Coxarthrosis of the hip joint is a degenerative-dystrophic process that occurs in the articular joint of the femoral head and acetabulum of the pelvis. The disease is more typical of the middle-aged and elderly, although it can also occur in young people, including children. Most often, its development is preceded by injuries, as well as by a number of pathologies of an inflammatory and non-inflammatory nature, and pain and stiffness of movements become the main signs of a degenerative-dystrophic process in the hip joint. In its development, the disease goes 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 with surgery. Otherwise, the pathology will lead to serious disorders or even complete immobilization.
What is coxarthrosis of the hip joint and the mechanism of its development
Coxarthrosis, also called osteoarthritis and deforming arthropathy, 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.
The two hip joints are the largest joints in the body. Each of them is formed by the femur and the acetabulum of the pelvis. The femoral head is located in the cup-shaped recess of the pelvic bone and moves freely in various directions. This joint structure enables flexion and release, adduction and abduction, and rotation of 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 this that allows the femoral head to slide easily into the acetabulum. Also, hyaline cartilage provides stabilization and absorption of the hip joint during movements.
The entire joint is encased in a kind of sheath called the joint capsule. It contains the synovial membrane that composes the synovial fluid. It is she who lubricates the surface of the cartilage, ensures the flow of water and nutrients to it, i. e. she is responsible for maintaining the normal structure of cartilage tissue.
Above the capsule of the joint 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 ensure the stability of its position within normal limits.
Since the hip joint is subjected to heavy loads every day, it is prone to rapid wear and tear and injury. The risk of such changes greatly increases the impact of some adverse factors that are practically unavoidable in the modern world, but 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 quantity decreases and its qualitative composition also changes: it becomes thick, viscous and is no longer able to fully nourish the cartilage. This leads to acute nutritional deficiencies and progressive dehydration of the hyaline cartilage. As a result of such changes, the strength and elasticity of the 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 hip coxarthrosis.
Gradually, the interarticular space narrows, the friction between the joint surfaces of the bones increases, and the pressure of the bones on the hyaline cartilage increases. This leads to even more injury and wear and tear, which can only affect the biomechanics of the hip joint and a person's well-being.
As the pathological changes progress, the vitreous layer gradually disappears completely, which leads to the exposure of the 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 against the surface of the pelvic acetabulum. In addition to the fact that it severely limits mobility and causes excruciating pain, the bones are pressed against each other, flattening at the same time.
As the bones of the joint deform, bony outgrowths (osteophytes) form on their surface. They can have sharp edges and seriously injure the surrounding muscles. This causes severe pain in the groin, legs and buttocks. Therefore, the patient unconsciously tries to save the affected hip joint and avoid movements in it. The lack of sufficient load on the muscles leads to their gradual atrophy, which further aggravates motor problems. This results in lameness.
Development reasons
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 without an obvious reason. Secondary coxarthrosis is the result of a series of changes in the state of the musculoskeletal system or lifestyle characteristics, in particular:
- injuries of the hip joint, including bone fractures, dislocations, bruises, sprains or tears of the surrounding ligaments, chronic microdamages, etc.
- grueling physical work;
- sedentary life?
- portliness;
- chronic infectious processes in the body;
- rheumatoid arthritis, gout, tendonitis, bursitis.
- endocrine diseases, metabolic and hormonal disorders, including diabetes mellitus.
- congenital malformations of the hip joint (dislocation, dysplasia).
- aseptic necrosis of the femoral head.
- spinal pathologies of various kinds.
- genetic predisposition?
- smoking 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 factors other than the above only increases the risk of its occurrence and increases the rate of progression.
Symptoms and grades
During the coxarthrosis, 4 degrees of development are distinguished, of which 1 is the easiest. Initially, the disease may be asymptomatic or manifest as mild pain. More often they appear after intense physical exertion, a long walk or at the end of a tiring 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.
Visible signs of coxarthrosis begin to appear in the 2nd stage of its development, 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 pains become unbearable and can bother the 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 are formed on the bone surfaces, independent movement in such situations is impossible. Therefore, patients are forced to use a cane or crutches.
Thus, 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 they are joined by morning stiffness and swelling of the HJ. Because of these, a person needs several minutes to warm up and, say, walk to restore a normal range of motion. Gradually, it becomes more and more difficult for the patient to make leg movements.
- Characteristic bending - occurs when walking, as well as bending or extending the hip joint. It is a consequence of the bone surfaces rubbing against each other and with coxarthrosis it is accompanied by sharp or dull pain.
- Pain syndrome - initially the pains appear after physical exertion and subside somewhat after a long rest. An acute attack can be caused by weight lifting or hypothermia, as coxarthrosis is often complicated by the addition of synovial inflammation. As the disease progresses, the pain becomes more frequent, lasts longer and worsens.
- Femoral muscle spasm - is a consequence of nerve pinching and weakening of the ligamentous apparatus, so that the muscles break compensatory to hold the head of the femur in the acetabulum. Also, muscle spasm can be caused by adding arthritis.
- Lameness - occurs in the last stages of the development of the disease, as the deformation of the bone surfaces causes contraction 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 transfer weight to the healthy half of the body, as this helps to reduce the intensity of the pain.
- Shortening of the leg - seen with 3rd degree coxarthrosis. The leg on the side of the affected hip joint may be shortened by 1 cm or more as a result of joint space narrowing, decreased muscle tone, and flattening of the femoral head.
At the same time, degenerative-dystrophic changes may be observed in one or both hip joints. Accordingly, characteristic symptoms will be observed either on one side or on both at the same time, but in the latter case, their severity on the left and right may differ.
Diagnostics
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. 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 pelvic bones and any bony structure of the knee, ankle or heel. But if both hip joints are simultaneously affected by the coxarthrosis, the data obtained will not be informative.
But since the typical symptoms of coxarthrosis can accompany a number of other inflammatory and non-inflammatory diseases, organ examination methods are mandatory for the patient to accurately diagnose the pathology. It could be:
- CT or x-ray of the hip joint - the images show destructive changes in it, narrowing of the joint space, formation of osteophytes and deformation of bone surfaces.
- Magnetic resonance imaging is the most informative examination method that allows you to accurately assess the nature of changes in cartilage structures, ligaments and the nature of blood circulation in the hip area.
Patients are also assigned laboratory tests to evaluate their general health and detect diseases that could cause coxarthrosis. The:
- UAC and OAM.
- blood chemistry;
- Rheumatic tests;
- puncture of the hip joint with biochemical study.
The task of diagnosis is to differentiate coxarthrosis of the hip from gonoarthrosis (damage to the knee joint), as well as the root syndrome that occurs with osteochondrosis, as well as protrusions and herniations of the intervertebral discs. Also, the symptoms of coxarthrosis can resemble manifestations of trochanteric bursitis and atypical course of ankylosing spondylitis, which requires a full examination to determine the true causes of pain and mobility limitations.
Conservative therapy
Conservative treatment of hip coxarthrosis is effective only in the initial stages of the disease. It is chosen for each individual patient and may include a whole range of different methods, each of which will complement 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 must eliminate the influence of certain factors that contribute to the development of hip coxarthrosis. 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 should also stop smoking and normalize the way of physical activity, avoid overloading, but do not sit all the time. To avoid further damage to the hip joint, it is recommended to use special bandages and braces. They provide secure fixation of the joint and support it during movement.
Medical care
The nature of drug therapy is selected strictly individually. In most cases, patients are prescribed:
- NSAIDs - drugs that have both 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 give a strong effect.
- chondroprotectors - they contribute to the activation of cartilage tissue regeneration processes, but their effectiveness has not been proven.
- muscle relaxants - drugs that reduce muscle tone and eliminate spasms, which is necessary when spasms of certain muscles or groups against the background of severe pain.
- preparations to improve blood circulation - are most often used in the form of injectable solutions and help to improve the nutrition of the tissues surrounding the joint.
- B vitamins - they seem to normalize the transmission of nerve impulses, which is especially important when nerves are compressed by deformed bone structures.
For acute pain that cannot be eliminated with the help of tablets, intra-articular or peri-articular blocks can be given to patients. They are performed exclusively by qualified health professionals in a medical institution and involve the introduction of corticosteroid anesthetic solutions into the joint cavity or directly around it.
exercise therapy
Therapeutic exercise is an effective method of dealing with decreased muscle tone and limited mobility. 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 atrophy and help eliminate spasms if coxarthrosis is accompanied by pinching of nerve fibers, which reflexively leads to spasm of individual muscles.
Exercise therapy classes can improve blood circulation in the area of the degenerative-dystrophic process. Due to this, the quality of nutrition of the affected joint increases and the course of regenerative processes is accelerated.
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
Physiotherapy procedures and massage have an anti-inflammatory, analgesic, tonic, anti-edematous effect. In addition, they help to maintain the normal muscle tone of the legs, preventing their weakness and atrophy.
With coxarthrosis of the hip joint, courses of 10-15 procedures are prescribed:
- ultrasound therapy;
- magnetotherapy?
- laser therapy;
- electrophoresis?
- hyperphonophoresis?
- UHF?
- paraffin treatment.
Also, many patients are offered mud therapy. Such procedures have a positive effect only in the 1st stage of the development of coxarthrosis of the hip joint or during rehabilitation after surgical treatment. Thanks to the therapeutic mud, it is possible to achieve an improvement in the quality of blood circulation and to accelerate the restoration of the motor abilities of the affected joint.
Plasmolifting
Plasmolifting or PRP-therapy is a procedure that involves the introduction of platelet-rich plasma from the patient's own blood into the hip joint cavity. This allows you to activate the restoration processes of the hyaline cartilage.
But, according to some scientists, such a process can cause the formation of malignant tumors. This opinion is based on the fact that plasmolifting promotes the formation of a large number of stem cells, the effect of which on the body has 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 exhausted.
With advanced pathology, surgery is a necessary measure. Only a 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 medication, physical therapy procedure, can restore severely damaged cartilage. At best, painful intra-articular injections and medications can reduce the pain. But this will be a temporary phenomenon, after which the pain will return again with the same or even greater force.
Indications for hip surgery are:
- disappearance of the interarticular space.
- persistent pain in the hip joint, not amenable to relief.
- critical mobility disorders;
- hip fracture.
Depending on the severity of joint destruction and bone deformity, patients may be offered different types of surgical treatment, namely:
- arthrodesis?
- endoprosthetic;
- osteotomy.
Arthrodesis
Arthrodesis is an affordable operation that involves strong fixation of the joint 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 restoring mobility or significantly improving the quality of life.
Endoprosthetic
Endoprosthetics with arthroplasty is the only way to fundamentally solve the problem of coarthrosis of the hip joint by restoring all its functions and motor capabilities. 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 the limitations of pain and mobility. Thanks to the use of modern endoprostheses, it is possible to fully restore motor support functions and provide the patient with a normal life.
The operation involves resection of the femoral head and part of her neck. Surgical preparation of the acetabulum is also performed, which includes removal of osteophytes, alignment of its surface, and excision of necrotic tissue. The endoprosthesis can even be used to treat elderly patients with hip coxarthrosis.
The operation is performed under general anesthesia and lasts 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 smoothing of the acetabulum and femoral head with further coating with smooth implants that replace the damaged hyaline cartilage (the method is rarely used due to the possibility of inflammation in the peri-articular 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 provides smoother movements in the joint.
- total is the most effective and safe method for solving the problem of coxarthrosis of the hip joint, which involves complete excision of the femoral head with the capture of part of its neck, as well as the acetabular fossa and their replacement with acomplete artificial articular joint.
Thus, patients may be advised to have various types of stents installed. Most hip replacements are manufactured in the USA and the UK. Chemically and biologically inert metals are used for their manufacture: cobalt, chromium, titanium alloys. Ceramics are also often used. In most modern models, additional polymer pads are used, which make it possible to provide natural shock absorption, stabilization and sliding properties to the artificial TBS.
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 endoprosthetics is simple, but still requires physiotherapy, massage and exercise.
osteotomy
An osteotomy is a surgical procedure that is a temporary measure before a major replacement of the hip joint with an artificial endoprosthesis. The essence of the operation is the alignment of the axis of the femur due to its intentional fracture. The resulting fragments are placed in the most suitable place, thus slightly relieving the affected joint. As a result, it is possible to temporarily reduce the severity of pain and improve mobility.
Thus, coxarthrosis of the hip is a rather terrible disease that can completely deprive a person of the opportunity to move independently. It progresses over a long period of time and its symptoms, especially in the early stages, are often perceived by patients as a normal condition after physical exertion. But this is precisely where the insidious disease lies, because 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 bone surfaces and even more to their flattening, only surgery can help the patient. Fortunately, the modern level of medicine and surgery, in particular, makes it possible to completely restore the normal state of the hip joint and its functions.