Symptoms of osteoporosis in osteoarthritis

Systemic osteoporosis is a complex multifactorial disease characterized by usually slow asymptomatic progression until the appearance of bone fractures, which in most cases are the first reliable signs of osteoporosis, characterized by the appearance of spontaneous non-traumatic or inadequate fracture injury severity.

In one of the studies, a comparative assessment of bone tissue was performed in patients with osteoarthritis, rheumatoid arthritis and practically healthy individuals. 348 patients with RD were examined: 149 patients diagnosed with osteoarthritis, established according to the criteria proposed by ACR (1994), and 199 patients with a reliable diagnosis of rheumatoid arthritis according to ARA criteria. Patients were clinically examined, including determination of body mass index (BMI), and using instrumental methods. 310 patients received OPA; part of the patients (n = 38) was examined by ultrasound densitometry (USD) of the calcaneus (Achilles ultrasound densitometer, "LUNAR"). All patients underwent radiography of the spine with subsequent calculation of morphometric indices of the radiographs - the central index of Barnett, Nordin for the evaluation of bone tissue. Correlation analysis was performed (r <0.35 was qualified as a weak link).

As the main symptoms accompanying generalized bone mineralization in the RGS, anatomical changes and pain syndrome are distinguished.

[1], [2], [3], [4], [5], [6]

Anatomical changes

Anatomical changes in the form of a decrease in growth (an average of 4.8 + 0.31 cm) during the period of the disease were noted by 46 examined, or 23.11% of their total number, and posture disorders were registered in 76% of patients. Decrease in height was determined by measuring the distances of the head-symphysis (1) and symphysis-stops (2): a decrease in the ratio (1) to (2) by more than 5 cm indicated osteoporosis. When conducting the correlation analysis, a very weak correlation was found between anatomical changes and osteoporosis severity (r = 0.09).

[7], [8], [9], [10], [11], [12], [13], [14]

Pain

Pain syndrome caused by pathological processes in the bone tissue, accompanied by its rarefaction, was noted in 72% of patients in whom dysentometric abnormalities were detected.

Pain syndrome included:

1. The localized pain, which we divided into the "periosteal", characterized by a sharp beginning and a sufficiently clear localization, "pseudo-radical" (of the lumbago type), slightly differentiated and tending to chronization, with muscle stiffness (muscle spasm) as a reflex response to pain and, as a rule , with the absence of compression pain, and "radicular" - both acute and chronic.
2. Generalized pain in the spine, reaching the greatest intensity mainly in its "transitional" zones (cervicothoracic, lumbosacral, lumbosacral).

Clinical variants of the course of osteoporosis of the vertebrae were as follows:

• acute pain syndrome, usually associated with a fresh compression fracture of the vertebra or several vertebrae, characterized by acute intense pain in the affected spine, followed by acute reactive muscle tension in the affected area, often in the form of girdle, irradiating pseudo-radical pain in the thorax, abdomen or femur ;
• chronic: complaints of dull pain in the back for a long time, constant or recurring, accompanied by the above-described anatomical changes - decreased growth, deformity of the spine (stoop was observed in 60% of all examined patients). Symptomatic in these patients slowly increased with increasing duration of the disease, and was characterized by an alternation of periods of exacerbation with remissions, when the pain became less pronounced or almost absent. It is assumed that the cause of this course of osteoporosis is the creeping deformation of the vertebral bodies (multiple microbe fractures of the trabeculae) with a progressive decrease in vertebral height, deformation of the spine by an increase in the thoracic kyphosis.

3. Pain in various bones of the skeleton (ossalgia). Previously, it was believed that since there are no pain receptors in the bone, the pain syndrome in osteoporosis can not occur without the deformation of the vertebral body, but this assumption has now been disproved. Thus, diffuse bone pain, sensitivity in flickering of ribs and pelvic bones, and general sensitivity to shaking were noted in patients under the condition of recording on the X-ray diffraction patterns of the trabecular structure of the CTK and the absence of deformation of the vertebral bodies. Such pain can be caused by bone micro-fractures or irritation of the perioste with a protruding porous bone. The existence of a dependence of the intensity of pain on the severity of osteoporosis in patients with RCD was confirmed by other researchers. The strongest positive correlation was noted between generalized pain in the spine and osteopenic syndrome (r = 0.62).

Thus, anatomical changes in the spine and pain syndrome (localized pain, generalized pain in the spine, ossalgia) are the main clinical manifestations that accompany generalized bone tissue scarification in the RCD. Identification of relevant clinical signs at an early stage of osteopenia development in this category of patients will allow the practical doctor to purposefully conduct differential diagnosis of such disorders and timely prescribe adequate therapy taking into account the risk factors for the development of spontaneous (pathological) fractures - the age of the patients (especially in women in early postmenopausal period), systemic manifestations, as well as specific therapy (systemic administration of GCS, etc.).

Let us emphasize that it is impossible to establish the diagnosis of osteoporosis only on the basis of clinical and anamnestic data and requires confirmation with the help of laboratory and instrumental research methods.

In symptomatic therapy of pain syndrome in osteoporosis, novocaine, trimecaine blockades, and non-narcotic analgesics are well established. Tramadol is especially effective in patients with rheumatological profile, which allows to significantly reduce the severity (or eliminate completely) of the pain syndrome caused by both osteoporosis and joint damage (arthritis, arthralgia).

Pathological fractures

It is known that the clinical stage of osteoporosis development is characterized by pathological (spontaneous, brittle, osteoporotic) fractures that occur in the absence of a traumatic factor or when the severity of the injury does not correspond. The data available in the current literature indicate a close correlation between predisposition to fractures and osteoporosis.

The parameters influencing the bone tissue state and, accordingly, on the frequency of development of osteoporotic fractures include: mass or BMD (in foreign literature - BMD, g / cm ² ), a tendency to lose balance, bone geometry (especially the cervix femoral bone), "quality" of bone, microarchitectonics of CTK.

Especially important for the appearance of fractures in the age of up to 65 years, most researchers attach an IPC, which, independently of other causes, is closely correlated with bone strength and the risk of fractures. Reduction of BMD in any part of the skeleton by 1 SD from the norm leads to a 1.5-fold increase in the risk of fractures.

In prospective and retrospective studies, a direct correlation was established between the presence of fractures in the anamnesis and / or an increased risk of fracture and low bone mass. SR Cummings and co-authors (1993) have shown that in women with a femoral neck necrosis factor (<-2 SD), the risk of hip fracture is 8.5 times higher than in those whose MIC> 2 SD. A decrease in the BMD of the femoral neck per SD increases the risk of a fracture by a factor of 2.6, which indicates a reliable association of the BMD with a fracture probability.

In the group of patients with RGS, examined by us, fractures in the anamnesis were noted in 69 (19.8%) people. The greatest number of fractures occurred at the age of 52 years - 56 years for women and about 60 years for men. It should be noted that in 76.7% of cases the fractures occurred as a result of the action of only the minimum load, i.e. There was a discrepancy between the severity of the injury and the strength of the provocative moment.

Despite the fact that in osteoporosis all parts of the skeleton have increased brittleness, some of them are typical places of localization of osteoporotic fractures, namely, the body of the lower thoracic and upper lumbar vertebrae (the so-called transitional zones of the spine), the proximal end of the femur (head, interturn, the prone part), the proximal end of the humeral and distal radius (fracture of the Colles).

Fractures of long tubular bones, most characteristic of the femur, occur about 15 years later than compression fractures of the vertebrae; the average age of the patient with a fracture of the wrist is 65 years, and the fracture of the femur is 80. This is most likely due to the fact that the femur, including the neck, contains more compact bone than in the body of the vertebra .

The presence of compression fractures of vertebral bodies (including wedge deformation and lenticular shape of vertebral bodies with a decrease in their height) was confirmed by data from the central Barnett-Nordin index.

In the group of patients with fractures, BMI was 17.15-33 conventional units. (on the average - 24.91 ± 4.36 standard units) and did not differ significantly from the BMI in the main group as a whole (p> 0.1). We assume that obschetroficheskie violations themselves do not serve as an important predictor of pathological fractures.

Although the decrease in BMD is the leading factor determining the risk of osteoporotic fractures, according to clinical and epidemiological studies, the risk of skeletal bone fractures does not always correlate with a decrease in BMD from densitometry data, i.е. We do not mean "quantitative", but "qualitative" changes in bone tissue.

This is well illustrated by the contradictory data available to date, obtained by different researchers. Thus, S. Boen and co-authors (1996) found in population studies that patients with osteoarthritis (and even their blood relatives) have a reduced risk of fracture of the skeleton bones (OR -0.33-0.64), especially the femoral neck . At the same time, the results of prospective studies indicate that in patients with osteoarthritis, despite an increase in BMD, there is no decrease in the risk of "invertebrate" fractures compared with patients without osteoarthritis. Moreover, patients with coxarthrosis have a 2-fold increase in the risk of fracture of the femur. These data are extremely important, since they indicate the need to carry out measures to prevent osteoporetical bone fractures in the skeleton, not only in patients with osteoarthritis with a reduced, but also "normal" and even "elevated" BMD. It should also be taken into account that the "high" MIC according to the densitometry data is often an artifact caused by degenerative changes in the elderly (osteophytes, scoliosis, etc.). Finally, in patients with osteoarthritis, as in rheumatoid arthritis, the development of periarticular osteoporosis of bones adjacent to the affected joint was found. It is believed that the propensity to osteoporetic fractures in osteoarthritis, despite the absence of a pronounced decrease in BMD, is associated with a violation of the "quality" of bone tissue and a violation of muscle mass, creating the prerequisites for accidental loss of balance.

Separately, we should mention the destruction of bone tissue in the departments that are "targets" for aseptic (avascular) necrosis - the necrosis of the bone site due to malnutrition or complete cessation of it with the preserved vital activity of adjacent bone areas, especially the femoral head heads. This complication was observed in 7 (3.52%) patients with rheumatoid arthritis and in 2 (1.34%) with osteoarthritis. The death of bone cells while preserving the interstitial substance is a characteristic feature of this process (the mineral composition of the dead bone does not change). The necrotic area of the bone loses the fluid elements of blood, lymph and tissue fluid, as a result of which more inorganic substances are needed per unit of dead bone mass than per unit of living weight. In the surrounding living bone tissue, vascularization and bone resorption intensify, therefore on the roentgenogram the area of osteonecrosis appears more intense than the surrounding bone tissue.

It can be assumed that avascular necrosis represents an extreme degree of severity of bone mineralization with loss of both mineral and organic components.

Effect of duration of osteoarthritis disease on bone mineral density

Dependence of the IPC on the duration of the disease is a poorly understood issue. The lowest densitometric parameters were registered in patients with osteoarthritis for 6-10 years. In the group of patients with a duration of osteoarthritis 1 year-5 years and more than 10 years, the bone mass is somewhat larger, although in general the group does not reach the indices of persons of the same age without the defeat of the musculoskeletal system, as well as those suffering less than a year. There was also a tendency for an increase in BMD in patients with osteoarthritis who have been ill for more than 10 years. In our opinion, this is explained by the development of compensatory processes in bone tissue, which reduce its metabolism and slow down the rate of loss of the mineral component by the skeleton.

[15], [16], [17], [18]

Features of osteoporosis in patients with osteoarthritis

According to clinical studies, it has been established that the BMD of the spine and femoral neck, as well as the body weight, are greater in patients with hip osteoarthrosis compared with patients with predominant lesion of small joints of the hands and controls (without pathology of the musculoskeletal system).

Persons with lesion of many joints (polyosteoarthrosis) had a significantly lower BMD. IPC-Z was in patients with polyostoarthrosis and oligo (mono) osteoarthrosis in the spongy substance of bone tissue (-1.39 + 0.22) and (-0.15 + 0.29) (p <0.01), and in the compact (-1,13 + 0,47) and (+ 0,12 + 0,52), respectively. It should be noted that in 69 (76.7%) patients with mono- or oligoartrosis, the MIC was significantly higher than the age norm. Probably, in this case the degenerative-dystrophic process, caused by osteoarthritis, had a protective action in relation to loss of bone mass.

[19], [20], [21], [22], [23]