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 varying severity, which depends on the stage of development. And if at the initial stages it is possible to cope with coxarthrosis by conservative methods, then at the 3rd stage it is possible to save the situation and maintain the working capacity of the hip joint, that is, to avoid disability, only by performing an operation.

It belongs to the number of arthrosis and may be accompanied by 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. As the disease progresses, the appearance of deformation of the surfaces of the bones and the formation of bone growths on them, called osteophytes, are observed.

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

The entire hip joint is enclosed in a specific case, which is called the articular 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 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 adverse factors, it becomes thicker and 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, areas of delamination of the fibers forming it, cracks form in it, and the thickness also decreases. These changes can be noticed 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 bone structures that form the hip joint and an increase in pressure on the already degrading hyaline cartilage. This provokes even more damage to it, which affects the work of the joint and the condition of the person, since the deformed areas prevent the femoral head from sliding easily in the acetabulum. As a result, there are symptoms of coxarthrosis.

If left untreated, pathological changes worsen, and hyaline cartilage wears out more and more. Subsequently, in some areas, it completely disappears, which leads to the exposure of the bones and a sharp increase in the load on the joint. Since when moving inside the acetabulum, the femoral head 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.

Formed osteophytes can have sharp parts that can injure the muscles and ligaments surrounding the hip joint. This leads to the appearance of powerful pains both directly in the joint area and in the groin, buttocks and thigh. As a result, the patient spares the injured leg, puts less stress on it and tries to avoid making unnecessary movements with it. This causes the development of muscle atrophy, which further exacerbates mobility disorders and ultimately 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 speak of 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:

• injuries of the hip joint of various nature, including fractures, dislocations, bruises, sprains or torn ligaments;
• hard physical labor, professional sports, especially weightlifting, parachuting, jumping sports;
• sedentary lifestyle;
• excess weight, 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, in particular 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 diseases of the joints, including rheumatoid arthritis, bursitis, tendinitis;
• diseases of the spine;
• genetic predisposition;
• the presence of bad habits, especially smoking.

Nevertheless, 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, at the initial stages, it can be asymptomatic or only occasionally cause anxiety to patients, but subsequently the condition of the hip joint worsens, which leads to an increase in the severity of signs of coxarthrosis up to unbearable pain and significant limitation of mobility.

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

• Pain of varying strength, initially arising after physical exertion or walking and subsiding after rest. Gradually, the severity of the pain syndrome increases, it appears more often, lasts longer and the periods between the moment of applying the load on the joint and the appearance of pain are reduced. Later, the pain is present almost constantly, including at rest, and becomes unbearable. Increased pain at any stage of the development of the disease during hypothermia and lifting heavy objects is characteristic.
• Restrictions on the mobility of the hip joint, which are initially manifested by minor difficulties in the implementation of rotational movements of the leg. Over time, morning stiffness appears, which disappears after the patient "disperses. "This may be accompanied by the appearance of edema in the hip joint. As the disease progresses, mobility restrictions 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 subsequently completely lose the ability to perform certain movements.
• Cracking in the hip joint that appears when walking or performing physical work, especially when performing extension. It becomes the result of 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 may be the result of the attachment of various intra-articular disorders, including compression of the nerves, excessive stretching of the ligaments surrounding the joint, as well as the development of synovitis, i. e. , inflammation of the synovial membrane and the accumulation of inflammatory effusion in the cavity of the hip joint.
• Lameness, which at first is the result of the patient's unconscious desire to reduce the load on the diseased joint and transfer weight to the healthy leg in order to avoid the appearance or intensification of pain, and then the development of muscle contracture. The latter phenomenon occurs already in the later stages of coxarthrosis and leads to the fact that the patient is not able 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 narrowing of the joint space, but also by 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 one hip joint, 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 just be bilateral, but will also differ in intensity. It depends on the degree of destruction of each hip joint.

Degrees 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. At the initial stages of the occurrence of degenerative-dystrophic changes in the hip joint, only episodic pains can be observed. As a rule, this occurs after intense physical exertion, 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, coxarthrosis of the 1st degree is diagnosed only in isolated cases, which usually occurs during an examination for another reason.

As the disease progresses, its symptoms intensify and already with coxarthrosis of the 2nd degree they make themselves felt. This stage of 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 further progression of the pathology, the joint space narrows even more and with the 3rd degree of coxarthrosis is almost completely absent. This is already accompanied by the formation of multiple osteophytes. At this stage of the development of the disease, the pain becomes not just 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 infringe on the nerves passing here, which leads to pain radiating to the groin, buttocks, as well as the thigh and even the lower leg. This also provokes the inability to move independently without the use of assistive devices, such as crutches or canes.

Coxarthrosis of the 3rd degree is a direct indication for surgical treatment. If the operation is not performed on time, the femoral head will firmly fuse with the surface of the acetabulum with osteophytes. This will lead to a shortening of the leg, the complete absence of the possibility of independent movement, since the joint will completely lose mobility, i. e. , to disability.

Diagnostics

If signs of coxarthrosis occur, 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 to the examination and performance of 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 diseases of the hip joints, 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 degree of its development, which means choosing the most effective treatment tactics.

Today for the diagnosis of coxarthrosis are used:

• X-ray of the hip 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 highly informative method for examining joints, 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 number of laboratory tests, including KLA, OAM, rheumatic tests, biochemical blood tests, and others.

Conservative treatment of coxarthrosis

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

As part of the treatment of coxarthrosis, 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, he 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 special bandages and orthoses that will fix the hip joint and unload it during physical exertion.

Medical therapy

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

• NSAIDs - an extensive 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 form of application);
• corticosteroids - drugs that have a powerful 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 deal with muscle spasms, often observed in coxarthrosis;
• chondroprotectors - a group of drugs containing components used by the body for the regeneration of cartilage tissue;
• preparations that improve microcirculation - help to improve the nutrition of soft tissues and activate the course of metabolic processes in the affected area;
• B vitamins - are indicated for disorders of nerve conduction 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 periarticular 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 carried out by a qualified health worker in a specially prepared room. Performing such procedures at home is not shown.

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 concomitant diseases (special attention is paid to cardiovascular pathologies).

Thanks to daily exercise therapy, you can:

• reduce the severity of pain;
• increase the mobility of the hip joint;
• reduce the risk of muscle atrophy;
• eliminate spasms of the thigh muscles;
• activate blood circulation and thereby improve the nutrition of the affected joint.

All exercises should be performed smoothly, avoiding sudden movements and jerks. But if pain occurs during exercise therapy, you should definitely contact your doctor in order to correct the selected complex or conduct a re-diagnosis to exclude the progression of the disease and the need for an operation.

Physiotherapy

Comprehensive treatment of coxarthrosis involves 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;
• magnetotherapy;
• laser therapy, etc.

Recently, plasmolifting has been increasingly used as part of the conservative treatment of coxarthrosis, which can significantly increase the speed of the 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 powerless. Unfortunately, such situations are extremely common today, since a very large number of patients seek medical help when they can no longer endure pain or have serious mobility restrictions that deprive them of their 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 the joint space by more than 80%;
• the presence of severe pain in the hip joint, which cannot be eliminated;
• pronounced mobility disorders;
• fracture of the femoral neck.

The gold standard for the treatment of severe coxarthrosis, including in the elderly, is hip arthroplasty. This operation involves the replacement of 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-fledged 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 need to prepare the surface of the acetabulum for the installation of the endoprosthesis, i. e. , remove all the formed osteophytes and achieve the maximum restoration of its normal shape. After that, an endoprosthesis of the selected type is installed, which is fixed with a special cement (preferably for the treatment of the elderly) or in a cementless way. In the latter case, the endoprosthesis has a special spongy part in contact with bone structures. Its fixation in the acetabulum is provided by the germination of bone tissue through the sponge.

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

If the patient has the preservation of normal hyaline cartilage on the surface of the acetabulum, he can undergo partial arthroplasty with the replacement of only 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 rate of tissue repair. As part of the recovery, exercise therapy, physiotherapy and therapeutic massage are prescribed.

Prior to 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 the fixation of the bone 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 carried out.

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 rather dangerous disease, which can result in disability. It seriously reduces the quality of life and deprives a person of working capacity. But if you pay attention to the early signs of pathology and get advice from an orthopedist in a timely manner, you can slow down its progression and achieve a significant improvement in well-being. But with already running 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.