DRIVES (gonitis; grech, gony a knee + - itis) — an inflammatory disease of a knee joint. — the most often found type of monoarthritis or one of displays of polyarthritis. Uniform classification of G. does not exist. According to the domestic working classification of diseases of joints accepted by the I All-Union congress of rheumatologists in 1971, gahnites, as well as arthritises of any other localization in some cases are manifestation independent nozol, forms of inflammatory diseases of joints or can be connected with other diseases.
Etiology, pathogeny, pathological anatomy — see. Arthritises .
A clinical picture
In spite of the fact that depending on an etiology and a pathogeny a wedge, manifestations of an inflammation of a knee joint have the features, it is possible to allocate a number of the general signs which intensity defines acute, subacute or hron, a current of.
At acute G. all signs of an inflammation (spontaneous joint pain, reddening of integuments over it, increase in local temperature, puffiness of hypodermic cellulose in a joint, exudate in cavities of a joint, morbidity of a joint at a palpation, restriction of function) are expressed sharply and develop quickly. Contours of a joint are maleficiated, its volume is increased. The myogenetic contracture develops, gives edges to forced, halfbent — to so-called bonnetovsky situation (fig. 1). In this situation the joint is in a condition of the greatest rest since the tension of a joint bag, the copular device and muscles is least of all expressed that weakens or eliminates increase in a muscle tone. Bonnetovsky situation is characteristic of G. with an exudative component of an inflammation.
In blood at acute G. the leukocytosis (sometimes to 25 000), considerable acceleration of ROE (to 70 mm/hour), sharp shifts biochemical, indicators comes to light. In some cases the acute current of G. passes into chronic.
At subacute G. all described symptoms are expressed to a lesser extent.
At hron. Not necessarily all symptoms of an inflammation of a knee joint are defined. Pain arises hl. obr. at the movement in a joint. Permanent changes of a shape of a joint (fig. 2) as a result of organic lesion of the joint capsule, a muscular atrophy, development of an artromiogenny contracture are characteristic. Hron. Of monoarticulary type can proceed without fervescence, acceleration of ROE.
Due to a variety etiol, factors, and also anatomo-funktsio nalny features of the knee joint which is characterized by the big area of the jointed joint surfaces, the extensive joint capsule, G.'s current differs in big variability.
There can be acute, short and completely reversible forms and also progressing, chronic with full defunctionalization of a joint.
Diagnosis is carried out on the basis of the anamnesis, a wedge, pictures, these laboratory and special tool methods of a research and does not represent big difficulties at patients with the established diagnosis of joint, infectious, dystrophic diseases or traumatic damages of a knee joint.
However diagnosis of monoarticulary defeats when the general joint disease begins with a knee joint or proceeds in the form of true monoarthritis of this joint, is quite difficult. Along with carefully collected anamnesis carry out tsitol., biochemical, immunol., bacterial, research synovial fluid (see), a puncture biopsy of a synovial membrane and a cartilage with the subsequent morfol, their analysis, an arthroscopy (see. Joints ), scanning and rentgenol. research of a joint.
Differential diagnosis it is necessary to carry out with bone diseases of a knee joint — fibrous osteodystrophies, a giant-cell ostoclastoma, sarcoma, and also with new growths of soft tissues of a knee joint — a pigmental villonodulyarny synovitis, a synovioma (see. Knee joint ).
The great value for diagnosis and differential diagnosis of various forms G. has rentgenol, a research of a joint — artrografiya (see): apply a X-ray analysis in standard projections with use of special laying, napr, to a research of a femoropatellyarny joint, tomography (see), and also contrast and dublkontrastny (a combination an artropnevmografiya — fig. 3 — with administration of the iodated drugs) methods of a research for detection of pathology of a cartilage, meniscuses and myagkotkanny elements of a joint.
Treatment — see. Arthritises .
Drives gahnites at separate nosological forms of arthritises at Bekhterev's disease
Defeat of a knee joint at Bekhterev's disease in one cases can appear long before damage of a backbone, in others — along with it, in the third — later when there are already expressed changes in a backbone, joints and internals. The greatest difficulties for diagnosis are presented by G. preceding damage of a backbone and which is an early and only symptom of a disease of Bekhterev. In most cases it arises after cooling, physical. tension, develops slowly, can have recurrent character with the long periods of remission. Joint pains usually weak, exudative changes are expressed moderately. Function of a joint, as a rule, is not broken. Quite often such G. passes without treatment, but later certain time under the influence of any negative factor its symptoms appear again. At the same time there are no general a wedge, signs of an inflammation, body temperature remains normal.
The roentgenogram of a joint does not reveal changes at early stages, and further are found circumarticular osteoporosis (see), narrowing of a joint crack, osteophytes at the edges of joint surfaces (see. Osteophytes ), it is very rare — an uzuration of a joint cartilage and anchylosis (see).
At a biopsy of a synovial membrane it is possible to observe a picture of a nonspecific synovitis — acute, subacute or chronic. At the same time sharp increase in quantity of plasmocytes at moderate proliferative reactions of synovial cells is characteristic.
From laboratory researches great diagnostic value has detection in blood serum of HLA-27 antigen which comes to light at 70 — 80% of patients with Bekhterev's disease, irrespective of a stage of a disease.
Treatment and the forecast — see. Bekhtereva disease .
Drives at a disease of Reuters
One of displays of the polyarthritis characteristic of this disease; monoarticulary defeats of a knee joint meet seldom and have no pathognomonic signs — see. Reuters disease .
Infectious and allergic drives — manifestation of infectious and allergic polyarthritis (see).
Brucellous drives infectious specific gahnites — one of displays of brucellous polyarthritis (see. Arthritises ).
Gonorrheal drives there is a hl. obr. at the men (at women seldom) who are ill acute and hron, gonorrhea, is also the most characteristic localization of gonorrheal arthritis. Distinguish bakterialnometastatichesky, infectious and allergic and sometimes mixed forms of gonorrheal. Most often it is a synovitis with a serous, seroznofibrinozny or purulent exudate, then the joint bag, sheaves, sinews is involved in process. Bacterial and metastatic G. (monoarthritis with an acute or subacute current) which is characterized by the intolerable affected joint pains, the high temperature, a serious general condition of the patient accelerated by ROE is most characteristic. Quickly the necrosis of soft tissues, destruction and lysis of a cartilage, the secondary reparative phenomena which are coming to an end with an early anchylosis of a knee joint develops. Gonorrheal G. of the toksiko-allergic nature (acute and hron.) can be manifestation oligo-or polyarthritis.
For gonorrheal G.'s diagnosis the anamnesis, existence of primary gonorrheal center, positive skin test with a gonovaccine given bulk analysis of blood, a research of the exudate received at a puncture of a knee joint matters. Crops of exudate on special environments give culture of a gonokokk. At tsitol, a research of exudate in mkl find from 50 to 100 content of 90% of thousand leukocytes polimorfonuklearov.
Radiological reveal the osteoporosis expressed circumarticular, narrowing of a joint crack, destruction of joint surfaces, the secondary phenomena of an osteoarthrosis.
Treatment: intra joint injections of benzylpenicillin to 10 000 000 PIECES daily, no more than 3 — 5 days, and also use of antibiotics in high doses intramusculary. For recovery of function of the affected joint the physical therapy, a resort therapy is used further.
The forecast at timely treatment, as a rule, can lead favorable, but acute purulent process to dysfunction of a joint. At hron, gonorrheal G. the phenomena secondary develop arthrosis (see).
See also Gonorrhoea .
Dysenteric drives— one of options of a course of the dysenteric arthritis which more often is shown in the form of polyarthritis (see. Arthritises ).
Pneumococcal drives meets extremely seldom at croupous pneumonia. Develops in the bacterial and metastatic way and proceeds as acute purulent.
Septic drives can develop against the background of the general sepsis (see) along with damage of other large joints. It has, as a rule, bacterial and metastatic genesis and proceeds as acute purulent.
Syphilitic drives meets exclusively seldom. It can appear both at inborn late syphilis, and at tertiary. At inborn syphilis of G. can be one of forms of the syphilitic arthritis sometimes proceeding with defeat of both knee joints. As a rule, it hron, hyperplastic fleecy synovitis (see) with a significant amount of a serous exudate, in Krom more often than in blood serum, there is positive Wassermann reaction (see. Wasserman reaction ). Knee joints have characteristic spherical shape — Klatton's joints.
In the third stage of syphilis there can be gummous G. (as well as arthritis of other large joints) which is shown hydrarthrosis (see) with protrusion of torsions of a synovial membrane.
Night pains, lack of a muscular atrophy, discrepancy between extensive changes in tissues of a joint and insignificant functional disturbances are characteristic of syphilitic G.
The diagnosis and the forecast — see. Arthritises .
Tubercular drives — the most often found mono-arthritis at tuberculosis. Tubercular G. can be a bakterialnometastatichesky origin. The tubercular stick at the same time gets to a synovial membrane or a part of a bone, adjacent to a joint, in the hematogenous way from primary center of tuberculosis. In most cases the synovitis of a knee joint begins gradually and develops slowly, for months, proceeds chronically, often causing considerable changes in a joint with destruction of the joint ends of bones. Not always it is possible to find instructions on the postponed tuberculosis infection or contact with the tubercular patient in the anamnesis. Patients show complaints to persistent pains in the struck knee joint. Its contours are moderately changed for the account a nek-swarm of a hypertrophy of a synovial membrane. As a rule, from a cavity of a joint it is possible to pump out a small amount of exudate. Sometimes at break of a tubercular hillock the tubercular stick gets to a joint cavity in synovial fluid, to-ruyu Guinea pigs can find out by an inoculation of the studied liquid that it confirms the diagnosis of a tubercular synovitis. However in some cases at a typical tubercular synovitis of a knee joint biol, test can be negative. At tsitol, a research of exudate in 1 mkl on average find 25 000 leukocytes with dominance of polimorfonuklear. A valuable diagnostic method is the puncture biopsy of a synovial membrane, morfol, the research a cut allows to find signs of tubercular defeat in a type of epithelioid hillocks and colossal cells of Langkhans. Radiological at a tubercular synovitis of a knee joint only nonspecific signs — osteoporosis, consolidation of soft tissues of a joint come to light.
The final diagnosis of a tubercular synovitis of a knee joint can be established sometimes only after an operative measure or a wide operational biopsy when big sites of a synovial membrane are explored and symptoms of a disease come to light morfol. Treatment of a tubercular synovitis of a knee joint complex (see. Tuberculosis of bones and joints ) with use of antibacterial therapy. Sometimes make synovectomy (see) with the subsequent long immobilization of a knee joint therefore motive function of a joint can be limited. The forecast at the correct and timely treatment favorable, however in some cases restriction or total loss of motive function of a knee joint is possible.
Tubercular changes in a knee joint are more often are secondary, coming from primary bone center located near a joint. Distinguish the following three phases of such G. Pervaya — preartritichesky when in bones there is a center of a specific inflammation menacing to a joint. A wedge, its manifestations are changeable and insufficiently typical. The second phase — arthritic when inflammatory destructive process in the joint develops. Symptoms gain more expressed constant character, a current cyclic. For a start G. are characteristic hl. obr. functional disturbances, an atrophy by the four-head of a muscle of a hip with a thickening of a skin fold (Alexandrov's symptom). At the height of a disease signs of an inflammation, the accruing contracture and proliferation of tissues of joint, sometimes with formation of congestive abscesses come to light (see. Natechnik ). Disappearance of the inflammatory phenomena, formation of hems, dystrophic changes, destruction (fig. 4 and 5) are characteristic of a stage of a zatikhaniye. The third phase — post-arthritic — is characterized by the residual phenomena of the postponed disease: dysfunction, deformation of a joint, vicious position and shortening of an extremity; aggravations and a recurrence of a disease are possible. Treatment of this option of tubercular G. complex — a combination of conservative and surgical methods in various options depending on a phase of a disease. In a preartritichesky phase timely recognition of the bone center (primary osteitis) and its removal for the prevention of transition of process to a joint is necessary. At limited damage of a joint make intra joint necretomy (see), if necessary with substitution of defects of the joint ends of bones osteoarticular gomotransplantata (radical recovery operations). At heavier destructive changes in a joint make an economical resection of a knee joint of the closed or open type, and in case of need — wider resections of reconstructive type for the purpose of receiving a strong bone anchylosis, leading not only to full treatment, but also to recovery of an oporosposobnost of an extremity. At an anchylosis in vicious situation apply epicondylic osteotomies (see) or crescent and wedge-shaped resections. Conservative actions — antibacterial therapy, an immobilization of an extremity (fig. 6) and a sanatorium therapy — hold in the preoperative period with the purpose to achieve a zatikhaniye and an otgranicheniye of inflammatory process, and after operation — for achievement of permanent treatment and the prevention of a recurrence.
The alternating edema of a knee joint occurs most often at women at the age of 20 — 30 years. The etiology is not known. There are observations that sometimes this disease precedes a pseudorheumatism. Defeat of one knee joint — monoarthritis, a recurrent wavy current with accurate cycles of increase and reduction of symptoms of an inflammation is characteristic. In intervals between aggravations of process which last from 10 days to 2 months symptoms of a disease are absent. G.'s aggravation arises suddenly, there are accruing pains, the amount of exudate gradually increases and reaches in a definite time (of one days to 1 — 2 week) maximum, and then again decreases, or exudate completely disappears. At the time of the greatest accumulation of liquid in a cavity of a joint there is the greatest morbidity of a joint, its mobility is limited.
Laboratory and rentgenol, researches at the beginning of a disease do not reveal any changes. Further secondary signs of a gonartroz develop. At a biopsy of a synovial membrane it is possible to find proliferation of synovial cells. Find in synovial fluid a nek-swarm increase in number of leukocytes with weak neutrophylic shift.
Treatment consists in intra joint injections of 25 mg of a hydrocortisone — a single injection at an aggravation (but no more than 3 injections in general). In the absence of effect of conservative treatment sometimes apply physical destruction (radioactive gold) or an operational synovectomy that can give good effect, but does not exclude also a recurrence of a disease. The good temporary effect gives a resort therapy (Pyatigorsk).
Psoriasis drives develops very seldom, in cases of generalization of joint process at psoriasis — see. Arthritises .
Rheumatic drives — one of displays of rheumatic polyarthritis — see. Rheumatism .
Rhematoid drivescan sometimes be the beginning of rhematoid polyarthritis, proceeding at a part of patients a long time as monoarthritis. Of rhematoid G. it is characteristic a wedge, a picture of an inflammatory disease of a joint with acute, subacute or hron, a current. Joint pains constants. Progressing of changes of joint and periartikulyarny fabrics, a tendency to formation of contractures and an anchylosis, simultaneous or in later terms involvement in patol is characteristic, process of other joints and it is frequent internals — see the Pseudorheumatism.
The gahnites connected with other diseases
G. as well as arthritises of any other localization, can be manifestation of a number of diseases. The nonspecific synovitis having unstable character is the cornerstone of them. Treatment of these forms G. shall be directed to elimination of a basic disease.
Can take place at allergic diseases. At a drug and serum disease of G. — one of manifestations of a multiple synovitis of flying character. At a capillary toxicosis of a gonalgia (as well as in other joints) are caused by a hemorrhagic vasculitis. G.'s development at a knotty erythema is most characteristic.
At collagenoses G. in the form of monoarthritises meet extremely seldom. They can sometimes be manifestation a floor of civil defeat at diseases of this group, and also at a sarcoidosis, malignant diseases of internals (as display of paracarcinomatous arthritises).
Is one of displays of gouty polyarthritis (see. Gout ), can sometimes be one of displays of bone and joint pathology at leukoses.
The damages of large joints caused by recurrent hemorrhages and most often knee are characteristic of hemophilia. Clinically distinguish acute and hron, forms of gemofilichesky. Acute forms develop at children's age after injuries of a knee joint. The joint becomes swelled up a little, his cavity is expanded, in a synovial membrane of the phenomenon of a hyperplasia, sites of blood pigmentation, development of fibrosis. Results from repeated hemorrhages hron, gemofilichesky G.'s form, at a cut secondary signs of an osteoarthrosis develop (see. Arthroses ). At a puncture of a joint it is possible to find bloody liquid. Radiological at acute forms G. find a thickening and consolidation of periartikulyarny fabrics, for hron. forms the phenomena of an osteoarthrosis — narrowing of a joint crack, an erosion of joint surfaces, especially in an intercondyloid eminence of tibia are characteristic. Treatment — punctures of a knee joint with suction of blood in combination with therapy hemophilias (see).
Can develop at long existence of arthrosis of a knee joint. The reactive synovitis in these cases arises in connection with constant traumatization of a synovial membrane regional osteophytes. Clinically it is shown by strengthening of gonalgias at rest and at night that is characteristic of inflammatory process. The joint is a little deformed, local temperature over it is increased. At a palpation in a cavity of a joint the insignificant amount of liquid is defined, to-ruyu in number of 10 — 20 ml it is possible to take at a puncture of a joint. Synovial fluid viscous, transparent, contains in 1 mkl up to 1000 leukocytes which 25% make neutrophils. At morfol, a research of the synovial membrane received at a puncture biopsy find a picture of a sclerosis and fatty regeneration of synovial fabric with moderately expressed cellular reaction. Radiological typical signs of an osteoarthrosis in the form of regional osteophytes, uneven narrowing of a joint crack, a subchondral sclerosis are found.
Treatment complex. To the patient appoint a bed rest, intra joint introduction of Trasylolum (3 — 4 injections on 25 000 PIECES with a 3-day interval). After subsiding of the acute phenomena of a synovitis paraffin applications, a resort therapy with use of radonic or hydrosulphuric bathtubs are shown.
Acute purulent drives
Acute purulent G. arises owing to penetration into a joint of a pyogenic infection (staphylococcus, streptococci, pneumococci, kolibakterin, salmonellas, a pyocyanic stick) with the subsequent development of an acute purulent inflammation.
Depending on a way of infection distinguish: primary purulent G. after gunshot wounds or open damages of a knee joint, puncture of a joint, intra joint administration of medicines and especially steroids, a puncture biopsy, operative measures; the secondary purulent G. developing when an infection gets into a joint from the next fabrics (in the presence of osteomyelitis, abscess, etc.) or a hematogenous way (at sepsis, osteomyelitis, etc.). At the closed damages of a knee joint and existence in it of inflammatory changes speak about posttraumatic synovitis (see).
Purulent G.'s clinic is characterized by the acute beginning of a disease. Inflammatory process causes severe pains in a joint, erubescence over it, a local hyperthermia, sharp swelling of a joint at the expense of hypostasis of circumarticular fabrics and accumulation of exudate in a joint cavity. At a significant amount of exudate the symptom of balloting of a patella is noted (see. Balloting ). Function of a joint is broken — the volume of active and passive mobility sharply decreases. The leg is in forced halfbent situation, at Krom the volume of a joint cavity increases that reduces morbidity. The general condition of the patient worsens, body temperature increases, edges are accepted by gektichesky character, the fever, the general weakness appear. In the absence of timely treatment purulent G. quickly leads to sharp deformation of a joint, formation of a contracture and rigidity or osteomyelitis of the joint ends of a hip or shin.
At a laboratory research: a leukocytosis with band shift, the accelerated ROE, increase in contents alfa-2-and gamma-globulins in blood serum. At a puncture of a knee joint (fig. 7) contents have character of pus or muddy exudate, in Krom the huge amount of Neutrophilic leukocytes — to 200 000 in 1 mkl is found; punctate is used for definition of character of microflora and its sensitivity to antibiotics.
Radiological at prolonged purulent G. find heavy destructive changes. Early there is expressed osteoporosis; the joint crack is narrowed, destruction of the joint ends of a hip and shin in the form of superficial or deep irregular shape uzur is noted.
Acute purulent G.'s diagnosis is made on the basis of the above described data.
Treatment complex. At repeated punctures of the struck knee joint with suction of pus enter high doses of antibiotics of a broad spectrum of activity (lincomycin, tseparin), and then antibiotics taking into account sensitivity of microflora to them. Carry surely out the general to lay down. actions which volume depends on weight of process and the general condition of the patient.
If conservative treatment of purulent G. does not give effect and process progresses, it is necessary to pass to operational treatment, a cut consists in a wide bilateral parapatellyarny arthrotomy with obligatory drainage of a cavity of a joint (see. Knee joint ).
In is more modern artrol. to practice use a method of treatment of purulent G. by constant suction of exudate and irrigation of a cavity of a joint antibiotics and antiseptic solutions by means of the special system consisting of a tank for antiseptic liquids, the rubber tube passing through a cavity of a joint, and the suction allowing to create vacuum in this system for forced outflow of pus and the irrigated liquid from a joint. This installation is used round the clock within 7 — 10 days. If the purulent discharge from a joint disappears and crops of liquid from a joint become sterile, dismantle installation, and places of an entrance and an exit of a rubber tube from a joint sew up tightly. This method allows not only to stop purulent G., but also to keep function of a joint since during treatment it is possible to make the movements in a joint.
The forecast, prevention — see. Arthritises , acute purulent arthritis.
Bibliography: Velyaminov N. A. The doctrine about diseases of joints, the lake 285, L., 1924; To about r N of e in P. G. Hirurgiya of bone and joint tuberculosis, the p. 2, page 5, L., 1971; The Multivolume guide to tuberculosis, under the editorship of V. L. Einys, t. 3, page 437, M., 1960, bibliogr.; Reynberg S.A. Radiodiagnosis of diseases of bones and joints, Sh. 4, 1 — 2, M., 1964; With to l I r e of the Tax Code about E. T. >of лй$ургия joints of extremities, Kiev, 1975, bibliogr.; About ren d i C. Kpo-chen-Gelenk und Weichteilerkrankungen im Rontgenbild, Jena, 1968, Bibliogr.
P. G. Kornev, V. P. Pavlov, V. M. Chepoy.