Coxarthrosis of the hip joint is a degenerative-dystrophic process that occurs in the joint of the femoral head and in the pelvic acetabulum. The disease is more typical of middle-aged and older 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 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, in the latter stages the treatment of coxarthrosis of the hip joints is effective only with surgery. Otherwise, the pathology will lead to severe ailments or even complete immobilization.
What is coxarthrosis of the hip joint and the mechanism of its development
Coxarthrosis, also called osteoarthritis and deforming osteoarthritis, is a complex disease of the hip joints (HJ), accompanied by a progressive destruction of the cartilage. Over time, this leads to deformation of the surfaces of adjacent bones, as well as the formation of bone 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 onset, it is second only to knee joint gonarthrosis, but the risks of contracting 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 head of the femur is located in the cup-shaped cavity of the pelvic bone and moves freely in different directions. This joint structure allows you to flex and stretch, adduct and abduct, and even rotate your thigh.
To prevent movement from causing discomfort, the surfaces of the bones that touch are covered with an elastic layer called hyaline cartilage. It is he who allows the head of the femur to slide easily into the acetabulum. In addition, the hyaline cartilage provides stabilization and cushioning of the hip joint during movements.
The entire joint is immersed in a kind of pouch called the joint capsule. Contains the synovial membrane that synthesizes synovial fluid. It is she who lubricates the surface of the cartilage, ensures the flow of water and nutrients into it, i. e. it is responsible for maintaining the normal structure of the 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 which ensure the stability of its position within physiological limits.
Since the hip joint is subjected to heavy loads every day, it is prone to rapid wear and injury. The risk of such changes significantly increases the effect of a number of unfavorable 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 viscous, dense and is no longer able to completely nourish the cartilage. This leads to acute nutritional deficiencies and progressive dehydration of the hyaline cartilage. As a result of these changes, the strength and elasticity of the cartilage tissue decreases, exfoliates, cracks and decreases in volume. All this prevents the smooth sliding of the femoral head in the acetabulum of the pelvis, which leads to the appearance of signs of hip coxarthrosis.
Gradually, the interarticular space narrows, there is an increase in friction between the articular bone surfaces, and the pressure of the bones on the hyaline cartilage increases. This leads to even greater injuries and wear, which cannot fail to 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 limbs, but also the entire musculoskeletal system. This often results in disability.
As pathological changes progress, the hyaline layer gradually disappears completely, which leads to exposure of the bone surfaces and a critical increase in the load on the bone joint. During the movements, the head of the femur 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 unbearable pain, the bones press against each other, flattening at the same time.
When the bones of the joint are deformed, bone growths (osteophytes) form on their surface. They can have sharp edges and severely injure surrounding muscles. This causes severe pain in the groin, legs and buttocks to occur. Therefore, the patient subconsciously tries to spare the affected hip joint and avoid movements in it. Lack of adequate load on the muscles leads to their gradual 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, it is not possible to find the reasons for its development, that is, the disease develops on its own for no apparent reason. Secondary coxarthrosis is the result of a series of changes in the state of the musculoskeletal system or lifestyle features, in particular:
- hip joint injuries, including bone fractures, dislocations, bruises, sprains or ruptures of surrounding ligaments, chronic micro-injuries, etc. ;
- exhausting physical work;
- sedentary lifestyle;
- obesity;
- 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;
- addiction to smoking.
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 among the above only increases the risk of its occurrence and increases the rate of progression.
Symptoms and degrees
During coxarthrosis, 4 degrees of development are distinguished, of which 1 is the simplest. Initially, the disease can be asymptomatic or manifest with mild pain. Most often they occur after heavy 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 in the early stage of development.
Perceptible signs of coxarthrosis begin to appear in the 2nd stage of its progression, when the joint space is narrowed by almost half and the head of the femur is displaced and deformed. With the passage to the 3rd stage the pains become unbearable and can disturb 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 more 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 restrictions - initially, patients may notice the appearance of difficulty in performing rotational movements of the leg, but over time morning stiffness and swelling of the HJ join. Due to them, a person needs several minutes to warm up and, as it were, walk to restore a normal range of motion. Gradually, it becomes more and more difficult for the patient to perform the movements of the legs.
- A characteristic crunch - occurs when walking, as well as flexion or extension of the hip joint. It is a consequence of the friction of the bone surfaces against each other and with coxarthrosis is accompanied by sharp or dull pain.
- Pain syndrome: initially the pains appear after physical exertion and subside slightly after a long rest. An acute attack can be provoked by weight lifting or hypothermia, as 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 thigh muscles - is a consequence of pinching of the nerves and weakening of the ligament apparatus, so muscle spasm is compensatory to keep the femoral head in the acetabulum. Also, muscle spasm can be provoked by the addition of synovitis.
- Lameness - occurs in the late stages of the development of the disease, as the deformation of the bone surfaces provokes the appearance of contracture of the flexor muscles. Therefore, a person cannot fully straighten the leg and keep it in this position. In addition, 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 3rd degree coxarthrosis. The leg on the side of the affected hip joint may be shortened by 1 cm or more due to joint space narrowing, decreased muscle tone, and flattening of the femoral head.
In the last stage of development, the head of the femur fuses with the acetabulum, which leads to complete immobilization of the leg and disability.
At the same time, degenerative-dystrophic changes can be observed in one hip joint or both. As a result, the characteristic symptoms will be observed on one side or both at the same time, but in the latter case their severity on the left and right may differ.
Diagnostics
The doctor may suspect the presence of coxarthrosis of the hip joint based on patient complaints, external examination, and functional test results. Be sure to measure the length of your 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 bone structure in the knee, ankle, or heel. But if both hip joints are simultaneously affected by 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, instrumental examination methods are mandatory for the patient to accurately diagnose the pathology. It could be:
- CT or radiography 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 method of examination 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 assess their overall health and detect diseases that could cause coxarthrosis. It:
- UAC and OAM;
- blood chemistry;
- rheumatic tests;
- puncture of the hip joint with a biochemical study.
The task of diagnosis is to differentiate coxarthrosis of the hip with 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. Additionally, the symptoms of coxarthrosis can resemble manifestations of trochanteric bursitis and an atypical course of ankylosing spondylitis, which requires a thorough examination to find out the true causes of pain and limitations in mobility.
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, each of which will complement the others. Therefore, as part of the treatment of coxarthrosis of the hip joint, patients can be prescribed:
- pharmacological therapy;
- physical therapy;
- Physiotherapy;
- plasmolifting.
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 will reduce the load on the affected joint and the risk of progression of the degenerative-dystrophic process.
You should also quit smoking and normalize the mode of physical activity, avoid overload, but don't always sit down. To prevent further destruction of the hip joint, it is recommended to wear special bandages and orthoses. 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 powerful anti-inflammatory effect, which are prescribed if NSAIDs do not give a pronounced effect;
- chondroprotectors: they contribute to the activation of the regeneration processes of cartilage tissues, but their effectiveness has not been proven;
- muscle relaxants - drugs that reduce muscle tone and eliminate spasms, which are necessary when contracting certain muscles or groups against the background of severe pain;
- preparations to improve blood circulation - are often used in the form of solutions for injection and help improve the trophism of the tissues surrounding the joint;
- B vitamins - have been shown to normalize the transmission of nerve impulses, which is especially important when the nerves are compressed by deformed bone structures.
For acute pain that cannot be eliminated with the help of tablets, intra-articular or periarticular blocks can be performed on patients. They are carried out exclusively by qualified health professionals in a medical institution and involve the introduction into the joint cavity or directly to the surrounding area of anesthetic solutions with corticosteroids.
physical therapy
Therapeutic exercise is an effective method of dealing with decreased muscle tone and limited mobility. Thanks to a series of appropriately selected 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 the nerve fibers, which consequently leads to spasm of individual muscles.
Physical therapy classes 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 regenerative 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 in the legs, preventing atony and atrophy.
With coxarthrosis of the hip joint, courses of 10-15 procedures are prescribed:
- ultrasound therapy;
- magnetotherapy;
- laser therapy;
- electrophoresis;
- ultraphonophoresis;
- UHF;
- paraffin treatment.
In addition, many patients are offered mud therapy. Such procedures have a positive effect only at the first 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 obtain an improvement in the quality of blood circulation and accelerate the restoration of motor skills of the affected joint.
Plasmolifting
Plasmolifting or PRP therapy is a procedure that involves introducing platelet-rich plasma from the patient's blood into the hip joint cavity. This allows to activate the recovery processes of the hyaline cartilage.
But, according to some scientists, such a procedure can cause the formation of malignant tumors. This view 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 significant discomfort in the hip joint, many seek medical attention too late, when pathological changes in the joint reach 3 or even 4 degrees of severity and function is irreversibly exhausted.
With advanced pathology, surgery is a necessary measure. Only timely surgical intervention will help to restore normal mobility and save the patient from excruciating pain, that is, to achieve a significant improvement in the quality of human life. No medicine, physiotherapy procedure, can restore badly 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 again with the same or even greater force.
The 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 the joint destruction and bone deformity, patients may be offered various types of surgical treatment, namely:
- arthrodesis;
- endoprosthesis;
- osteotomy.
Arthrodesis
Arthrodesis is an inexpensive 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 supportive function of the leg, eliminate pain, but there is no need to talk about the restoration of mobility or a significant improvement in the quality of life.
Today, arthrodesis is practically not used, as it deprives a person of the opportunity to move completely.
Endoprosthesis
Endoprosthesis with arthroplasty 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 limitations in mobility. Thanks to the use of modern endoprostheses, it is possible to achieve full restoration of motor support functions and provide the patient with a normal life.
The operation involves resection of the femoral head and part of its neck. The surgical preparation of the acetabular bed is also performed, which involves the removal of osteophytes, the alignment of its surface and the resection of tissues that have undergone necrosis. The endoprosthesis can also be used for the treatment of elderly patients with coxarthrosis of the hip.
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 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 of the periarticular tissues);
- unipolar: removal of the femoral head and its 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, it differs 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 to solve 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 acetabular fossa and their replacement with a real and just artificial joint.
Therefore, patients may be advised to install various types of endoprostheses. Most hip replacements are manufactured in the United States and the United Kingdom. Chemically and biologically inert metals are used for their manufacture: cobalt, chromium, titanium alloys. Ceramic is also often used. In most modern models, polymer bearings are also used, which allow to provide natural shock absorbing, stabilizing and sliding properties to the artificial TBS.
When performing endoprosthesis, 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 is discharged from the clinic. Rehabilitation after the endoprosthesis is simple, but still requires physiotherapy, massage and physical therapy.
osteotomy
Osteotomy is a surgery that is a temporary measure prior to 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 appropriate position, thereby slightly relieving the diseased joint. As a result, it is possible to temporarily reduce the severity of pain and improve mobility.
Therefore, coxarthrosis of the hip is a rather formidable disease that can completely deprive a person of the opportunity to move independently. It progresses for a long time and its symptoms, especially in the early stages, are often perceived by patients as a normal condition after physical exertion. But it is precisely in this that the insidiousness of the disease lies, because only at the initial stage of its development can it be addressed in a non-surgical way. 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, allows to achieve a complete restoration of the normal state of the hip joint and its functions.