Coxarthrosis of the hip joint is a degenerative-dystrophic process that occurs in the articular joint of the head of the femur and the pelvis. The disease is more typical of middle-aged and elderly people, although it can also occur in young people, including children. Most often, its development is preceded by injuries, as well as a number of inflammatory and non-inflammatory pathologies, and pain and rigidity of movement become the main signs of a degenerative-dystrophic process in the hip joint. In its development, the disease passes through several stages, and if in the early stages it can be treated conservatively, in the last stages, the treatment of coxarthrosis of the hip joints is effective only with surgery. Otherwise, the pathology will lead to serious disruption or even complete immobilization.
What is coxarthrosis of the hip joint and the mechanism of its development?
Coxarthrosis, also known as osteoarthritis and deforming arthrosis, is a complex disease of the hip joints (HJ) that is associated with progressive cartilage destruction. Over time, this leads to deformation of the surfaces of adjacent bones and the formation of bony outgrowths called osteophytes on them.
According to statistics, coxarthrosis accounts for about 12% of all diseases of the musculoskeletal system. In terms of the frequency of occurrence, it is second only to gonarthrosis of the knee joint, but the risks of becoming disabled with it are much higher.
The two hip joints are the largest joints in the body. Each of them is formed by the femoral bone and the acetabulum of the pelvis. The femoral head lies in the bowl-shaped depression of the pelvic bone and can move freely in different directions. This structure of the joint allows the femur to flex and relax, adduct and abduct, and rotate.
To prevent movement from causing discomfort, the surfaces of the bones that touch are covered with an elastic layer called hyaline cartilage. It is it that allows the femoral head to slide easily in the acetabulum. In addition, hyaline cartilage provides stabilization and cushioning of the hip joint during movement.
The entire joint is immersed in a kind of covering called the joint capsule. It contains the synovial membrane, which synthesizes synovial fluid. It is she who lubricates the surface of the cartilage, ensures the flow of water and nutrients, i. e. H. responsible for maintaining the normal structure of cartilage tissue.
Above the joint capsule is a group of thigh and pelvic muscles that help move the joint. The hip joint is also surrounded by a group of ligaments that ensure the stability of its position within physiological limits.
Since the hip joint is subjected to heavy loads on a daily basis, it is prone to rapid wear and tear and injury. The risk of such changes significantly increases the impact of a number of unfavorable factors that are practically inevitable in the modern world, but they will be discussed below. This explains the high prevalence of coxarthrosis.
As a result of the influence of negative factors, there is a violation of the production of synovial fluid. Gradually, its amount decreases, and its qualitative composition also changes: it becomes viscous, viscous, and is no longer able to fully nourish the cartilage. This leads to acute malnutrition and progressive dehydration of the hyaline cartilage. As a result of such changes, the strength and elasticity of cartilage tissue decreases, it exfoliates, cracks and decreases in volume. All this prevents the smooth sliding of the head of the femur in the acetabulum of the pelvis, which leads to the appearance of signs of hip coxarthrosis.
Gradually, the interarticular gap narrows, increased friction occurs between the articulating bone surfaces, and the pressure of the bones on the hyaline cartilage increases. This leads to even greater injuries and wear and tear that must affect the biomechanics of the hip joint and a person's well-being.
The failure of the hip joint affects not only the biomechanics of the lower extremities, but the entire musculoskeletal system. This often leads to disability.
Gradually, with the progression of pathological changes, the hyaline layer completely disappears, which leads to the exposure of bone surfaces and a critical increase in the load on the bone joint. During movements, the femoral head is no longer covered by anything and rubs directly on the surface of the pelvic socket. Aside from severely limiting mobility and causing excruciating pain, the bones press against each other and become flat at the same time.
When the joint bones deform, bony outgrowths (osteophytes) form on their surface. They can be sharp and seriously injure surrounding muscles. This provokes the appearance of severe pain in the groin, legs and buttocks. Therefore, the patient unconsciously tries to protect the affected hip joint and avoid movements in it. Inadequate loading of the muscles leads to their gradual atrophy, which further aggravates mobility problems. This leads to lameness.
reasons for development
Coxarthrosis of the hip joint can be primary or secondary. In the first case, the reasons for their development cannot be found, i. e. H. The disease develops on its own for no apparent reason. Secondary coxarthrosis is the result of a number of changes in the state of the musculoskeletal system or lifestyle features, in particular:
- Hip joint injuries, including fractures, dislocations, contusions, sprains or tears of the surrounding ligaments, chronic microdamage, etc. ;
- strenuous physical work;
- sedentary lifestyle;
- Obesity;
- chronic infectious processes in the body;
- rheumatoid arthritis, gout, tendinitis, bursitis;
- endocrine diseases, metabolic and hormonal disorders, including diabetes mellitus;
- congenital malformations of the hip joint (luxation, dysplasia);
- aseptic necrosis of the femoral head;
- pathologies of the spine of various kinds;
- genetic predisposition;
- Addiction to smoking.
In the overwhelming majority of cases, the development of coxarthrosis of the hip joint is due to inevitable age-related changes, and the presence of other factors from the above only increases the risk of their occurrence and increases the rate of progression.
Symptoms and Grades
With coxarthrosis, 4 degrees of development are distinguished, of which 1 is the lightest. Initially, the disease can be asymptomatic or manifest as mild pain. More often they appear after heavy physical exertion, a long walk or at the end of a hard day. In the first stages of the development of the disease, discomfort is usually attributed to fatigue and is considered the norm. Therefore, coxarthrosis of the hip joint in the 1st stage of development is diagnosed extremely rarely.
Noticeable signs of coxarthrosis appear in the 2nd stage of its progression, when the joint space narrows by almost half, and the head of the femur is displaced and deformed. With the transition to the 3rd stage, the pain becomes unbearable and can also bother a person at night, tending to radiate to the hips, shins, groin and buttocks. Since the joint space is already practically absent and several osteophytes are formed on the bone surfaces, independent movement in such situations is impossible. Therefore, patients are forced to use a cane or crutches.
So, the main symptoms of coxarthrosis of the hip joint are:
- Mobility limitations - initially, patients may notice the onset of difficulties in performing rotational movements of the leg, but over time, morning stiffness and swelling of the HJ are added. Because of them, it takes a person several minutes to warm up and, as it were, walk around to restore a normal range of motion. Gradually, it becomes more and more difficult for the patient to perform leg movements.
- A characteristic crunch - occurs when walking, as well as with flexion or extension of the hip joint. It is a consequence of the friction of bone surfaces against each other and is accompanied by stabbing or dull pain in coxarthrosis.
- Pain syndrome - pain first appears after physical exertion and subsides somewhat after prolonged rest. An acute attack can be provoked by weight lifting or hypothermia, since coxarthrosis is often complicated by the addition of inflammation of the synovial membrane. As the disease progresses, the pain becomes more frequent, lasts longer, and gets worse.
- Femoral spasm - is a result of pinching the nerves and weakening of the ligaments, so the muscle spasm counterbalances to keep the femoral head in the socket of the hip. Also, muscle spasms can be provoked by the addition of synovitis.
- Lameness - occurs in the last stages of the development of the disease, since the deformation of the bone surfaces provokes the appearance of contracture of the flexor muscles. Therefore, a person cannot fully straighten the leg and hold it in this position. Also, the patient may involuntarily limp to shift weight to the healthy side of the body, as this helps reduce pain intensity.
- Shortening of the leg - observed with coxarthrosis of the 3rd degree. The leg on the side of the affected hip joint may be shortened by 1 cm or more as a result of narrowing of the joint space, decreased muscle tone, and flattening of the femoral head.
In the final stage of development, the femoral head fuses with the acetabulum, resulting in complete immobilisation of the leg and disability.
At the same time, degenerative-dystrophic changes can be observed in one or both hip joints. Accordingly, characteristic symptoms are observed either on one side or on both at once, but in the latter case their severity can be different on the left and right side.
diagnosis
The doctor can suspect the presence of coxarthrosis of the hip joint based on the patient's complaints, external examination and the results of functional tests. Be sure to measure the length of the legs during a visual inspection. To do this, the patient is asked to stand up and stretch his legs as much as possible. The measurement is taken between the anterior axis of the pelvic bones and any bony structure of the knee, ankle or heel. However, if both hip joints are affected by coxarthrosis at the same time, the data obtained will not be meaningful.
However, since the symptoms typical of coxarthrosis can accompany a number of other inflammatory and non-inflammatory diseases, instrumental methods of examination are indispensable for the patient to accurately diagnose the pathology. It can be:
- CT or X-ray of the hip joint - the images show destructive changes in it, narrowing of the joint space, the formation of osteophytes and deformation of the bone surfaces;
- MRI is the most informative examination method, which allows you to accurately assess the nature of changes in cartilage structures, ligaments, the nature of blood circulation in the hip area.
Laboratory tests are also assigned to patients to assess their general health and detect diseases that could cause coxarthrosis. That:
- UAC and OAM;
- blood chemistry;
- rheumatic tests;
- Puncture of the hip joint with a biochemical study.
The diagnostic task is to distinguish hip coxarthrosis with gonarthrosis (damage to the knee joint), as well as radicular syndrome occurring with osteochondrosis, as well as protrusions and hernias of the intervertebral discs. Also, the symptoms of coxarthrosis can resemble manifestations of trochanteric bursitis and an atypical course of ankylosing spondylitis, which require a full examination to find out the true causes of pain and limitation of movement.
Conservative treatment
Conservative treatment of hip coxarthrosis is effective only in the initial stages of the disease. It is selected individually for each patient and can include a whole range of different methods that complement each other. Therefore, as part of the treatment of coxarthrosis of the hip joint, patients can be prescribed:
- drug therapy;
- exercise therapy;
- Physical therapy;
- plasma lifting.
In order for conservative treatment to be effective, patients must eliminate the effect of a number of factors contributing to the development of hip coxarthrosis. If you are overweight it is very important to reduce it as much as possible. This reduces the load on the affected joint and the risk of progression of the degenerative-dystrophic process.
You should also quit smoking and normalize the type of physical activity, avoid overwork, but not sit all the time. To prevent further destruction of the hip joint, wearing special bandages and orthoses is recommended. They ensure a secure fixation of the joint and support it during movements.
Medical treatment
The type of drug therapy is selected strictly individually. In most cases, patients are prescribed:
- NSAIDs - drugs that simultaneously have analgesic and anti-inflammatory effects (available in the form of tablets, injections and topicals);
- Corticosteroids - drugs with a strong anti-inflammatory effect, which are prescribed when NSAIDs do not have a pronounced effect;
- Chondroprotectors - contribute to the activation of regenerative processes of cartilage tissue, but their effectiveness has not been proven;
- muscle relaxants - drugs that reduce muscle tone and eliminate spasms, which is necessary when spasm of certain muscles or groups against the background of severe pain;
- Preparations to improve blood circulation - are most often used in the form of injection solutions and help to improve the trophism of the tissues surrounding the joint;
- Group B vitamins - have been shown to normalize the transmission of nerve impulses, which is especially important when nerves are compressed by deformed bone structures.
In patients with acute pain that cannot be eliminated with the help of tablets, intra-articular or periarticular blockades can be performed. They are carried out exclusively by qualified health workers in a medical institution and involve the introduction of anesthetic solutions with corticosteroids into the articular cavity or directly in its vicinity.
exercise therapy
Therapeutic exercise is an effective way to deal with a decrease in muscle tone and mobility limitations. Thanks to a properly selected set of exercises, it is possible to increase the range of motion and reduce the severity of pain. They also prevent muscle wasting and help eliminate spasms when coxarthrosis is accompanied by pinching of nerve fibers, which leads to reflex spasms of individual muscles.
Exercise therapy courses can improve blood circulation in the area of \u200b\u200bthe degenerative-dystrophic process. As a result, the quality of the trophism of the diseased joint increases and the course of regenerative processes accelerates.
For each patient, a set of exercises should be developed individually by a specialist. Not only the degree of destruction of the hip joint is taken into account, but also the physical development of the patient.
physical therapy
Physiotherapeutic procedures and massage have anti-inflammatory, analgesic, toning, anti-edematous effects. In addition, they help maintain normal muscle tone in the legs and prevent their atony and atrophy.
With coxarthrosis of the hip joint, 10–15 procedures are prescribed:
- ultrasound therapy;
- magnetotherapy;
- laser therapy;
- electrophoresis;
- ultraphonophoresis;
- UHF;
- paraffin treatment.
In addition, many patients are offered fango therapy. Such procedures have a positive effect only at the 1st stage of the development of coxarthrosis of the hip joint or during rehabilitation after surgical treatment. Thanks to medicinal mud, it is possible to achieve an improvement in the quality of blood circulation and accelerate the restoration of motor skills in the affected joint.
plasma lifting
Plasmolifting, or PRP therapy, is a procedure in which platelet-rich plasma from the patient's own blood is injected into the hip joint cavity. This allows you to activate the hyaline cartilage repair processes.
However, according to some scientists, such a procedure can lead to the formation of malignant tumors. This point of view is based on the fact that plasmolifting promotes the formation of a large number of stem cells, the effects of which on the body have not yet been fully studied.
Surgical treatment of coxarthrosis of the hip joint
Despite the significant discomfort in the hip joint, many seek medical help too late, when pathological changes in the joint reach 3 or even 4 degrees of severity and functionality is irreversibly depleted.
With advanced pathology, surgery is a necessary measure. Only timely surgical intervention will help restore normal mobility and save the patient from excruciating pain, that is, achieve a significant improvement in the quality of human life. No drugs, no physiotherapeutic procedures can restore badly damaged cartilage. At best, painful intra-articular injections and medication can relieve pain. However, this will be a temporary phenomenon, after which the pain will return with equal or even greater strength.
Indications for hip surgery are:
- disappearance of the interarticular space;
- persistent pain in the hip joint that cannot be relieved;
- critical mobility disorders;
- hip fracture.
Depending on the severity of joint destruction and bone deformity, patients can be offered different types of surgical treatment, namely:
- arthrodesis;
- endoprosthesis;
- osteotomy.
arthrodesis
Arthrodesis is an inexpensive surgery that uses metal plates to strongly fix the joint bones. The result is complete immobilization of the joint. Therefore, with the help of arthrodesis, it is possible to correct only the supporting function of the leg, eliminate pain, but it is not necessary to talk about restoring mobility or significantly improving the quality of life.
Today, arthrodesis is practically not used, since it deprives a person of the opportunity to fully move.
endoprosthetics
Endoprosthetics with endoprosthetics is the only way to radically solve the problem of coxarthrosis of the hip joint with the restoration of all its functions and motor skills. This is a high-tech method of solving the problem of coxarthrosis, which allows you to completely forget about it for 15–30 years, as well as pain and limited mobility. With the use of modern endoprostheses, it is possible to achieve a complete restoration of motor support functions and allow the patient to lead a normal life.
The operation involves resection of the head of the femur and part of its neck. Surgical preparation of the acetabular bed is also performed, which includes removal of osteophytes, alignment of its surface, and resection of necrotized tissue. Elderly patients with hip coxarthrosis can also be treated with endoprosthetics.
The operation is performed under general anesthesia and takes about an hour. Depending on the severity of the degenerative-dystrophic process, the operation can be performed using one of the following methods:
- superficial - involves grinding the acetabulum and femoral head with further coating with smooth implants replacing the destroyed hyaline cartilage (the method is rarely used due to the possibility of inflammation in the periarticular tissues);
- unipolar - removal of the femoral head and replacement with an endoprosthesis (used when cartilage is preserved on the surface of the acetabulum, and only the femoral head is destroyed);
- bipolar - similar to the previous technique, differing only in the design of the endoprosthesis used, which has a lower coefficient of friction and provides smoother movements in the joint bed;
- total is the most effective and safe method of solving the problem of coxarthrosis of the hip joint, which requires a complete resection of the femoral head with capture of part of its neck, as well as the acetabulum and their replacement with a full-fledged artificial part joint.
Therefore, patients can be recommended to use different types of endoprostheses. Most hip replacements are made in the US and UK. Chemically and biologically inert metals are used for their manufacture: cobalt, chromium, titanium alloys. Ceramics are also often used. In addition, polymer pads are used in most modern models, which make it possible to give artificial TBS natural shock-absorbing, stabilizing and sliding properties.
When carrying out the endoprosthetics, the success of the operation is almost 100%.
After the operation, antibiotics are prescribed to prevent the development of infectious complications, and the threads are removed after 10 days. The size of the postoperative scar is about 8 cm. At the same time, the patient is discharged from the clinic. Rehabilitation after endoprosthetics is simple, but still requires physical therapy, massage and exercise therapy.
osteotomy
Osteotomy is a surgical procedure that is a temporary measure before cardinal replacement of the hip joint with an artificial endoprosthesis. The essence of the operation is to align the axis of the femur due to its intentional fracture. The resulting fragments are placed in the most appropriate position, slightly relieving the diseased joint. This makes it possible to temporarily reduce the intensity of the pain and improve mobility.
Therefore, hip coxarthrosis is a rather formidable disease that can completely deprive a person of the ability to move independently. It progresses for a long time and its symptoms, especially in the initial stages, are often perceived by patients as a normal condition after physical exertion. But this is precisely the insidiousness of the disease, because it can only be treated non-surgically at the initial stage of its development. But if the degenerative-dystrophic process has already completely destroyed the hyaline cartilage and led to the exposure of the bone surfaces, and even more so to their flattening, then only surgery can help the patient. Fortunately, the modern state of the art in medicine and surgery makes it possible to completely restore the normal condition of the hip joint and its functions.