Pain in the large joints.
Pain in the large joints. This is the most common cause of the patients visit to the orthopedist. There are many causes of pain in large joints. The most common cause is trauma to the joint with damage to cartilage, meniscus, ligaments, fractures. If we exclude this group of patients very simple for diagnosis and treatment in the first place there is a group of patients with osteoarthritis of the knee. They are the champions of visits to orthopedist with pain in the joint. In this group, undoubtedly, the most outstanding representatives are the patients with edema and necrosis of the bone marrow of the epiphysis of the articular ends.
We know the acronym SPONK (spontaneous osteonecrosis) or just AVN (avascular necrosis). These abbreviations we can use only having the result of deep non-invasive probing of the knee – MR imaging. This diagnosis is very simple, when the patient has a good quality tomograms of the joint. In the absence of this kind of research to put this diagnosis is impossible, especially at the stage of edema of the bone marrow. The treatment of this disease requires a lot of knowledge and art from the doctor. The epidemiology of this suffering is still not sufficiently studied.
A screening study conducted by us in conjunction with radiation diagnosticians, aimed at identifying SPONK, allowed for a new look at the etiology and prevalence of this disease.
Every day we come to the initial reception of a few patients with spontaneous osteonecrosis or bone marrow edema of the large joints. We have experience in the diagnosis and treatment of several thousand patients every day and their army is growing.
The prognosis is not as good as with bone marrow edema. Long-existing and untreated osteonecrosis inevitably turns into osteoarthritis of one degree or another. Treatment of osteoarthritis has its own characteristics, quite long and expensive. Over time, osteoarthritis, in its final stage, inevitably leads to joint endoprosthetics.
The most common questions to the orthopedist:
– I was treated for several weeks in a policlinic at a surgeon (traumatologist) and nothing helps, what will you appoint me yet?
– I have a severe nocturnal pain in the joint, there was no injury, what have I?
– I have severe pain in the joint with loads and in the evening, what do I have?
– Do I need to do CT, ultrasound or MRI of the joint?
– I made an MRI of the joint, there were no injuries, the treatment does not help, what have I?
– I have found a fracture of the meniscus on the MRI, do I need an operation?
I will answer these questions at the end of the article.
The causes of pain in the large joints are many. The most common cause is joint trauma, with cartilage damage, meniscus, ligament, fracture. If we exclude this group that is the easiest to diagnose and treat, the group of patients with non-traumatic joint pain (osteoarthrosis, osteonecrosis, stress fracture) comes first. They are the champions of the appeal to the orthopedist with pain in the joint. From 12 to 21% of visits to the orthopedist per year. And in this group, undoubtedly, the most complex and bright representatives are patients with edema and necrosis of the bone marrow of the epiphyses of the articular ends. To put the exact diagnosis, having on hands only roentgenograms, – it is impossible. Only the result of deep non-surgical sounding of the joint – MR tomography – can give us an answer to the question – what is the cause of pain – bone marrow edema (Figure 1), osteonecrosis (Fig. 2), subchondral dystrophic fracture (Fig. 3) or stress fracture Fig. 4). In the absence of this type of study, it is impossible to put these kinds of diagnoses, especially at the stage of the edema of the bone marrow. Treatment of this pathology requires great knowledge and skill from the doctor. Screening a study conducted by us in conjunction with radiotherapy, aimed at identifying spontaneous osteonecrosis allowed a different look at the etiology and prevalence of the disease. Every day several patients with spontaneous osteonecrosis or bone marrow edema of large joints come to us for initial reception. We have experience in the diagnosis and treatment of many hundreds of patients. The earlier the edema of the bone marrow is revealed, the better the treatment prognosis. At the stage of already developed osteonecrosis – treatment is very long and stubborn. The prognosis is not as good as with bone marrow edema. Long-existing and untreated osteonecrosis inevitably turns into osteoarthritis of one degree or another. Treatment of osteoarthritis has its own characteristics, quite long and expensive. Over time, osteoarthritis, in its final stage, inevitably leads to joint endoprosthetics.
Pic .1 – Edema of the bone marrow of the inner condyle of the femur
Pic.2 – Avascular necrosis of the bone marrow of the inner condyle of the femur with a prognostically unfavorable necrotic angle of Kerbula
Pic. 3 – Subchondral dystrophic fracture of the inner condyle of the tibia
Pic.4 – Stress fracture and massive edema of the bone marrow of the tibial diaphysis
Question: I was treated for several weeks in a policlinic by a surgeon (traumatologist) and nothing helps, you again prescribe medications to me, some of them I have already taken, is it going to help me?
Answer: even a long period of treatment in a polyclinic does not mean at all that this treatment was correct and pathogenetically justified. Often the list of medications prescribed to the patient is chaotic and the attending physician himself does not quite understand what goals he pursues with such a combination and can not explain the choice of just such a set of medicines.
Question: I have a severe nocturnal pain in the joint, there was no injury, what have I?
Answer: The nighttime nature of pain is often accompanied by effusion in the joint or the onset of the onset of non-traumatic edema of the bone marrow, or avascular necrosis of the bone. The diagnosis is confirmed only on the MR (magnetic resonance) tomogram of the joint.
Question: I have severe pain in the joint with loads and in the evening, what do I have?
Answer: Basically, this type of pain corresponds to arthrosis of the knee joint, popliteal Baker’s cyst, pronounced joint hodromalacia (cartilage wear).
Question: Doctor, do I need to do CT, ultrasound or MRI of the joint?
Answer: All types of research are performed at the discretion of an orthopedic physician, CT is done with suspicion of bone marrow disintegration in tumors, osteomyelitis, ultrasound is informative only with the Baker’s cyst and its rupture, MRI (magnetic resonance tomogram) is the most informative research method for various injuries and diseases of the bone marrow and ruptures of the meniscus-ligament apparatus.
Question: I made an MRI joint, there were no injuries, treatment does not help, what have I?
Answer: MRI depends very strongly on the strength of the tomograph field, for a qualitative assessment of the joint condition, the strength of the MR tomograph field should be at least 1.5 Tesla. The level of training and experience of the radial diagnostician working on the MR (magnetic resonance) tomograph is also very important. Interpretation of the radial diagnostician seen on an MRI and an orthopedist separately by a doctor can be radically different.
Question: I was found at the MRI rupture of the meniscus, I need an operation?
Answer: Given the high saturation of Krasnodar MR tomographs, such diagnoses are not uncommon. It is necessary to know that the conclusion of the radial diagnostician is a conclusion and in no case a definitive diagnosis. Only the probability of discontinuity in powers of Stoller is determined. The diagnosis is made by the orthopedic doctor after the conversation, examination of the joint and the MR shots themselves. A rupture of the meniscus even of a high degree of probability is not an indication for surgery. Often, treatment starts with conservative methods and they often bring success. Only the ineffectiveness of conservative treatment and persistent characteristic symptoms, provoking even after treatment the discomfort of the patient, make one think about the need for surgical treatment.