Coxarthrosis of the hip joint is a degenerative-dystrophic process that occurs in the articular joint of the femoral head and pelvic acetabulum. The disease is most typical in 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 pathologies of an inflammatory and non-inflammatory nature, and pain and stiffness in movement become the main signs of a degenerative-dystrophic process in the jointof the hip. In its development, the disease passes through several stages, and if in the early stages it can be treated conservatively, then in the later stages the treatment of coxarthrosis of the hip joints is effective only by surgery. Otherwise, the pathology will lead to serious disorders, even complete immobilization.
What is coxarthrosis of the hip joint and the mechanism of its development
Coxarthrosis, also called osteoarthritis and osteoarthritis deformans, is a complex disease of the hip joints (HJ), accompanied by progressive cartilage destruction. Over time, this leads to deformation of the surfaces of adjacent bones, as well as the formation of bony growths on them, called osteophytes.
According to statistics, coxarthrosis accounts for about 12% of all diseases of the musculoskeletal system. In terms of frequency of occurrence, it comes second only to gonarthrosis of the knee joint, but the risks of disability with it are much higher.
The two hip joints are the largest joints in the body. Each of them is formed by the bone of the femur and the acetabulum of the pelvis. The femoral head is located in the cup-shaped recess of the pelvic bone and freely moves in different directions. This structure of the joint allows for flexing and straightening, adducting and abducting, as well as rotating the thigh.
To prevent movement from causing discomfort, the surfaces of the bones that touch each other are covered with an elastic layer called hyaline cartilage. It is he who 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 sort of casing 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, that is, is responsible for maintaining the normal structure of cartilage tissue.
Above the joint capsule is a group of femoral and pelvic muscles, with the help of which the joint is set in motion. The hip joint is also surrounded by a group of ligaments that provide stability of its position within physiological limits.
Since the hip joint is subjected to heavy loads every day, it is subject to rapid wear and injury. The risk of such changes greatly increases the effect of a number of adverse factors that are practically unavoidable in the modern world, but they will be discussed below. This explains the high prevalence of coxarthrosis.
Due to the influence of negative factors, there is a violation of the production of synovial fluid. Gradually, its quantity decreases, and its qualitative composition also changes: it becomes viscous, thick and is no longer able to fully nourish the cartilage. This leads to acute nutritional deficiencies and progressive dehydration of 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 femoral head into the acetabulum of the pelvis, which leads to the appearance of signs of coxarthrosis of the hip.
Gradually, the interarticular gap narrows, increased friction occurs between the articular bone surfaces, and the pressure of the bones on the hyaline cartilage increases. This leads to even greater injury and wear and tear, which can only affect the biomechanics of the hip joint and a person's well-being.
Failure of the hip joint negatively affects not only the biomechanics of the lower extremities, but also the entire musculoskeletal system. This often results in a disability.
As the pathological changes progress, the hyaline layer gradually completely disappears, which leads to the exposure of bone surfaces and a critical increase in the load on the bone joint. During movement, the femoral head is no longer covered with anything and rubs directly against the surface of the pelvic acetabulum. Besides seriously limiting mobility and causing unbearable pain, the bones press against each other, simultaneously flattening.
As the bones in the joint deform, bony growths (osteophytes) form on their surface. They can have sharp edges and seriously injure surrounding muscles. This provokes the appearance of severe pain in the groin, legs and buttocks. Therefore, the patient subconsciously tries to spare the affected hip joint and avoid movements in it. The lack of adequate load on the muscles leads to their progressive atrophy, which further aggravates mobility problems. This results in lameness.
Reasons for development
Coxarthrosis of the hip joint can be primary or secondary. In the first case, the reasons for its development cannot be found, that is, the disease develops on its own for no apparent reason. Secondary hip osteoarthritis results from a number of changes in musculoskeletal condition or lifestyle characteristics, including:
- injuries to the hip joint, including bone fractures, dislocations, bruises, sprains or ruptures of surrounding ligaments, chronic micro-injuries, etc. ;
- strenuous physical labor;
- 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 (dislocation, dysplasia);
- aseptic necrosis of the femoral head;
- pathologies of the spine of various types;
- genetic predisposition;
- tobacco addiction.
In the vast 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 riskof its occurrence and increases the rate of progression.
Symptoms and degrees
During coxarthrosis, 4 degrees of development are distinguished, 1 of which is the easiest. Initially, the disease may be asymptomatic or manifest as mild pain. More often they occur after intense physical exertion, a long walk or at the end of a busy day. In the early stages of the development of the disease, discomfort is usually attributed to fatigue and is considered the norm. Therefore, extremely rarely, coxarthrosis of the hip joint is diagnosed at the 1st stage of development.
Noticeable signs of coxarthrosis begin to appear at the 2nd stage of its progression, when the joint space narrows by almost half and the femoral head is displaced and deformed. With the transition to the 3rd stage, the pains become unbearable and can bother a person even at night, they tend to radiate to the hips, shins, groin and buttocks. Since the joint space is already practically absent and multiple osteophytes form 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 restrictions - initially, patients may notice the onset of difficulty performing rotational movements of the leg, but over time morning stiffness and swelling of the HJ joins them. Because of them, a person needs several minutes to warm up and, so to speak, walk around in order to regain 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 flexing or extending the hip joint. It is a consequence of the friction of bone surfaces against each other, and coxarthrosis is accompanied by sharp or dull pains.
- Pain syndrome - pains initially appear after physical exertion and somewhat subside after a long rest. An acute attack can be provoked by weightlifting 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.
- Spasm of the muscles of the thigh - is a consequence of pinching of the nerves and weakening of the ligamentous apparatus, so the muscle spasms compensate for keeping the head of the femur in the acetabulum. In addition, muscle spasms can be caused by the addition of synovitis.
- Lameness - occurs in the late 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 his leg and hold it in this position. Also, the patient may involuntarily limp to transfer weight to the healthy half of the body, as this helps reduce the intensity of pain.
- 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 due to 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 leg immobilization and disability.
At the same time, degenerative-dystrophic changes can be observed in one or both hip joints. Accordingly, characteristic symptoms will be observed either on one side or on both at once, but in the latter case their severity on the left and on the right may differ.
Diagnostic
The doctor may 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 leg length during a visual inspection. For this, the patient is asked to stand up and straighten his legs as much as possible. The measurement is taken between the anterior axis of the bones of the pelvis and any bony structure of the knee, ankle or heel. But if both hip joints are simultaneously affected by coxarthrosis, the data obtained will be uninformative.
But since the typical symptoms of coxarthrosis can accompany a number of other inflammatory and non-inflammatory diseases, instrumental methods of examination are mandatory so that the patient can accurately diagnose the pathology. It might be:
- CT or X-ray of the hip joint - the images show destructive changes, narrowing of the joint space, formation of osteophytes and deformation of the bone surfaces;
- MRI is the most informative method of examination that allows you to accurately assess the nature of changes in cartilaginous structures, ligaments and the nature of blood circulation in the hip area.
Patients are also subjected to laboratory tests to assess their general state of health and to detect diseases that may cause hip osteoarthritis. This:
- UAC and OAM;
- blood chemistry;
- rheumatic tests;
- puncture of the hip joint with a biochemical study.
The diagnostic task is to differentiate coxarthrosis of the hip from gonarthrosis (damage to the knee joint), as well as the radicular syndrome that occurs with osteochondrosis, as well as protrusions and hernias of the intervertebral discs. In addition, the symptoms of coxarthrosis can resemble manifestations of trochanteric bursitis and an atypical course of ankylosing spondylitis, which requires a full examination in order to discover the true causes of pain and mobility restrictions.
Conservative treatment
Conservative treatment of coxarthrosis of the hip is effective only in the initial stages of the disease. It is selected for each patient individually and can include a whole range of different methods, each of which is complementary to the others. Therefore, as part of the treatment of coxarthrosis of the hip joint, patients can be prescribed:
- drug therapy;
- exercise therapy;
- physiotherapy;
- plasmolifting.
In order for conservative treatment to be effective, patients need to eliminate the effect of a number of factors that contribute to the development of coxarthrosis of the hip. If you are overweight, it is very important to reduce it as much as possible. This will reduce the load on the affected joint and the risk of progression of the degenerative-dystrophic process.
You also need to quit smoking and normalize the mode of physical activity, avoid overloading, but do not sit still all the time. To prevent further destruction of the hip joint, it is recommended to wear special bandages and braces. They provide secure fixation of the joint and support it during movement.
Medical treatment
The nature 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 topical agents);
- corticosteroids - drugs with a strong anti-inflammatory effect, which are prescribed if NSAIDs do not produce a pronounced effect;
- chondroprotectors - contribute to the activation of cartilaginous tissue regeneration processes, 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 for improving blood circulation - are most often used in the form of injection solutions and help to improve the trophism of the tissues surrounding the joint;
- B vitamins - have been shown to normalize nerve impulse transmission, which is especially important when nerves are compressed by deformed bone structures.
For acute pain that cannot be removed with tablets, intra-articular or peri-articular blocks can be performed on patients. They are performed exclusively by qualified health workers in a medical institution and involve the introduction into the joint cavity or directly into the area around it of anesthetic solutions with corticosteroids.
exercise therapy
Therapeutic exercise is an effective method to deal with decreased muscle tone and limited mobility. Thanks to a correctly selected set of exercises, it is possible to increase the range of motion and reduce the intensity of pain. They also prevent muscle atrophy and help eliminate spasms if coxarthrosis is accompanied by pinching of nerve fibers, which reflexively leads to spasm of individual muscles.
Exercise therapy courses can improve blood circulation in the area of the degenerative-dystrophic process. Due to this, the quality of the trophism of the diseased joint increases, and the course of regeneration processes accelerates.
For each patient, a set of exercises should be developed individually by a specialist. At the same time, not only the degree of destruction of the hip joint is taken into account, but also the level of physical development of the patient.
Physiotherapy
Physiotherapeutic procedures and massage have an anti-inflammatory, analgesic, tonic, anti-edematous effect. In addition, they help maintain normal muscle tone of the legs, preventing their atony and atrophy.
With coxarthrosis of the hip joint, courses of 10-15 procedures are prescribed:
- ultrasound therapy;
- magnetic therapy;
- laser therapy;
- electrophoresis;
- ultraphonophoresis;
- UHF;
- paraffin treatment.
In addition, many patients are offered mud 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 therapeutic mud, it is possible to improve the quality of blood circulation and accelerate the restoration of motor skills in the affected joint.
Plasmolifting
Plasmolifting or PRP therapy is a procedure that involves the introduction of platelet-rich plasma from the patient's blood into the cavity of the hip joint. This allows you to activate the processes of restoring hyaline cartilage.
But, according to some scientists, such a procedure can provoke 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 effect of which on the organism has not yet been fully studied.
Surgical treatment of coxarthrosis of the hip joint
Despite the significant discomfort in the hip joint, many consult a doctor too late, when the pathological changes in the joint reach 3 or even 4 degrees of severity, and the functionality is irreversibly exhausted.
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, significantly improve the quality of human life. No medicine, no physiotherapeutic procedure can restore severely destroyed cartilage. At best, painful intra-articular injections and medications can reduce pain. But this will be a temporary phenomenon, after which the pain will return with the same force or even more.
The indications for hip surgery are:
- disappearance of the interarticular space;
- persistent pain in the hip joint, which cannot be relieved;
- critical mobility disorders;
- hip fracture.
Depending on the severity of joint destruction and bone deformity, different types of surgical treatment may be offered to patients, namely:
- arthrodesis;
- stent;
- osteotomy.
Arthrodesis
Arthrodesis is an affordable operation that involves strong fixation of the articular bones with metal plates. 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, to eliminate pain, but it is not necessary to talk about the restoration of mobility or asignificant improvement in quality of life.
Today, arthrodesis is practically not used, since it deprives a person of the ability to fully move.
Stents
Endoprosthesis with arthroplasty is the only way to radically solve the problem of coxarthrosis of the hip joint with the restoration of all its motor functions and abilities. This is a high-tech method of solving the problem of coxarthrosis, which allows you to completely forget about it for 15-30 years, along with pain and mobility restrictions. Thanks to the use of modern endoprostheses, it is possible to achieve complete restoration of motor-assist functions and provide the patient with a normal life.
The operation consists of a resection of the femoral head and part of its neck. Surgical preparation of the acetabular bed is also performed, which involves removal of osteophytes, alignment of its surface and resection of tissues that have undergone necrosis. Stents can even be used to treat elderly patients with coxarthrosis of the hip.
The operation takes place under general anesthesia and lasts approximately one hour. Depending on the severity of the degenerative-dystrophic process, the operation can be performed using one of the following methods:
- superficial - consists in grinding the acetabulum and the femoral head with additional coating with smooth implants that replace 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 its replacement with an endoprosthesis (used when the 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 allows 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 involves a complete resection of the femoral head with the capture of part of its neck, as well as the fossaacetabular and their replacement with a full-fledged artificial articular joint.
Thus, patients may be recommended to install different types of stents. Most hip replacements are made in the United States and the United Kingdom. For their manufacture, chemically and biologically inert metals are used: cobalt, chromium, titanium alloys. Often ceramic is also used. In most modern models, polymer pads are also used, which helps to provide natural shock absorption, stabilization and sliding properties to the artificial TBS.
When performing stents, the success of the operation is almost 100%.
After the operation, antibiotics are prescribed to prevent the development of infectious complications, and the stitches are removed after 10 days. The size of the postoperative scar is about 8 cm. At the same time, the patient leaves the clinic. Rehabilitation after a stent is simple, but still requires physiotherapy, massage, and exercise therapy.
osteotomy
Osteotomy is a surgical procedure that is a temporary measure before a 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 suitable position, thereby slightly unloading the diseased joint. As a result, it is possible to temporarily reduce the intensity of pain and improve mobility.
So, coxarthrosis of the hip is a rather formidable disease that can completely deprive a person of the ability to move independently. It evolves over a long period of time, and its symptoms, especially in the early stages, are often perceived by patients as a normal state after physical exertion. But it is precisely in this that the insidiousness of the disease lies, since only at the initial stage of its development can it be treated non-surgically. But if the degenerative-dystrophic process has already completely destroyed the hyaline cartilage and led to the exposure of the surfaces of the bones, and even more so to their flattening, only surgery can help the patient. Fortunately, the modern level of medicine and surgery, in particular, makes it possible to achieve a complete restoration of the normal state of the hip joint and its functions.