Coxarthrosis of the hip joint

Hip joint coxarthrosis is a degenerative-dystrophic process that occurs in the joint joint of the femoral head and pelvic acetabulum. The disease is more 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, in addition to various 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 passes through several stages, and if in the early stages it can be treated conservatively, 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 or 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 destruction of cartilage. 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 is responsible for about 12% of all diseases of the musculoskeletal system. In terms of frequency of occurrence, it is second only to gonarthrosis of the knee joint, but the risks of becoming disabled are much greater.

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 moves freely in different directions. This joint structure allows for flexing and unfolding, adducting and abducting, and also rotating the thigh.

To prevent movement from causing discomfort, the surfaces of bones that touch are covered with an elastic layer called hyaline cartilage. It is he who allows the femoral head to slide easily into the acetabulum. In addition, hyaline cartilage provides stabilization and cushioning of the hip joint during movements.

The entire joint is immersed in a kind of box called the joint capsule. It 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 to it, that is, it 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 ensure the stability of its position within physiological limits.

As the hip joint is subjected to heavy loads every day, it is prone to rapid wear and tear and injuries. The risk of such changes significantly increases the effect of a number of unfavorable factors that are virtually unavoidable 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 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 the hyaline cartilage. As a result of such changes, the strength and elasticity of cartilage tissue decrease, exfoliate, crack and shrink. 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, friction between the articulating bone surfaces increases, and the pressure of the bones on the hyaline cartilage increases. This leads to even greater injuries and wear and tear, which cannot but 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 locomotor apparatus. This often results in disability.

As the pathological changes progress, the hyaline layer gradually disappears completely, which leads to exposure of the bony surfaces and a critical increase in the load on the bony 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 seriously limiting mobility and causing excruciating pain, bones press against each other, simultaneously flattening.

As the bones of the joint deform, bony outgrowths (osteophytes) form on its surface. They can have sharp edges and severely injure surrounding muscles. This causes the occurrence of severe pain in the groin, legs and buttocks. Therefore, the patient unconsciously tries to spare the affected hip joint and avoid movement in it. The lack of adequate loading on the muscles leads to their gradual atrophy, which further exacerbates mobility problems. This results in lameness.

reasons for development

Hip joint coxarthrosis 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 coxarthrosis is the result of various changes in the state of the musculoskeletal system or lifestyle characteristics, in particular:

• hip joint injuries including bone fractures, dislocations, bruises, sprains or tears of surrounding ligaments, chronic microdamage, etc. ;
• exhausting 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 (dislocation, dysplasia);
• aseptic necrosis of the femoral head;
• spinal pathologies of various types;
• genetic predisposition;
• smoking addiction.

In the vast majority of cases, the development of hip joint coxarthrosis is due to unavoidable 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 easiest. Initially, the disease may be asymptomatic or manifest as mild pain. Most often they occur after strenuous physical exertion, a long walk, or at the end of a busy day. In the early stages of disease development, discomfort is usually attributed to fatigue and is considered the norm. Therefore, very 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. As the joint space is practically absent and several osteophytes are formed on the bone surfaces, independent movement in these 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 Restrictions - Initially, patients may notice the onset of difficulties in performing rotational leg movements, but over time, morning stiffness and JH swelling joins them. Because of them, a person needs several minutes to warm up and, so to speak, walk to restore a normal range of motion. Gradually, it becomes more and more difficult for the patient to perform leg movements.
• A characteristic crisis - occurs when walking, as well as flexion or extension of the hip joint. It is a consequence of the friction of bone surfaces against each other and with coxarthrosis it is accompanied by sharp or dull pain.
• Pain syndrome - initially the pain appears after physical exertion and decreases a little 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 the compression of the nerves and weakening of the ligament apparatus, so that the muscles spasm compensatory to keep the head of the femur in the acetabulum. Also, muscle spasm can be provoked by the addition of synovitis.
• Claudication - occurs in the last stages of the development of the disease, as the deformation of the bone surfaces causes the appearance of contracture of the flexor muscles. Therefore, a person cannot fully straighten the leg and hold it in that position. In addition, the patient may involuntarily limp to transfer weight to the healthy half of the body as this helps to reduce the intensity of pain.
• Leg shortening - 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.

In the last stage of development, the femoral head fuses with the acetabulum, which leads to complete immobilization of the leg and disability.

At the same time, degenerative-dystrophic changes can be seen in one or both hip joints. Thus, 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 the right may differ.

Diagnosis

The physician 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 length of the legs during a visual inspection. For this, the patient is asked to stand up and stretch the legs as far 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 affected simultaneously by coxarthrosis, the data obtained will be uninformative.

But as the typical symptoms of coxarthrosis can accompany various other inflammatory and non-inflammatory diseases, instrumental examination methods are mandatory for the patient to accurately diagnose the pathology. It could be:

• CT or X-ray of the hip joint - images show destructive changes, joint space narrowing, osteophyte formation and deformation of bone surfaces;
• MRI 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 also receive laboratory tests to assess their general health and detect conditions that can cause coxarthrosis. This:

• UAC and OAM;
• blood chemistry;
• rheumatic tests;
• puncture of the hip joint with biochemical study.

The diagnostic task is to differentiate hip coxarthrosis from gonarthrosis (damage to the knee joint), as well as radicular syndrome that occurs with osteochondrosis, as well as bulges 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 thorough examination to discover the true causes of pain and mobility restrictions.

Conservative treatment

Conservative treatment of hip coxarthrosis is effective only in the early stages of the disease. It is selected for each patient individually 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 may be prescribed:

• drug therapy;
• exercise therapy;
• physiotherapy;
• plasmolifting.

For conservative treatment to be effective, patients need to eliminate the effect of a number of 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 mode of physical activity, avoid overload, but not sit all the time. To avoid further destruction of the hip joint, the use of special bandages and orthoses is recommended. 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 have both 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 - 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 spasming certain muscles or groups against the background of severe pain;
• preparations for improving blood circulation - they are most often used in the form of injection solutions and help to improve the trophism of the tissues around the joint;
• B group vitamins - are shown to normalize the transmission of nerve impulses, which is especially important when nerves are compressed by deformed bony structures.

For acute pain that cannot be eliminated with the help of pills, intra-articular or periarticular blocks can be performed on patients. They are performed exclusively by qualified healthcare professionals in a medical institution and involve the introduction into the joint cavity or directly into the surrounding area of anesthetic solutions containing corticosteroids.

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 compression 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 the trophism of the diseased joint increases and the course of regenerative processes accelerates.

For each patient, a set of exercises must be individually developed 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 and 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 receive mud therapy. Such procedures have a positive effect only at the 1st stage of 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 the motor skills of the affected joint.

Plasmolifting

Plasmolifting or PRP-therapy is a procedure that involves introducing platelet-rich plasma from the patient's own blood into the cavity of the hip joint. This allows you to activate the processes of restoration of 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 hip joint coxarthrosis

Despite significant discomfort in the hip joint, many seek medical help very 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 human quality of life. No medication, physical therapy 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 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 can receive various types of surgical treatment, namely:

• arthrodesis;
• endoprosthesis;
• 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, eliminate pain, but it is not necessary to talk about restoring mobility or a significant improvement in quality of life.

Today, arthrodesis is practically not used, as it deprives the person of the opportunity to move fully.

endoprostheses

Endoprosthesis with arthroplasty is the only way to radically solve the hip joint coxarthrosis problem with the restoration of all its functions and motor skills. This is a high-tech method to solve the problem of coxarthrosis, which allows you to completely forget about it for 15-30 years, as well as about pain and mobility restrictions. Thanks to the use of modern endoprostheses, it is possible to achieve complete 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. Surgical preparation of the acetabular bed is also performed, which involves the removal of osteophytes, surface alignment and resection of necrotic tissues. The stent may even be used to treat elderly patients with hip coxarthrosis.

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 subsequent covering with smooth implants that replace the destroyed hyaline cartilage (a method 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 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 to solve the problem of coxarthrosis of the hip joint, which involves the complete resection of the femoral head with the capture of part of its neck, as well as the acetabular fossa and replacing them with an artificial full right joint joint.

Thus, patients can be recommended to install various types of endoprostheses. Most hip replacements are made in the US and UK. For its manufacture, chemically and biologically inert metals are used: cobalt, chromium, titanium alloys. Ceramic is also often used. In most modern models, polymer pads are used additionally, which makes it possible to provide natural shock-absorbing, stabilization and glide properties to artificial TBS.

When performing endoprostheses, 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 approximately 8 cm, at the same time the patient is discharged from the outpatient clinic. Rehabilitation after endoprosthesis is simple, but still requires physical therapy, massage, and exercise therapy.

osteotomy

Osteotomy is a surgical intervention 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 appropriate position, slightly unloading the diseased joint. As a result, it is possible to temporarily reduce the severity of pain and improve mobility.

So, coxarthrosis of the hip is quite a 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 resides, because only in 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.