Head of the department of traumatology and orthopedics of the Bogomolets National Medical University MD, professor A. A. Buryanov

1. Theme:
«Degenerative - dystrophic diseases of
joints».
Head of the department of traumatology and orthopaedics
of the N M U named after.O.O Bogomolets,
Doctor of Medical Science, professor A. A. Buryanov

2. Сlinic-roentgenologic classification:
1. deformative arthrosis
2. aseptic osteonecrosis
3. cystic alteration of bones

3. metabolic,
endocrinal
immunal status
Functioning of an articulate
cartilage depends from :
synovial membrane,
which producing
synovial fluid
Ecological factors biomechanical loadings
influence
subchondral bones
(subchondral plate, bone
trabecula, intertrabecular
space, vascularization)

4. Disorders of synovial
membranes are
results
Disturbances of an articulate
cartilage is shown:
Disorders of subchondral
bones is resulted
• in change of a feed of a cartilage
• failure of structure and viscosity
synovial fluid
• fibrosis
• synovitis
• change of function chondrocytes,
•biosynthesis proteoglycanes,
•biosynthesis of collagen
•in change of a cartilage,
• discongruence of articular
surfaces,
•to change vascularization,
•with loss of durability
«deformative arthrosis»

5. Who is prone to get osteoarthritis?
• Middle-aged patients (Age more than 40 years)
• Women have a greater tendency than men
• One in three people over 60 years are affected and
more than three in four persons over the age
of 70 show some radiographic evidence of the condition
• Very rarely it can be seen in younger people

6. Classification osteoarthritis
Osteoarthritis (deformative arthrosis)
primary secondary osteoarthritis spine
the causal factor
it is not possible
to make
Genetically caused
(heredity)
Generalized form
(disorders of metabolic processes)
Local (dysplasia, an inflammation
(Rheumatoid arthritis , TB )
Trauma -intra-articular fractures ,
diabetes,
Overuse of intra-articular steroid therapy
intoxication)

7. the European Association of Rheumatologists
Classification osteoarthritisClinical forms
Monoosteoarthritis
Oligoosteoarthritis (lesion of two and more joints)
Polyosteoarthritis (lesion of three and more articulate groups)
Localization
Osteoarthritis knee
Osteoarthritis hip
Synovitis
1. With synovitis
2. Without synovitis
Radiological stage (for J.Kellgren and Lawrence): 0, I, II, III, IY
Functional ability of the patient (Functional insufficiency of joints)
1. Work capacity is temporarily limited
2. Work capacity no
3. The patient requires assistance
Joint of the hand
Joint of the foot
Spine
other

8. How to make a diagnosis - osteoarthritis?
• Symptomatology
Instrumental diagnostic methods:
1. Radiography , basically DS- hallmark (signs) :
Radiological stages for Kellgren и Lawrence: 0, I, II, III, IY
Loss of joint space (due to destruction of articular cartilage).
Subchondral osteosclerosis (due to increase cellularity and bone deposition).
Osteophytes (due to revascularisation of remaining cartilage and capsular traction).
2. Arthroscopy – direct visual research of a cavity of a joint
« The Gold standard »
3. Arthrosonography
4. MRI : noninvasive, informative, harmless
Laboratory diagnostics
-Biological markers in synovial liquids:
ceratansulfates,  chondroitinsulfates (CS),  proteoglycane,  СS4/СS6,
 protease,  С-propeptide of collagen II type,  fibronectin,  cytokines,
 hyaluronidasum of serum
- Blood tests
immunological markers: antibodies to collagen, CS
• Physical examination

9. Stage1Prearthrosis
Stage2 Arthrosis
Stage3 Osteoarthrosis
Stage4 arthroso-arthritis
The department of traumatology and orthopaedics
of the N M U named after.O.O Bogomolets
Classification deformative arthrosis
(osteoarthritis)

10. Stage1 Prearthrosis
No radiology changes are seen.

11. Stage2 Arthrosis
Radiological features of the unicompartmental osteoarthritis knee:
Loss of joint space more 25% (due to destruction of articular cartilage)
Subchondral osteosclerosis medial compartment of the knee .

12. Stage 3 Osteoarthrosis
Loss of joint space( >75% ) medial compartment of the knee
Subchondral osteosclerosis
Osteophytes

13. Stage4 arthroso-arthritis.
Deformity, usually genu varum.

14. Stage 4 arthroso-arthritis
Osteophytes
(due to revascularisation of remaining
cartilage and capsular traction).
↑↑↑ Loss of joint space , but
Not ankylosis never

15. Sonography of the knee
Longitudinal scanning in frontal plane
Cross-section scanning in sagittal plane
Anatomical structure of knee joint

16. Stage 1- 2
Medical- diagnostic
arthroscopy of the knee
•«lavage»
•»debridment»
•«osteochondroplasty»

17. MRI and CT scan also helps to
diagnose, subchondral cysts,
osteophytes, etc.

18. Purpose of Treatment
ﾷ To slow down progressing osteoarthritis
ﾷ To reduce a pain
ﾷ To increase functional activity

19. Treatment
Conservative methods:
• Reduction of weight.
• Non-steroidal anti-inflammatory drugs (NSAIDs) and
muscle relaxants.
• Antiosteoarthritis preparations
• The preparations improving microcirculation
• Intra-articular injections of steroids (not more than 2
recommended, local anaesthetic is avoided for fear of
developing neuropathic joint).
• Antioxidizer therapy: vitamin Е
• Local application of ointments, gels, aerosols with NSAIDs
• Rest, walking exercises, massage, traction, isometric
exercises..
About 50 per cent of patients respond to conservative treatment

20. chondroitinum sulfate (Struktum)
•glucosaminm sulfate (Dona - 200-S)
• Preparations hyaluronic acids (Gyalganum)
• Non-saponifying substances of an avocado and a
soya
•Diacyreinum (ART - 50)
Slowly acted (effectived) preparations
for treatment (chondroprotectors,
chondromodulators)

21. Surgical Methods
1. tear meniscus → meniscectomy,
joint instability (tear ligaments) → reconstruction
ligaments
2. Excision of osteophytes is rarely done alone.
3. Excision of loose bodies
4. joint debridement are best done by arthroscopy.
5. osteotomy
6. Total arthroplasty

22. Arthroscopy – direct visual research of a cavity of a joint
« The Gold standard »
Lavage of knee joint

23. joint
debridement are best
done by arthroscopy.
Debridement

24. correction
62%
Varus or valgus deformity,
unicompartmental osteoarthritis knee
with pain
Indicated Proximal tibial osteotomy
(Slocum's) or Distal femoral osteotomy

25. Deformity correction.
Osteotomy for hip
after operation
Varus osteotomy
Valgus osteotomy
Displacement osteotomy
(Mc Murray's)

26. In the late stages of osteoarthritis, in elderly and in restriction
of flexion less than 70°
The choice is total hip replacement (arthroplasty )

27. Total hip replacement

28. Total knee arthroplasty
This is indicated when both the compartments of the knee joint
are destroyed or if valgus or varus deformity is more than 15°.

29. Synonyms and related keywords:
aseptic necrosis,
avascular necrosis,
ischemic necrosis
•traumatic (the most common form)
•atraumatic.
Osteonecrosis
vascular etiology

30. Classification aseptic necrosis
Aseptic necrosis
primary secondary
idiopathic (1/3)
the causal factor
it is not possible
to make
Genetically caused
(heredity)
Local (dysplasia)
Trauma -intra-articular fractures
Diabetes,
Overuse of intra-articular steroid therapy
Chronic intoxication - alcohol abuse.
Coagulopathies, hyperlipidemia,
thyroid disorders.

31. Steroid-induced osteonecrosis often involves multiple bones,
in the case of the hip, results in nearly 100% bilateral involvement
Osteonecrosis associated with alcohol abuse usually occurs
in those who drink more than 400 mL of alcohol per week.
Male-to-female ratio is about 4:1
At least 50% of patients with atraumatic hip osteonecrosis
are thought to have bilateral involvement

32. Classification of aseptic necrosis
of head of thigh-bone.
1 stage - stage of the initial phenomena
2 stage - stage of compressive fracture
3. stage - stage of secondary arthrosis
4. stage - stage of output

33. Necrotic focus in anterosuperior part of head
hearths of osteoporosis and osteosclerosis.

34. normal-looking cartilage over the necrotic segment

35. The peripheral portion - fibrovascular zone
devoid of fat cells.
Osteonecrosis Histological pattern
necrotic segment

36. MRI
Sensitivity and specificity is greater
than 98% 1stage,
MRI should be performed in all
patients of osteonecrosis
to assess the extent of the disease.

37. Contours of head are broken due to an compressive necrotic
focus in anterosuperior part which most loads up, focus necrosis
differentiates distinctly due to increased roentgenologic density
around the area of osteolysis and reactive sclerosis, considerable
regional bone fragments.

38. Histological pattern
subchondral fracture

39. Subchondral fracture

40. Focus of necrosis differentiates distinctly, surrounded by the area
of osteolysis and sclerosis. The focus of necrosis is fragmented.
Signs of secondary arthrosis

41. regional bone excrescences appear, uneven narrowing
of joint crack, the changes of contours of head

42. Joint slit is narrowed significantly. Saddle like deformation of head,
there are considerable regional bone excrescences.

43. Conservative methods: 1 stage
which consists of the following measures.
•Reduction of weight (extension – 5 kg,. crutchs)
•Non-steroidal anti-inflammatory drugs (NSAIDs)
• muscle relaxants.
The preparations improving microcirculation
(nifedipine ,trental, curantil, reopoliglucin)

44. Decompression of intraosseous space –
lower interosseous pressure.
Core decompression and cancellous and cortical
bone autografting procedures 1 stage.
Correction osteotomy 2 stage
Surgical Methods
Total hip replacement ( arthroplasty ) – 3-4 stage

45. bone marrow harvesting and
Now
are done percutaneously
This centrifuging technique yields
a “concentrated myeloid
suspension”
reinjection,
in the treatment
of ONFH by bone
marrow autograft
Necrotic segment is monitored with fluoroscopy.

46. Cement injection technique:
The collapsed segment is lifted, and cement is injected
into the subchondral zone and below the segment.

47. Displacement
osteotomy
(Mc Murray's)
Correction osteotomy
.

48. Total hip replacement ( arthroplasty )

49. Cystlike alteration
beginning of formation of cyst.
1. stage –
origin of single cysts

50. 2 stage - expansion and confluence of cysts in a focus;
3. stage - breach of cysts in a joint cavity, deformation
of joint surfaces.

51. single cysts

52. Tunneling, excochlietion of necrotic focus of head and
autoplastic bone graft with spina illiaca - 1 stage
Surgical Methods
Total hip replacement ( arthroplasty ) – 2-3 stage

53. Thanks for attention!