an articulate crack, multiple остеофиты).
The IV Art. – the Expressed changes (the articulate crack practically is not traced, rough остеофиты).
Kliniko-rentgenologichesky classification of Hallux Valgus (HV)
The I Art. – a corner < 30?
of HV II of the Art. – HV 30-40 corner?
The III Art. – HV corner ? 40?
MRT-klassifikatsiya cartilage defeats
Accuracy of definition of defeat of a cartilage when using a magnetic and resonant tomography according to various researches varies within 50-97 %. At the heart of the real classification the arthroscopic classification of Beguin accepted around the world lies. J. – Locker B. Carrying out MRT is shown for an exception of the secondary reasons of OA, and also before carrying out surgical interventions.
0 Art. Normal cartilage
1 Art. Local hypostasis and emergence of vnutrikhryashchevy zones with a low signal.
2 Art. Superficial razvolokneniye and/or decrease in height of a cartilage of 3 Art. Deep cracks and/or decrease in height of a cartilage of ?50 %
Ogoleniye’s 4 Art. of a subkhondralny bone
Computer tomography (KT)
Carrying out KT of research at OA is shown at suspicion on development of the aseptic necrosis which early stages can not come to light on survey roentgenograms.
Other tool methods of research
In case of need volume specifications, topics of defeat of joints, exceptions of the hidden centers of an inflammation and/or a bone destruktsiya, carrying out a stsintigrafiya of a skeleton with tekhnetsiy (99Тс) is possible.
Osteoarthritis, part III: Differential diagnostics>>>
The roentgenogram from a site: meddean.luc.edu