Subchondral Bone Cyst: Symptoms, Causes, and Treatments

What Is a Subchondral Bone Cyst?

It’s a fluid-filled sac that forms in one or both of the bones that make up a joint. They’re especially common at the knee or hip. The cysts show up just under the tough spongy tissue (called cartilage) that covers the bone near the joint.

Your doctor might call them:

• Osteoarthritic cysts
• Pseudocysts
• Geodes
• Egger cysts (in the hip socket).

Causes of Subchondral Bone Cysts

Osteoarthritis (OA) is the most common. It breaks down the cartilage. OA can happen from simple wear and tear over time, or because of a sudden injury to a joint.

Either way, the normal, smooth, gliding of one bone against another in your joints starts to cause more friction. That leads to the cyst.

In cases of late rheumatoid arthritis, where your immune system attacks and inflames your joints, subchondral bone cysts can also form.

In other cases, a joint injury might lead to a cyst without OA.

Symptoms of Subchondral Bone Cysts

The cysts themselves don’t seem to cause symptoms. But in rare cases, they can push on soft tissue in the area. That can cause pain.

More often, if you have pain, it’s due to the osteoarthritis that causes the cysts. The pain tends to come and go at first. But it gets worse over time, or if you’re very active. It might be especially serious when you wake up. Eventually, the pain can become constant.

As OA gets worse, stiffness and swelling can make it harder for your joints to work the way they should. You might also feel weaker over time — so much so that it gets harder to do simple things, like open a jar or bend down.

With OA of the hip or knee — where cysts are more common — you might have pain in your:

• Groin
• Thigh
• Buttocks
• Area behind the knee

You might also feel a grinding or scraping sound when you move your joint.

Over time, the cyst itself can start to damage your joint. That can keep you from being able to make some movements.

Diagnosis of Subchondral Bone Cysts

Your doctor will examine you and ask about any pain or stiffness you’re having.

If you have pain, swelling, or stiffness that could be from OA or a joint injury, your doctor will order X-rays or other imaging tests. Any cysts you have will show up on these tests.

Treatment

Subchondral cysts may not cause any symptoms. But sometimes, they continue to grow. That may start to change the way your joint works. If this happens, your doctor might suggest using a needle to drain the cyst.

Other than that, your doctor will try to treat the cause of your cyst — in most cases, OA or a joint injury.

Though there is no cure for OA, your doctor can help you manage your symptoms with:

In rare cases, you might have surgery to replace a joint.

Talk with your doctor about which treatment might be best for you.

The Truth Behind Subchondral Cysts in Osteoarthritis of the Knee

Open Orthop J. 2014; 8: 7–10.

Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road, 169608, Singapore

^*Address correspondence to this author at the Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road, 169608, Singapore;
Tel: (65) 9004-5495; Fax: (65) 6667-8701; E-mail: moc.liamg@kazardimah

Received 2013 Jul 13; Revised 2013 Nov 13; Accepted 2013 Dec 12.

Copyright © Audrey et al.; Licensee Bentham Open.This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.This article has been cited by other articles in PMC.

Abstract

Background:

Subchondral cysts have always been taught to be one of the cardinal radiological features of knee
osteoarthritis but are not well understood. We aimed to evaluate the radiological prevalence and epidemiology of
subchondral cysts in patients with knee osteoarthritis to determine if they are truly a cardinal radiological feature.

Methods:

All patients of a single surgeon with symptoms of knee osteoarthritis were selected for this study. All patients
had failed a trial of conservative therapy and were planned for total knee arthroplasty. Patients with symptoms of and
documentary evidence of inflammatory arthritis, other neurological and orthopaedic problems causing functional deficits
were excluded from this study. A total of 806 plain radiographs were analyzed with the aid of an atlas for the presence of
narrowed joint space, osteophytes, subchondral sclerosis and subchondral cysts. The radiological prevalence of each
feature was then calculated. Demographics and pre-operative measurements were compared between patients with and
without radiological evidence of subchondral cysts.

Results:

Subchondral cysts were only present in 30. 6% of the study population. Narrowed joint space was present in
99.5%, osteophytes in 98.1% and subchondral sclerosis in 88.3% of all radiographs. The differences in prevalence were
statistically significant. There was a higher proportion of females in patients with radiological evidence of subchondral
cysts. These patients also had a greater varus deformity preoperatively.

Conclusion:

With a radiological prevalence of 30.6%, subchondral cysts should not be considered a cardinal radiological
feature of osteoarthritis. Subchondral cysts may be associated with the female gender and genu varum.

Keywords: Geodes, osteoarthritis, radiological features, subchondral cysts.

INTRODUCTION

Ageing of the population and increasing obesity contribute to morbidity across the world. Osteoarthritis (OA) is the most prevalent medically treated arthritic condition globally [1, 2]. Obesity has reached epidemic proportions in Asia and as a result, the continent faces a grave burden of obesity-related disorders, of which OA is one [3]. Diagnosis of OA is generally made on the basis of clinical examination and/or radiography. It has been taught generations after generations that there are four cardinal radiological findings of OA. These features are joint space narrowing, presence of osteophytes, subchondral sclerosis and subchondral cysts. However, evidence from two decades ago mentions subchondral cysts as a rare feature that is usually not seen on radiographs [4]. Despite the fact that subchondral cysts are often cited as a common finding in OA, their etiology is still not well understood. In 1940, Freund [5] found evidence that pressure-induced intrusion of synovial fluid may cause enlargement of cystic lesions. More recently, Durr et al. [6] proposed that stress-induced microfractures of the subchondral bone may be primary events in the development of subchondral bone cysts in OA. Although subchondral cysts are currently taught as being one of the cardinal features of OA, the authors of this study questioned their radiological prevalence in Asian patients with established OA of the knee. The purpose of this study is to evaluate the prevalence and epidemiology of subchondral cysts in pre-operative OA knees of Asian patients, in a bid to challenge the notion that presence of subchondral cysts is one of the four cardinal radiological features.

MATERIALS AND METHODOLOGY

From January 2006 to May 2012, all patients who underwent elective total knee arthroplasty for knee OA were retrospectively studied. A diagnosis of OA was made based on a combination of clinical, radiological and arthroscopic methods. Patients from a single surgeon, the senior author of the paper, were selected for consistency of diagnosis. Our Institutional Review Board approved the study.

Exclusion criteria were inadequacy of radiographs, diagnosis other than OA and patients with previous traumatic injury of the knee joint. Based on these exclusion criteria, a total of 78 knees were excluded. The final study group consisted of 806 patients (171 men and 635 women; age range, 50-84 years; average age, 66 years) with OA of the knee joint. Of these 806 knees, 393 (48.8%) were left and 413 (51.2%) were right. The plain radiographs of the knee most recent relative to the date of surgery were selected for review in all patients. Three views were available for all radiographs – the weight-bearing anteroposterior, lateral and skyline views. An independent reviewer used the K&L grading scale (Table ) to determine the presence of the radiological features of OA in each knee. The images from the original article were used as references [7].

Table 1.

Kellgren-Lawrence Grading System for Osteoarthritis

The prevalence of each of the four radiological features (narrowed joint space, osteophytes, subchondral sclerosis, subchondral cysts) of OA was then calculated for all the knees. A cross-proportion Z-score was calculated and subsequently P-values were interpreted from the Z-score to evaluate if the differences in proportions were significant. Demographics and preoperative data were compared between patients with and without radiological evidence of subchondral cysts. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) Version 20 (IBM^® SPSS Statistics, Armonk, New York, USA).

RESULTS

The prevalence of each radiological feature can be seen in Table . Whilst a large proportion of the patients had radiological evidence of narrowed joint space, osteophytes and subchondral sclerosis, only 247 patients showed radiological signs of subchondral cysts. Table shows that the differences observed in the prevalence of all four radiological features were statistically significant.

Table 2.

Prevalence of Each Radiological Feature

Radiological Feature	Present (%)	Absent (%)	95% CI of %
Narrowed joint space	802 (99. 5)	4 (0.5)	98.6 – 99.8
Osteophytes	791 (98.1)	15 (1.9)	96.9 – 98.9
Subchondral sclerosis	711 (88.2)	95 (11.8)	85.8 – 90.2
Subchondral cysts	247 (30.6)	559 (69.4)	27.6 – 33.9

Table 3.

Interpretation of p-Values from Z Score

	Narrowed Joint Space	Osteophytes	Subchondral Sclerosis	Subchondral Cysts
Narrowed joint space		0. 0097	< 0.0001	< 0.001
Osteophytes			< 0.0001	< 0.001
Subchondral sclerosis				< 0.0001
Subchondral cysts

Table shows the comparative statistics between patients with and without radiological evidence of subchondral cysts. A higher proportion of patients with evidence of subchondral cysts tended to be females with a more pronounced varus deformity.

Table 4.

Characteristics	Group 1	Group 2	P-Value
	Patients with Radiological Evidence of Subchondral Cysts (n=247)	Patients with No Radiological Evidence of Subchondral Cysts (n=559)
Demographics
Mean Age (range) (years)	66 (48-83)	66 (32-85)	1.00
Gender: Female (%)	84	76	0. 009
Percentage of Males with Subchondral Cysts (%)	23		0.007
Percentage of Females with Subchondral Cysts (%)	33
Mean Body Mass Index (range) (kg/m2)	28.6 (19.8-45.0)	28.1 (18.9-46.4)	0.165
Operated Limb: Right (%)	55.1	49.6	0.149
Race
Chinese (%)	88. 2	87.7	0.840
Malay (%)	6.9	6.4	0.795
Indian (%)	4.9	5.9	0.556
Pre-operative Measurements & Scores
Alignment (s.d.) (degrees)*	6 (±8)	4 (±8)	0.001
Genu Varus (%)	80.2	73. 7	0.039
Knee Society Score (s.d.)	37 (±8)	36 (±8)	0.102

DISCUSSION

The aim of this study was to evaluate the prevalence of subchondral cysts in pre-operative OA knees of Asian patients, in a bid to challenge the notion that presence of subchondral cysts is one of the four cardinal radiological features and to set the tone for future studies to correlate the clinical implications of subchondral cysts.

Although the focus of this paper is subchondral cysts associated with OA, it should not be forgotten that cystic changes in the bones are also associated with other conditions. Some of these conditions include rheumatoid arthritis [8], calcium pyrophosphate deposition disease [9] and osteonecrosis [10]. Various explanations have been offered with regards to the pathogenesis and location of the cysts in the above-mentioned conditions. In osteoarthritis, subchondral cysts occur on the pressure segment of the femoral head in association with loss of articular space. However in rheumatoid arthritis, they are initially noted at the chondro-osseous junction and subsequently involve the entire femoral head. The cysts appear in the necrotic segment of the femoral head in osteonecrosis while in calcium pyrophosphate deposition disease, they resemble those in osteoarthritis but are larger, more numerous, and more widespread [10].

Simon et al. [4] described subchondral cysts as being typically small, well-defined and located adjacent to the medial tibial cortex with their long axes in the sagittal plane. He added that they usually present no diagnostic difficulty. Cysts in osteoarthritic joints are usually viewed as a radioluscent osteolytic lesion with a sclerotic border beneath the articular cartilage. However, if based on the strictest definition of a cyst being a closed cavity lined by epithelial cells containing liquid or semisolid material, then these radioluscent lesions seen plain radiographs of an osteoarthritic knee should not be considered cysts because subchondral cysts are not surrounded by such a lining [11-14]. Thus, there have been other terms such as “geodes” used to describe subchondral cysts [10].

It is widely agreed that the pathogenesis of subchondral cysts remains obscure and uncertain [11]. There have been a number of theories postulated on the pathogenesis. The two main postulated theories are the synovial intrusion theory and the bony contusion theory. Freund [5] suggested that it could be secondary to pathology of the synovium extending into the bone due to the similarity of synovial fluid to the cystic fluid, abnormal articular cartilage over the cyst and displaced pieces of surface cartilage within the cyst. This is supported by the presence of a communication between joint cavities and the subchondral cyst. However, a communication is not observed all the time. The bone contusion theory seems to explain the absence of a communication. The bony contusion theory postulated by Rhaney and Lamb [15] suggests that impact between opposing surfaces of bone, which have lost its protective cartilage results in microfractures and bone necrosis. Synovial fluid intrudes the bone when the bone attempts to heal by osteoclastic resorption of the necrotic bone. This is supported by the lack of communication between the joint cavity and the subchondral cyst, presence of metaplastic cartilage and osteoclasts in the disrupted bone.

Even the correlation of subchondral cysts with clinical presentation is not clear. Most textbooks state that subchondral cysts are usually asymptomatic [13, 14]. Fritz [16] in 1979 reported that the subchondral cysts remain asymptomatic for years. Very occasionally, the ganglion of the underlying bone may exert pressure on the soft tissue causing it to swell, causing some pain. Otherwise, he reports that most of these cysts are clinically silent and are incidental finding when radiographs are taken for other reasons.

We did not find any literature reporting on the epidemiology of subchondral cysts. The results of our study show a significantly higher proportion of females in patients with radiological evidence of subchondral cysts. We do know that OA is more common in women after menopause [17]. Bay-Jensen et al. [17] in his review article explains that hypoestrogenaemia in menopause seems to augment OA progression, although estrogen does not block articular cartilage degradation. Estrogen receptors are present in most if not all tissues, suggesting that the pleiotropic actions of estrogen on cartilage and all other tissues may be important in the progression of OA. We postulate that the loss of articular cartilage augmented by hypoestrogenaemia may be a precursor to the formation of subchondral cysts by the pathogenesis suggested by Rhaney and Lamb [15]. Females are also known to have higher body percentage of fat than males. Leptin is secreted by adipocytes and regulates body weight through its effects on food intake and energy expenditure [18]. Leptin is a major regulator of bone remodeling that acts on osteoblasts, therefore preventing osteoporosis [19] but increasing the risk of OA by affecting subchondral bone morphology [20]. This could be the molecular basis for subchondral cyst formation in females.

Our results also show that there is a significantly higher proportion of genu varum deformity in patients with radiological evidence of subchondral cysts. It is well known that medial joint wear is more common in OA of the knees [21]. This differential wear causes the commonly seen genu varum deformity seen in OA of the knees, which in turn causes an imbalance in the condylar forces with greater contact forces in the medal aspect of the knee joint [22]. This may support the pressure-induced intrusion theory for formation of subchondral cysts suggested by Freund [5].

Subchondral cysts have been “traditionally” taught to be one of the four cardinal radiological features of osteoarthritis. However based on our results, subchondral cysts are only radiologically present in 30.6% of the knees we reviewed. Whereas, the other key features are present in close to 100% of the knees for narrowed joint space (99. 5%) and osteophytes formation (98.1%). The third most prevalent feature, subchondral sclerosis is present in close to 90% of the knees. Unfortunately, there are no other studies of a similar nature for comparison of our results. Should subchondral cysts still be considered a cardinal radiological feature of osteoarthritis and be taught as one? The authors believe not. However, the clinical relevance of detecting subchondral cysts radiologically is not well studied. Through this study, we hope to follow-up on correlation of subchondral cysts with intra-operative findings and management as well as post-operative pain. We found one study to date by Torres et al. which concluded that relationship with pain severity was of borderline significance for bone cysts [23]. Interestingly, our study suggests that subchondral cysts may be associated with the female gender and a more pronounced genu varum deformity.

The strengths of our study include a relatively large sample size with consistency of diagnosis as all patients belonged to a single surgeon. Inter-observer bias is not an issue in our study as all plain radiographs were evaluated by a single reviewer based on a standard atlas. Our study is probably the first one studying the epidemiology of subchondral cysts in patients with knee OA. However, the results of this study must be interpreted in context of its limitations. The major limitation of this study stems from its retrospective nature. Effects of confounders are inevitable especially in a retrospective study. Furthermore, causality cannot be implied as this is an observational study. Surgeon bias in patient selection invariably has its effect on our data too. In addition to these, there is likely to be sample bias due to a high proportion of females in our study group. This is likely due to the epidemiology of OA in our region. Our results also lack generalizability as we only included the knee joint and our patients are ethnically Asian. We also did not report functional outcomes of these patients due to a paucity of prospective data for a majority of these patients. However, we still believe that this study will promote future prospective studies evaluating the clinical impact of subchondral cysts.

CONCLUSION

Subchondral cysts may be a late feature of OA of the knee as part of the pathological basis for disease. However, based on its low prevalence as seen from our study, we believe that it should not be considered a cardinal radiological feature of knee OA. Subchondral cysts may be associated with the female gender and a more pronounced genu varum deformity. The way ahead will be to explore if presence or absence of subchondral cysts has any impact on surgical management and clinical outcomes of patients with knee OA.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflict of interest.

REFERENCES

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Cyst formation in the subchondral bone following cartilage repair

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doi: 10.1002/ctm2.248.

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• ¹ Center of Experimental Orthopaedics, Saarland University Medical Center and Saarland University, Homburg, Germany.

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Liang Gao et al.

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Abstract

Subchondral bone cysts represent an early postoperative sign associated with many articular cartilage repair procedures. They may be defined as an abnormal cavity within the subchondral bone in close proximity of a treated cartilage defect with a possible communication to the joint cavity in the absence of osteoarthritis. Two synergistic mechanisms of subchondral cyst formation, the theory of internal upregulation of local proinflammatory factors, and the external hydraulic theory, are proposed to explain their occurrence. This review describes subchondral bone cysts in the context of articular cartilage repair to improve investigations of these pathological changes. It summarizes their epidemiology in both preclinical and clinical settings with a focus on individual cartilage repair procedures, examines an algorithm for subchondral bone analysis, elaborates on the underlying mechanism of subchondral cyst formation, and condenses the clinical implications and perspectives on subchondral bone cyst formation in cartilage repair.

Keywords:

bone cyst; cartilage repair; osteochondral unit; subchondral bone.

© 2020 The Authors. Clinical and Translational Medicine published by John Wiley & Sons Australia, Ltd on behalf of Shanghai Institute of Clinical Bioinformatics.

Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

FIGURE 1

Radiographic images of a 30‐year‐old…

FIGURE 1

Radiographic images of a 30‐year‐old male patient with osteochondritis dissecans (OCD) (A) at…

FIGURE 1

Radiographic images of a 30‐year‐old male patient with osteochondritis dissecans (OCD) (A) at the left medial femoral condyle initially treated with the subchondral drilling and subsequent symptomatic subchondral bone cyst formation (B, C) at 60 months postoperatively. The white (A), yellow (B), and red arrows (C) indicate the subchondral bone cyst. The yellow arrowheads (B) designate the area of the OCD lesion surrounding the subchondral bone cyst in the CT image. The red arrowheads (C) denote the high signal intensity of the diffuse bone marrow edema (BME) around the cyst in the T2‐weighted MRI image

FIGURE 2

Adapted algorithm for a precise…

FIGURE 2

Adapted algorithm for a precise analysis of subchondral bone alterations in translational models…

FIGURE 2

Adapted algorithm for a precise analysis of subchondral bone alterations in translational models and in patients.
⁵²
The bottom schematics show each pattern of subchondral bone changes with articular cartilage and subchondral bone denoted in dark blue and dark green, respectively. The cartilaginous repair tissue and subchondral bone underlying the defect are depicted in light blue and with dashed border, respectively. The margin of the subchondral bone changes is outlined with red lines. A diffuse bone weakness (light green) is only seen in the generalized bone resorption

FIGURE 3

Schematic of the synergistic mechanism…

FIGURE 3

Schematic of the synergistic mechanism of external hydraulic intrusion and internal inflammatory for…

FIGURE 3

Schematic of the synergistic mechanism of external hydraulic intrusion and internal inflammatory for the subchondral bone cyst formation following articular cartilage repair procedures. The morphological change of the cyst is determined by the equilibrium status between the expansible force due to the synergistic drives and the restraining force from the peri‐cyst sclerotic rim at the cyst‐bone interface. The external hydraulic theory features an intrusion of synovial fluid into the subchondral bone through the canals generated by marrow stimulation techniques (A) or the canals that are possibly opened as a result from the surgically debrided subchondral bone plate in autologous chondrocyte implantation (B) or in a possible gap between the osteochondral unit of the graft and host in allograft/autograft transplantation (C) during the postoperative phase. The pathophysiological characteristics mainly include subchondral bone necrosis, peri‐cyst sclerotic rim formation, displaced original trabeculae and strain‐responsible formation of new bone. The internal inflammatory theory involves mechanisms such as chemotaxis and chemokinesis of inflammatory factors (e.g. PEG2, TNF‐α, IL1, and IL6) as well as bone turnover stimulated by bone necrosis

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The association between subchondral bone cysts and tibial cartilage volume and risk of joint replacement in people with knee osteoarthritis: a longitudinal study | Arthritis Research & Therapy

Study population

Subjects with knee OA were recruited by advertising through local newspapers and the Victorian branch of the Arthritis Foundation of Australia and in collaboration with general practitioners, rheumatologists, and orthopedic surgeons. The study was approved by the ethics committee of the Alfred and Caulfield Hospitals in Melbourne, Australia. All subjects gave informed written consent [16].

One hundred thirty-two subjects entered the study. Inclusion criteria were age older than 40 years, knee symptoms (at least one pain dimension of Western Ontario and McMaster University Osteoarthritis Index (WOMAC [17]) score >20% and osteophytes present), and radiographic knee OA (ACR radiographic and clinical criteria [18]). Subjects were excluded if any other form of arthritis was present, MRI was contradicted (for example, pacemaker, cerebral aneurysm clip, cochlear implant, presence of shrapnel in strategic locations, metal in the eye, and claustrophobia), inability to walk 50 feet without the use of assistive devices, hemiparesis of either lower limb, or planned total knee replacement.

Anthropometric and clinical data

Weight was measured to the nearest 0.1 kg (shoes and bulky clothing removed) by using a single pair of electronic scales. Height was measured to the nearest 0.1 cm (shoes removed) by using a stadiometer. Body mass index (BMI; weight/height² (kg/m²)) was calculated. Function and pain were assessed with WOMAC (VAS, 10 cm) [17].

Radiograph

At baseline, each subject had a weight-bearing anteroposterior tibiofemoral radiograph of the symptomatic knee in full extension. Where both knees had OA and were symptomatic, the knee with least severe radiographic OA was used. These were independently scored by two trained observers who used a published atlas to classify disease in the tibiofemoral joint according to the Kellgren and Lawrence (K-L) scale. The radiologic features of tibiofemoral OA were graded in each compartment, on a 4-point scale (0 to 3) for individual features of osteophytes and joint space narrowing [19]. In the case of disagreement between observers, the films were reviewed by a third independent observer, and consensus values were used. Intraobserver reproducibility (κstatistic) for agreement on features of OA was 0.93 for osteophytes (grade 0, 1 versus 2, 3) and 0.93 for joint-space narrowing (grade 0, 1 versus 2, 3). Interobserver reproducibility was 0.86 for osteophytes and 0.85 for joint-space narrowing [20].

Magnetic resonance imaging

Each subject had an MRI performed on the symptomatic knee at baseline and ~2 years later. Knees were imaged in the sagittal plane on the same 1.5-T whole-body magnetic resonance unit (Signa Advantage HiSpeed; GE Medical Systems, Milwaukee, WI) by using a commercial receive-only extremity coil. The following sequence and parameters were used: a T₁-weighted fat-suppressed 3D gradient recall acquisition in the steady state; flip angle, 55 degrees; repetition time, 58 msec; echo time, 12 msec; field of view, 16 cm; 60 partitions; 512 × 192 matrix; one acquisition time, 11 min 56 sec. Sagittal images were obtained at a partition thickness of 1.5 mm and an in-plane resolution of 0.31 × 0.83 mm (512 × 192 pixels).

Knee cartilage volume was determined by means of image processing on an independent work station by using the software program Osiris, as previously described [16, 20]. Two trained observers read each MRI. Each subject’s baseline and follow-up MRI scans were scored unpaired and blinded to subject identification and timing of MRI. Their results were compared. If the results were within ± 20%, an average of the results was used. If they were outside this range, the measurements were repeated until the independent measures were within ± 20%, and the averages were used [16, 20]. Repeated measurements were made blind to the results of the comparison of the previous results. The coefficients of variation (CVs) for the measurements were 3.4% for the medial, 2.0% for the lateral, and 2.6% for the total tibial cartilage volume [16]. Tibial plateau area was determined by creating an isotropic volume from the three input images closest to the knee joint, which were reformatted in the axial plane. The area was directly measured from these images. The CVs for the medial and lateral tibial plateau area were 2.3% and 2.4%, respectively [16, 20].

A subchondral bone cyst was defined as a well-demarcated hypersignal, whereas a BML was an ill-defined hypersignal. The assessments of subchondral bone cysts and BMLs were performed on the MRI slice that yielded the greatest lesion size. The intensity and extent of cysts and BMLs were assessed in the medial and lateral tibiofemoral compartments and were graded as 0, absence of lesion; 1, mild to moderate lesion; and 2, severe (large) lesion. A reliability study done by using a two-reader consensus measure of a specific lesion size twice at a 6-week interval showed an r = 0.96, p < 0.0001 for subchondral bone cysts and r = 0.80, p < 0.001 for BMLs (test-retest Spearman correlation) [6]. The medial and lateral cyst and BML scores were each calculated as a sum of the scores for the tibial, femoral, and femoral posterior sites (scores 0 to 6). As a low prevalence of subjects was found with cyst scores >3 for the medial and >1 for the lateral compartment, we collapsed the scores to give a range of 0 to 3 for the medial and 0 to 1 for the lateral compartment.

Identification of knee replacement

At year 4, all subjects were contacted and asked whether they had undergone a knee replacement because of OA of the same knee in which they had a baseline MRI. This was confirmed by contacting the treating physician in all cases.

Statistical analysis

Descriptive statistics for characteristics of the subjects were tabulated. Annual percentage change in cartilage volume was calculated by cartilage change (follow-up cartilage volume subtracted from initial cartilage volume) divided by initial cartilage volume and time between MRIs. Outcome variables (baseline tibial cartilage volume and annual percentage change in tibial cartilage volume) were initially assessed for normality and were found to approximate normal distribution. Estimated marginal means was used to explore the cross-sectional relationship between subchondral bone cysts and tibial cartilage volume at baseline, and longitudinally, the relationship between baseline subchondral bone cysts and annual percentage tibial cartilage volume loss. Logistic regression was used to examine the relationship between baseline subchondral bone cysts and risk of knee-joint replacement over a 4-year period. All analyses were performed by using the SPSS statistical package (version 16.0.0; SPSS, Cary, NC), with a P value < 0.05 considered statistically significant.

Subchondral bone in osteoarthritis: insight into risk factors and microstructural changes | Arthritis Research & Therapy

Frontiers | Multiple Subchondral Bone Cysts Cause Deterioration of Articular Cartilage in Medial OA of Knee: A 3D Simulation Study

Introduction

Osteoarthritis (OA) of the knee joint is a common degenerative joint disease. The advanced cases of OA are usually associated with formation of subchondral bone cysts (SBCs) (Ondrouch, 1963). Nearly 50% of knee OA cases present with SBCs (Wu et al., 2007; Raynauld et al., 2008). In the majority of cases, these are spherical or ellipsoidal in shape and located at the articular surface. These are thought to be specific bony adaptations in the weight-bearing areas of joints (Crema et al., 2010; Javaid et al., 2010). Two different theories (synovial intrusion theory and bony contusion theory) described the formation of SBCs in weight-bearing regions (Freund, 1940; Landells, 1953; Rhaney and Lamb, 1955; Ondrouch, 1963). However, more recently the concept of vascular pathology (hypertension) has been proposed about the formation of SBCs in non-load bearing regions (Chan et al., 2017).

Though there is no consensus about the exact relationship between SBCs and knee pain, it is widely accepted and several recent studies have argued that there is an association between SBCs and knee pain in OA knee patients (Landells, 1953; Kornaat et al., 2006; Torres et al., 2006; Javaid et al., 2012). In clinical practice, X-rays remain the key investigation for the diagnosis of osteoarthritis. Advanced imaging modalities, such as CT and MRI, show more accurate and precise structural morphology of these cystic lesions (Marra et al., 2008; Roemer et al., 2009; Crema et al., 2010). In a clinical study using MRI, Raynauld et al. (2008) found the correlation between change in mean cyst size in millimeters and loss of medial femoral condyle cartilage in individuals with knee osteoarthritis. The exact relationship between bone marrow lesions (BMLs) and SBCs is not clear; however, some recent studies have advocated that BMLs may develop into SBCs (Carrino et al., 2006; Crema et al., 2008, 2010).

On the other hand, biomechanical studies addressed stress changes in the osseous elements (Durr et al., 2004; McErlain et al., 2011). A 2D finite element (FE) study demonstrated that the SBCs produce stress effect and stress-induced micro-fractures in the femoral head. The authors hypothesized that these micro-fractures might be the first step in the development of SBCs in OA (Durr et al., 2004). Another study advocated that SBCs produce increased osseous stress around the cyst (McErlain et al., 2011). To our best knowledge, all of these studies have focused on stress changes in osseous elements only while ignoring subchondral bone and articular cartilage degeneration (Durr et al., 2004; McErlain et al., 2011).

The detailed effect of multiple cysts on the knee joint is lacking in the literature. Moreover, a comparison between a single cyst and multiple cysts in relation to cyst location has not been described before. It is meaningful to investigate associations between subchondral bone cyst parameters (e.g., number, size, and location) and associated articular degeneration in OA pathology. Finite element analysis is well known and widely accepted in orthopedics (Bosiakov et al., 2017; Trad et al., 2018; Bini et al., 2019). In this technique, 3D models are used with simulated loads to analyze and predict the outcomes. The aims of this simulation study were to (a) establish the biomechanical stress-strain profile of different-sized SBCs in tibia; (b) evaluate any correlations between cyst number, size, position, and quantitative stress changes; and (c) determine intra-osseous, intra-cystic compression variations and the resultant stress changes in subchondral bone and articular cartilage using the non-cystic and cystic 3D knee models. The results of this simulation study provide insight into the role of SBCs on biomechanical aspect of articular degeneration in OA pathogenesis.

Materials and Methods

Three-Dimensional Modeling

Institutional ethical approval was obtained before this study, and it was performed according to the Declaration of Helsinki. CT and MR images of an individual (52 years old, male) with early medial compartment knee OA were used for modeling. There was no past history of trauma. The geometrically accurate three-dimensional (3D) bony model of the knee joint was generated from CT scan images of the right knee in the neutral unloaded position. The 1.5 mm slice thickness CT DICOM images were imported into Mimics 10.1 software (Materialise, Leuven, Belgium) to reconstruct the surface geometry of the femur, tibia, and fibula. MR images were used for the reconstruction and reference points of soft tissues including the ligaments (ACL, PCL, MCL, and LCL), menisci and cartilaginous components of the distal femur, tibial plateau, and tibio-fibular joint (TFJ). In Geomagics Studio 11.0 software (Raindrop Company, United States) IGS files of the bony elements were used to get individual structure’s volumetric form. Soft tissues were also handled and assembled in Geomagics. These models were then assembled and exported as STP files representing the 3D knee complex as shown in Figure 1A. The coordinate axes of the assembled models were aligned as the X axis pointed medially (lateral to medial femoral condyle), the Y axis pointed posteriorly (anterior to posterior), and the Z axis pointed upward (knee to hip). To simulate the SBCs of different size, number, and location, computer-aided design (CAD) software (ProE CREO 3.0 PTC Corp., United States) was used. The 3D model of SBC is depicted in Figure 1B. To illustrate the exact fit SBC-bone model, there was no gap between bone and cyst capsule. The bone cysts were modeled with spherical morphology. Two different-sized (diameters: 4 and 12 mm), single and paired cysts located in upper and slightly lower position in relation to joint line were simulated (see Figure 2 and Table 2 for cysts parameters). In total, seven knee models were simulated in this study. All the models were meshed using the software HyperMesh 14.0 (Altair Engineering, Inc., United States). Based on mesh convergence study, the mesh size of 0.3 mm for bones, soft tissues (ligaments, menisci, cartilages) and SBCs was used. The type of mesh used in this study was quadratic tetrahedral elements to minimize elements stiffness. The cortical, cancellous, and subchondral components of bones were established as shown in Figure 1A.

Figure 1. 3D knee models. (A) Non-cystic 3D knee model showing different structures, (B) model of SBC knee model, and (C) finite element model showing loading and boundary conditions. SBC, subchondral bone cyst.

Figure 2. 3D tibial plateau models showing size, number, and location of SBCs in three sub-groups of group B and group C. SBCs, subchondral bone cysts.

Finite Element Modeling and Material Properties

The reconstructed 3D models (ING files) were imported into finite element analysis software Abaqus 6.14 (Simulia Corp., United States). Interactions were carried out between different parts of the models using this software. The cortical, subchondral, and cancellous bony portions were assigned the Young’s modulus (E) of 7,300, 3,000, and 1,100 MPa and Poisson ratio (υ) of 0.3, 0.3, and 0.26, respectively (Choi et al., 1990; Kim et al., 2011; Qiu et al., 2011; Raja Izaham et al., 2012). FE models of soft tissues included cartilage, menisci, and major ligaments (cruciate and collateral ligaments). The menisci and cartilage were modeled as linear-elastic materials (Donahue et al., 2002). Articular cartilage was defined as Young’s modulus of 12 MPa and Poisson’s ratio of 0.45, whereas menisci were modeled with Young’s modulus of 80 MPa and Poisson’s ratio of 0.3 (Hopkins et al., 2010). Interfaces between the cartilage and bones were fully bonded. Contact was assigned between the femoral cartilage and meniscus, between meniscus and tibial cartilage, and between femoral and tibial cartilage on both the medial and lateral sides. Surface friction coefficient of 0.02 was used, which is in the normal range for human articular joints (Mow et al., 1993). The ligament models were defined as rubber-like materials with stress-strain relationship according to previous studies (Takeda et al., 1994; Mesfar and Shirazi-Adl, 2005; Innocenti et al., 2009; Innocenti et al., 2014; Koh et al., 2019).

Validation of 3D Model and Boundary Conditions

A review of the literature shows that in the majority of SBCs cases, a secondary closure is more commonly found than an opening (Landells, 1953). Therefore, we simulated a complete cyst model without any opening at the joint surface. The 3D osseous and soft tissues models and material properties applied in this experiment were assigned according to the previous published studies (see Table 1). The simulated force was applied proximally to the femur, whereas the distal end of the tibia was fixed in all degrees of freedom (McErlain et al., 2011). All the models were tested for two different physiological conditions, i.e., two-leg and one-leg standing. The individual’s body weight was 75 kg in this study; therefore, about 50% (375 N) of the body weight was applied to simulate two-leg standing condition and a load of 750 N for single-leg standing in axial direction, as given in Figure 1C.

Table 1. Validation of material properties used in this study with literature.

Grouping

For the ease of results interpretation, models were categorized into three groups. Group A consisted of non-cystic knee model. Group B and group C were composed of SBCs knee models of 4 and 12 mm (diameters), respectively (data from clinical series given in Supplementary Table 1; the smallest SBC was 4 mm and largest 12 mm). We further simulated single and multiple cysts, of different locations (upper and lower) in respect to articular surface, as well as anterior and posterior halves of the medial tibial plateau. Groups B and C were further subdivided into three sub-groups: 1, 2, and 3. In sub-group 1, one cyst was present in the anterior half of medial tibial plateau adjacent to the joint line (Figure 2, represented by B-1 and C-1). In sub-group 2, a solitary cyst was modeled in the lower location of anterior half of medial tibia (∼4 mm from joint line) (Figure 2, represented by B-2 and C-2). Sub-group 3 demonstrated two cysts, one in anterior and another in posterior tibial half (Figure 2, represented by B-3 and C-3).

Statistical Analysis

The statistical analysis was done using SPSS 16.0 (SPSS Inc., Chicago IL). Descriptive statistics was used to determine means and standard deviations. One-way ANOVA and multiple comparison least significant difference (LSD) tests were used to determine the mean difference. p-value was considered significant when p < 0.05. Nodal analysis was done in the region of interest (ROI), using selected nodes (N = 20) from each sub-group of 3D model. Von Mises stress (VMS), Tresca stress, and cartilage shear stress distributions in the subchondral bones, the cancellous bones, and cartilage were analyzed. Strain analysis of the SBCs was also calculated.

Results

The total number of nodes and elements in the non-cystic knee model were 1,034,891 and 4,911,748 respectively, whereas the total number of nodes in solitary small cyst model were 1,488,268 and 1,488,268 elements. The knee model with solitary larger-sized SBC was composed of 1,504,518 nodes and 1,504,518 elements. The detail of individual 3D models is given in Table 2. The effect of SBCs on bony elements (subchondral and cancellous) and articular cartilage was compared with the stress changes in the non-cystic knee model.

Table 2. Detail of SBCs parameters and nodes and elements in different models.

Von Mises Stress Distribution in Subchondral Bones

The mean VMS in subchondral bone of SBC models was higher than the non-cystic knee model (Figure 3). During single-leg stand condition, the non-cystic model showed the mean stress value of 9.35 ± 1.94 MPa, whereas in group B (smaller-sized SBC), the mean stress values were 37.71 ± 19.52, 9.93 ± 1.94, and 41.97 ± 20.77 MPa in sub-groups 1, 2, and 3, respectively. There was a significant increase (p < 0.001) in subchondral bone plate stress in all the sub-groups of group C. Further detail is given in Table 3.

Figure 3. Von Mises stress distribution in subchondral bones during single-leg stance (750 N). (A) Non-cystic knee model. Groups B and C (represented by letters B,C) with the corresponding sub-groups 1, 2, and 3.

Table 3. Statistical analysis of stress in subchondral and cancellous bone and cystic strains.

Stress Analysis of Peri-Cystic Cancellous Bones

Tresca stress analysis of the cancellous portion of medial tibia showed the least mean stress of 5.27 ± 0.14 MPa (5.01–5.64) in the anterior medial tibial plateau of non-cystic knee model. The bony defect caused by SBCs in group B: 8.56 ± 0.27, 6.52 ± 0.28, and 8.76 ± 0.14 MPa and group C: 22.74 ± 1.13, 6.92 ± 0.68, and 23.08 ± 0.86 MPa produced the statistically significant (p < 0.001) stress changes in the individual sub-groups, respectively. The detailed description of stress changes in all the three groups are depicted in Figure 4 and Table 3.

Figure 4. Stress distribution in peri-cystic cancellous bones. (A) Non-cystic knee model. Groups B and C (represented by letters B,C) with corresponding sub-groups1, 2 and 3.

Strain (

E) Analysis of Cysts

On applying body weight, there resulted changes in the cysts. The resultant strain in all cysts is summarized in Figure 5 and Table 3. The inner section of individual cysts showed the peak areas of strain. The 12 mm-sized cyst in group C had highest mean strain value of 0.03 in the upper location near the joint line (sub-groups 1 and 3). Same-sized cyst at lower position showed nearly a 5 times less mean strain of 0.006. As the size of cysts increased from 4 to 12 mm, there was a prominent increase in strain (p < 0.001).

Figure 5. Strain distributions in SBCs. (A–C) Representing sub-groups 1, 2, and 3 of group B. Panels (D–F) showing sub-groups of group C with corresponding inner sections of cysts. The peak strain is pointed by “*,” and the dotted circle shows the direction of strain spread. SBCs, subchondral bone cysts.

Cartilage Shear Stress

The mean shear stress analysis of medial tibial cartilage showed that the presence of a single small-sized cyst (sub-groups 1 and 2 of group B) with mean shear stress of 0.66 ± 0.56 and 0.58 ± 0.54 MPa was not significant as compared to non-cystic model (group A) (p = 0.374 and p = 0.590). However, the paired cysts of same size caused significant increase in stress changes (p = 0.011). On the other hand, the comparison between group A and group C (larger-sized SBCs) showed statistically significant increase in cartilage stress in all sub-groups: C-1, C-2, and C-3 (p = 0.001, p = 0.006, and p < 0.001) with mean stress values of 1.25 ± 0.69, 1.01 ± 0.54, and 1.26 ± 0.59 MPa than non-cystic knee model (0.47 ± 0.67 MPa), respectively. These focal increments in medial tibial cartilage are shown in Figure 6a and Table 4. Figure 6b depicts the increase in articular stress during double-leg and single-leg stands.

Figure 6. (a) Articular cartilage shear stress changes in groups A, B, and C with associated sub-groups 1, 2 and 3. (b) Graphical representation of mean cartilage stress during double and single-leg stance.

Table 4. Statistical analysis of cartilage stress in various groups.

Discussion

According to our findings, on applying the tested loads (single- and double-leg stance) there was prominent increase in peri-cystic bone stress. We also noted significant increase (nearly 2 to 3 times) in mean cartilage stress in SBC models as compared to the non-cystic knee model. The mean shear stress of medial tibial cartilage in non-cystic model showed nearly uniform stress distribution (represented by letter “A” in Figure 6a), and the peak stress was in the antero-medial part of articular cartilage because in the standing position the medial compartment of the knee bears up to 2.2 times as much loading as the contrary lateral compartment (Johnson et al., 1980; D’Lima et al., 2007; Kutzner et al., 2010). However, SBCs increased the cancellous and subchondral bone stress, and there was a focal increase in the articular shear stress. For the cysts in group B, sub-group 3 affected the larger area in both the osseous and cartilaginous components. These altered areas of stress caused significant increase in cartilage stress. The small-sized solitary cyst (sub-groups 1 and 2 of group B) had higher mean cartilage stress than the non-cystic model but were statistically non-significant. On the other hand, there was a significant increase in focal cartilage stress (which may cause degeneration effect) caused by larger-sized SBCs (Table 4).

In a previous clinical study, the authors advocated that the presence of SBCs leads to degeneration and wasting of cartilage and also increases the risk of surgical knee replacements (Tanamas et al., 2010). Our findings provide the biomechanical bases of how SBCs of different parameters (size, numbers, and locations) can cause degenerative effect on cartilage (i.e., increased stress effect). These findings also strengthen the hypothesis proposed by Radin and Rose (1986) that the progression of articular degeneration is associated with perturbations in underlying bone.

The maximum strain was noted on the cyst surface facing the joint line. Inner sections of the cysts showed that the maximum strain was at the top of the cyst (represented by “^∗” in Figure 5). As this part of the cyst was very near to articular cartilage, the most deteriorating effect of SBCs on cartilage was in this position. This intra-cystic focal effect in 12 mm-sized cysts (C-1 and C-3) was nearly 4 times greater than that of SBCs in sub-groups B-1 and B-3. Only a 1.4-fold increase in strain was produced by cysts at lower joint position in group B (B-2) than the corresponding cyst in group C (C-2). The strain spread was toward peripheral regions of the cysts (dotted circle in Figure 5), which means that cysts may expand toward their peripheral regions. SBCs located at the lower joint positions (sub-groups 2 of groups B and C) and SBCs located in posterior tibial halves demonstrated lower strain values than the same-sized SBCs at higher joint positions. This difference is clearly seen in Figures 8A,B, where the green line represents the strains in different groups.

Sabokbar et al. (2000) implied that elevated pressure in bones surrounding the SBCs could evoke a macrophage response within subchondral marrow and contribute to bone resorption and cyst enlargement. Our results showed 1.6-fold increase in peri-cystic cancellous bone stress in group B than the non-cystic model (group A). This stress effect was increased up to 4.5-fold in SBC model of 12 mm size (group C). Increased intra-osseous stress may result in boney destruction and subsequent SBC expansion. The stress produced by cysts in cancellous bone in relation to strain is depicted in Figure 7. A similar phenomenon of cysts expansion has been previously described in the hip joint (Ondrouch, 1963; Durr et al., 2004). Ondrouch (1963) carried out photo-elasticity experiments and concluded that cysts in OA may develop as a result of stress-induced bone resorption. Durr et al. (2004) studied the etiology of SBCs in a 2D FE hip model and advocated that micro-fractures in subchondral bone may be the initial step in the formation of SBCs. Our results showed that the mean VMS in subchondral bone of SBCs was increased up to 4∼4.5-fold in sub-groups 1 and 3 of group B and nearly 16∼18.5-fold higher in sub-groups 1 and 3 of group C as compared to the mean VMS in group A. In sub-group 2 of group B, only a slight increase in mean stress was observed (p = 0.254). But a significant increase in mean stress was observed in sub-group 2 of group C (p < 0.001). Therefore, the location of SBC in relation to the joint line is also important in case of small-sized cyst to produce significant stress changes (p = 0.044 vs. p = 0.254). The blue lines in Figure 8B shows tremendous increase in subchondral bone stress in sub-groups C-1 and C-3 in contrast to the subchondral bone stress in sub-groups B-1 and B-3 in Figure 8A. This signifies the size effect of SBCs (12 vs. 4 mm). The different location of same-sized cysts (B-1 vs. B-2 and C-1 vs. C-2) also produced different stress effects as represented by red and blue lines for cancellous and subchondral bones, respectively (Figures 8A,B). We should also keep in mind that the repeated or increased loading beyond the body weight (single-leg standing) may further deteriorate the condition (further increase stress effect).

Figure 7. Graphical representation relationship between cancellous bone stress (bone resorption) and strain.

Figure 8. Plots showing impact of SBCs strain on subchondral and cancellous bones in (A) group B and (B) group C. SBCs, subchondral bone cysts.

Conclusion

In conclusion, the bigger-sized SBCs in anterior and immediate position in the medial tibial cartilage produce increased focal stress effect in articular cartilage. Multiple cysts further deteriorate the condition by increased osseous stress effect and high tendency of peripheral cyst expansion.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the corresponding author on reasonable request.

Ethics Statement

The studies involving human participants were reviewed and approved by the Institutional Review Board of First Affiliated Hospital of China Medical University. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

AA, ZH, YZ, YG, CT, MUN, YW, ZZhao, DL, ZZhan, HZ, and GL: study conception and design. AA, ZH, YZ, YG, CT, XW, MUN, YW, ZZhao, DL, ZZhan, and GL: acquisition of data. AA, ZH, YZ, YG, CT, XW, MUN, YW, ZZhan, DL, ZZhao, HZ, and GL: analysis and interpretation of data. All authors have revised and finally approved the manuscript.

Funding

This study was supported by the China Medical University Institutional Research Funds with Grant No. 219/1210618025.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fbioe.2020.573938/full#supplementary-material

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How do cysts form in the pathogenesis of osteoarthritis (OA)?

Treatment of a cyst of the hip joint in Moscow

A cyst of the hip joint is an articular hernia located in the inner cavity of the knee. The formation is mobile and elastic, it can be of different sizes, it resembles a bunch of grapes in shape. The causes of the disease are rheumatism, arthritis, obesity, physical exertion, trauma, etc.

Symptoms do not always appear, but in most cases they are pain and swelling in the area of ​​the tumor, limitation of the range of motion in the joint, discomfort while standing or squatting.Treatment is carried out with the introduction of corticosteroids into the cystic cavity, drainage using hormonal drugs, complete removal of the cyst is possible.

Orthopedists of Moscow – latest reviews

Today I was at the reception, well done doctor.I managed to calmly deal with my sores and did not impose additional expensive examinations. From a visit to the doctor, only positive impressions.

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12 October 2021

Yesterday I was at the reception with back pain.I liked the doctor, was on time and was attentive. He prescribed a treatment plan. It is difficult to say how effective it will be, but today I feel better. I am planning a return visit.

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I liked the doctor.He recommended that I go in addition to my analyzes, additional research, and then prescribed treatment. The relief passed literally on the second day of the course started. I hope for a lasting remission. Friends praised the doctor.

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Vladimir Ilyich is a unique, honored doctor.You can come to him for an appointment and immediately go out healthy. At this appointment, he examined and gave me recommendations.

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The doctor is a professional, polite, attentive, benevolent.I liked everything. I’ll go to the appointment again. Alexey Mikhailovich immediately got into the problem, sent him for the necessary tests. The consultation lasted 15-20 minutes, there was enough time. As a result, I received a step towards solving my question

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07 October 2021

An attentive and good specialist.She looked at the test results, explained everything and judged everything. The doctor also ordered X-rays, saw several other illnesses, referred to a neurologist, and prescribed medications. The doctor did everything in her power. We have no complaints. All perfectly! Everything triples us. We now know what medicines to take. The doctor explained everything to us. The patient felt a little better.

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Everything went well.The doctor is a very caring, attentive, qualified specialist. I am very pleased with the reception. The doctor offered everything he could and said what exactly I need to do. At the reception, Vladimir Sergeevich examined me, looked at my pictures, took another picture, together with the radiologist, they consulted and passed a verdict. As a result, the doctor wrote out appointments and recommendations. I will recommend a doctor to my friends.

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I felt better after taking it! Thank you very much Irina Gennadievna and the exercise therapy instructor! At the appointment, the doctor explained everything to me clearly what my problem was.I studied my pictures very carefully. Before that, I was already with another neurologist and there was almost no effect. I will sign up again. I was looking for a specialist for rehabilitation via the Internet. The clinic does not do blockade and other similar manipulations, manual therapy. It suited me very much!

Anonymous,

August 27, 2021

Show 10 reviews of 9,390 90,000 Bone cyst – causes, symptoms, diagnosis and treatment

Bone cyst is a cavity in the bone tissue resulting from local circulatory disorders and the activation of enzymes that destroy the organic matter of the bone.In the initial stages, it is asymptomatic or accompanied by minor pain. Often, the first sign of a pathological process is a pathological fracture. The duration of the disease is about 2 years, during the second year the cyst decreases in size and disappears. The diagnosis is made on the basis of radiography. Treatment is usually conservative: immobilization, puncture, administration of drugs into the cyst cavity, exercise therapy, physiotherapy. If ineffective, resection is performed, followed by alloplasty.

General information

Bone cyst is a disease in which a cavity forms in the bone tissue. The cause is unknown. Usually children and adolescents are ill. There are two types of cysts: solitary and aneurysmal, the former are three times more common in boys, the latter are usually detected in girls. The cyst itself does not pose a threat to the life and health of the patient, however, it can cause pathological fractures and sometimes becomes the cause of the development of contracture of the nearby joint.With an aneurysmal cyst in the vertebra, neurological symptoms may appear. Bone cysts are treated by orthopedic traumatologists.

Bone cyst

Pathogenesis

The formation of a bone cyst begins with circulatory disorders in a limited area of ​​the bone. Due to the lack of oxygen and nutrients, the site begins to collapse, which leads to the activation of lysosomal enzymes that break down collagen, glycosaminoglycans and other proteins. A fluid-filled cavity with high hydrostatic and osmotic pressure is formed.This, as well as the large amount of enzymes in the fluid inside the cyst, leads to further destruction of the surrounding bone tissue. Subsequently, the pressure of the fluid decreases, the activity of enzymes decreases, from an active cyst it turns into a passive one and eventually disappears, gradually being replaced by new bone tissue.

Types of bone cysts

Solitary bone cyst

Boys 10-15 years old suffer more often. At the same time, earlier development is also possible – a case of a solitary cyst in a 2-month-old child has been described in the literature.In adults, bone cysts are extremely rare and usually represent a residual cavity after an undiagnosed illness suffered in childhood. As a rule, cavities arise in long tubular bones, the first place in prevalence is occupied by bone cysts of the proximal metaphysis of the femur and humerus.

The course of the disease in the initial stages in most cases is asymptomatic, sometimes patients notice a slight swelling and slight unstable pain.In children under the age of 10, swelling is sometimes observed, contractures of the adjacent joint may develop. With large cysts in the proximal femur diaphysis, lameness is possible, with damage to the humerus, discomfort and discomfort with sudden movements and raising the arm.

The reason for going to the doctor and the first symptom of a solitary bone cyst is often a pathological fracture that occurs after a minor traumatic effect. Sometimes the trauma cannot be detected at all.When examining a patient with the initial stages of the disease, local changes are not pronounced. There is no edema (the exception is edema after a pathological fracture), there is no hyperemia, the venous pattern on the skin is not pronounced, local and general hyperthermia is absent. Minor muscle atrophy may be present.

On palpation of the affected area, in some cases, it is possible to find a painless clavate thickening with bone density. If the cyst reaches a significant size, the wall of the cyst can bend when pressed.In the absence of a fracture, active and passive movements in full, support is preserved. In case of violation of the integrity of the bone, the clinical picture corresponds to a fracture, however, the symptoms are less pronounced than in the case of ordinary traumatic injury.

Subsequently, a staged course is noted. Initially, the cyst is localized in the metaphysis and connects to the growth zone (osteolysis phase). With large cavities, the bone at the site of the lesion “swells”, repeated pathological fractures may develop.Formation of contracture of a nearby joint is possible. After 8-12 months, the cyst turns from active to passive, loses its connection with the growth zone, gradually decreases in size and begins to shift to the metadiaphysis (demarcation phase). After 1.5-2 years from the onset of the disease, the cyst appears in the diaphysis and does not manifest itself clinically (recovery phase). At the same time, due to the presence of a cavity, the strength of the bone at the site of the lesion decreases, therefore, pathological fractures are also possible at this stage.The outcome is either a small residual cavity or a limited area of ​​osteosclerosis. Complete recovery is observed clinically.

To clarify the diagnosis, an x-ray examination of the affected segment is performed: x-ray of the femur, x-ray of the humerus, etc. Based on the x-ray picture, the phase of the pathological process is determined. In the phase of osteolysis, the image shows a structureless rarefaction of the metaphysis in contact with the growth zone.In the phase of delimitation, a cavity with a cellular pattern is visible on the roentgenograms, surrounded by a dense wall and separated from the growth zone by a section of normal bone. In the recovery phase, the images show a site of bone compaction or a small residual cavity.

CT stop. Calcaneus cyst on the right (on the left – for comparison – the norm).

Aneurysmal bone cyst

Solitary cyst is less common. Usually occurs in girls 10-15 years old. It can affect the bones of the pelvis and vertebrae, less often the metaphyses of the long bones are affected.Unlike a solitary bone cyst, it usually occurs after an injury. The formation of the cavity is accompanied by intense pain and progressive edema of the affected area. On examination, local hyperthermia and expansion of the saphenous veins are revealed. When localized in the bones of the lower extremities, there is a violation of support. The disease is often accompanied by the development of contracture of the nearby joint. With bone cysts in the vertebrae, neurological disorders appear due to compression of the spinal roots.

There are two forms of aneurysmal bone cysts: central and eccentric. During the course of the disease, the same phases are distinguished as in solitary cysts. Clinical manifestations reach their maximum in the osteolysis phase, gradually decrease in the delimitation phase and disappear in the recovery phase. On radiographs in the osteolysis phase, a structureless focus with an extraosseous and intraosseous component is revealed, with eccentric cysts the extraosseous part is larger in size than the intraosseous one. The periosteum is always preserved.In the phase of demarcation between the intraosseous zone and the healthy bone, a sclerosis site is formed, and the extraosseous zone becomes denser and decreases in size. In the recovery phase, an area of ​​hyperostosis or a residual cavity is found on radiographs.

MRI of the pelvis. Bone cyst in the ilium on the left with a hyperintense signal.

Treatment of a bone cyst

Treatment is carried out by pediatric orthopedists, in small settlements – by traumatologists or pediatric surgeons. Even if there is no fracture, it is recommended to relieve the limb using crutches (in case of damage to the lower limb) or by hanging the hand on a bandage (in case of damage to the upper limb).In case of a pathological fracture, a plaster cast is applied for a period of 6 weeks. In order to accelerate the maturation of the tumor-like formation, punctures are performed.

The contents of the cyst are removed using special needles for intraosseous anesthesia. Then, multiple perforations of the walls are performed to reduce the pressure inside the cyst. The cavity is rinsed with distilled water or saline solution to remove cleavage products and enzymes. Then, washing with 5% e-aminocaproic acid solution is performed to neutralize fibrinolysis.At the final stage, aprotinin is injected into the cavity. With a large cyst in patients over 12 years old, it is possible to administer triamcinolone or hydrocortisone. With active cysts, the procedure is repeated once every 3 weeks, with closing cysts – once every 4-5 weeks. Usually 6-10 punctures are required.

X-rays are monitored regularly during treatment. When signs of a decrease in the cavity appear, the patient is sent to exercise therapy. With the ineffectiveness of conservative therapy, the threat of compression of the spinal cord or the risk of significant destruction of the bone, surgical treatment is indicated – marginal resection of the affected area and alloplasty of the resulting defect.In the active phase, when the cyst is connected to the growth zone, operations are carried out only in extreme cases, since the risk of damaging the growth zone increases, which is fraught with lag in the growth of the limb in the long term. In addition, when the cavity comes into contact with the growth zone, the risk of relapse increases.

Forecast and prevention

The forecast is usually good. After reduction of the cavity, recovery occurs, the ability to work is not limited. Long-term consequences of cysts can be caused by the formation of contractures and massive destruction of bone tissue with shortening and deformation of the limb, however, with timely adequate treatment and following the doctor’s recommendations, such an outcome is rarely observed.

cyst under the knee joint treatment with folk remedies

cyst under the knee joint treatment with folk remedies

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Right arm shoulder joint pain treatment Therapeutic methods of treatment of Baker’s cyst.There are two approaches to how to treat Becker’s cyst. Conservative therapy includes: unloading the knee joint. Treatment of Becker’s cyst without surgery using conservative therapy rarely leads to the complete elimination of the pathology. It is also not always possible to cure Becker’s cyst with classical intervention – often the formation is detected again after some time. A full 30-day refund guarantee for the device if it is ineffective is a unique opportunity to try Neurodoctor on yourself.Use the Neurodoctor device. Baker’s cyst is a neoplasm in the posterior part of the knee joint. Symptoms and degrees of Baker’s cyst. Medication and non-medication methods of treating the disease. Baker’s cyst: an overview of symptoms and key treatments. Inflammations localized in the joint of the lower extremities can provoke the appearance of neoplasms in the popliteal tissues, which is commonly called Baker’s cyst. Clinical manifestations of a neoplasm are traced only after reaching a cyst of a certain size, in which nerves and blood vessels are compressed.In particular, the knee joint. This part of the body is an anatomical structure that allows various types of leg movement. Unfortunately, diseases can develop in such an important site for a person. Ganglion cyst – originates from the innermost areas of the knee joint. It is filled with a liquid consistency. On palpation, a compacted elastic formation is felt. You can use folk remedies. In fairness, it should be noted that surgical methods are preferable to conservative ones, since after the use of the latter, the possibility of recurrence of this disease is not excluded.In the event that the cyst is a by-product, after the treatment of the underlying disease, it disappears by itself. Baker’s cyst is a benign neoplasm that occurs as a result of inflammation of the knee joint. The synovial fluid, the production of which is intensified due to inflammation, from the joint cavity enters the popliteal region, where it accumulates. It is possible to diagnose an ailment at an early stage of the development of the disease by feeling. If the disease is advanced, the cyst under the knee becomes convex and visible even during a visual examination.Using folk remedies. Effective treatment of Baker’s cyst is possible with folk remedies. All used funds can be conditionally divided into: compresses; ointments; means for oral administration. Baker’s cyst of the knee joint in the treatment of folk remedies can be reduced in size if you use a joint composition of burdock leaves and celandine. With a cyst under the knee, treatment with folk remedies will reduce the response to compression of soft tissues, and help stop the course of inflammation.The green parts are chopped or minced. Together with the juice, apply to the affected area for 3 hours. The course is one month. The emerging Baker’s cyst in the treatment of folk remedies with dandelion and clove root with the help of applications from the prepared mass can also decrease in volume. Treatment methods. Baker’s cyst is treated conservatively and surgically. Conservative therapy includes anti-inflammatory compresses and ointments. During the recovery period, it is recommended to perform physical exercises on the knee joint under the supervision of a specialist.You will have several sessions in the clinic, then you can perform these simple manipulations at home. To achieve the best and fastest result, it is necessary to massage the damaged area. What is a Baker cyst? We will analyze the causes of occurrence, diagnosis and treatment methods in the article by Dr. Pavlyuchenko. Yu., Orthopedist with 5 years of experience. In such cases, a cyst may appear due to trauma and anatomical features of the structure of the knee joint. Baker’s cyst is named after the British surgeon William Morant Baker, who described 8 cases of popliteal cysts.He concluded that the cysts were the result of effusion (fluid accumulation) from osteoarthritis. They communicate directly with the knee joint and fluid can flow from the joint to the cyst, but not vice versa. Despite the eponymous name, several other surgeons have described popliteal cysts prior to Baker. How to treat Baker’s cyst of the knee. Therapeutic tactics for Baker’s cyst depends on the duration of the development of pathology, the size of the formation, and the clinical picture. Treatment can be both conservative and surgical.Conservative methods include physiotherapeutic procedures, prescribing symptomatic drugs, puncturing a cyst. The puncture consists in the evacuation of the liquid contents of the cyst with a syringe and the further introduction of one of the glucocorticoid drugs (diprospan, phlosterone). All manipulations are performed under general or local anesthesia and with mandatory ultrasound control. From medications, which drug is prescribed which relieves joint pain inflammation of the foot joint treatment of pain in the ankle joint treatment with folk remedies

The best remedy for joints
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Joint Treatment Center Yaroslavl
home treatment of joints with gelatin prescription

She suffered a knee injury as a child.In principle, there was nothing serious, there were no serious consequences. But from time to time, my knee joint, which I injured, begins to hurt, mainly due to the change in the weather. I constantly used anti-inflammatory ointments for the joints. It helped, but I decided to drink the drug Artrofish, which was advised to me. It is based on the cartilage tissue of marine organisms. After a knee injury, I often had pain in the joint for the change of weather. I could not walk fully, so I decided to try Artrofish.I liked this remedy because the pain syndrome became less pronounced after the first receptions. But I continued the course of treatment until the end. Arthrofish is widely used for the treatment and prevention of joint diseases, as it is characterized by a complex effect. When using the medication: the condition of the joints improves. The medicine is characterized by the presence of anti-inflammatory action; eliminates the need to use drugs with anesthetic effect; ensures joint health for many years.Thanks to the active components of the drug, the inflammatory process in the joints is reduced and their destruction is reduced. The drug ensures the health of the spine and knees for a long period of time, which is calculated in years; mobility returns. The action of the drug is aimed at eliminating the stiffness that appears in the morning. With the help of the medication, a full-fledged fight against aching pain is ensured; discomfort is eliminated. While taking the medication, stiffness in the joints is eliminated and motor activity increases, which allows a person to return to their usual way of life.Arthritis of the fingers: causes and symptoms. Effective treatment of joint diseases: nutrition, folk remedies, drugs, ointments and exercises. Arthritis of the fingers is a characteristic symptom of rheumatoid arthritis, but it can also be one of the manifestations of some other disease. It is very important to seek medical help in a timely manner, identify the cause of the disease and begin treatment in order to avoid serious complications and disability. In this article you will find all the information you need to know about this disease. General information about the disease.Finger arthritis is an inflammation of the metacarpophalangeal and interphalangeal joints of the fingers. How to treat arthritis of fingers, folk remedies. The reasons for the development of arthritis. Content. Possible causes of arthritis. The main ones are: Arthritis of the fingers – symptoms and treatment, photo. Photo of arthritis. Stages of disease progression. Classification of arthritis. Treatment. Use of medications for arthritis. Physiotherapy. With arthritis of the fingers, treatment with folk remedies is shown as part of complex therapy.Before starting the procedures, it is necessary to consult a doctor and his approval. Arthritis of the fingers must be treated comprehensively. Description of the pathology. The causes of arthritis are not fully understood, there are several theories of its appearance: hereditary, infectious, etc. Pathology has common symptoms, slight differences in different forms of the disease. The main manifestation of arthritis is pain syndrome. Unpleasant sensations are more common with a sharp change in weather conditions, with dampness and cold.Symptoms of arthritis of the fingers. Symptoms for arthritis of the joints of the hands are: pain, and if at first it occurs when moving the hands or fingers, then later the pain in the joints torments the patient even at rest; discomfort and stiffness in the affected joints and fingers. Reactive arthritis is a very common pathology of the joints of the fingers with uneven tissue damage. The first symptoms are similar to the common cold, which is expressed by malaise, high fever, headaches. Chondroprotective agents with chondroitin and glucosamine are also used for treatment.They are designed to help repair the damaged cartilage tissue in the fingers. For pain in the joints of the fingers, treatment with folk remedies gives good results. However, you first need to consult a doctor and carry out tests. Since arthritis is only a consequence, in order to successfully get rid of the disease, you need to find out its cause. If it is eliminated, the treatment will be successful. Compresses for pain in the fingers. There are a huge number of alternative methods for treating joint inflammation, so choosing the best one is not difficult.Sea salt will help to cope with the problem. It needs to be heated in a skillet, placed in a cotton napkin or gauze and applied to your fingers for 10 minutes. Arthritis of the fingers: causes and symptoms of joint disease. Effective treatment of finger arthritis includes a whole range of measures: drug treatment, physiotherapy, exercise therapy and proper diet. Finger arthritis is an inflammatory joint disease that affects the cartilage between the phalanges of the fingers. Over time, if left untreated, the disease spreads to the heads of the bones and leads to irreversible deformation of the fingers.A particular danger of the disease is that in the later stages it leads to disability and even basic self-care skills. Consider the symptoms and treatment of finger arthritis. Rub each finger on the other hand alternately with the thumb and forefinger of one hand: from the base to the nail, and then back. Wrap your hand around your finger and rotate as if you were sharpening a pencil. Arthrosis and arthritis of the hands have many common symptoms, but they are completely different diseases. What are their differences? Commentary by the famous doctor, professor Bubnovsky.In the early stages, you will be offered conservative treatment that will reduce soreness and increase the mobility of your fingers. Some physiotherapy methods for arthrosis will improve blood circulation and restore metabolism, activate tissue regeneration and reduce pain. Such techniques are also practiced Arthritis of the fingers – a disease that women most often suffer. The reasons for this are in the peculiarities of a number of purely female professions and everyday tasks, as well as in the fact that the female body as a whole is more susceptible to osteoarthritis than the male due to its hormonal background.In particular, in the diagnosis of rheumatoid arthritis of the fingers, treatment also includes the use of immunosuppressive agents. In particular, in the treatment of arthritis of the joints of the fingers, Don’s chondroprotective drug has proven itself well. Its active ingredient is crystalline glucosamine sulfate, a natural component of human cartilage.

cyst under the knee joint treatment with folk remedies

hallux valgus of knee joints in children treatment

The warehouse of the company constantly has Artrofish in large quantities, which ensures the possibility of its immediate purchase.You can buy the product at an affordable cost. Thanks to constant promotions and discounts, it is possible to save money on purchases. A meniscus cyst is a fluid-filled cavity in the thickness of the meniscus. Chronic. The main complaint of patients with a meniscus cyst is pain that arises and increases with movements in the joint. On examination, swelling is found on the lateral surface of the knee. The final diagnosis is made by arthroscopy, ultrasound or MRI of the knee joint.Treatment consists in dissection of the cyst or complete removal of the altered meniscus. Surgeries are usually performed using arthroscopic equipment. ICD-10. M23.0 Cystic meniscus. Causes. Meniscus cyst symptoms. Diagnostics. Meniscus cyst treatment. Treatment prices. Causes. A meniscus cyst is a fluid-filled cavity in the thickness of the meniscus. Chronic. The main complaint of patients with a meniscus cyst is pain that arises and increases with movements in the joint. When osm. Cyst of the medial meniscus of the knee joint.Cyst of the internal meniscus of the knee joint. Parameniscus cyst of the knee joint. Knee ganglion cyst. The meniscus cyst is a cavity fluid formation in the thickness of the knee joint meniscus. This disease is a reaction of the meniscus to prolonged overload of the joints. In this case, a mucoid (mucoid) substance is formed in the tissues of the meniscus, which accumulates over time. Further, the substance is converted into a cyst. In most cases, the cyst forms at the edge of the meniscus.The main danger of the disease is that rupture can occur with light loads. Most often, patients with a knee meniscus cyst, a lateral meniscus cyst, and a medial meniscus cyst turn to specialists. Meniscus cyst is a fluid cavity formation in the thickness of the knee joint meniscus. It is generally accepted that this is a kind of reaction of the menisci to a long-term strong overload of the joint. At risk are athletes and people whose work requires the use of physical strength.Cystic degeneration of the meniscus in most cases occurs in people of working age. A mucoid (mucoid) substance forms in the meniscus tissue. It accumulates by stretching the meniscus tissue and transforms into a cyst. In most cases, the cyst forms at the edge of the meniscus. This cyst is called parameniscal. Specialists of the Center for Sports Injury treat meniscus cysts of the knee joint. We provide outpatient and inpatient treatment of sports injuries. You can make an appointment by calling.(without consumables, the price includes accommodation in a 2-bed ward for 1 day, services of an anesthesiological team, surgery, consultation of a therapist). Make an appointment Ask a question to a specialist. Meniscus cyst is a capsule with a mucus-like substance formed in the cavity of the knee joint. Causes pain on movement. A meniscus cyst is a chamber filled with a liquid substance. There are two menisci inside the knee. In fact, these are just cartilages, acting as cushions, similar to a sickle.Their task is to cushion the joint. This is where this foreign reservoir appears. Subchondral cyst – occurs mainly in older people. Ganglion cyst – originates from the innermost areas of the knee joint. It is filled with a liquid consistency. On palpation, a compacted elastic formation is felt. Causes, symptoms and treatment of knee meniscus cysts. Meniscus cyst is a formation filled with synovial fluid, which normally nourishes the joint cavity. These formations can be located in the thickness of the cartilage, and in advanced stages they go beyond it, forming parameniscus cysts.As in the case of a baker’s cyst or hygroma, increased stress or injury to the knee leads to cystic degeneration, in this case of the cartilaginous plates. Menisci are triangular cartilaginous plates bent along the edge with thickened peripheral edges. Their shape compensates for the discrepancy between the articular surfaces of the bones. Baker’s cyst is a neoplasm in the posterior part of the knee joint. Symptoms and degrees of Baker’s cyst. Medication and non-medication methods of treating the disease. Baker’s cyst: an overview of symptoms and key treatments.Inflammations localized in the joint of the lower extremities can provoke the appearance of neoplasms in the popliteal tissues, which is commonly called Baker’s cyst. Clinical manifestations of a neoplasm are traced only after reaching a cyst of a certain size, in which nerves and blood vessels are compressed. What is a Baker cyst? We will analyze the causes of occurrence, diagnosis and treatment methods in the article by Dr. Pavlyuchenko. Yu., Orthopedist with 5 years of experience. This means that the process is long-standing and could be caused by a joint injury: damage to the ligament or meniscus and the formation of blood in the joint.Histological examination of symptomatic and asymptomatic cysts did not reveal any difference under the microscope [7] [8] [9]. Classification and stages of development of Baker’s cyst. cyst under the knee joint treatment with folk remedies . foot joint inflammation treatment.

90,000 causes of occurrence, symptoms of the disease, diagnosis and treatment methods

IMPORTANT!

The information in this section cannot be used for self-diagnosis and self-medication.In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For a diagnosis and correct prescription of treatment, you should contact your doctor.

Coxarthrosis: causes, symptoms, diagnosis and treatment.

Definition

Coxarthrosis is the most frequent and severe form of osteoarthritis of the hip joints, which usually leads to progressive dysfunction of the joint, up to its complete loss.In the general structure of articular pathology, coxarthrosis consistently ranks second after gonarthrosis in terms of incidence and first in terms of temporary and permanent disability.

Coxarthrosis can be unilateral or bilateral and is characterized by degradation of cartilage tissue, bone remodeling, the formation of osteophytes (pathological growths), inflammation, etc.

Thus, coxarthrosis is considered as an organ disease of the entire joint, in which cartilage, subchondral bone, synovial membrane, ligaments, capsule, muscles are involved in the process.Distinguish between primary (idiopathic) coxarthrosis and secondary, arising against the background of various diseases. Primary coxarthrosis is one of the most common degenerative-dystrophic pathologies of the hip joint. In some patients, it accompanies the process of natural aging of the body.

Causes of coxarthrosis

Risk factors for coxarthrosis are divided into genetic, acquired (nongenetic) and environmental. The development of coxarthrosis is regarded as a consequence of the influence of various biological and mechanical factors, such as degenerative-dystrophic diseases of the hip joint, congenital dislocation of the hip, aseptic necrosis of the femoral head, inflammation, trauma (contusion, dislocation, fracture, microtrauma), metabolic disorders, genetic or hereditary predisposition, age, vascular malformations, overweight and unfavorable working conditions.

Although all joint tissues are involved in the pathological process in coxarthrosis, the leading signs of the disease are degeneration and destruction of the articular cartilage.

The inflammatory process affects almost all structures of the joint with the formation of chondritis, synovitis and osteitis.

Classification of the disease

The most common and widely used classification is considered to be according to NS. Kosinskaya (1961):

Stage I – slight restriction of movement, small, indistinct, uneven narrowing of the joint space, slight sharpening of the edges of the articular surfaces (initial osteophytes).

Stage II – limited mobility in the joint, rough crunch during movement, moderate amyotrophy, pronounced narrowing of the joint space by 2-3 times compared with the norm, significant osteophytes, subchondral osteosclerosis and cystic enlightenment in the pineal glands.

Stage III – joint deformity, stiffness, absence of joint space, deformation and compaction of the articular surfaces of the epiphyses, extensive osteophytes, articular “mice”, subchondral cysts.

There is also a four-stage classification of Kellgren and Lawrence:

Stage I – minor marginal osteophytes are determined without changing the height of the joint space.

Stage II – significant marginal osteophytes are determined without changing the height of the joint space.

Stage III – significant marginal osteophytes with a moderate decrease in the height of the joint space are determined.

Stage IV – significant marginal osteophytes, subchondral osteosclerosis, significant narrowing of the joint space are determined.

Tonnis classification:

Stage I – sclerosis of the head and acetabulum increases, a slight narrowing of the joint space and a slight sharpening of the edges of the joint space.

Stage II – Small cysts in the head or acetabulum, moderate joint space narrowing and moderate loss of sphericity of the femoral head.

Stage III – large cysts in the head or acetabulum, the joint space is absent or significantly narrowed, severe deformity of the femoral head, signs of necrosis.

Symptoms of coxarthrosis

The clinical picture of the disease corresponds to internal changes in the tissues of the joint.Symptoms increase gradually, and in the early stages, the patient does not pay enough attention to them. This is dangerous, because it is at the beginning of the degenerative process that the treatment has a greater effect.

The first clinical symptoms (pain, limited range of motion) appear in the absence of X-ray changes in the joint, they are caused by muscle spasm. Pain in the hip joint in the case of primary coxarthrosis occurs with exertion or movement and increases after walking. With coxarthrosis, pain at the onset of the disease is often localized not in the area of ​​the affected joint, but in the knee joint, along the outer surface of the thigh, buttock, in the lumbar region, which complicates the diagnosis.The limitation of the range of motion in the joint gradually increases, and in a number of patients there is a symptom of “blockade” of the joint. In such patients, limitation of movement in the joint, pain during internal rotation in a bent position, pain on palpation of the groin area lateral to the site of pulsation of the femoral artery are determined.

With a long course of the disease, atrophy of the muscles of the thigh and gluteal muscles appears.

The limb takes a forced position – slight flexion in the hip joint with impaired rotation and abduction, compensatory lumbar lordosis, pelvic tilt towards the affected joint and scoliosis occur.All this can lead to the appearance of back pain.

Diagnosis of coxarthrosis

For the diagnosis of coxarthrosis, pain in the hip joint and at least two of the following three symptoms are required:

Osteoarthritis of the hip joint | Dikul center

Osteoarthritis of the hip joint (coxarthrosis) is characterized by a progressive course and impaired statodynamic function of the musculoskeletal system. It occupies one of the first places among degenerative-dystrophic diseases of the musculoskeletal system.The dystrophic process begins with the articular cartilage – its thinning, dissociation, fragmentation occur, and its cushioning properties are lost. As a compensatory reaction of the articular surfaces of the hip joint, marginal bone growths are formed. In the future, sclerosis develops and cysts are formed (see Bone cyst) in the articulating sections of the femoral head and acetabulum.

Distinguish between primary TS arthrosis or TS arthrosis of unclear etiology, and secondary TS arthrosis arising against the background of TS dysplasia or congenital dislocation of the hip, aseptic necrosis of the femoral head, Perthes disease, trauma (contusion, fracture, dislocation, microtrauma), inflammatory process ( coxitis).

One or both hip joints may be affected. In primary arthrosis, other joints (usually the knee) and the spine are often simultaneously affected.

There is no unified theory of the pathogenesis of the disease. Most scientists believe that the triggering mechanism is impaired blood circulation in the joint due to both deterioration of venous outflow and impaired arterial inflow. As a result of tissue hypoxia, under-oxidized metabolic products accumulate, activating proteolytic enzymes and synovial fluid hyaluronidase, which destroy cartilage proteoglycans.One cannot but reckon with mechanical factors causing joint overload, incongruence of articular injuries leading to a redistribution of the load per unit area of ​​the articular surface of the cartilage, as well as biochemical changes in the cartilage itself.

Clinical picture. The main complaint of patients is pain, the nature, intensity, duration and localization of which depend on the severity of the dystrophic process, i.e. from the stage.

There are three stages of arthrosis of the hip joint.

• In stage I, periodically after physical exertion (long walking, running), pain occurs in the joint area, less often in the hip or knee joint. As a rule, after rest, the pain disappears. The range of motion in the joint is not limited, muscle strength is not changed, gait is not disturbed. On radiographs, insignificant bony growths are visible that do not go beyond the articular lip. They are usually located around the outer or inner edge of the articular surface of the acetabulum.The head and neck of the femur are practically unchanged. The joint gap is unevenly slightly narrowed.
• In stage II, pains are more intense, radiate to the thigh, groin, and occur at rest. After a long walk, lameness appears. Joint function is impaired. First of all, internal rotation and hip abduction are limited, i.e. flexion and adduction contracture is formed. The strength of the muscles abducting and extending the thigh decreases, their hypotension and hypotrophy are determined.On the roentgenogram, significant bone growths are visible along the outer and inner edges of the acetabulum, extending beyond the cartilaginous lip. Deformation of the femoral head, its increase and contour irregularity are noted. Cysts can form in the most stressed part of the head and acetabulum. The femoral neck is thickened and widened. The joint gap is unevenly narrowed (up to 1 / 3-1 / 4 of the original height). There is a tendency towards upward displacement of the femoral head.
• Stage III pains are permanent, occurring even at night.When walking, patients are forced to use a cane. A sharp limitation of all movements in the joint (flexion-adduction contracture) and hypotrophy of the gluteal muscles, as well as the muscles of the thigh and lower leg, are noted. A positive Trendelenburg symptom may appear. Flexion-adduction contracture causes an increase in pelvic tilt and an increase in lumbar lordosis. The tilt of the pelvis in the frontal plane, associated with the weakness of the abductor muscles of the thigh, leads to a functional shortening of the limb on the affected side.The patient is forced to step on the toes to reach the floor, and to tilt the body to the affected side when walking to compensate for the tilt of the pelvis and shortening of the limb. This compensation mechanism leads to a shift in the center of gravity and an overload of the joint. On radiographs, extensive bone growths are determined from the side of the roof of the acetabulum and the head of the femur, a sharp narrowing of the joint space. The femoral neck is significantly widened and shortened.

The diagnosis is based on clinical and radiological data.In addition to the stage of the disease, X-ray examination helps to clarify the etiology of the process. In dysplastic arthrosis of the TS, flattening, sloping of the acetabulum, changes in the value of the cervical-shaft angle, etc. are determined. In arthrosis of the TS as a result of Perthes disease, or juvenile epiphysiolysis, the shape of the proximal end of the femur changes mainly. There is a deformation of its head and neck (shortening, expansion), a decrease in the cervico-diaphyseal angle with the formation of a plow vara.The X-ray picture of post-traumatic arthrosis of the hip joint depends on the nature of the injury and the shape of the articular surfaces after the fusion of the bones that form the hip joint.

To clarify the nature and severity of joint and neuromuscular dysfunctions such methods of functional diagnostics as electromyography, rheovasography (see Geography), podography can be used. Radionuclide scanning allows one to judge the degree of blood flow disturbance in the femoral head and thus to trace the dynamics of the dystrophic process in the TS during treatment, which helps to objectively evaluate its results.

Differential diagnosis is carried out with osteochondrosis of the lumbar spine, coxitis and tumors of the pelvis and hip.

Treatment of arthrosis

Due to the lack of a single pathogenetic mechanism for the development of the disease, treatment is symptomatic, aimed at reducing pain and statodynamic disorders of the musculoskeletal system. In this case, it is necessary to take into account the stage of the disease, the patient’s age, his general condition and features of clinical manifestations.

At the I-II stages of the disease, treatment can be carried out in an outpatient setting. It is aimed at reducing pain, aseptic inflammation in the periarticular tissues, improving tissue trophism and blood circulation in the limb, increasing joint stability and preventing other static disorders of the musculoskeletal system.

During the period of exacerbation with severe pain syndrome, it is recommended to reduce the vertical load on the limb (exclude prolonged standing, carrying heaviness, running).When walking for a long time, additional support on the cane is required. Analgesic and anti-inflammatory drugs are used (analgin, reopyrin, amidopyrine, brufen, indomethacin, ortofen). To improve the redox processes in the cartilage tissue, vitamins, aloe, vitreous, rumalon and other drugs are prescribed. At home, you can use compresses with Dimexide (10-15 procedures). In a polyclinic, electrophoresis of a solution of novocaine, Dimexide, etc., as well as ultrasound therapy, magnetotherapy, laser therapy are used.

After pain syndrome is reduced, manual massage of the lumbar region, hip joint, thigh and therapeutic exercises are performed, aimed at normalizing muscle tone, restoring mobility in the affected joint, followed by strengthening the surrounding muscles. Therapeutic gymnastics includes movements in the vehicle in positions of unloading the joint (lying on the back, sideways, standing on a healthy leg, etc.). Uses exercises aimed at strengthening the muscles that abduct and extend the hip.Standing on a healthy leg on a support, holding on to the gymnastic wall, the patients withdraw and unbend the thigh (freely, with a load, holding for 5-7 s, overcoming the resistance of a rubber bandage). It is better to extend the hip while lying on your stomach with an amplitude of 10-20 °, you can do this lying on a couch with your legs lowered to a horizontal level, or standing on all fours. Special exercises for TS are carried out against the background of general developmental physical exercises, special exercises to strengthen the muscles of the back, abdominal wall in order to increase the stability of the lumbar spine.

In a hospital setting, in addition, joint traction and hydrokinesis therapy are prescribed. The stretching is carried out on the patient’s bed with a load of 5-7 kg for 3-5 hours a day, on a special traction table with a dosed load for 20-40 minutes, as well as in water. During traction (10-15 procedures), patients are advised to walk with crutches, unloading the leg. Traction of the joint is combined with manual massage of the thigh muscles, underwater jet massage with a water jet pressure of 0.5-1 atm for 5-8 minutes and physical exercises in water.These procedures are aimed at relaxing tense muscles, improving blood circulation in the limb and increasing diastasis between the articulating articular surfaces of the vehicle. In the future, the main attention is paid to therapeutic exercises aimed at increasing the stability of the joint by strengthening the periarticular muscles. Electrical stimulation of the gluteal muscles is performed (10-15 procedures).

After treatment, patients are recommended to practice therapeutic exercises at home, self-massage of the gluteal muscles and thighs, swimming, skiing.Long-term static loads on the legs, hard physical labor, sports and rhythmic gymnastics, figure skating, aerobics, wrestling, weightlifting are contraindicated.

At stage III, conservative treatment, in addition to the indicated measures, includes intra-articular administration of kenalog or arthroporone. Treatment is carried out in a hospital, which provides the necessary mode of unloading the joint. Traction of the joint and physical exercises to increase the mobility of the joint are contraindicated.persistent (arthrogenic) contracture of the TS does not allow an increase in mobility, and this attempt only causes additional microtraumatization and increases the pain syndrome.

The main therapeutic measures are aimed at reducing pain syndrome, unloading the joint, training compensatory-adaptive mechanisms. Apply an orthopedic regime and exercise therapy. You need constant additional support when walking on a cane, and during an exacerbation – on crutches. Hydrokinesis therapy and remedial gymnastics should help to increase the stability of the joint, strength and endurance of the muscles that abduct and extend the hip, relax and stretch the muscles that flex and adduce the hip.Isometric and dynamic exercises are used with an amplitude of motion within the limits of preserved mobility (until pain is felt). Apply manual and underwater massage with a water jet pressure of 1-2 atm for 10-15 minutes, electrical stimulation of the gluteal muscles.

A well-trained muscular system helps to develop compensatory mechanisms even with gross changes in the joint. The period of formation and improvement of compensatory mechanisms is long and requires systematic training.Therefore, therapeutic exercises should be continued at home; strict adherence to the orthopedic regime of unloading the joint is recommended.

Surgical treatment includes operations that maintain joint mobility (osteotomies, arthroplasty, endoprosthetics) and closing the joint (arthrodesis). When determining the indications for the choice of the method of surgical intervention, the stage of the dystrophic process, the general condition, age and profession of the patient, the condition of the other hip joint and the lumbar spine are taken into account.At the I-II stage of the disease and a slight limitation of the function of the hip joint, various types of osteotomies of the hip are most widely used. For stable fixation of bone fragments, a Trotsenko-Nuzhdin plate is used. With this type of fixation in the postoperative period, additional external immobilization is not required. To restore the function of the joint from the first days, therapeutic exercises are prescribed (general developmental breathing exercises, isometric muscle tension). From the 3-4th day, they begin to make light movements in the knee and hip joints of the operated leg.From the 14th to 16th day, they are allowed to walk with crutches without support on the limb. Up to 4 weeks the exercises are lightweight, after removing the stitches, exercises in the water can be used. In the future, manual and underwater massage is prescribed, exercises to strengthen the muscles surrounding the hip joint. Partial load on the limb is allowed after 4 weeks. after surgery, complete – after 6 months.

In dysplastic arthrosis of the TS, various types of pelvic osteotomies are performed to increase the coverage of the femoral head with the articular surface of the acetabulum, improve its centering, and reduce the load on the articular cartilage, which improves the biomechanical conditions in the joint.The most widespread is the Chiari osteotomy of the pelvis.

At stage III, it is impossible to suspend the dystrophic process, therefore the listed operations are considered pollative. In this case, the most promising is hip arthroplasty, which is performed in the presence of a bilateral process with ankylosis in one of the joints, severe arthrosis and significant changes in the lumbar spine, with arthrosis of the hip joint and ankylosis in the knee joint on the same side.After the operation, a derotation boot is applied to the foot and lower leg for 3-4 weeks. From 2-3 days, facilitated movements are allowed in the operated joint in the sagittal plane, after 10-12 days – in the frontal plane. After 4 weeks. patients begin to walk with crutches without support on the operated leg. Partial loading is allowed after 3-4 months, full – from 5-6 months, provided that the endoprosthesis is stable. After the start of walking, therapeutic exercises are prescribed to strengthen the muscles surrounding the endoprosthesis (in the supine position, side, abdomen).Classes continue in outpatient or home conditions. At the same time, manual massage is carried out.

Arthrodesis of the hip joint is carried out for unilateral disease of the III stage in young people engaged in physical labor. After the operation, a plaster cast is applied for 5-6 months. During the period of immobilization, therapeutic exercises are prescribed (general developmental, breathing exercises, isometric muscle tension under a plaster cast and free movements in non-immobilized joints).When using Umyarov’s plate for arthrodesis, plaster immobilization is not performed. In this case, from the 3-4th day, lightweight movements in the knee joint are performed. They are allowed to get up after 3 weeks, walk with crutches with partial load on the operated leg – after 4 weeks, with full load – not earlier than 4-5 months. when X-ray signs of fusion of the femoral head with the pelvic bones appear.

Spa treatment after surgery is indicated in 6-8 months.

The prognosis for life is favorable, the progression of arthrosis of the hip joint of unknown etiology is slow. With aseptic necrosis of the femoral head, the course of TS arthrosis is the most unfavorable.

Prevention

Methods of specific prophylaxis of TS arthrosis have not been developed. Early detection and treatment of congenital hip dislocation and TS dysplasia, as well as dispensary observation of adolescents with TS pathology, can be considered as primary prevention measures.

Secondary prevention consists in the timely diagnosis of stage I arthrosis, systematic conservative treatment with a frequency of 1-2 times a year, regardless of the severity of the pain syndrome, adherence to the orthopedic regimen for unloading the joint, focus on “sedentary” professions, rational physical education, control over body weight …

Bibliography: Abalmasova E.A. and Luzina E.V. Development of the hip joint after treatment of congenital subluxation and dislocation of the hip in children, Tashkent, 1983; Guryev V.N. Coxarthrosis and its surgical treatment, Tallinn, 1984; A.A. Korzh and other Dysplastic coxarthrosis, M., 1986; A.P. Krisyuk Deforming coxarthrosis in children and adolescents, Kiev, 1982; Therapeutic physical culture, ed. V.A. Epifanova, p. 424, M., 1987.

Training · Dental clinic “Totem”

Announcement!
Dear Colleagues.We present to your attention a new unique special course by Dmitry Vasilyevich Rogatskin, which will be held on February 18, 19, 2017 in Kemerovo.
Seminar Topics:
1. Acute Tooth Trauma (OTZ)
2. Radiation diagnostics of the temporomandibular joint (CT), (MRI).
3. Three-dimensional visualization of jaw cysts.
4. 3D diagnostics of changes in bone tissue in inflammatory diseases of the jaws – from periodontitis to osteomyelitis.
5. Tumors and tumor-like formations of the maxillofacial region.

Brief seminar program:
Plan 1st day. Three-dimensional radiodiagnostics for dental trauma and trauma to the maxillofacial region. Features of visualization and comparison of the degree of information content of two- and three-dimensional images. Acute trauma to the teeth. Modern classification of HTA according to Andreason et al. 2007. Three-dimensional visualization of different variants of HTA. Long-term consequences of acute tooth trauma. Periapical changes after trauma are temporary (TAB) and require intervention. Modern concepts of OTZ supervision.Odontoclasia or trauma-induced resorption of dental hard tissues is a modern classification and visualization of manifestations. Internal, external, cervical invasive, replacement and pre-eruptive resorption diagnostics of lesion curability. Diagnostics of the condition of tooth rudiments after acute trauma of the dairy. Hypoplasia and dilatation. Chronic trauma manifestations. CT scans for signs of cracked vital teeth. Damage to non-vital teeth. 2D and 3D diagnostics of the longitudinal root fracture. Radiation diagnostics of the temporomandibular joint.Comparison of the information content of the known methods of radio diagnostics. Typical misconceptions when assessing the state of the temporomandibular joint. CT scan of the joint – features of the method, advantages and disadvantages. How to look and what can be seen on a CT scan. Anatomy and three-dimensional radioanatomy of the joint. Principles of virtual positioning in three-dimensional examination of the temporomandibular joint. Normal conditions, deviations from the norm, compensated conditions and diseases of the joint in three-dimensional display. Modern classification of joint lesions in 3D.TMJ MRI and TMJ CT – what is the difference and what can be recognized where. Acute trauma to the condylar process and long-term consequences of trauma. Subchondral erosions, osteophytes and tumors of the TMJ region. Unilateral condylar hypoplasia and mandibular elongation. Joint remodeling in case of malocclusion. Osteoarthritis – what it really looks like, five signs on a CT scan. 3D visualization of jaw cysts. Principles of virtual positioning of cysts and neoplasms in the CT program. Modern classification and differential diagnostics.Cysts and pseudocysts, inflammatory and non-inflammatory, odontogenic and non-odontogenic. Etiology, localization and radiosemiotics of inflammatory radicular cysts. Popular myths and legends about cysts. Signs of repair of inflammatory cysts after endodontic treatment. Collapse of cysts in 3D. Differential diagnosis of a radicular cyst with chronic periapical, abscess, retention cyst and cementodysplasia.
Plan 2nd day. Non-inflammatory odontogenic cysts of the jaws. Dental and periodontal cysts in children, etiology and variety of manifestations, consequences of untimely and incorrect diagnosis.Follicular, tooth-bearing, or eruption cyst? Visualization of cysts in a mixed bite – how it should be done in order not to make mistakes. Adult odontogenic cysts. Keratocyst – cyst or tumor? Etiology, pathogenesis, topography and radiosemiotics of other jaw cysts. Cyst-like formations. Rare jaw cysts. 3D diagnostics of changes in bone tissue in inflammatory diseases of the jaws – from periodontitis to osteomyelitis. Features of visualization of manifestations of condensing osteitis.CT signs of inflammatory spongy remodeling in children, adolescents and adults. Radiosemiotics of osteomyelitis. Radiodiagnostic classification of osteomyelitis. Chronic sclerosing osteomyelitis in adolescents as a complication of endodontic treatment. Radiation necrosis and phosphorus necrosis of the jaws. Bisphosphonate remodeling of jaw bone tissue and drug-induced osteonecrosis – causes, effects, diagnosis. Complications of tooth extraction and implantation surgery while taking bisphosphonates and chemotherapy.Squestration in periodontitis and orthodontic treatment. Tumors and tumor-like formations of the maxillofacial region. Cementodysplasia – local, focal and generalized. Differential diagnosis of cementodysplasia with complications of caries. Bone and fibrous dysplasia. Local facial dysplasias. Variants of manifestation of fibrous osteocementodysplasia in different parts of the MAP. Differential diagnosis with tumor and osteomyelitis. “What are these spots in the picture?” – diagnostics of osteomas and osteoporotic defects of the lower jaw.Benign tumors are characteristic features and radiosemiotics. Fibroids, giant cell tumors, myxoma, schwannoma, ameloblastoma, and other tumors in 3D and 2D. Benign and malignant tumors originating from periodontal tissues are common signs and differ from ordinary periodontitis. Histiocytosis X or eosinophilic granuloma. “Good” and “evil” – how to distinguish and whether it can be distinguished from the picture. Typical signs of malignant neoplasms. Osteosarcoma, myeloma, jaw cancer, metastases in the maxillofacial region – as it looks in 3D.Rare neoplasms of the maxillofacial region – what you need to see on CT in order not to miss the disease.
Organizer: Dental clinic “Totem” LLC “DentKlass” Kemerovo
Sign up for a seminar, get an invoice for payment and ask additional questions:
+ by phone: (3842) 455-299, tel .: 8-950-269-2118
+ by e-mail: [email protected] or the site “klinikatotem.rf”. The location is being specified.
Participation fee: RUB 11,000; if paid before 31.11.2016 RUB 8,000, until 12/31/2016 RUB 9,000, until 01/31/2017 RUB 10,000
Coffee breaks are included in the price. At the end of the seminar, a certificate is issued.

Ganglion ( synovial cyst, tendon-synovial cyst, when localized in the popliteal region – Becker’s cyst ; ICD-10: M67 Other lesions of synovial membranes and tendons) – thin-walled lesions always associated with (but not associated with) the joint capsule, synovial sac or sheath of the tendon.The ganglion can be single-chambered or multi-chambered. It is more often localized on the back of the hands and feet, less often it is found on the palmar surface of the hand, the inner surface of the forearm, in the area of ​​the knee joint, etc. The multichamber ganglion has numerous lateral branches spreading among collagen fibers. It occurs at any age, somewhat more often in women. It develops as a result of the degeneration of collagen fibers. Intraosseous ganglion – a disease in which a synovial cyst causes bone deformation by erosion of the cortical layer; usually subchondral localization near the joint.

Clinical picture. Cystic weakly mobile formation, sometimes aching pains that increase with physical exertion. On palpation, it has a dense consistency, slightly painful or painless, sometimes fluctuates. There are no signs of inflammation in the surrounding tissues. The increase in the size of the ganglion is slow.

Pathomorphology.

Macroscopically, a cavity with a colorless viscous gelatinous liquid containing a large amount of mucin.

Microscopy. Rounded tumor-like formation measuring from 0.