Arthritis is the damage of articular cartilage. There are several types of arthritis: osteoarthritis or degenerative arthropathy, post-traumatic arthritis, inflammatory arthritis, arthritis caused by lens deposition, seronegative arthritis, infectious arthritis and other types. Osteoarthritis is the most common type. 2
Osteoarthritis, or degenerative arthropathy, is the most common of all arthritis. Its incidence increases exponentially with age; People over 65 years old, 80%~90% will suffer from arthritis. Other causes of secondary arthritis include obesity, hemochromatosis, xanthosis and Ehrlich-Dane syndrome.
Middle-aged and elderly people are prone to primary or idiopathic arthritis, and young people are prone to secondary arthritis after trauma.
Age, strain from excessive activity, trauma (ankle fracture accompanied by rotating external force, unstable ankle), poor or untimely reduction of joint fracture and dislocation (so-called traumatic arthritis), overweight.
Secondary to ankle injury, too long fixation time and insufficient functional exercise, the physiological pressure to stimulate cartilage deficiency is insufficient.
Fracture malunion or developmental deformity
Rheumatoid arthritis is the most common, and its typical inflammatory lymphoid follicles lead to pannus formation and cartilage and subchondral bone destruction. Psoriatic arthritis can also affect the ankle joint and its surrounding skin and soft tissue. Metabolic lens arthropathy, such as gout or pseudogout (pyrophosphate arthropathy), can lead to acute and recurrent ankle arthritis. Inflammatory mediators and hyperplastic synovium can cause irreversible damage to articular cartilage surface. Suppurative arthritis and osteomyelitis may have the same failure mode, leading to the degeneration of the affected joints. Proteolytic enzymes, increased intra-articular pressure and nutritional deficiency eventually lead to the destruction of articular cartilage. In hemophilia patients, repeated joint hematocele will lead to chronic inflammation of synovium, and finally affect the integrity of joint itself through enzyme digestion. six
Pathological features: articular surface destruction 6.
Articular cartilage plays an important role in joint function. These cartilage surfaces are protected by two main stabilization mechanisms: the punctate bone structure around talus and the ligament structure that supports and connects the distal ends of tibia and fibula with the hind foot. six
The disease is characterized by the inherent defects of chondrocytes and the cartilage matrix produced by them. Microscopically, the normal smooth cartilage surface appears cracks and thinning. The synovium becomes fibrotic and congested, accompanied by chronic inflammatory cell infiltration. After repeated mechanical injury, articular cartilage fragments will fall into the joint and form a free body. Gradually, the subchondral bone is exposed, forming a polished ivory bone surface. There will be cracks in the bones, which will cause synovial fluid of joints to penetrate into the joint surface and form subchondral capsule. Osteophytes form around the joints. These cartilage and bone injuries lead to limited joint movement, pain and limited function. 2
1. articular cartilage injury and degeneration
2. Synovitis
3. Hypertrophic osteophyte
4. Tenosynovitis of tendon around ankle
Causes of joint pain
1. The stimulation of peripheral nerves to nerve endings is the main cause of osteoarthritis pain;
2. Pain also comes from joint capsule and its surroundings, such as muscle spasm around synovial joint, inflammation of ligament or subchondral bone around joint, etc. three
1. joint stiffness: stiffness in the morning, rarely more than 15~30 minutes, mostly related to weather changes.
2. Pain: (Timeline) Pain after exercise → Exercise pain → Rest pain. Deep dull pain.
3. Joint swelling: swelling after standing for a long time in the early stage and getting better in the morning; Late persistent swelling.
4. Signs: diffuse tenderness, joint swelling and limited activity at the joint turnover.
X-ray signs generally suggest shooting the positive, lateral and ankle points of the ankle joint in the weight-bearing position.
The main positive signs: narrowing of joint space (asymmetry), subchondral sclerosis and cystic change, osteophyte formation, joint loose body and force line changes.
End-stage arthritis is grade ⅳ arthritis.
Clinical manifestations combined with imaging examination can make a diagnosis.
Symptoms are not positively correlated with the results of X-ray examination.
When the ankle is complicated with other diseases, it may also cause pain; It is feasible to inject lidocaine (5ml) into ankle joint for differential diagnosis. If the pain disappears, it should be attributed to the disease of ankle joint.
The classic injection method is to inject about 5 ml of 1%-2% lidocaine (without adrenaline) 6 through anterolateral (lateral third fibula) or anterolateral (medial tibialis anterior tendon) route.
Non-surgical treatment mainly focuses on eliminating or alleviating pain, improving joint mobility, increasing joint stability and preventing deformity.
1. Rest: In case of acute joint inflammation, stay in bed;
2. Reduce the load: use walkers and straps to lose weight.
3. Traction and strengthening muscle strength exercises around joints
4. Physical therapy, hot compress and massage
5. Drugs:
5. 1 Analgesics: non-steroidal anti-inflammatory drugs (side effects: inhibition of prostaglandin and platelet aggregation)
5.2 Glucocorticoid: Intra-articular injection of glucocorticoid 4 is feasible for severe OA patients who are unresponsive to NSAIDs for 4-6 weeks, or who are intolerant to NSAIDs, with persistent pain and obvious inflammation. When osteoarthritis has obvious synovitis and swelling of joint effusion, intra-articular injection can achieve rapid and good results. Intra-articular injection of long-acting glucocorticoid can relieve pain and reduce exudation, and the curative effect lasts for weeks to months. However, the injection should not react in the same joint, and the injection interval should not be shorter than April to June 5. Taboo: ① local or systemic suppurative infection; ② Diabetes, tuberculosis and hypertension; ③ Multiple joints have severe arthritis symptoms.
5.3 Hyaluronic acid, glucosamine and chondroitin sulfate.
Takakura's grade is above grade 2, but after systematic conservative treatment, it is ineffective, and the pain symptoms are getting worse. When joint function is seriously affected by movement disorder, deformity and joint disorder, surgery is recommended.
The main surgical methods are: hyperplastic inflammatory synovial excision, osteophyte excision, free body excision, articular cartilage repair, joint distraction, arthroplasty, and focal extra-articular osteotomy caused by correcting joint force line deviation. For severe end-stage osteoarthritis, artificial joint replacement or ankle joint fusion is feasible.
1. Joint debridement: Remove thickened synovial tissue, damaged or detached cartilage fragments or osteophytes. It is suitable for ankle osteoarthritis with symptomatic intra-articular loose bodies, symptomatic joint fibrosis, symptomatic osteophyte or cartilage defect in 1 and 2 stages. During arthroscopy, we should pay attention to cauterizing the bone wound of osteophyte with electrocautery or radio frequency to prevent the regeneration of osteophyte.
2. Articular cartilage surface repair. It is suitable for ankle osteoarthritis with articular cartilage destruction within stage 3. If the cartilage surface injury is too deep and the area is small, or exfoliative osteochondritis can be treated by micro-fracture (that is, drilling several holes in the bone marrow cavity with 1mm steel needle or drill bit), so as to grow granulation tissue and generate articular chondroid tissue, and the ankle joint should be moved early after operation (Rui Lin: When? )。
3. Joint retraction. After the pressure on ankle joint surface is reduced, articular cartilage has certain self-repair ability; At this time, the fluid pressure in the joint cavity can be restored, and subchondral sclerosis can be gradually reduced. It is suitable for traumatic arthritis of teenagers or young patients with narrow joint space and osteophyte or not; Patients with almost complete disappearance or deformation of joint space. External fixators are generally used.
4. Cartilage transplantation. Autologous cartilage is mostly taken from the non-load-bearing knee surface. Mosaic bone grafting was used.
5. Surgery to change joint load. Including muscle relaxation, transfer to balance muscle strength around ankle joint and osteotomy.
6. Artificial joint replacement.
Indications: Elderly patients with severe degenerative osteoarthritis, severe pain, difficulty in bearing weight, ineffective after the above treatment, and low requirements for physical activity. Light weight and little activity.
Tip: Pay attention to adjusting the force line.
Disadvantages: Prosthesis failure.
Ankle prosthesis: Inbone total ankle prosthesis (the only one in China) [7].
7. Ankle fusion and fixation.
Principle: large area of healthy cancellous bone bleeding, compression of fusion site and strong internal fixation. The fusion position of tibiotalar joint is still the most important factor to reduce the related problems after fusion. The best fusion position is flexion-extension neutral position and 5 degrees valgus of hind foot. It should also keep 10 degree external rotation, or be symmetrical with the contralateral ankle joint (if the contralateral ankle joint is not involved). Slight receding of the talus relative to the distal tibia can reduce the tendency to form an arched gait, thus contributing to biomechanical fusion. Generally speaking, patients need to bear weight for 6 weeks after operation, and then use walking braces for 4 ~ 6 weeks. Then use walking plaster boots until satisfactory bone and clinical healing are achieved. six
Disadvantages: After fusion, the joints around the ankle joint will undergo secondary degeneration.
1. Foot and Ankle Surgery (2nd Edition), edited by Wang Zhengyi, P36 1-370.
2. Mann's Foot and Ankle Surgery (9th Edition)
3. Zhao Liang (Southern Hospital of Southern Medical University) graded diagnosis and treatment of osteoarthritis (good medical skills)
4. Guidelines for diagnosis and treatment of osteoarthritis (2007 edition)
5. Guidelines for diagnosis and treatment of osteoarthritis by Rheumatology Branch of Chinese Medical Association, Chinese Journal of Rheumatology, 20 10, 14(6)
6. Essentials of Foot and Ankle Surgery (Second Edition)