Every year, diseases of the musculoskeletal system worry more and more people, and their development at a young age is observed more and more often. This is facilitated not only by a change in lifestyle, but also by an increase in the level of injuries, which is largely interrelated. One of the most common pathologies of the musculoskeletal system is osteoarthritis of the hip, which is characterized by the appearance of progressive pain and limited mobility. Eventually, the disease can lead to complete joint immobility and disability. To avoid such side effects, it is important to start treatment for osteoarthritis as early as possible. And if in the early stages of development it can be stopped by conservative methods, then in case of severe changes it is possible to restore the functions of the hip joint and eliminate unbearable pain only with the help of high-tech surgery.
What is osteoarthritis of the hip
Osteoarthritis of the hip joint is a chronic degenerative-dystrophic disease in which there is a gradual destruction of the hip joint. At the same time, all its components are gradually involved in the pathological process, but the hyaline cartilage is particularly affected, which leads to narrowing of the joint space and deformation of its other components. More often, pathological changes occur in only one hip joint, although both can be affected simultaneously.
The hip joints are the largest in the human body, as they carry the greatest load during the day. Each is formed by the head of the femur and the acetabulum, which is a bowl-shaped recess in the pelvis. Both surfaces are covered with smooth, moderately elastic hyaline cartilage. It ensures the smoothness and unobstructed sliding of the femoral head in a natural depression and thus makes it possible to perform movements in different planes.
The movement of the hip joint is provided by a group of muscles connected to it by fascia. In addition, he is surrounded by connections whose tasks are to limit his mobility within physiological limits and to ensure the stability of his position.
The entire joint is surrounded by a joint capsule covered with a synovial membrane. Its main task is the synthesis of synovial fluid, which lubricates the adjacent parts of the hip joint and at the same time acts as a carrier of nutrients for it. It is from the synovial fluid that the hyaline cartilage, which covers the head of the femur and the surface of the acetabulum, constantly receives components for the formation of new cells, ie regeneration. This is extremely important for this cartilage formation, as it wears out with each movement of the thigh, but normally recovers immediately. But when injured or under the influence of other factors, this does not happen, which leads to the development of osteoarthritis of the hip joint, ie thinning and destruction of its hyaline cartilage.
As a result, deformed areas are formed in perfectly smooth cartilage, which increase with the progression of the pathology. As it rubs, the surfaces of the bones that make up the joint are exposed. On contact with them there is a characteristic crunch and severe pain. This provokes the formation of osteophytes and in the final stages of development the head of the femur merges completely with the acetabulum, which makes any movement in the hip joint impossible.
At the same time, osteoarthritis of the hip joint can provoke the development of various inflammatory processes inside the joint, including:
- bursitis - inflammation of the synovial sac;
- tendovaginitis - an inflammatory process in the lining of the lining of the tendons of the muscles;
- tunnel syndrome - compression of the nerves, which causes radiating pain along the strangled nerve.
The reasons
One of the common causes of osteoarthritis of the hip is mechanical damage, not only direct injuries but also microdamages caused by the destructive effect of excessive stress on it. One of the most common causes of the disease is a fracture of the femoral neck.
It deviates from the femur at an angle of 120 ° and connects it to the head. The presence of osteoporosis significantly increases the likelihood of a fracture of the thigh, but this type of injury can also be the result of a car accident, falling from a height, impact and more.
A fracture of the femoral neck may be accompanied by aseptic necrosis of the femoral head, which will cause the development of degenerative-dystrophic changes in the joint. The presence of dysplasia or subluxation of the hip joint, rupture of its ligaments, transcondylar fractures or fractures of the acetabulum also creates favorable conditions for damage to its structures. In such situations, post-traumatic osteoarthritis of the hip is diagnosed.
Post-traumatic osteoarthritis of the hip is common in professional athletes and weightlifters, skydivers, loaders and skaters.
The development of osteoarthritis of the hip joint after injury is due to impaired congruence (comparability) of joint surfaces, reduced quality of blood supply to joint components and prolonged immobilization. As a result of prolonged immobility, there is not only a deterioration of blood circulation in the fixed area, but also shortening of muscles, reduction of their tone. The likelihood of post-traumatic osteoarthritis increases significantly when an inappropriate situation or untimely treatment is performed, which leads to the preservation of defects of varying severity. Also, the risks of its development increase with excessive early loading of the joint and inadequate therapy, including too intensive, started late or vice versa early.
Sometimes the disease occurs after hip surgery due to scarring and additional tissue trauma. Although in some cases surgery is the only way to remove the effects of the injury.
Excessive exercise can also provoke changes in the hip joint, as it leads to microtrauma. Regular tissue damage activates the process of chondrocyte (cartilage tissue) division. This is accompanied by an increase in the intensity of the production of cytokines, which are usually produced in small quantities. Cytokines are mediators of inflammation, in particular the cytokine IL-1 leads to the synthesis of specific enzymes that destroy hyaline cartilage of the hip joint.
In addition, high loads can provoke microfractures of the subchondral plate. This leads to its gradual compaction and the formation of bone growths on the surface, called osteophytes. They can have sharp edges and cause more joint damage as well as damage to surrounding tissues.
The subchondral plate is the end part of the bone that is in direct contact with the hyaline cartilage.
In some cases, it is not possible to determine exactly what provoked the development of degenerative-dystrophic changes in the hyaline cartilage of the femoral head and acetabulum. In such situations, idiopathic or primary osteoarthritis of the hip is diagnosed.
Today it has been established that the tendency to develop it can be inherited, ie the presence of this pathology in close relatives significantly increases the chances of developing osteoarthritis of the hip. It is assumed that there is a polygenic inheritance, ie its development depends on the presence of many genes. Each of them individually creates mild preconditions for the development of the disease, but when combined, it is a matter of time, especially when leading a sedentary lifestyle and obesity, or vice versa, hard physical labor.
There is a theory that osteoarthritis of the hip is the result of a congenital or acquired mutation in the procollagen type II gene.
There is also secondary arthrosis of the hip joint, which develops against the background of the presence of concomitant diseases and age-related changes.
Symptoms
The disease is characterized by the appearance of pain, limited mobility and crunch in the hip joint, the severity of which directly depends on the degree of neglect of pathological changes. In the final stages of development, shortening of the affected leg and complete immobility of the hip joint can be observed, which is due to the complete fusion of the bone structures that form it.
Initially, the disease may be asymptomatic and cause mild, short-lived pain. As a rule, they appear after physical exertion, in particular walking, carrying heavy loads, squatting, bending over. But as the degenerative-dystrophic changes in the joint progress, the pain intensifies. Over time, they not only become more intense, but also last longer, and the interval between the onset of physical activity and their onset also decreases. At the same time, a break, even a long one, may not bring relief. Subsequently, the pain can torment a person even with prolonged immobility of the hip joint, for example after a night's sleep.
If the intra-articular structures affect nearby nerves, the pain can spread to the groin, buttocks, thighs and knees. However, they tend to worsen with hypothermia. In the last stage of the disease, the pain becomes unbearable. This causes an unconscious desire to feel sorry for the leg and put less strain on it, which leads to lameness.
Another symptom of osteoarthritis of the hip is a decrease in range of motion. Most often there is a limitation in the ability to turn the leg inward and outward, to lift the leg bent at the knee to the chest. Over time, the so-called morning stiffness appears, which disappears after the patient "passes". Subsequently, compensatory distortion of the pelvis is possible, which leads to a change in gait. In the future, patients completely lose their ability to make certain movements. with the affected leg.
If the arthrosis of both hip joints develops simultaneously, the development of the so-called duck gait is observed with the pelvis retracted and the body deflected forward.
All this can be accompanied by the formation of swelling in the hip joint. But if you are overweight, they can go unnoticed.
Often during movements, especially extensor, there is a crunch in the affected joint. This is due to the exposure of the bony surfaces of the femoral head and acetabulum and their friction with each other. In this case there is a sharp increase in pain.
Painful spasms of the thigh muscles can also occur with osteoarthritis of the hip. In extremely advanced degenerative-dystrophic diseases, when the joint almost completely disappears and the head of the femur begins to flatten, there is a shortening of the affected limb by 1 cm or more.
In general, there are 3 degrees of osteoarthritis of the hip:
- Grade 1 - the joint space of the hip joint is narrowed and the edges of the bone structures are slightly pointed, which indicates the beginning of the formation of osteophytes. Clinically, there is mild pain and some movement limitations.
- Grade 2 - the joint space is narrowed by more than 50%, but less than 60%. Significant osteophytes are observed, as well as signs of cysts in the epiphyses of the bones. Patients note significant limitations of movement in the hip joint, the presence of crunch during movement, can be observed pain and atrophy of the thigh muscles of varying severity.
- Grade 3 - joint space is reduced by more than 60% or completely absent, and osteophytes occupy a large area and are large in size, subchondral cysts are observed. The hip joint is stiff, the pain can become unbearable.
Diagnosis
The appearance of pain and other symptoms characteristic of osteoarthritis of the hip joints is the reason to contact an orthopedist. The doctor will be able to suspect its presence, especially if he has had injuries to the thigh or pelvis in the past, already based on the data obtained during the interview and examination.
The presence of osteoarthritis of the hip is indicated by pain, the intensity of which increases over several years. Rapid development of degenerative-dystrophic changes is much less common when several months pass from the appearance of the first signs to a strong permanent pain syndrome. This is characterized by increased pain when standing up or doing physical work. Osteoarthritis is also characterized by the presence of morning stiffness, which lasts up to half an hour, which occurs after prolonged immobility. Gradually there is an increase in mobility restrictions and deformity of the hip joint, which in the later stages of development the orthopedist may notice during the examination.
Nevertheless, all patients must be prescribed instrumental methods of examination, with which it will be possible to confirm the presence of hip osteoarthritis and to determine its degree, as well as to distinguish it from some other diseases accompanied by similar symptoms. . As a rule, the diagnosis is performed with the help of:
- Radiography - allows you to detect the main signs of osteoarthritis, in particular narrowing of the joint space and the presence of osteophytes. But recently, CT has become a more informative research method that makes it possible to assess the condition of the hip joint with greater accuracy.
- MRI is a highly informative method for diagnosing various changes in the condition of soft tissue structures, including cartilage tissue, which makes it possible to detect even the smallest signs of hyaline cartilage degeneration.
Patients may also be prescribed laboratory tests, including KLA, OAM, biochemical blood test, and more. They are obliged to identify concomitant diseases that have created the preconditions for the development of secondary osteoarthritis of the hip joint.
Treatment of osteoarthritis of the hip without surgery
The treatment of degenerative-dystrophic changes in the hip joint by the methods of conservative therapy is possible only in arthrosis of the 1st and 2nd degree. Prescribed measures can improve the patient's condition, stop or at least slow the progression of the pathology and thus maintain performance. But they are not able to lead to a complete regression of the changes that have already occurred in the joint.
Today, as part of the conservative treatment of osteoarthritis of the hip, the following are prescribed:
- drug therapy;
- exercise therapy;
- physiotherapy.
In addition, patients are advised to make certain lifestyle adjustments. So, in the presence of overweight, it is worth taking measures to reduce it, ie to increase the level of physical activity and to reconsider the nature of nutrition. If the patient is actively involved in sports and overloads the joint, which causes microtrauma in it, it is recommended to reduce the intensity of training.
Medical therapy
Drug therapy for osteoarthritis of the hip is always complex and includes drugs from different groups aimed at reducing the severity of the symptoms of the disease and improving the course of metabolic and other processes in the joint. To:
- NSAIDs - drugs with anti-inflammatory and analgesic action, produced both orally and in the form of topical agents, which allows you to choose the most effective and convenient option for use;
- corticosteroids - drugs that have powerful anti-inflammatory properties and are used in most cases in the form of an injectable solution, as the choice of systemic therapy causes the development of unwanted side effects;
- chondroprotectors - drugs synthesized on the basis of natural components of cartilage tissue used by the body for its recovery (prescribed for long courses);
- muscle relaxants - drugs indicated for muscle spasm, which causes pain of varying severity;
- B vitamins - help improve nerve conduction, which is necessary for the development of carpal tunnel syndrome;
- preparations that improve microcirculation - help to increase the intensity of blood circulation in the affected area, which increases the speed of metabolic processes and helps to repair damaged cartilage.
When co-morbidities are detected, consultation with related specialists and appropriate treatment is indicated.
In very severe, disabling pain syndrome that cannot be eliminated with prescribed NSAIDs, intra-articular or periarticular blockades may be performed. These include the injection of a local anesthetic in combination with a corticosteroid directly into the joint cavity, which quickly leads to improved well-being. But procedures of this type can be performed only in a medical institution by a qualified specialist, otherwise there is a high risk of complications.
exercise therapy
Physiotherapy exercises play one of the leading roles in the non-surgical treatment of osteoarthritis of the hip, both idiopathic and post-traumatic. But a set of exercises should be chosen individually, taking into account the nature of the previous injury, the level of physical development of the patient and existing comorbidities.
Therapeutic therapy should be performed daily in comfortable conditions without haste. All movements should be performed smoothly, without sudden movements, so as not to injure the already deformed hip joint. This will allow:
- reducing the intensity of the pain syndrome;
- increase joint mobility;
- reducing the risk of muscle atrophy;
- increase the intensity of blood circulation and metabolic processes.
Physiotherapy
To increase the effectiveness of prescribed measures, it is often recommended that patients with osteoarthritis of the hip undergo a course of physiotherapy procedures. Traditionally, those that have anti-inflammatory, anti-edematous and analgesic effects are chosen. To:
- ultrasound therapy;
- electrophoresis;
- magnetic therapy;
- laser therapy;
- shock wave therapy, etc.
In some cases, plasmalifting is indicated, ie the introduction of purified and platelet-saturated blood plasma of the patient. To obtain, venous blood is taken, which is then centrifuged. As a result, it is divided into erythrocyte mass and plasma, which is used to treat degenerative-dystrophic changes in the hip joint.
Surgery for osteoarthritis of the hip
When patients with grade 3 hip osteoarthritis are diagnosed, patients are indicated for surgery. It can also be performed in case of ineffectiveness of conservative therapy and constant limitations of pain and mobility at the 2nd stage of the disease development.
In general, the indications for hip surgery are:
- significant reduction in the size of the joint space;
- the presence of constant, severe pain;
- significant restrictions on mobility.
The most effective and safe operation for osteoarthritis of the hip is arthroplasty. Today it is recognized as the gold standard for the treatment of this pathology, regardless of the reasons for its development. The essence of this type of surgery is to replace some or all of the components of the hip joint with artificially created endoprostheses. The prostheses themselves are made of biocompatible materials and are durable.
Their installation allows you to fully restore the normal mobility of the pathologically altered hip joint, eliminate pain and give the patient the opportunity to lead a full life. For each patient the type of arthroplasty is chosen individually based on the degree of destruction of various components of the joint.
Total or total hip arthroplasty is the most effective. This involves replacing the entire joint with an artificial endoprosthesis, ie the acetabulum, the head of the femur and its neck. Such prostheses are able to serve continuously for 15-30 years and provide restoration of the full volume of joint function.
They are installed without cement or with the help of special cement. The first method is more suitable for young patients, as it involves fixing the prosthesis in the pelvis by ingrowing into the spongy layer of its own bone in it. For older people, the method of placing an endoprosthesis with cement is more suitable, which firmly holds the artificial material to the bone surfaces even in the presence of osteoporosis.
If the normal hyaline cartilage covering the surface of the acetabulum is preserved, patients may be offered partial arthroplasty. Its essence is to replace only the head and neck of the femur with an endoprosthesis. Today there are 2 types of structures of this type: monopolar and bipolar.
The former are less reliable; after their installation, the need for total arthroplasty subsequently arises. This is due to the fact that the replaced artificial head of the femur when performing movements rubs directly into the cartilage of the acetabulum, which provokes its faster wear.
Bipolar endoprostheses do not have such a disadvantage, because in them the artificial head of the femur is already closed in a special capsule, which is adjacent to the acetabulum. Therefore, the cartilage covering it does not deform, as the capsule serves as a kind of buffer and an artificial substitute for the natural hyaline cartilage on the head of the femur.
However, regardless of the type of endoprosthesis performed, postoperative rehabilitation is indicated for all patients. It consists of the appointment of drug therapy, therapeutic exercise and therapeutic massage. Recovery time depends on individual characteristics. But it is important to remember that the effectiveness of the operation directly depends on the quality of compliance with the doctor's recommendations during the rehabilitation period.
Thus, osteoarthritis of the hip joint is a common disease of the musculoskeletal system, which can occur even in the absence of direct prerequisites for its development. This pathology can lead not only to severe pain, but also to disability, so it is important to diagnose and take measures to stop its progression even at the first signs. However, the current level of development of medicine allows us to deal with advanced cases of osteoarthritis of the hip and to restore the full range of motion in it, as well as to get rid of severe pain permanently.