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Boala ArtrozicaBoala Artrozica
Prof.Univ.Dr. Prof.Univ.Dr. Mihai V. PopescuMihai V. Popescu
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Definitie
= boala non-inflamatorie a articulatiilor sinoviale,
caracterizate prin :
A. pierderea progresiva a cartilajului articular prin: - deteriorare in zonele de sprijin- uzare-abrazare
B. tentativa de reparare a leziunilor cartilaginoase:- remodelarea si scleroza osului subcondral- formarea chisturilor subcondrale- formarea osteofitelor in zonele de descarcare
Terminologie:
- osteoarthritis versus osteoarthrosis
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Manifestarile bolii
A. clinic:- durere- deformare si marire de volum- limitarea mobilitatii articulareB. patogenic: alterarea biochimica si structurala prin dezechilibru intredegradare si sinteza la nivelul cartilajului si osului subcondral:- leziuni destructive cartilaginoase- scleroza subcondrala- chiste osoase - osteofitozeC. terapeutic:- saracia agentilor curativi specifici
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Clasificarea artrozelor
Primare (idiopatice)
a. artroza articulatilor periferice
b. artroza coloanei vertrebrale- articulatii apofizeale- articulatii intervertebrale
Secundare:
1. postraumatice:- fracturi articulare- microtraumatisme cronice
(sportivi)
2. dupa boli articulare:- Infectii- Poliartrita reumatoida
3. bolile depunerii de cristale:- pseudoguta (pirofosfat de Ca)- guta (urat de Na)
4. dupa boli metabolice sau endocrine:
- ocronoza- boala Wilson- boala Kashin- Bek- acromegalia- hiperparatiroidism5. dupa boli neurologice:- Tabes dorsalis- diabet zaharat- administrare intraarticulara
de corticosteroizi6. diverse:- displazie osoasa- degeratura
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Clasificarea Collins
OA primare:- grad I - distructie superficiala, fibrilare precoce- grad II - acelasi tip, mai extinse- grad III - pierderea totala a cartilajului in zona portanta
(scleroza osului subcondral, osteofiti) - grad IV - pierderea totala a cartilajului pe zone mari,
neregularitati mari,osteofiti marginali, fibroza capsulara si sinoviala
OA secundare:- posttraumatice- displazice- metabolice- endocrine- postinflamatorii
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Epidemiologie
a. Incidenta bolii creste cu varsta, fiind foarte rara la copil si adultul tanar, ajungand la 2 % sub 45 de ani, 30 % intre 45-64 ani si aproape 70 % peste 65 ani
b. <55 ani distributia bolii este egala intre femei si barbati, intre 55- 75 ani F/B = 2/1
c. > 17% din populatia USA in varsta de peste 65 ani sufera de gonartroza
d. > 12% din femei in varsta de peste 65 de ani sufera de coxartroza
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Factori de riscVarsta:-constituie cel mai important factor de risc-prin el insusi nu determina aparitia OA-diferente intre imbatranire si OA-fibrilatie progresiva in OA-clumping condrocitar in OA-cresterea continut de apa in OA Sexul:-artroza interfalangiana la femei-coxartroza peste 65 ani la barbatiRasa:-frecventa crescuta pentru rasa alba (caucaziana) Profesie:-artroza gleznei la balerini-artroza metacarpofalangiana la boxeri-artroza cotului la lucratorii cu pick-hammerGreutate corporala
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Particularitati structurale ale cartilajului hialin
lipsa vaselor de sange (avascular) lipsa vaselor limfatice lipsa terminatiilor nervoase (aneural) hipocelular lipsa celulelor nediferentiate care sa participe la raspunsul reparator lipsa unei semnificatii imunologice posibilitati de reparare diferite pentru leziunile cartilaginoase fata de
cele osteocartilaginoase
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Structura histologica
lamina splendens zona tranzitionala zona radiala tidemark zona calcifiata
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Compozitia chimica:
- 40% matrice (ECM) + 60% apa
- compusi organici - colagen II 60 % se leaga de PG
- proteoglicani 40% (PG) si aggrecani = PG mici
- ac.hialuronic 1%- compusi anorganici -
hidroxiapatitata
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Structura moleculara:
- o molecula de ac. hialuronic ataseaza 150 monomeri proteoglicani
- exista sarcini fixe negative pe PG (radicali condroitin 4-6 sulfat) - nori de cationi hidratati (Na, K)+ care neutralizeaza sarcinele
negative- lanturile vecine se resping reciproc (rigidizare)- osmoza atrage apa (presiunea >3atmosfere)
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Etiopatogenie
teoria vasculara Trueta (complexul fleboartrozic Krieg, episoade de insuficienta circulatorie)
teoria osteocondrala Axhauser (debut prin alterarea circulatiei in osul subcondral)
teoria morfofunctionala Rutishauser (dezechilibrul functional prin repartitia anormala a presiunilor duce la dezechilibru morfologi)
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Etiopatogenie
teoria mecanica Freeman si Meachim:- fibrele de colagen cedeaza prin rupturi de oboseala- repararea lor nu se poate face (turnover lent)- reteaua se dezorganizeaza (se pierd proteoglicani si
apa)- scade rezistenta cartilajului la stress (fisuri si fibrilare)- raspunsul condrocitar: clumping (aparitia clonelor,
sinteza crescuta GAG)
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Manifestari clinice
durere (de tip mecanic):- prin sinovita - prin microfracturi- prin staza venoasa (nocturna)- prin capsulita si entezita- prin contractura musculara- prin compresie nervoasa redoare articulara:- dupa repaus indelungat- matinala crepitatii deformare articulara mersul patologic scale de apreciere clinica (Harris sau Merle D’Aubigne – Charnley)
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Manifestari clinice
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Explorari paracliniceExamen radiologic:- ingustarea spatiului articular
in zona portanta- osteofitoza marginala- osteoscleroza subcondrala- geode- chisturi osoase- modificarea conturului
suprafetelor articulare
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Examen artroscopic
Examen artroscopic:- cartilaj de consistenta moale - fisuri (fibrilatii) liniare- fisuri scamosate- corpi liberi in articulatie- ulceratii profunde- vizualizare os subcondral
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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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Tipuri de leziuni cartilaginoase
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Diagnosticul diferential
cu osteonecroze- primitive- secundare artropatia neuropatica Charcot sinovita vilonodulara condromatoza sinoviala
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Tratamentul medicamentos
analgezice (paracetamol 1000 mg) AINS (diclofenac, piroxicam, coxibi, nimesulid) corticosteroizi locali (diprophos) condroprotectoare :
• Ateparon (GAG esterificat H2SO4)• Rumalon (GAG din cartilaj bovin)• Cartofen (pentosan de sodiu)• Dona (glucozaminosulfat)• Alflutop (extract din organisme marine)
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Tratamentul medicamentos
• ac. hialuronic (hyalgan) uz intraarticular SYMOADs = symptom modifying OA drugs DMOADs = disease modifying OA drugs
impiedica sau intarzie progresiunea unei leziuni caracteristice OA (distructia cartilajului, osteofitoza, osteoscleroza):
hialuronan, diacetyIrhein, condroitin sulfat, avocado nesaponificabil
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Debridarea articulara (Magnusson)
Metode de regenerare:- foraje Pridie- microfracturi- mozaicoplastie- tractiune (distractie) articulara- interpozitie parti moi- transplant condrocite (Carticell)- factori de crestere- matrice artificiala
Tratament chirurgicalintraarticular
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Tehnica
mozaicplastiei
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Tratamentul chirurgicalmajor
osteotomia juxtaarticulara (corectia axului mecanic)
allogrefa osteocartilaginoasa artrodeza artroplastie
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ARTROPLASTIA CU PROTEZA TOTALA CIMENTATA-Proteza
Charnley
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Protasul™-100, a grit-blasted Titanium Niobium alloy
ARTROPLASTIA CU PROTEZA TOTALA NECIMENTATA
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Artroza femuro-tibiala – compartiment intern clasificarea Ahlbäck
1 2 3 4 Stadiul 1 – pensare articulara incompleta (spatiul articular < 3 mm) Stadiul 2 – pensare articulara completa fara uzura osoasa Stadiul 3 – uzura osoasa mai mica de 5 mm Stadiul 4 – uzura osoasa intre 5-10 mm Stadiul 5 - uzura osoasa peste 10 mm
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2 exemples de destructions cartilagineuse, osseuse et ligamentaire relevant de prothèses contraintes
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Les indications dépendent de l’importance de la destruction
Prothèse contrainte Prothèse à glissement
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Tipuri de proteza de genunchi
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Proteza de revizieProteza primara
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Proteza de revizie - Proteza GSB -
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Proteza de revizie
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VA MULTUMESC !
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Greffe en mosaïque
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evolutia dupa 6 ani
Post op
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