Gonarthrosis

Synonyms in the wider sense

Gonarthritis, Arthrosis deformans, arthrosis of the knee joint

German: Gonarthrose

Definition

By gonarthrosis / arthrosis of the knee joint all degenerative (wear-out-related) illnesses of the knee joint are understood, which are characterized by an increasing destruction of the joint cartilages. Also participated are joint structures like bones, joint capsule as well as joint-near musculature.

Arthrosis of the knee joint

The scaffolding of the knee joint consists of three bones together with a complex capsule and ribbon apparatus (sides and crucial ligaments).

These are:

• the thigh (thigh roles or condyle of femur)
• the shin head (tibial plateau) (those are not lettered in the picture)

Thigh musculature (Musculsus quadriceps femoris) Thigh bone (femur) Thigh tendon (quadriceps tendon) Knee cap (patella) Knee cap tendon (patellar tendon) attachment for patellar tendon (tuberositas tibiae) Shin (tibia) calf bone (fibula)

By means of the picture one recognizes that the bones show a close contact. So that a painless and undisturbed movability of the knee joint can take place also at the contact surfaces, the bones are covered at the respective contact surfaces with a very smooth, whitish cartilage layer. A painless and undisturbed movability of the knee joint is possible only because of that.

In case of gonarthritis there is wear of the knee joint present. Signs of wear can appear isolatedly or concern the inner or outer part of the knee joint preferentially.

Using the nearer definition of the gonarthritis one recognizes which part of the knee joint is mainly concerned:

• middle gonarthritis: the inner part is mainly concerned
• lateral gonarthrosis: the outer part of the knee joint is mainly concerned
• Retropatellar arthrosis: the kneecap joint area is mainly concerned
• Pangonarthrosis: all three joint parts are concerned
• Arthrosis of the thigh role (condyle of femur)
• Arthrosis of the shin head / plateau of shinbone (tibial plateau)

Sex distribution

The female sex is clearly more frequently affected by a knee arthrosis / gonarthrtiis.

Frequency

Die Gonarthrose / Kniegelenksarthrose ist eine häufige Erkrankung des Erwachsenen mit einer hohen Prävalenz (je nach Studie 27 - 90%) der über Sechzigjährigen. Aufgrund dieser Tatsache liegt eine hohe sozialmedizinische Bedeutung vor. Durch eine Kniearthrose wird einerseits die Arbeitsfähigkeit, aber auch die persönliche Lebensqualität beeinträchtigt.

Causes

Reasons for the origin of arthsosis of the knee joint / gonarthritis:

• Axis deviations (in- or out knee)
• Injuries of the knee joint, e.g. fracture with participation of the joint
• System illnesses, e.g. hemophiliac illness
• Rheumatoid arthritis (rheumatism, chronical polyarthritis)
• Bacterial arthritis (= inflammation of the knee joint by bacteria)
• Dystopia of the patella (= knee cap bud missing)
• muscular dysbalances, e.g. paralyses
• Osteochondrosis dissecans
• Dysplasias of the joint
• Osteonecrosis ( e.g. M. Ahlbäck )
• Chondromatosis
• Metabolism illnesses, e.g. gout

Important influencing factors which favor arthrosis of he knee joint:

• Overweight
• Wrong straining
• endocrine factors (e.g. hormones, increasing appearance of arthrosis after menopause)
• torn cruciate ligament

Medical history

Which facts play an important role when checking the medical history?

Localisation, functional impairment, duration, intensity, rhythm of day, radiation of the pain

• Capacity
• Limping
• Movability
• incarceration, blockade, feeling of instability
• Painless walking distance
• liability to swelling, complaints while walking downstairs / downhill
• Walking aids
• previous accidents
• previous patellar luxation (dislocation of the knee cap)
• earlier affections of the knee joint
• Previous conservative or operative treatment

Symptoms

After sitting or laying for a while the affected person often complains about a feeling of stiffness within the knee joint, combined with a pain when starting to walk.

The knee joint tends to swell and build effusions through which the pain increases in spite of lower loads.

Stimulation-attacks, which at first rather seldom appear, more frequently manifest. In addition the knee joint needs more time to return into an attraction-free condition again.

The load sensibility increases more strongly. Walking upstairs as well as walking downstairs or downhill gets painfull more quickly. The knee joint seems insecure to the patient, the appearances of stimulation increase.

In the further course of the illness more and more severe pains force patients to stop walking. Due to this the distance patients are able to walk decreases considerably. Because of the pain-related rest the musculature of the thigh fades. Attentive observers have the impression that the stability of the knee joint decreases especially on uneven ground.

This finally leads as far as the joint movability keeps further decreasing and partly intense troubles appear even in a resting condition (e.g. in the sleep). Axis changes of the knee joint, such as bandy legs (=Varus - gonarthritis or varusgonarthritis) or knock-knees (= Valgus - gonarthritis or Valgusgonarthritis) also can occur.

Diagnose

Clinical diagnostics

• Inspection (consideration):
• Judgement of leg axis: Muscle atrophy, leg length difference,
• Take a look at the way ok walking, knee swelling, skin changes

Palpation (touching)

• hyperthermia
• Effusion, swelling, dancing patella
• Krepitation, i.e. rubbing noticeably behind the kneecap
• Kneecap movability
• Pain on motion of the patella (Zohlen - sign)
• Pain on palpation of the Patellafacetten ( pain on palpation on the right and on the left the kneecap )
• Pain on palpation at the joint cavity
• Baker´s cyst
• Plica mediopatellaris

Function testing and pain testing

Judging range and pain of movement, stability of ligaments Meniscus sign - to proof damages in the area of the inner meniscus or outer meniscus

Instrumental diagnostics

Necessary instrumental examination:

• X-ray the knee joint in 2 levels

In the individual case useful apparative examinations:

• Function photos (x-ray) and special projections (e.g. recording the patella, tunnel photo according to Frik, standing - on - one - leg photo, whole leg photo) X-ray
• Sonography (ultrasound)
• Magnet resonance imaging (MRI)
• Computed tomography
• Skeleton, szintiscanning
• A clinical, chemical laboratory for differential diagnostics = blood test
• Aspiration to analyse the synovia

Therapy

Aims: Improvement of pain, "quality of life", movability, extension of the ability to walk, delay of the progressing of the arthrosis.

Conservative therapy

Advice: The advice always has to be given individually and covers the anamnesis with regard to the everyday behavior, the physical strains in profession and sports. In addition there will be given advice regarding overweight, lack of exercise, regular exercises to eliminate muscle deficits and also advice on knee school.

The consultation also includes the clearing up about the illness itself, the natural course, but also with regard to the influenceability of the course by a conservative or operative therapy.

Medicinal therapy

The medicinal treatment serves the reduction of pain and retardation of inflammation. It can be systemically (e.g. by tablets, drops ect.) and locally (e.g. by ointments, syringes ect.) carried out with different substance groups.

• Antiphlogistics (NSAR), e.g. Diclofenac (Voltaren), Ibuprofen and the new Cox 2 Inhibitors (e.g. Celebrex) are included
• Steroids (only local) as a syringe into the knee joint
• therapeutical lokal anesthesia
• Chondroprotectives
• Natural remedies, especially there has to be named the devils claw. The devils claw can be used alone at slight pain and to support the existing therapy at more severe pain. The devils claw shall reduce the symptoms of the knee arthrosis.
• Vitamins E and C

Physical therapy

• Physical therapy
• Knee school
• Mobilization, strengthen the muscles, muscle stretching and coordination training
• Thermal therapy (warmth therapy)
• Hydro and Balneotherapy (water- and air-therapy)
• Electrotherapy (Sonophoresis, Jontophoresis)
• pulsating signal therapy (PST)

Orthopedics technology

• the way shoes are made: heels that buffer your steps, higher outer or inner edge of the shoe
• Cane or crutches, which you put under your arm pit
• Heel cushion
• Bandages

Operative therapy

General indication criteria:

• Etiology of arthritis, stage of the illness, previous course
• Pains, in which way and how much the suffering harms you
• Other joint diseases
• Ages, general condition and accompanying illnesses
• Compliance (cooperation and motivation of the patient), work situation, social status, patient´s activity level

Frequent operation methods

The following methods are possible on principle:

• Arthroscopy (if necessary open)
• Lavage (washing out the knee joint)
• Elimination of mechanical irritations
• Synovectomy (removing the joint´s mucous membrane)
• Soft tissue intervention to improve the sliding of the patella / kneecap sliding and to keep it in place
• Osteotomies close to the joint to correct bowlegs and knock-knees
• Correction in frontal and / or lateral level, replacing or moving the tuberositas
• artificial knee joint
• sledge prosthesis (artificial limb of the thigh roles), which is placed in one part of the joint
• artificial limb, which is placed in two parts of the joint but uncombined
• combined artificial limb, which is placed in two parts of the joint, with and without substitution behind the patella, if necessary including patellar modeling

Osteotomies of the joint

Correction of the axis deviation close to the knee joint (knock-knee or bandy legs) to reduce the mechanical use of it and therefore to delay the progressing of the arthrosis. At Retropatellararthritis (arthrosis of the kneecap) additional surgery at the insertion of the tendon might be necessary after previously having tried all other methods and therapies.

Joint replacement operations: We have dedicated a whole category to the prosthesis of the knee joint. You can find detailed information about it there.

Aim

It must be the aim of every treatment of gonarthritis to prevent an operation and to achieve a pain relief.

Depending on the severness, in most of cases this goal can be accomplished by a conservative therapy.

In rare cases operative methods must "repair" the suffered damages.

An important aim of the treatment is the reduction of the detritus-indicated (cell garbage producing) synovialitis (growth of the joint´s mucous membrane).

For that purpose you can use lavage (washing-out), débridement (cleaning), elimination of mechanical irritations like faulty parts of the meniscus, osteophytes (bone cultivations). Additional operations within the soft tissue can be required on kneecap diseases. At relapsing formation of effusion due to synovialitis a Synovialectomy (removal of the joint´s mucous membrane) can be indicated. These methods shall reduce the symptomatology of discomforts at times.

Provided that pains and troubles cannot be improved, the last solution that can be offered is an endoprosthetical supply (artificial knee joint).