How to treat coxarthrosis of the hip joint

Coxarthrosis is a common degenerative-dystrophic disease of the hip joint, in which, due to age-related changes or other factors, there is a gradual destruction of the articular joint of the femoral head and the acetabulum of the pelvis. It is accompanied by pain and limitation of the amplitude of movements of different severity, which depends on the stage of development. And if in the initial stages it is possible to cope with coxarthrosis with conservative methods, then in the 3rd stage it is possible to save the situation and maintain the working ability of the hip joint, that is, to avoid disability, only by performing an operation.

It belongs to the number of arthrosis and can be associated with the development of similar processes in other joints, and this pathology accounts for about 12% of all diseases of the musculoskeletal system. But the term "coxarthrosis" can only be used to describe degenerative-dystrophic changes in the hip joint.

What is coxarthrosis?

Coxarthrosis is a complex pathology of one or both hip joints, in which the cartilaginous layers covering the femoral head and acetabulum are destroyed, which leads to a decrease in the size of the joint space. With the progression of the disease, the appearance of deformation of the bone surfaces and the formation of bone growths on them, called osteophytes, is observed.

Coxarthrosis is the second most common disease of the musculoskeletal system. Most often, only gonarthrosis is diagnosed, that is, a degenerative-dystrophic change in the knee joint. However, the probability of disability in coxarthrosis is significantly higher.

The entire hip joint is enclosed in a specific case, which is called the joint capsule. It has a so-called synovial membrane, which produces synovial fluid. This fluid is essential for the proper functioning of the joint, as it not only lubricates the hyaline cartilage, but is also a source of nutrients for it.

Normally, the cartilage is constantly worn out and immediately restored due to the continuous regeneration process, which is carried out with the help of substances that enter it from the synovial fluid. But with injuries or age-related changes, the rate of regeneration processes decreases, which leads to the gradual wear of hyaline cartilage and the development of coxarthrosis.

This is due to changes in the amount of synovial fluid produced and its composition. Under the influence of negative factors, it becomes thicker and is produced in a smaller volume. As a result, the synovial fluid is no longer able to provide the hyaline cartilage with all the substances it needs in the right amount, which leads to its rapid dehydration and thinning. Gradually, the strength and elasticity of the cartilage decreases, the areas of delamination of the fibers that form it, cracks are formed in it, and the thickness also decreases. These changes can be observed during instrumental diagnostic methods, in particular the narrowing of the joint space draws attention to itself.

The narrowing of the joint space leads to increased friction between the bony structures that make up the hip joint and an increase in pressure on the already degraded hyaline cartilage. This provokes even more damage to it, which affects the functioning of the joint and the condition of the person, since the deformed areas prevent the femoral head from sliding easily into the acetabulum. As a result, there are symptoms of coxarthrosis.

If left untreated, the pathological changes worsen and the hyaline cartilage wears away more and more. Then, in some areas, it disappears completely, which leads to the exposure of the bones and a sharp increase in the load on the joints. Since when moving inside the acetabulum, the head of the femur rubs directly against the bone, this provokes the appearance of severe pain and a sharp limitation of mobility. In this case, the pressure of bone structures on each other leads to the formation of bone growths on their surface.

The osteophytes that form can have sharp parts that can damage the muscles and ligaments surrounding the hip joint. This leads to the appearance of severe pain both directly in the joint area and in the hips, buttocks and thighs. As a result, the patient saves the injured leg, puts less stress on it and tries to avoid unnecessary movements with it. This causes the development of muscle atrophy, which further worsens mobility disorders and eventually leads to lameness.

Causes

There are many reasons for the development of coxarthrosis, although in rare cases it occurs against the background of the absence of any prerequisites. In this case, they talk about the presence of primary or idiopathic coxarthrosis. In the vast majority of cases, secondary coxarthrosis is diagnosed, which becomes a logical consequence of a number of diseases or changes in the state of the musculoskeletal system. It can be provoked by:

• hip joint injuries of various natures, including fractures, dislocations, bruises, sprains or torn ligaments;
• heavy physical work, professional sports, especially weightlifting, skydiving, dance sports;
• sedentary lifestyle;
• being overweight, which significantly increases the load on the hip joints;
• foci of chronic infection in the body;
• congenital malformations of the hip joints, such as dysplasia or dislocation;
• metabolic pathologies and endocrine disorders, especially gout, diabetes mellitus, especially in a decompensated form;
• aseptic necrosis of the femoral head, which may be the result of a fracture of the femoral neck, especially during conservative treatment;
• inflammatory joint diseases, including rheumatoid arthritis, bursitis, tendinitis;
• diseases of the spine;
• genetic predisposition;
• the presence of bad habits, especially smoking.

However, the main cause of coxarthrosis is still the inevitable age-related changes, and the presence of the above factors only increases the likelihood and speed of its development.

Symptoms of coxarthrosis

The disease is characterized by a gradual progression with a systematic increase in the intensity of symptoms. Therefore, in the initial stages, it can be asymptomatic or only occasionally cause anxiety to patients, but then the condition of the hip joint worsens, which leads to an increase in the severity of the signs of coxarthrosis up to unbearable pain and limitationconsiderable mobility. .

So, degenerative-dystrophic changes in the hip joint are accompanied by:

• Pains with different strengths, which first arise after physical exercises or walking and subside after rest. Gradually, the severity of the pain syndrome increases, appears more often, lasts longer, and the periods between the moment of applying the load to the joint and the appearance of pain decrease. Later, the pain is present almost constantly, including at rest, and becomes unbearable. It is characteristic that the pain increases at any stage of the disease's development during hypothermia and lifting heavy objects.
• Limitations in the mobility of the hip joint, which are initially manifested by small difficulties in the implementation of rotational movements of the leg. Over time, morning stiffness appears, which disappears after the patient "disperses". This may be associated with the appearance of edema in the hip joint. As the disease progresses, mobility limitations become more pronounced and persistent, that is, they do not disappear after a warm-up. Patients notice a decrease in the amplitude of leg movements, and then completely lose the ability to perform certain movements.
• Cracking in the hip joint, which occurs when walking or doing physical work, especially when doing extension. It is the result of the friction of bare bone structures against each other, which is accompanied by a sharp increase in pain.
• Spasm of the thigh muscles, which leads to diffuse pain in the thigh. This can be the result of the adhesion of various intra-articular disorders, including nerve compression, excessive stretching of the ligaments surrounding the joint, as well as the development of synovitis, d. m. th. , inflammation of the synovial membrane and the accumulation of inflammatory. effusion in the cavity of the joint of the hip.
• Lameness, which is initially the result of the patient's unconscious desire to reduce the load on the diseased joint and transfer the weight to the healthy leg to avoid the appearance or intensification of pain and then the development of muscle contracture. The last phenomenon occurs already in the later stages of coxarthrosis and leads to the fact that the patient is unable to fully straighten the leg and, moreover, keep it in this position. Thus, the lower limb with the affected hip joint is constantly in a slightly bent position, which provokes lameness.
• A decrease in the length of the leg, which mainly occurs already with severe degenerative-dystrophic changes in the hip joint, accompanied not only by the narrowing of the joint space, but also by the flattening of the femoral head, muscle atrophy. As a result, the diseased leg becomes shorter than the healthy one by 1 or more centimeters.

Coxarthrosis can affect both hip joints and both at the same time. But if in the first case the symptoms of the disease will be observed only on one side, then in the second they will not only be bilateral, but also vary in intensity. It depends on the degree of destruction of each hip joint.

Levels of coxarthrosis

The nature of the manifestations of the disease depends on the stage of its development. In total, there are 3 degrees of coxarthrosis, of which the first is considered the easiest. In the initial stages of the appearance of degenerative-dystrophic changes in the hip joint, only episodic pain can be observed. As a rule, this happens after an intense physical strain, playing sports or a long walk. Therefore, patients usually do not pay attention to them, attributing them to fatigue and considering them normal age-related changes. In this regard, grade 1 coxarthrosis is diagnosed only in isolated cases, which usually occurs during examination for another reason.

As the disease progresses, its symptoms intensify and already with 2nd degree coxarthrosis they are felt. This stage of the development of the pathology is characterized by a narrowing of the joint space by 50%, as well as the appearance of signs of deformation of the femoral head with its displacement.

With the further progress of the pathology, the joint space narrows even more and with the third degree of coxarthrosis it is almost completely absent. This is already associated with the formation of numerous osteophytes. At this stage of the development of the disease, the pain becomes not only strong, but unbearable and often occurs even in a state of complete rest, including at night. Since the hip joint is severely deformed, its elements can affect the nerves that pass here, which leads to pain that radiates to the hip, buttocks, as well as the thigh and even the lower part of the leg. This also provokes the inability to move independently without the use of assistive devices, such as crutches or a cane.

Coxarthrosis of the 3rd degree is a direct indication for surgical treatment. If the operation is not performed in time, the head of the femur will be firmly fused with the surface of the acetabulum with osteophytes. This will lead to a shortening of the leg, a complete lack of the possibility of independent movement, since the joint will completely lose mobility, d. m. th. , in disability.

Diagnosing

If signs of coxarthrosis appear, it is recommended to contact an orthopedist as soon as possible. Initially, the doctor will interview the patient and find out the nature of the complaints and then proceed with the examination and performing functional tests, comparing the length of the legs. As a rule, the data obtained are sufficient to speak with a high degree of confidence about the presence of coxarthrosis.

But since such a clinical picture can accompany a number of other hip joint diseases, both inflammatory and non-inflammatory in nature, instrumental diagnostic methods are required. With their help, a specialist will be able not only to confirm the presence of coxarthrosis, to differentiate it from radicular syndrome caused by pathologies of the spine, but also to correctly assess the rate of its development, which means the choice of tacticsmore effective treatment. .

Today, the following are used to diagnose coxarthrosis:

• X-rays of bone joints - the resulting images allow you to detect signs of destructive changes, the presence of osteophytes, the nature of the deformation of bone structures and measure the thickness of the joint space.
• CT is a more modern method for diagnosing bone pathologies, providing clearer data than X-rays, but more expensive. Therefore, CT is prescribed in controversial cases, when it is necessary to clarify the diagnosis and the degree of destruction of the hip joint.
• MRI is a very informative method for joint examination, providing the maximum amount of information about the state of the joint and all its structures, especially hyaline cartilage, ligaments and blood supply features.

Patients are prescribed a series of laboratory tests, including KLA, OAM, rheumatic tests, biochemical blood tests and others.

Conservative treatment of coxarthrosis

When coxarthrosis of 1 or 2 degrees is diagnosed, treatment is carried out with conservative methods. For each patient, they are selected individually, taking into account the concomitant diseases detected. Therefore, it may often be necessary to consult not only an orthopedist, but also doctors of other specialties, who will choose the necessary treatment to combat associated diseases.

As part of coxarthrosis treatment, patients are prescribed:

• drug therapy;
• exercise therapy;
• physiotherapy.

It is mandatory for all patients to take measures to eliminate the effects of factors that increase the load on the legs and contribute to the progression of degenerative changes in the hip joint. This includes adjusting your diet and increasing your level of physical activity if you are overweight. If the patient is regularly exposed to excessive physical exertion, it is recommended to change the type of activity or reduce the intensity of training, if the load is due to sports. In some cases, it is recommended to use bandages and special orthoses that will fix the hip joint and relieve it during physical exertion.

Medical therapy

As part of drug treatment, patients are selected medications individually, taking into account existing concomitant diseases. As a rule, drugs of the following pharmacological groups are indicated for coxarthrosis:

• NSAIDs - a wide group of drugs that exhibit analgesic and anti-inflammatory effects (available in various dosage forms, including tablets, capsules, gels, creams, injection solutions, which allows you to choose the most effective and convenient formof the application);
• corticosteroids - drugs that have a strong anti-inflammatory effect, but due to the high risk of side effects, especially when using oral forms, they are prescribed only for short courses in the form of injections;
• muscle relaxants - drugs that help reduce muscle tone, which allows you to effectively cope with muscle spasms, often observed in coxarthrosis;
• chondroprotectors - a group of drugs that contain components used by the body to regenerate cartilage tissue;
• preparations that improve microcirculation - help to improve the nutrition of soft tissues and activate the flow of metabolic processes in the affected area;
• B vitamins - are indicated for nerve conduction disorders caused by nerve compression by altered components of the hip joint.

If coxarthrosis caused an attack of acute pain, which cannot be stopped with the help of prescribed NSAIDs, intra-articular or peri-articular blockade is recommended for patients. Its essence lies in the introduction directly into the cavity of the hip joint of an anesthetic solution in combination with corticosteroids. This will allow you to quickly eliminate pain and reduce the inflammatory process. But the blockade can only be performed by a qualified health worker in a specially prepared room. Carrying out such procedures at home is not indicated.

exercise therapy

When diagnosing coxarthrosis, regular exercise therapy is mandatory. In the same way as drug therapy, a set of exercise therapy exercises for each patient is selected individually, taking into account the degree of destruction of the hip joint, the level of physical development of the patient, the nature of accompanying diseases (special attention is paid to pathologiescardiovascular).

Thanks to daily exercise therapy, you can:

• reduce the severity of pain;
• increased mobility of the hip joint;
• reduce the risk of muscle atrophy;
• elimination of thigh muscle spasms;
• activate the blood circulation and in this way improve the nutrition of the affected joint.

All exercises should be performed smoothly, avoiding sudden movements and jerks. But if the pain appears during exercise therapy, you should definitely contact your doctor to correct the chosen complex or carry out a rediagnosis to rule out the progression of the disease and the need for surgery.

Physiotherapy

Comprehensive treatment of coxarthrosis includes courses of physiotherapy procedures that have anti-inflammatory, analgesic, decongestant and tonic effects on the body. Therefore, most often patients are prescribed 10-15 procedures:

• ultrasound therapy;
• electrophoresis;
• UVT;
• magnetic therapy;
• laser therapy etc.

Recently, plasmolifting has been increasingly used as part of the conservative treatment of coxarthrosis, which can significantly increase the speed of regeneration of hyaline cartilage. The essence of the procedure is the introduction into the cavity of the hip joint of purified blood plasma, which is obtained by centrifugation from the patient's own blood.

Surgery for coxarthrosis

If a patient is diagnosed with coxarthrosis of the 3rd degree, he is indicated for surgical intervention, since conservative methods in such cases are already ineffective. Unfortunately, such situations are extremely common today, as a very large number of patients seek medical help when they can no longer endure pain or have serious mobility limitations that deprive them of the ability to work and move independently. .

Timely surgical intervention can completely eliminate these disorders and restore the patient's ability to move normally, significantly improving his quality of life. The indications for its implementation are:

• a significant decrease in shared space by more than 80%;
• the presence of severe pain in the hip joint, which cannot be eliminated;
• pronounced mobility disorders;
• femoral neck fracture.

The gold standard for the treatment of severe coxarthrosis, including in the elderly, is hip arthroplasty. This operation involves replacing a destroyed hip joint with an artificial endoprosthesis made of durable and at the same time biologically compatible materials. Endoprosthetics allows you to fully restore the functionality of the hip joint, eliminate pain and return a person to a full active life.

The essence of this type of surgical intervention is the resection of the femoral head and a small fragment of its neck. Also, the surgeon will have to prepare the surface of the acetabulum for the installation of the endoprosthesis, d. m. th. , to remove all formed osteophytes and achieve the maximum restoration of its normal shape. After that, an endoprosthesis of the selected type is placed, which is fixed with special cement (preferably for the treatment of the elderly) or without cement. In the latter case, the endoprosthesis has a special spongy part in contact with the bone structures. Its fixation in the acetabulum is provided by the sprouting of bone tissue through the sponge.

For each patient, the type of arthroplasty is selected individually. The most effective is total arthroplasty, which includes the complete replacement of the entire hip joint, d. m. th. , the neck and head of the femur, as well as the acetabulum.

If the patient has preservation of normal hyaline cartilage on the surface of the acetabulum, he can undergo partial arthroplasty with single replacement of the femoral head and/or neck. For this purpose, endoprostheses of different designs are used: monopolar and bipolar.

The only disadvantage of arthroplasty can be considered the need to replace the installed endoprosthesis after 15-30 years.

After endoprosthesis replacement, patients are shown rehabilitation, the duration of which depends on the degree of tissue repair. As part of recovery, exercise therapy, physiotherapy and therapeutic massage are prescribed.

Before the advent of modern endoprostheses, patients with grade 3 coxarthrosis were prescribed osteotomy or arthrodesis. Today these techniques are used less and less, as they have a number of disadvantages. Thus, arthrodesis involves fixing the bony structures of the hip joint with metal plates. As a result, the pain syndrome is completely eliminated, but the joint completely loses its mobility. Thus, after arthrodesis, the patient can only stand, but is no longer able to walk independently due to the lack of movement in the hip joint. Therefore, today arthrodesis is practically not performed.

Osteotomy involves the execution of an artificial fracture of the femur with such a combination of bone fragments that will reduce the load on the affected hip joint. But the operation gives only a short-term effect and in the future the need for arthroplasty still arises.

Thus, coxarthrosis of the hip joint is a very dangerous disease, which can result in disability. It seriously reduces the quality of life and deprives a person of the ability to work. But if you pay attention to the early signs of pathology and get advice from an orthopedist at the right time, you can slow down its progress and achieve a significant improvement in well-being. But with already developed coxarthrosis, there can be only one solution - arthroplasty. Fortunately, this method can be used even with serious degenerative-dystrophic changes and completely restore the normal functioning of the hip joint.