coxartroza nicolescu
DESCRIPTION
curs ortopedie SUUBTRANSCRIPT
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COXARTROZA
Prof. Dr. Mihai NICOLESCU
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CUPRINS
1. ISTORIC. DEFINITIE. FRECVENTA.
2. ETIO-PATOGENIE. CLASIFICARE.
3. ANAT. PATOLOGICA.
4. CLINIC. EVOLUTIE.
5. RADIOLOGIE.
6. Dg. CLINIC. RX. CLASIFICARI.
7. TRATAMENT (conservator, chirurgical)
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ISTORIC
1759 HUNTER – prima descriere AP
“ATLASUL ANATOMIC”
CRUVEILHIER – uzura cartilajului
condensarea osoasa
osteofitele
Sir JOHN CHARNLEY – 1960
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COXARTROZA
Definitie – afectiune cronica DEGENERATIVAA.P. – cartilajul
- sinoviala - osul epifizar
Clinic – durerea - schiopatarea - redoarea - pozitia vicioasa
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COXARTROZA
Frecventa – 3-6 % din populatia peste 55 ani
Gonartroza/coxartroza = 2/1
Debut (durere) – 61 ani cox. primitiva
- 51 ani cox. secundara
Femei > barbati
Bilateral 45 –50 %
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CUPRINS
1. ISTORIC. DEFINITIE. FRECVENTA.
2. ETIO-PATOGENIE. CLASIFICARE.
3. ANAT. PATOLOGICA.
4. CLINIC. EVOLUTIE.
5. RADIOLOGIE.
6. Dg. CLINIC. RX. CLASIFICARI.
7. TRATAMENT (conservator, chirurgical)
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Etiologie = factori de risc
- multifactoriala
Anamneza
– surmenajul articular 7%
- ereditari – familiali 60%
- tulburari de statica+dinamica
Ancheta negativa – coxartroza esentiala 36%
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Factori de risc radiologici
29% Displazia, subluxatia congenitala
Caput varum (retrotorsa) 15%Protruzia acetabulara 5%Coxa plana
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Coxarthrose sur coxa valga et dysplasie des cotyles
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Coxarthrose centrale (protrusion)
Pincement
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Coxa vara
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Coxarthrose et ostéochondrite de la hanche
La coxa plana est génératrice de coxarthose
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ClasificareI. Coxartroza primitiva (esentiala)
Frecvent bilateralDebut 60 aniFactori de risc generali alterarea cartilajului uzura
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Clasificare
II. Coxartroza secundara = Cauze localeTulb statica articulara tulb
mecanica articularaLocul I – congenitale (vezi factorii de
risc)Necroza – copil L.C.P.
- adult N.A.C.F.Fracturi, luxatii
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Clasificare
III. CoxiteInfectioase nespecifice, specificeReumatismale (PR, SA)Sinovite , condromatoza
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Anatomie – patologicaCruveilhier – cap artrozic – mare, deformat si
turtit “in maciuca”Deformarea – turtire superioara+ eroziunea
cartilajului in zona de sprijinosteofitoza -apozitii osoase
- “capital drop”
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Cartilajul hialin – leziuni caracteristice zonei de hiperpresiune:Luciul pierdut rugosGalben, opacElasticitate scazutaFisurarea (“demascaj fibrilar”) – detasarea de
fragmente/lambouri eroziuni/ulceratii in zona portanta (“escara de decubit”) denudarea osului subcondral
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Usure = Pincement de l’interligne
Hanche normale Coxarthrose
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Leziuni osoase : Leziunea esentiala- necrobioza osteocitului (oncoza) Zona portanta :
remaniere (resorbtie osteoclastica si apozitie de lamele osteoide condensare trabeculara “os compact” cu structura pseudohaversiana
MicrofisuriPetrificari – precipitare de saruri de Ca in substanta
fundamentala si in osteocit
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Macroscopic :Zona triunghiulara ( conul de presiune Trueta) de
hipercondensare – culoare alb-galbuieZona de delimitare hipervasculara geode (5-25
mm) pseudochisteUlterior – sechestrare – separare tesut osos viabil
de osul necroticCapul este deformat in “oglinda” subluxatie
progresiva
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Enorme géode remplie de liquide gélatineux
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Osteofite ( proliferare marginala)- in zona de descarcare – inf.-mediala
- supero-laterala- “capital drop” (“tête coulée”)- Osteofitoza pericartilaginoasa
- Cap (burelet osos)- Cotil – idem + fund dublu
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Leziunile cotilului – in oglinda (De Marneffe) - zona portanta – osteocondensare (conul de
presiune Trueta)- cotil plat, largit, “in farfurie” cu cap
subluxat si “fund dublu”- geode in oglinda “ kyssing cysts”- uzura cartilaginoasa- osteofite marginale (pericotiloidiene)
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Capsula – sinoviala- leziunea initiala – cartilajul- Sinoviala – leziune secundara, neinflamatorie- Proc.: hiperplazie reactiva (franjuri)
metaplazie condroida scleroza domina scena ! hipervascularizatie
- Lichid sinovial : redus, vascozitate , mucina , proteine
- Coxartroza = “artrita uscata”
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Capsula- se fibrozeaza- Se ingroasa scade elasticitatea si
mobilitatea REDOARE- Se retracta pozitii vicioaseVascularizatia- initial staza venoasa in zona portanta
angorjare fibroza medulara fibroza ischemica (De Marneffe)
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CUPRINS
1. ISTORIC. DEFINITIE. FRECVENTA.
2. ETIO-PATOGENIE. CLASIFICARE.
3. ANAT. PATOLOGICA.
4. EX. CLINIC. EVOLUTIE.
5. RADIOLOGIE.
6. Dg. CLINIC. RX. CLASIFICARI.
7. TRATAMENT (conservator, chirurgical)
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Examen clinicAnamneza – adulti /varstnici – “morbus
coxae senilis”- factori de risc – copilarie
- displazii congenitale 40%- boala L.C.P- epifizioliza- coxa vara- coxita (T.B.C., piogeni, P.R.)
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Examen clinic- factori de risc – adult
- Traumatisme – fracturi: cap, cotil - luxatii +/- fracturi
- Necroza – esentiala /postcorticoterapie - drepanocitoza (thalasemie)
- Terenul – dismetabolic – obezitate, guta - poliartrozic
- Fara antecedente coxartroza primitiva
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Evolutie – 3 faze:1.Debut – insidios, evolutie lenta, progresiva
– 6 luni-3 ani – Grasset: ” boala nu are inceput ”– Simptomatologie:
Oboseala Durere – de tip mecanic (la efort)
- inghinala, iradiata in genunchi - moderata, intermitenta
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Douleur de la coxarthrose
D0 D1 : Douleur de temps en tempsD2 : Douleur fréquenteD3 : Douleur à la marcheD4 : Douleur au reposD5 : Douleur la nuit
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Evolutie – 3 faze:2. Perioada de stare – 3 simptome
I. Durerea – in triunghiul lui Scarpa
- iradieri – f. rar gonalgie solitara 10%
- obturatoare, fals sciatalgie
- la mers – 200 –1000 m
- scari, teren denivelat, ortostatism
- dispare la repaus
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Evolutie – 3 faze:2. Perioada de stare – 3 simptome
II. Redoarea – rotatie interna, extensie, abductie
- dificultati – incaltare, pantaloni
- poz. picior/picior, ghemuit
III. Pozitia vicioasa
- cauza : contractura antalgica retractii
- FLEXIE – ROTATIE EXTERNA – ADD.
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Attitudes vicieuses
Raideur en abduction Raideur en adduction
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COXARTROZAEvolutie – 3 faze:3. Perioada terminala
- impotenta functionala cvasitotala
- blocarea miscarilor
- dureri continue
- mers penibil, nu urca scarile
!! Factor agravant = bilateralitatea
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CUPRINS
1. ISTORIC. DEFINITIE. FRECVENTA.
2. ETIO-PATOGENIE. CLASIFICARE.
3. ANAT. PATOLOGICA.
4. CLINIC. EVOLUTIE.
5. RADIOLOGIE.
6. Dg. CLINIC. RX. CLASIFICARI.
7. TRATAMENT (conservator, chirurgical)
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Examenul radiologic
- neconcordanta clinic/Rx/AP
- ingustarea spatiului articular
- modificarea raporturilor anatomice
- structura osoasa + osteofite
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Examenul radiologic
Pensarea:
- cauza – uzura /subtierea cartilajului
- localizare – polar superior = displazie (cauza – supraincarcarea zonei portante)
- forma axiala – cox. profunda
- cox. primare
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Pincement, condensation, géodes , ostéophytes
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Osteofitele- proces constructiv osos – prelungirea
suprafetei cartilaginoase la insertia sinovialei
- Diverse denumiri :
capul femural – “guleras”, ciuperca, tampon
- “capital drop”= picatira de ceara
- in bereta
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Osteofitele – cotil- externe – in “cioc de papagal”
(coviltir) - prag (“seuil”)
- interne – perdea fund dublu
- alterarile structurilor osoase , zona portanta
- condensare (osteo-scleroza)- cap = “conul de uzura” Trueta- cotil = banda – con in oglinda
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Geode = pseudo-chiste
- in zona portanta condensanta
- in oglinda
Alterari morfologice
- cap – turtire polara superioara ovoidal sau “tampon de vagon”
- cotil – tesirea supero-laterala cotil oblic (ovalizare)
- col - scurtare
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Géodes
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Pincement, condensation, géodes , ostéophytes
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Deplasarile
- migratie supero-laterala (cox. secundara)
- cox. protruziva (preexistenta)
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Investigatii imagistice
- CT diagnostic = structura osoasa, leziuni discrete profunde, geode, condensare
- CT trat. – modificarile cotilului (displazie)
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CUPRINS
1. ISTORIC. DEFINITIE. FRECVENTA.
2. ETIO-PATOGENIE. CLASIFICARE.
3. ANAT. PATOLOGICA.
4. CLINIC. EVOLUTIE.
5. RADIOLOGIE.
6. Dg. CLINIC. RX. CLASIFICARI.
7. TRATAMENT (conservator, chirurgical)
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Diagnostic pozitiv – clinic + radiologic- durerea – inghinala, demaraj- limitarea miscarilor – RI +RE, Abd+Add, semnul pantofului- poz. vicioasa : add + RE +/- flexie, scurtare aparenta- deficit functional – perimetru, scari, scaun- stare generala + biologica normala-varsta
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Clasificare functionala
1. Neinvalidante
2. Moderat invalidante
3. Invalidante
Bilateralitatea – uni/bilaterala
- simetrica / asimetrica
Etiologie – primitiva
- secundara
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Evolutie :
- Coxartroza la debut- Coxartroza moderat evoluata- Coxartroza foarte evoluata
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TRATAMENT
Conservator
-igiena vietii
-ortopedic
-medical
-B.F.T. si recuperare functionala
Chirurgical
-osteotomii
-artroplastia (prevaleaza)
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TRATAMENT CONSERVATOR
Cand?-contraindicatii chirurgicale-varsta-tare-refuza interventia-prea tineri pentru PTS
Scop-reduce evolutia coxartrozei-amelioreaza suferinta (efect antalgic al AI)
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IGIENA VIETII1. Evita surmenajul articular
Schimbarea modului de viata
2.Mentinerea mobilitatii
-CFM-bicileta ergo-innot
-ortostatism / pauze-mersul / bicicleta-scarile-greutatile-obezitatea (sprigin
monopodal = 4 x G)-Baston!!!
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Coxarthrose - biomécanique
La hanche supporte excentriquement la force P et la force musculaire M : soit P + M
La hanche normale supporte 4 fois le poids du corps car le bras de levier CP est 3 fois le bras de levier CM
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TRATAMENT ORTOPEDIC
Scop: - corectarea poz. vicioase manevre sub anestezie + orteze, ap. gipsat
-antalgic tractiune continua - cresterea mobilitatii manipulari ± anestezie aparato – terapie Kinetek
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TRATAMENT MEDICAMENTOS
Condroprotectoare
- Condrocit sinteza GAG→proteo glicani→agregate proteoglicanice
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FLEXODON
Aport exogen de glucozamina + condroitina
Calea directa GAG
Echivalente Piascledine
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LUBRIFIANTE
Lichid sinovial : rol = lubrifiere
atenuarea socurulor
În artroză L.S. se modifică→dureri, reducerea mobilităţii
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L.S. conţine şi hylani cu rol visco-elastic
Synvisc (hylan A+B) –glicuronat Na + dizaharide (acetol glicozamină)
Similare – hyart, hyalgan...
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A.I.N.S.
Ex. Celebrex (Celecoxib) – inhibitor al COX2 (ciclooxigenază)
Stimuli proinflamatori→COX2→sinteza prostaglandinelor – mediatori ai durerii, inflamaţiei,
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ALTE MIJLOACE
Balneo-Fizioterapia
-antalgic, decontracturant
Recuperare
-redoarea, contractura, tonifierea musculară,atitudini vicioase
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TRATAMENT CHIRURGICAL
Ostetomiile
-Femur
-Cotil- Corectează viciile arhitectonice- Efect biotrofic
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Ostéotomie de varisation(Pauwels)
L’ostéotomie allonge le bras de levier h des muscles abducteurs M et en modifie la direction.
Cela diminue la résultante R et la ramène plus profondément dans le cotyle (de plus, détente des adducteurs et du psoas).
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Ostéotomie du bassin (Chiari)
Translation de la tête et couverture
La force M est verticalisée, ce qui augmente son bras de levier CM et diminue le bras de levier CP ’
CM est sup au 1/3 de CP. La force qui équilibre P est inférieure à 3P
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ARTROPLASTIA
Scop + mobilitate
+ stabilitate - durere
Componente – tijă femurală - cap - cupă
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Prothèse de hanche cimentée
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MATERIALE!! BIOCOMPATIBILE
1. Oţel (Cr-Co-Mo)2. Titaniu – perfect bio-comp.-Cuplul Ti/Os este mai “calm” biomecanic
= ↑ bone ingrowth = ↓ loosening3. Alumina (ceramica)!! Densitatea =
diamant – nu uzură, coroziune, fricţiune↓
4. Polietilena cu densitate molec. înaltă
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FIXAREA?!
CIMENT ACRILIC (metilmetacrilat) -HABOUSCH
BIOLOGICA
-porometal (porous coating) osificare endostala
-mese de titanium osteointegrare
(bone ingrowth)
-hidroxiapatita - osteoinductie
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Tiges modulaires Tiges sur mesures
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INDICAŢII
PTŞ o modă?Charnley - !! Nu recurgeţi la PTŞ de cât atunci când nu se mai poate face altceva!!Criterii
coxartroza infirmizantă ( durerea, redoarea, deficit funcţional, vârsta, bilateralitatea, gonartroza)
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TEHNICĂ
COMPLICAŢII
RECUPERAREA