Conservative therapy: medications and local management
The basis of conservative management for patients with osteoarthritis is improving the properties of the synovial fluid, relieving inflammation, and reducing pain. Normally, hyaluronic acid ensures the viscoelasticity of the synovial fluid. In osteoarthritis, its concentration and molecular size drop, which impairs cartilage nutrition.
Intra-articular injections of exogenous hyaluronic acid are pathogenetically justified:
- First generation: low molecular weight, persists in the joint for about two days.
- Subsequent generations: high molecular weight, retained from 5 to 15 days.
- Latest generation: molecular weight close to native, half-life is about 4 weeks (administered once a year).
The drugs are used in courses (usually 3–5 injections) strictly in the absence of synovitis. Technique violation and paraarticular drug administration lead to exacerbation.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for rapid relief of exacerbations. However, their long-term intake is undesirable. Complex homeopathic remedies serve as an alternative. For example, the drug Traumeel S has a pronounced anti-inflammatory effect, while Zeel T is prescribed for chondroprotective purposes. A typical pain relief regimen: 3–5 days of NSAIDs followed by oral Traumeel S for 3–4 weeks. Also, in the acute phase, counterirritants (menthol, capsaicin, turpentine) are applied locally, but only briefly to avoid skin irritation.
Minimally invasive surgery: arthroscopy and chondroplasty
Surgical treatment is most often required for lesions of the lower extremity joints (coxarthrosis, gonarthrosis, first metatarsophalangeal joint involvement). Arthroscopy allows intra-articular manipulations to be performed without arthrotomy (opening the joint).
Main arthroscopic techniques:
- Joint cavity lavage: fluid irrigation to remove aggressive enzymes, microscopic cartilage fragments, and loose bodies.
- Joint debridement: excision of scars, damaged menisci, and non-viable cartilage using shavers, lasers, or cold plasma.
Arthroscopic chondroplasty, the goal of which is cartilage tissue restoration, is considered the most pathogenetically justified. It includes:
- Mechanical treatment of subchondral bone (abrasive plasty down to "bloody dew", tunneling, microfractures).
- Mosaic chondroplasty (transfer of osteochondral plugs from non-weight-bearing areas to the defect zone).
- Cellular technologies (implantation of autologous chondrocytes cultured in vitro).
Radical surgical interventions
When articular surfaces are significantly destroyed or biomechanics are disrupted, more extensive surgeries are employed.
Osteotomy is used to redistribute the load on the joint. It is relevant in the absence of severe bone deformations. The use of modern internal fixation devices allows early weight-bearing without casting.
Arthrodesis is a disabling surgery that creates bony fusion (ankylosis). It completely deprives the joint of mobility, but radically eliminates pain and restores limb support. It is performed by removing cartilage remnants down to well-perfused bone. Arthrodesis is rarely used in major joints due to resulting disability, but remains the method of choice for small joints of the foot.
Joint replacement (replacement arthroplasty) has replaced arthrodesis in major joint surgery. Complete (total) or partial (hemiarthroplasty) joint replacement with an artificial implant reliably relieves pain. Modern prostheses last over 10–15 years, after which revision surgery is possible. Thanks to minimally invasive approaches and computer navigation, joint replacement has become accessible even to elderly patients with severe comorbidities.
Class and exam questions
In which cases is intra-articular administration of hyaluronic acid strictly contraindicated?
Administration of hyaluronic acid preparations is strictly contraindicated in the presence of clinical signs of synovitis (inflammation of the synovial membrane with effusion).
What is the essence of joint lavage?
This is the irrigation of the joint cavity with a continuous stream of fluid to mechanically wash out aggressive enzymes, cartilage breakdown products, and loose joint bodies.
Why is arthrodesis predominantly used on small joints?
Arthrodesis leads to complete immobilization (ankylosis). For major joints, this causes severe disability, whereas the loss of mobility in one of the small joints of the foot does not critically affect overall limb function.
What else to study on this topic
- Technique and instruments of arthroscopic debridement (shaving, ablation).
- Comparative characteristics of hyaluronic acid drug generations.
- Biomechanical principles of osteotomy (valgus, McMurray).
- Features of revision arthroplasty and types of component wear.
- Mechanisms of action of homeopathic drugs in the alternative therapy regimen.
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