Arthrosis of the knee joint (ICD-10 - M17) is a chronic progressive disease characterized by the development of degenerative-dystrophic changes in the cartilage, subchondral bone, capsule, synovial membrane, muscles. It presents with pain and difficulty in movement. The progression of the disease leads to disability. Osteoarthritis of the knee joints affects 8-20% of people. Frequency increases with age.
Classification of Kosinskaya N. S
There are several classifications - for reasons, for radiological signs. It is more convenient in practice to use the classification of Kosinskaya N. S.
- 1 stage - x-ray picture of a slight narrowing of the joint space and minor subchondral osteosclerosis. Patients complain of pain in the knee joints when walking for a long time, when climbing or descending stairs. There are no functional disorders of the joint.
- 2 stage - articularthe gap narrows by 50% or 2/3. Subchondral osteosclerosis is pronounced. Osteophytes (bone growths) appear. The pain is moderate, there is lameness, the muscles of the thigh and lower leg are hypotrophic.
- 3 stage - the joint space is completely absent, there is a pronounced deformation and sclerosis of the articular surfaces with necrosis of the subchondral bone and local osteoporosis. The patient has no movements in the joint, the pain is severe. There is muscle atrophy, lameness, deformity of the lower limb (valgus or varus).
International Classification of Diseases ICD-10
Deforming arthrosis of the knee joint in ICD-10 is designated M17 (gonarthrosis). Belongs to the 13th class - diseases of the musculoskeletal system and connective tissue (M00 - M99). Osteoarthritis of the knee joint (ICD-10 code) is in the group - arthrosis M15 - M19.
- If damage to both joints begins without any external cause, then this is primary bilateral arthrosis of the knee joint. In ICD-10 - M17.0. Also called idiopathic arthritis.
- The next option is another primary arthrosis of the knee joint. In ICD-10 - M17.1. This includes unilateral arthrosis. For example, M17.1 - arthrosis of the right knee joint in ICD-10. Osteoarthritis of the left knee has the same code.
- Trauma is a common cause of illness, especially in young people and athletes. If both joints are affected, then in the classification it sounds like post-traumatic bilateral deforming arthrosis of the knee joints, the ICD-10 code is M17.2.
- In case of a one-sided defeat, the code changes. According to ICD-10unilateral post-traumatic arthrosis of the knee joint is designated M17.3.
- If a patient has a history of causes that led to damage to the structure of the joints, for example, acute or chronic overload, arthritis, arthropathy of various etiologies, somatic diseases affecting the joints, then this is secondary bilateral arthrosis. Arthritis of the knee in the ICD-10 occupies different positions depending on the cause.
- M17.5 - another secondary arthrosis of the knee joint, according to ICD-10 - M17.5. This is a unilateral organ lesion.
- Unspecified arthrosis of the knee in ICD-10 - M17.9.
Structure of the knee joint
The knee joint combines three bones: the femur, tibia and patella, covering the joint in front. The connecting areas of the femur and tibia are uneven, so between them there is a dense hyaline cartilage to absorb the load (meniscus). The bony surfaces inside the joint are also covered with cartilage. All components of the joint hold the ligaments: lateral medial and lateral, cruciate anterior and posterior. Outside, all this is covered with a very strong joint capsule. The inner surface of the capsule is lined with a synovial membrane, which is densely supplied with blood and forms synovial fluid. It nourishes all structures of the joint by diffusion, since there are no blood vessels in cartilage. It consists of chondrocytes (up to 10%), and the intercellular substance (matrix), which consists of collagen fibers, proteoglycans (they are formed by chondrocytes) and water (up to 80%).glycosaminoglycans and chondroitin sulfate, bind water and fiber.
Etiopathogenesis
Causes of cartilage tissue destruction can be a history of infectious or crystalline arthritis (rheumatoid, reactive arthritis, gout, psoriatic arthropathies), acute or chronic joint overload (sports, weight), trauma, physical inactivity in aged patients. All this causes a metabolic disorder, a decrease in the level of proteoglycans, and water loss. The cartilage loosens, dries out, cracks, becomes thinner. Its destruction occurs, then regeneration with a loss of congruence, bone tissue begins to become exposed and grow. In the absence of treatment, the joint space disappears, the bones are in contact. This causes acute pain and inflammation, deformity, necrosis of the bone.
Clinic
The first manifestations of the disease are pain in the knee joints during physical exertion, after a long walk, when cooling, in cold wet weather, when going up and down stairs, lifting weights. The patient takes care of his leg. Lameness occurs. As the disease develops, crunching, crepitus, difficulty in movement, and joint deformity are noted. Synovitis occurs periodically. On examination, the joint area may be edematous, hyperemic, painful on palpation. Possible deformation of the joint or the entire limb.
Diagnosis
To find the cause of the disease and determine the degree of its severity, it is necessaryassign:
- Complete blood count.
- Complete urinalysis.
- Biochemical analysis: CRP, RF, liver enzyme activity (AST, ALT), total protein, creatinine, uric acid, glucose.
- X-ray of knee joints.
- Ultrasound (if there is a Becker cyst, effusion in the joint).
- When hospitalized, in addition to the studies above, MRI and densitometry are also performed according to indications.
X-ray of the knee joint is done in lateral and frontal projections. The radiological signs of arthrosis include: a decrease in the height of the joint space, bone growths, osteophytes, subchondral osteosclerosis, cysts in the epiphyses, deformity.
In the initial stages of the development of the disease, when there are no radiological signs yet, magnetic resonance imaging (MRI) will be a more informative research method. This method allows you to see changes in the cartilage, its thinning, cracking, to assess the condition of the synovial membrane. Of the invasive methods, arthroscopy is informative. It allows you to visually inspect all the internal components of the joint.
Differential Diagnosis
Differential diagnosis is carried out in the initial stages of arthrosis, when the clinical and radiological picture is not yet expressed. It is necessary to exclude arthritis of various etiologies: rheumatoid, psoriatic, infectious, reactive, as well as gout, joint damage in ulcerative colitis (NUC), Crohn's disease. With arthritis, there will be general and local symptoms of inflammation,corresponding changes in the picture of blood and x-rays. It is necessary to make an appointment with a rheumatologist.
Non-drug treatment
Treatment of patients with gonarthrosis is surgical and non-surgical, and it depends on the stage of the disease. In the first and second stages, treatment without surgery is possible. In the second, if there was no effect from conservative therapy, as well as the third, surgical treatment is indicated.
Non-surgical treatment is non-drug and drug. Non-drug therapy includes:
- Weight loss.
- Exercise therapy to strengthen the muscles of the lower leg and thigh.
- Elimination of factors that increase the axial load on the joint (running, jumping, long walking, weight lifting).
- Using a cane on the opposite side of the affected joint.
- Wearing orthoses to relieve the joint.
- Massage of the leg and thigh muscles, hydromassage.
- Hardware physiotherapy: SMT, electrophoresis with dimexide, analgin, novocaine, ultrasound or phonophoresis with hydrocortisone, chondroxide gel, magnetotherapy, laser. Also, with positive dynamics, paraffin-ozocerite, mud applications are prescribed. Radon, hydrogen sulfide, bischofite baths, hydrorehabilitation have a good effect.
Medicated treatment
In accordance with the European guidelines (ESCEO) 2014 for the treatment of patients with osteoarthritis, a 4-step algorithm for the treatment of osteoarthritis is recommended:
- At the first stageuse of paracetamol on demand for a quick analgesic effect is indicated. If the patient has gastrointestinal diseases, it is recommended to combine NSAIDs with gastroprotectors. Reception of structure-modifying drugs of slow action is shown. These include glucosamine sulfate and chondroitin sulfate. Outwardly on the joint - NSAID ointment. Methods of non-drug therapy are also shown. Each next step does not cancel the previous one.
- At the second stage, patients with severe clinical symptoms (acute pain) or frequent synovitis are prescribed courses of NSAIDs (selective or non-selective, depending on the comorbidity). In case of ineffectiveness - intra-articular injection of glucocorticoids (with effusion into the joint, the effect is fast, duration up to three weeks, betamethasone 1-2 ml or methylprednisolone acetate 20-60 mg is administered) or hyaluronic acid (with contraindications to NSAIDs, the strength of pain relief is the same, the effect is 6 months, injected up to 2 ml 3-5 times once a week).
- The third step is the last attempts at drug therapy before preparing for surgery. Mild opioids and antidepressants are prescribed here.
- The fourth step is the surgical treatment. Partial or total arthroplasty, corrective osteotomy, arthroscopy are indicated.
Surgical treatment
With arthroscopy, the following are possible: visual inspection inside the joint, removal of cartilage fragments, inflammatory elements, resection of damaged areas, leveling of cartilage that has become filamentous, removal of osteophytes. But the main purpose of arthroscopy is to setdiagnosis in order to plan further actions.
Corrective osteotomy of the femur or tibia is performed to restore the axis of the lower limb in order to relieve the load from the affected area. The indication for this operation is gonarthrosis stage 1-2 with valgus or varus deformity of the lower limb.
Arthroplasty is total and partial. Usually performed on patients over 50 years of age. The indications are:
- arthrosis of the second or third stage;
- damage to areas of the joint with valgus or varus deformities of the lower extremities;
- bone necrosis;
- contractures.
Resection arthroplasty is performed in patients after arthroplasty, if there is a recurrence of surgical infection. After this operation, you need to walk in an orthosis or with a support.
In the terminal stage of arthrosis, when the joint is unstable (hangs), with severe deformity, acute symptoms, if it is impossible to perform arthroplasty due to high risks or rejection of the endoprosthesis, an operation is performed - arthrodesis. This method allows you to get rid of pain and save the limb as a support. Shortening of the limb in the future causes the progression of degenerative-dystrophic processes in the spine.
