Osteoarthritis, part I: risk factors, classification, clinic
Osteoarthritis (OA) – the multifactorial, polietiologichesky heterogeneous group of diseases having similar clinical, morphological, biological manifestations and an outcome at the heart of which degenerate and dystrophic defeat of all components of a joint, first of all, a cartilage, a subkhondralny bone, and also a sinovialny cover, sheaves, paraarticulary muscles lies. It is characterized by local loss of an articulate cartilage of the sinovialny joints, the adjacent bone associated with a hypertrophy (formation остеофитов and a subkhondralny sclerosis), a thickening of an articulate capsule. Any joint can be involved in process. Knee, coxofemoral joints, joints of brushes, feet, a backbone most often are surprised. Terminological definitions – osteoart roses, art roses, the osteoarthritis, deforming art roses – in the X-th International classification of diseases are presented now as synonyms. On joint Plenum of rheumatologists and orthopedists в2003. the decision on unification of definition was made and it is recommended to use the term of osteoart roses, as most fully reflecting this chronic, progressing disease of sinovialny joints.
The disease is widespread around the world, prevailing among the white population of North America and Europe. According to experts of WHO (2003) – 9,6 % of men and 18,0 % of women are more senior than 60 years have these or those clinical manifestations of a disease. Peak of incidence of women of 65-74 years (13,5 for 1000), men fall ill less often (about 9 people for 1000) and at later age – ?75 years. The increase in expected life expectancy of the population of Earth predicted by 2020 puts forward OA on the fourth place among the leading reasons of disability of the population. Carried out in 7 cities of the former USSR large-scale research revealed manifestny (being accompanied clinical symptoms) OA at 6,43 % surveyed.
OA – a multifactorial disease with polygene type of inheritance. The carried-out researches revealed the essential genetically determined distinctions in volume of a cartilage of a knee joint and density of a bone fabric at children, OA possibly important in development in later period of life. In families of patients with generalizovanny OA, this disease meets in 2 times more often than in the general population. Also there is a genetic predisposition to formation of the small knots meeting in 10 times is more often at women: existence of knots of Geberden at mother increases risk of their emergence at daughters in 2 times.
The most proved risk factors of development and radiological progressing of OA are: age, female and superfluous mass of a body. At twins (the woman of middle age), increase in weight of a body на1 кгсопровождается increase of risk of development гонартроза for 9-13 %. Genetically determined risk factors of development of OA treat: hereditary violations and mutations of collagen II of type, hereditary diseases of bones and joints, congenital displaziya of joints.
Clinical classification of OA (Altman, 1986)
- Primary (idiopathic) OA
Localized (defeat less than three articulate groups)
- Knee joints
- Coxofemoral joints
- Brushes: erozivny, inflammatory OA (Crane’s illness); distalny interphalanx joints (Geberden’s knots); proksimalny interphalanx joints (Bouchard’s knots); 1st pyastno-phalanx joints.
- Feet: 1st plusnefalangovy joints (Hallux valgus).
- Backbone: osteochondrosis; widespread idiopathic гиперостоз skeleton (Forestye’s illness).
Generalizovanny polyosteoarthritis (Kellgren’s illness) – defeat of three and more articulate groups.
- Secondary OA
- The post-traumatic
- Congenital diseases: coxofemoral joint (Legg-Kalve-Pertesa illness; congenital dislocation of a hip; displaced эпифиз femur heads; congenital thickening of a vertluzhny hollow; other);
- Displazy: Displaziya эпифиза; spondiloepifizarny displaziya
- Violation of mechanics of joints: syndrome of hyper mobility of joints; unequal length of feet; varusno/valgusny deformations; scoliosis.
- Metabolic diseases: гемахроматоз; illness to Gosha; охроноз; gemoglabinopatiya.
- Endokrinopaty: Akromegaliya; hypo / гипертиреоидные conditions.
- Neuropathies: Sharko’s illness; syphilis
- Illness of adjournment of calcium: calcium phosphate; calcium hydroxyapatite.
- Other diseases: illness Pedzheta, avaskulyarny necrosis, RA, etc.
The joints, which defeat it is atypical for primary (idiopathic) OA
- Pyastno-falangovye joints of brushes
- Luchezapyastnye joints
- Elbow joints
- Humeral joints
- Ankle joints
- 2-5 plusne-phalanx joints
OA place in the International Classification of Diseases of the X-th revision:
M15-M19 – Artroza:
М15 – Primary generalizovanny polyosteoarthritis
М151 – Geberden’s Knots
М152 – Bouchard’s Knots
М16 – Koksartroz
М17 – Gonartroz
М18 – Artroz of the 1st carpal пястного a joint
М19 – Other art roses
The clinical picture of an illness is determined by a being by local semiology in the most struck joints, one or several: pain syndrome, change of a shape of a joint and violation of its functional ability. As a rule osteoart roses begins gradually, gradually. The first symptoms are a short-term tugopodvizhnost in a joint after rest, the small pains arising periodically at small physical activity. Weakness, fast fatigue of regionarny muscles, a krepitatsiya in a joint are noted. In process of illness development the specified semiology progresses: the tugopodvizhnost and constraint become longer, the articulary krepitatsiya passes to a rough crunch. Intensity and duration of local morbidity in joints which arises at small overloads increase. The pain syndrome at OA – the phenomenon non-uniform also includes a number of causal factors. Main of them are: inflammatory process in soft okolosustavny fabrics, jet синовит, vascular disorders (the blood-groove in a subkhondralny bone is especially complicated), a long spasm of regionarny muscles, entezopatiya. At периартрите (тендобурсите) painful there are the movements connected with participation of the struck sinew. As a whole for a disease the mechanical rhythm of pains – emergence under the influence of day physical activity and a stikhaniye during night rest is characteristic in the evening. The short-term "starting" pain arising after a dormant period, especially in the morning, and passing soon against impellent activity is possible. The painful zones which are defined palpatorno (a forward surface humeral, internal knee etc.) are observed characteristic for this or that joint . Sharply expressed pain syndrome arises at joint "blockade" owing to special localization остеофитов or emergence of «an articulate mouse» with infringement of a slice of a nekrotizirovanny cartilage or a bone between articulate surfaces. The moderate swelling of the struck joint caused by inflammatory sinovialny or periartikulyarny hypostasis (jet синовит) is periodically observed. Deformation of joints as a result of bone growths (ос
теофитов) gradually accrues. At the same time weakness of the sukhozhilno-copular device, hypotonia and an atrophy of regionarny muscles promote emergence of incomplete dislocations. Functional violations at an early stage of OA are caused by a pain syndrome and a reflex spasm of muscles, and further – sukhozhilno-muscular contractures, остеофитами, sometimes emergence intra articulate «free bodies».
Koksartroz – most the OA heavy form, in connection with progressing violation of mobility of a coxofemoral joint. Within several years the invalidizatsiya of the patient is possible, especially at bilateral defeat. Pains are characteristic at movement in a hip, sometimes in a groin, a buttock, a waist, a knee (irradiatsiya places). Reduction of a tone of muscles of a hip, their fast fatigue is observed when walking and standing. The pains first moderate, intermittiruyushchy, gradually become is ill intensive and constant in the conditions of loading (a support on a foot, walking). Restriction of movements, and first of all internal and external rotation of a hip, after assignment and bending appears and progresses. Periodic "blocking" of a joint, an atrophy of muscles of a hip and a buttock, local morbidity is noted at a palpation, mainly in a hip. Gait with the advent of "lameness" (changes especially when shortening extremity). For bilateral defeat of joints "duck" gait is characteristic. In clinical practice most often it is necessary to differentiate коксартроз and коксит (is more often infectious генеза). For коксита sharper beginning and faster progressing of a disease, pain of inflammatory character in the mornings and in the second half of night, unlike evening, mainly mechanical character, pains is characteristic at коксартрозе. At коксите more expressed violation of mobility in a joint with primary restriction of bending whereas for коксартроза primary restriction of rotation and foot assignment is characteristic is noted. Early radiological signs коксита – okolosustavny osteoporosis, a roentgenogram illegibility in the struck joint owing to an ekssudativny propityvaniye of periartikulyarny fabrics and an exudate in a joint cavity. Also коксартроз it is necessary to differentiate with isolated periartrity a coxofemoral joint (trokhanterity) at which the pain syndrome is localized in the field of a femur and groin spit. Painful points here are defined at a palpation. Feature is restriction and morbidity of all active movements while passive movements are free and painless.
Gonartroz – more favorable localization of OA which is seldom leading to an invalidizatsiya. Are characteristic emergence of pains in a joint, especially at a rising, descent on a ladder, their localization in a medial part of a joint with an irradiatsiya in a hip and a shin. In an initial stage progressing restriction of a razgibaniye, after joint bending with formation of a sgibatelny contracture is noted. Deformation of a knee joint, deviation (About-shaped X-shaped feet) and its instability, an atrophy of muscles of a hip and a shin gradually develops. In some cases the syndrome of "blockade" of a joint is observed. Periodically arises jet синовит at which pains amplify at movements, appear in rest, are accompanied by a joint swelling, formation of a popliteal cyst is possible.
Osteoarthritis of brushes
Defeat of distalny interphalanx joints
Is the most frequent localization of OA of brushes and makes not less than 20 % of all cases of OA. On back and lateral surfaces of distalny interphalanx joints the dense knotty thickenings caused by formation regional остеофитов – Geberden’s knots develop. They are a characteristic sign of primary (idiopathic) OA, as a rule arise at women in a menopause. Knots happen multiple symmetric, are accompanied by a tugopodvizhnost. At late stages restriction of movements in joints develops. At considerable deformation the curvature of nail phalanxes is observed. Emergence jet синовитов with reddening, a swelling and morbidity of soft fabrics of this area is possible.
Defeat of proksimalny interphalanx joints
Changes similar are observed by the aforesaid in proksimalny interphalanx joints – Bouchard’s knots (make ~50 % of patients with geberdenovsky knots). Knots распологаютсся only on lateral surfaces that gives them a veretenoobrazny form. In rare instances Bouchard’s knots come to light separately on one or several joints.
Defeat of a pyastno-carpal joint of a thumb (ризартроз)
Most often the given form of OA develops at women in a postmenopause. The bilateral defeat, clinically being shown a krepitatsiya, mechanical pains on internal edge of a wrist is characteristic at thumb movement, restriction of its mobility. Radiological classical signs of OA of a pyastno-trapetsividny joint are noted
Osteoarthritis of feet
Defeat of an ankle joint
In most cases OA of an ankle joint has secondary (usually traumatic) генез. Violation of walking is caused not only a pain syndrome, but also formation of the compelled position of a joint
Defeat of the 1st plusnefalangovy joint
Meets big frequency, it is caused by statics violation (longitudinal and/or cross-section platypodia), a frequent mikrotravmatizatsiya. As a rule happens bilateral. The progressing deviation of a thumb to the outer side (Hallux valgus) is caused by cross-section platypodia. Besides mechanical pains, it is noted бурсит, often accepting a chronic current.
Most typically slowly progressing current of OA with gradual (for 5-10 years) increase of clinical and radiological semiology, deterioration of functional ability of a joint. For quickly progressing option early generalization of pathological process, frequent recurrence синовита, considerable negative evolutions of a radiological picture in a joint, decrease, and quite often disability of the patient for some years from an onset of the illness are characteristic. OA current without appreciable progressing for the long period of time (10 and more years) is possible.
Studying of volume and quality of active and passive movements in joints (see tab. 3) is necessary for an assessment of reserves of their impellent function. Active movements are made by the patient, passive – the doctor makes at a full relaxation of muscles of the patient.
Indicators of normal impellent function of joints
In recent years for diagnostics of OA classification criteria of R.Altman and совт are used.
Classification criteria of OA (Altman, etc., 1991)
Clinical, laboratory, radiological criteria
- 1. Pain
2.б Morning constraint (? 30 minutes)
2.в Age of ?38 years
3.б Morning constraint (? 30 minutes)
3.в Bone growths
Sensitivity – 89 %
Specificity – 88 %
3.а Sinovialnaya liquid, characteristic for OA (or age of ?40 years)
3.б Morning constraint (? 30 minutes)
Sensitivity – 94 %
Specificity – 88 %
2.а Internal rotation
3.а Internal rotation
3.б Morning constraint (? 60 minutes)
3.в Age of ?50 years
3.с Pain at internal rotation
Sensitivity – 86 %
Specificity – 75 %
and not less 2 of 3 criteria:
2.в Narrowing of an articulate crack
Sensitivity – 89 %
Specificity – 91 %
Joints of brushes. Classification criteria of OA (Altman, etc., 1991)
- 1. Long pain or constraint (? 30 minutes)
- 2. Bone growths of the 2nd and more joints from 10 estimated (the 2nd and 3rd distalny interphalanx joints; 2nd and 3rd proksimalny interphalanx joints; the 1st carpal пястный joint of both brushes).
- 3. Less than 2 swelled up a little pyastno-phalanx joints
4. And the Bone growths which are including 2 and more distalny interphalanx joint (the 2nd and 3rd distalny interphalanx joints can be taken into consideration in two criteria: 2 and 4А)
4. In Deformation of one or more joints from 10 estimated (the 2nd and 3rd distalny interphalanx joints; 2nd and 3rd proksimalny interphalanx joints; the 1st carpal пястный joint of both brushes).
Sensitivity and specificity of the presented criteria – 93 % and 91 % respectively.
Osteoarthritis, part II: laboratory, morphology, X-ray.>>>
The roentgenogram from a site: glucosamine-arthritis.org