atrozele final
DESCRIPTION
artroze floreascaTRANSCRIPT
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(ARTROZELE)
Conf. Dr. Popescu Gheorghe
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Boala artrozica= grup de afectiuni de etiologie si patogenie plurifactoriala ce
determina distrugerea cartilajului articular si a osului subcondral
= caracterizata prin:
A. pierderea progresiva a cartilajului articular prin:
- deteriorare in zonele de sprijin
- abrazare
B. tentativa de reparare a leziunilor cartilaginoase:
- remodelarea si scleroza osului subcondral
- formarea chisturilor subcondrale
- formarea osteofitelor in zonele de descarcare
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=boala non-inflamatorie, degenerativa, caracterizata prin:
A. clinic:- durere- deformare si marire de volum- limitarea mobilitatii articulare
B. patogenie: dezechilibru intre degradare si sinteza la nivelul cartilajului si osului subcondral:
- leziuni destructive cartilaginoase- scleroza subcondrala- chiste osoase - osteofitoze
C. terapeutic:- saracia agentilor curativi specifici
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Epidemiologie
• Varsta
- incidenta creste cu varsta, maximum intre 55-75 ani
• Sexul
- artrozele interfalangiene sunt mai frecvente la femei
- coxartroza este mai frecventa la barbati > 65ani
• Rasa
- mai frecventa la caucazieni
• Profesia
- artroza gleznelor la balerini
- artroza metacarpofalangiana la luptatori
• Greutatea corporala
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Articulatiile sinoviale - structura
• Capsula ligamentara - formata din fibre de colagen tip I
• Membrana sinoviala - captuseste pe interior capsula ligamentara
• Cartilaj articular - acopera cele 2 oase ce participa la formarea articulatiei
• Lichid sinovial < 2 ml
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Cartilajul articular
• 2 functii esentiale:
1. Transmiterea incarcaturii mecanice de la un os la celalalt2. Asigurarea unei suprafete netede autolubrifiate pentru ca oasele sa
alunece in interiorul articulatiei
• avascular– nutritia este asigurata de lichidul sinovial prin difuziune
• alimfatic• aneural – durerea artritica este determinata de activarea receptorilor
din capsula ligamentara si alte structuri periarticulare
• hipocelular
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Cartilajul articular
a) Condrocite - sintetizeaza proteoglicani, colagen, enzime catabolice (colagenaze, proteaze, catepsina D), acid hialuronic
- responsabile de procesul continuu de remodelare interna
b) Matrice extracelulara - hiperhidrata - apa se afla in schimb liber cu lichidul
sinovial- formata in special din proteoglicani si colagen de tip II,
care impreuna cu apa formeaza un gel- mai contine: hidroxiapatita, matrice proteica necolagenica,
colageni de alte tipuri, lipide, acid hialuronic si alte zaharide, condronectina
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COLAGENUL
- cartilajul articular contine in special colagen de tip II, VI, IX, X, XI
- colagenul de tip II - reprezinta 90-95% din colagenul articular
- condrocitele sintetizeaza si excreta un precursor (protocolagen), dar fibrogeneza are loc extracelular
- triplu helix - la suprafata caruia se gasesc fibre de colagen IX ce leaga fibrele de colagen II intre ele, prin intermediul proteoglicanilor
- in interior sunt legate cantitati mici de colagen XI - restul tipurilor de colagen sunt distribuite in matricea
extracelulara
ACIDUL HIALURONIC = HA- polizaharid sintetizat de condrocite si sinoviocite tip B- se gaseste in - matricea cartilaginoasa
- lichidul sinovial (rol de lubrefiere) – HA cu greutate moleculara mare, in concentratie de 2-4 mg/ml
- functioneaza ca proteina de legatura pentru stabilizarea macromoleculelor de proteoglicani
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PROTEOGLICANII- molecule hidrofile alcatuite dintr-un centru proteic la care se ataseaza
glicozaminoglicani - acid hialuronic - condroitin sulfat –
predomina - keratan sulfat - dermatan sulfat
- sarcinile electrice negative ale GAG atrag cationi => osmolaritate inalta => retin apa in cartilaj
- cartilajul articular contine 2 clase majore de proteoglicani:A. Aggrecani = proteoglicani agregati cu acid hialuronic
- in cartilajul normal sunt comprimati pana la 1/5 din volumul lor potential = au tendinta la umflare- contribuie la - fixarea proteoglicanilor in matrice – previn deplasarea lor in timpul deformarii tesutului
- organizarea si stabilizarea legaturii dintre proteoglicani si reteaua de colagen- hidratarea lor confera rezistenta si elasticitate cartilajului => faciliteaza functia de purtator de greutate
B. Proteoglicani mici - biglican-decorina- fibromodulina
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Structura cartilajului hialin
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Teorii etiopatogenice
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COXARTROZA
A. PRIMARE (idiopatice)
B. SECUNDARE1. Tulburari de statica articulara cu afectarea mecanicii articulare
- Malformatii congenitale – displazia luxanta de sold, coxa antetorsa/ vara congenitala/ valga congenitala
- Deformatii coxo-femurale castigate – posttraumatice, artrite infectioase, necroza aseptica de cap femural
2. Afectiuni cu alterarea sinoviei si cartilajului articular
- coxite, sinovite, hemofilia
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Simptomatologie
1. DUREREA
- sediul: in trigonul femural
- iradiaza spre genunchi
- de tip mecanic
2. LIMITAREA PROGRESIVA A MOBILITATII ARTICULARE
- Initial sunt afectate miscarile de rotatie interna, abductie si extensie
3. ATITUDINEA VICIOASA- initial: determinata de contractia antalgica a musculaturii
periarticulare, urmata apoi de retractii si fibroza - Flexie, adductie si rotatie externa
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Examen obiectiv
1. INSPECTIE- pozitia vicioasa a membrului inferior- hipotrofia musculaturii periarticulare + cvadriceps
2. BILANTUL ARTICULAR AL SOLDULUI
- evidentiaza amplitudinea miscarilor articulare active si pasive
3. MASURAREA LUNGIMII MEMNRELOR INFERIOARE
- scurtare aparenta/ reala
4. STUDIUL MERSULUI
- schiopatat – bolnavul scurteaza timpul de sprijin pe piciorul afectat
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Examen radiologic
1. PENSAREA SPATIULUI ARTICULAR
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Examen radiologic
2. OSTEOFITOZA
- la nivelul acetabulului sau la nivelul
femurului
3. MODIFICARILE OSOASE
- Osteoscleroza subcondrala = condensare osoasa in zona portanta a tavanului acetabular
- Geode = apar in zonele portante ale capului femural si acetabul
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Examen CT
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COMPLICATII
- bilateralizarea afectiunii
- protuzia acetabulara a acpului femural
- supraponderabilitatea – stil de viata sedentar
- afectarea coloanei lombare si genunchiului de aceasi parte
- fractura extremitatii proximale a femurului
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TRATAMENT1. Terapia fizica si kineterapia
2. Farmacologic
- Analgezice
- Corticosteroizi intraarticular
3. Chirurgical
- Osteotomii de corectie la nivelul soldului sau femurale
- Artrodeze
- Artroplastii
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Osteotomii de corectie la nivelul soldului
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Artroplastii
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Artroplastii
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Artroplastii
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Artroplastii
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Artroplastii
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GONARTROZA
- mai frecventa la femei
- rezultatul unui dezechilibru functional intre
rezistenta structurilor articulare si tensiunile la care
acestea sunt supuse
- debut insidios – este mai bine tolerata decat
coxartroza
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Anatomie patologica• cartilaj- eroziuni, fibrilari- clumping condrocitar• os subcondral:- condensare, osteoscleroza- chiste osoase (geode)• osteofite- raspuns profilativ in zonele
de descarcare• capsula articulara:- sinovita - fibroza capsulara - retractii
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Simptomatologie
1. DUREREA- sediul: regiunea interna a genunchiului, spatiu popliteu sau subrotulian- iradiaza spre coapsa sau gamba- de tip mecanic
2. SENZATIA DE INSTABILITATE A GENUNCHIULUI AFECTAT
- datorat pierderii bruste a constrolului muscular a stabilitatii genunchiului
- initial la miscari bruste, apoi la orice denivelare de teren
- determina impotenta functionala
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Simptomatologie
3. PSEUDOBLOCAJUL ARTICULAR - dupa pastrarea indelungata a aceleiasi pozitii
4. TUMEFIEREA GENUNCHIULUI- apare dupa efort, dispare in repaus- se datoreaza revarsatului intraarticular
5. CRACMENTE ARTICULARE
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Examen obiectiv
1. INSPECTIE
- tumefactia articulatiei
- hipotrofia musculaturii coapsei
- chist popliteu Baker
2. SEDIUL DURERII PROVOCATE
3. EXAMENUL MOBILITATII GENUNCHIULUI
- evidentiaza cracmente articulare sau subluxatia externa
a rotulei
4. EXAMENUL DEVIATIEI AXIALE
5. EXAMENUL MERSULUI
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Gonartroza grava bilateralaGenu valgum dr., genu varum stg.
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Examen radiologic
1. Rx STANDARD
- fata + profil
2. Rx AXIALA DE ROTULA- evidentiaza eventuale anomalii – displazii rotuliene,
luxatii/subluxatii recidivante- Stabilesc importanta modificarilor artrozice
3. Rx IN POZITII DINAMICE – genu varum/valgum
4. Rx INTREGULUI MEMBRU INFERIOR IN ORTOSTATISM
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Explorari paraclinice
1. ARTROSCOPIA
2. SCINTIGRAFIA
3. CT
4. RMN
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Clasificarea Ahlbäck
2 4 pensare incompleta pensare completa uzura osoasa 5-10mm uzura osoasa > 10mm
1
3
42 5
Uzura osoasa < 5 mm
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TRATAMENT
1. MIJLOACE NEFARMACOLOGICE
- educarea pacientilor pentru evitarea sporturilor agresive, etc.
- Fiziokinetoterapie + hidrokinetoterapie
2. MIJLOACE FARMACOLOGICE
- Corticosteroizi intraarticular
- Analgezice – opioide/ neopiacee/ topice
- AINS
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TRATAMENT
3. CHIRURGICAL
- Osteotomii de corectie la nivelul tibiei sau femurului
- Artrodeze
- Artroplastii
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Osteotomia juxtaarticulara de corectie in gonartroza unicompartimentala mediala
Osteotomii de corectie
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Osteotomie juxtaarticulara pentru genu valgum patologic de cauza femurala
Artroza compartimentului lateral
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Proteza GSB
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Proteza unicompartimentala genunchi
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Les indications dépendent de l’importance de la destruction
Prothèse contrainte Prothèse à glissement
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Gonartroza cu genu varum
grav Ahlback IV