Classification of osteoarthritis

Currently, there is no unified approach to the terminology and classification of osteoarthrosis in world clinical practice. When writing this chapter, the authors tried to unify the available information and justify the use in rheumatological practice (as well as in the practice of doctors of related specialties) terminology and classification of osteoarthritis, proposed by the Association of Rheumatology of Ukraine, in the development of which the authors took part.

Confusion in the terminology of osteoarthritis has been around for a long time. Clinicians dealing with the problem of diseases of the joints, variously designated this pathology. For example, the list of osteoarthrosis is far from complete.

• Deforming arthritis (Virchow)
• Degenerative arthritis
• Hypertrophic arthritis (Goldthwaite)
• Senile hypertrophic arthritis (Hench)
• Dry Arthritis (Hunter)
• Senile arthritis (Hench)
• Deforming arthropathy (Barcelo)
• Degenerative Arthropathy (Abrams)
• Multiple Degenerative Arthropathy
• Arthrosclerosis (Lucherini)
• Deforming arthrosis
• Dry artrosynovit
• Dry arthrosis
• Senile arthrosis
• Degenerative hypertrophic chondroosteoarthritis (Weil MP)
• Degenerative joint disease (Lunedei; Bauer and Bennett)
• OcTeoapTpHT(A.Garrod)
• Chronic degenerative osteoarthritis (Bezancon and Weil)
• Hypertrophic degenerative osteoarthritis (Bezancon and Weil)
• Osteoarthritis
• Progressive dry polyarthritis (Weissenbach and Francon)
• Ambulatory rheumatism
• Chronic articular rheumatism (Cruveilhier)
• Incomplete chronic articular rheumatism (Charcot)
• Chronic degenerative rheumatism (Nichols and Richardson)
• Chronic hypertrophic rheumatism (Nichols and Richardson)
• Chronic ossalgic rheumatism
• Chronic osteophytic rheumatism
• Incomplete chronic rheumatism
• Simple chronic rheumatism (Besnier)
• Deforming rheumatism (Virchow)
• Degenerative rheumatism
• Geberd's Rheumatism (Charcot)
• Synovial rheumatism

Some of the above terms reflect an objective clinical and pathogenetic meaning, such as "senile hypertrophic arthritis" and, most importantly, oppose osteoarthritis to other diseases of the joints.

Currently, the most common in the world is the term "osteoarthritis", in the CIS countries, as well as in some European countries (Germany, France), the term "osteoarthrosis". In light of current knowledge of the pathogenesis of osteoarthritis, the first term to a greater extent reflects the essence of the disease. At the same time, we do not see the need to change the terminology generally accepted in our country and recommend using the term “osteoarthrosis”.

You can still find the diagnosis “deforming (osteo) arthrosis” or “metabolic-dystrophic polyarthritis” in the medical records (medical history, outpatient card, referral for consultation, etc.). Both terms are outdated and absent in ICD-10, they should not be used when formulating a clinical diagnosis. In the first case, it is advisable to avoid the word "deforming", and in the second - to use the term "polyosteoarthrosis".

Many unsolved problems in the classification of osteoarthritis. Consider the main ones.

To the question of spinal osteochondrosis. Most classifications (for example, in the ACR classification below) include osteochondrosis in the group of osteoarthritis of the spine, but by definition, pathogenesis and clinical picture of spinal osteoarthrosis and spinal osteochondrosis are completely different diseases:

• By definition, osteoarthrosis is a disease of the synovial joints (diarthrosis); in the case of the spine, osteoarthrosis of the so-called apophysial joints (articulation between the upper articular processes of the underlying and lower articular processes of the overlying vertebrae), osteochondrosis-degenerative lesion of the cartilage joints of the overlying vertebrae), and osteochondrosis-degenerative lesion of the cartilaginous arteries. Intervertebral discs. Osteoarthritis and osteochondrosis are combined into a group of degenerative diseases of the joints;
• spine osteoarthritis is characterized by dissociation between the radiological and clinical picture of the disease - even significant progression of morphological changes in the apophysial joints, including the formation of large osteophytes, as a rule, does not manifest clinically; in osteochondrosis - on the contrary, there is a clear connection between the destruction of the intervertebral discs, determined radiographically, and clinical manifestation (radicular syndrome).

Of course, spinal osteoarthritis and osteochondrosis are diseases that often accompany each other, since changes in the synovial joints dramatically increase the load on the discs, which leads to osteochondrosis, and vice versa. However, the American College of Rheumatology, the Italian Society of Rheumatology, and others (see below) combined these two different diseases into one group.

All of the above is reflected in ICD-10. According to this classification, osteoarthrosis belongs to the heading ARTHROSES M15-M 19, OA of the spine belongs to the heading M47, and osteochondrosis of the spine - to the heading M40-M43 DEFORMING DORSOPATIA.

On the question of the nodular form of polyosteoarthrosis A. In the classifications of the CIS countries (for example, in the classification of VA Nasonova and MG Astapenko, 1989) there are two clinical (italics) forms of polyosteoarthrosis (PAA) - nodular and nasal. According to the ACR (1986) classification, nodular and non-nodular variants are noted in osteoarthritis of the hand joints: the presence of Bouchard and Heberdain nodules is classified as nodular osteoarthritis of the hands, and the presence of "erosion" (this is not classical erosion of RA, but rather a dashed cortical line on roentgenograms of the hands) - as nasal or erosive osteoarthritis of the hands. Therefore, the question remains about the advisability of extending the gradation of osteoarthritis of the hands to the entire POA (or generalized osteoarthrosis, in the opinion of English-speaking authors).

On the issue of polyosteoarthrosis (generalized osteoarthrosis). Domestic classifications and monographs do not indicate which osteoarthrosis is considered polyosteoarthrosis. According to JH Kellegren, the author of the term “generalized osteoarthritis” who first described this option, generalized osteoarthritis means “... The presence of radiological signs of osteoarthrosis in 6 or more groups of joints, usually in the metacarpophalangeal I finger and proximal interphalangeal II-V fingers of the hand ( knots of Geberden), apophysial joints of the spine, knee, hip joints, as well as in the tarsus-metatarsal joints of the first toe. " ACR (1986) reduced the number of groups of joints to establish the diagnosis of an ASA to three: “Generalized osteoarthritis is the defeat of three or more groups (and not joints, as rheumatologists often consider) of the joints.

To the question of osteoarthritis of the knee. At present, the domestic literature does not indicate the division of the knee joint into regions or sections (in the foreign literature - compartment) - patellofemoral (patellar-femoral) and lateral and medial tibiofemoral (tibial-femoral). At the same time, in all foreign manuals the importance of such a division is pointed out. Thus, according to PA Dieppe (1995), isolated osteoarthrosis is most common in the medial tibiofemoral joint and combined lesions of the medial tibiofemoral and patellofemoral departments; osteophytosis is more often found in the lateral tibiofemoral region, and the destruction of articular cartilage is usually more pronounced in the medial, which leads to the development of varus deformity. According to the testimony of E.E. McAlindon et al. (1993), the medial tibiofemoral region is affected in 75% of cases, the lateral - in 26%, and the patellofemoral - in 48%. ACR highlights gonarthrosis of the medial tibiofemoral joint, lateral tibiofemoral joint and patellofemoral joint.

Classification of osteoarthrosis according to ICD-10

Arthrosis (Ml5-M 19)

Note. In this block, the term "osteoarthritis" is used as a synonym for the term "osteoarthritis" or "osteoarthritis". The term “primary” is used in its usual clinical meaning.

Excluded: osteoarthritis of the spine (M47.-)

M15 Polyarthrosis

Included: arthrosis of more than one joint

Excluded: bilateral damage of the same joints (M l6-M19)

M15.0 Primary generalized (osteo) arthrosis

M15.1 Heberden nodes (with arthropathy)

M15.2 Bushar nodes (with arthropathy)

M15.3 Secondary multiple arthrosis

Posttraumatic polyarthrosis

M15.4 Erosive (Osteo) Arthrosis

M15.8 Other polyarthrosis

М15.9 Polyarthrosis, unspecified

Generalized Osteoarthritis NOS

M16 Coxarthrosis [hip joint arthrosis]

M16.0 Primary coxarthrosis bilateral

M16.1 Other primary coxarthrosis

Primary coxarthrosis:

• BSU
• unilateral

Ml6.2 Coxarthrosis as a result of bilateral dysplasia

M16.3 Other dysplastic coxarthrosis

Dysplastic coxarthrosis:

• BSU
• unilateral

M16.4 Posttraumatic coxarthrosis bilateral

M16.5 Other posttraumatic coxarthrosis

Posttraumatic coxarthrosis:

• BSU
• unilateral

M16.6 Other secondary coxarthrosis bilateral

M16.7 Other secondary coxarthrosis

Secondary coxarthrosis:

• BSU
• unilateral

М16.9 Coxarthrosis unspecified

M17 Gonarthrosis [osteoarthritis of the knee joint]

M17.0 Primary gonarthrosis bilateral

M17.1 Other primary gonarthrosis

Primary gonarthrosis:

• BSU
• unilateral

M17.2 Post-traumatic gonarthrosis bilateral

M17.3 Other post-traumatic gonarthrosis

Posttraumatic gonarthrosis:

• BSU
• unilateral

M17.4 Other secondary gonarthrosis bilateral

M17.5 Other secondary gonarthrosis

Secondary gonarthrosis:

• BSU
• unilateral

М17.9 Gonarthrosis, unspecified

M18 Arthrosis of the first carpometacarpal joint

M18.0 Primary arthrosis of the first carpal-metacarpal joint bilateral

M18.1 Other primary arthrosis of the first carpal-metacarpal joint

Primary arthrosis of the first carpometacarpal joint:

• BSU
• unilateral

M18.2 Post-traumatic arthrosis of the first carpal-metacarpal joint bilateral

M18.3 Other post-traumatic arthrosis of the first carpal-metacarpal joint

Post-traumatic arthrosis of the first carpometacarpal joint:

• BSU
• unilateral

M18.4 Other secondary osteoarthritis of the first carpal-metacarpal joint bilateral

M18.5 Other secondary arthrosis of the first carpal-metacarpal joint

Secondary arthrosis of the first carpometacarpal joint:

• BSU
• unilateral

M18.9 Arthrosis of the first carpometacarpal joint, unspecified

M19 Other arthrosis

Excluded:

• arthrosis of the spine (M 47.-)
• rigid big toe (M20.2)
• polyarthrosis (M15.-)

M19.0 Primary arthrosis of other joints

Primary Arthrosis NOS

M19.1 Post-traumatic arthrosis of other joints

Posttraumatic arthrosis NOS

M 19.2 Secondary arthrosis of other joints

Secondary arthrosis NOS

M19.8 Other specified arthrosis

M19.9 Arthrosis, unspecified

M47 Arthrosis of the spine

[1], [2], [3], [4], [5], [6], [7]

Classification of osteoarthritis American Collage of rheumatology (ACR)

I. Idiopathic (primary)

A. Localized

1. Brushes:

• nodules of Geberden and Bouchard (knot form)
• erosive osteoarthritis of the interphalangeal joints (non-nodular form)
• osteoarthritis of the navicular-metacarpal joint
• osteoarthritis of the navicular trapezius joint

2. Feet:

• hallux valgus
• rigid tow
• flexion / extensor contracture of the fingers
• osteoarthritis of the calcaneus-navicular

3. Knee joint:

• osteoarthritis of the medial part of the tibiofemoral joint
• osteoarthritis of the lateral part of the tibiofemoral joint
• osteoarthritis of the patellofemoral joint

4. Hip joint:

• eccentric (upper)
• concentric (axial, medial)
• diffuse (coxae senilis)

5. Spine (mainly cervical and lumbar):

• apophysial joints
• intervertebral discs
• spondylosis (osteophytes)
• ligaments (hyperostosis, Forestier disease, diffuse idiopathic hyperostosis of the skeleton)

6. Other locations:

• shoulder joint
• acromioclavicular joint
• tibial-heel joint
• ileal-sacral joints
• temporomandibular joint

B. Generalized (includes three or more groups of joints described above)

• Small joints and spinal joints
• Large joints and spinal joints
• Small and large joints and spinal joints

Ii. Secondary

A. Posttraumatic

1. Acute
2. Chronic (associated with certain professions, sports)

B. Congenital diseases and developmental pathology

1. Localized:

A) disease of the hip joint:

• Legg-Calvé-Perthes disease
• congenital hip dysplasia
• femoral epiphysis

B) local and mechanical factors:

• shortening of the lower limb
• valgus / varus deformity
• hypermobile syndrome
• scoliosis

2. Generalized:

A) bone dysplasia

B) metabolic diseases:

• hemochromatosis
• ochronosis (alkaptonuria)
• Wilson-Konovalov disease
• Gaucher disease

B. Diseases of calcium deposits

1. Calcium pyrophosphate crystal deposits disease
2. Calcium hydroxyapatite crystal deposits disease

G. Other diseases of bones and joints

1. Localized

• Fractures
• Avascular necrosis
• Infections
• Gouty arthritis

2. Diffuse

• Rheumatoid arthritis
• Paget's Disease
• Osteopetrosis
• Osteochondritis

D. Other

• Acromegaly
• Hyperpathiroididism
• Diabetes
• Obesity
• Hypothyroidism
• Arthropathy Sharko
• Others:
  • Frostbite
  • Caisson disease
  • Kashin-Beck disease
  • Hemoglobinopathies

Benefits of ACR classification:

• osteoarthritis of the hands is divided into nodular and non-nodular (erosive) options
• osteoarthrosis of the knee joints is divided into three anatomical zones - osteoarthrosis of the tibiofemoral (medial and lateral) joint and osteoarthrosis of the patellofemoral joint
• secondary osteoarthritis is described in detail (however, this item can also be attributed to the classification deficiencies, since the extended second part makes it too voluminous, complicates the perception and use in formulating a diagnosis).

Disadvantages of ACR classification:

• not only degeneration of intervertebral discs, but also calcification of ligaments are attributed to osteoarthritis of the spine
• osteoarthrosis refers to the defeat of the sacroiliac joints, which do not belong to the synovial group, and therefore cannot be affected by osteoarthritis.

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

Classification of osteoarthritis of the Italian Society of Rheumatology (SIR)

I. Primary osteoarthritis

A. Diffuse

B. Local:

• Heberden and Bouchard knots
• osteoarthritis of the navicular-metacarpal joint
• erosive osteoarthritis of the interphalangeal joints of the hands, etc.

Ii. Secondary osteoarthritis

1. Dysplasia and dysmorphism
2. Traumatic
3. Functional overload

A) obesity, scoliosis, shortened lower limb, etc.

B) associated with certain professions and sports

1. Arthritis
2. Congenital connective tissue diseases
   • marfan syndrome
   • morchio syndrome
   • mucopolysaccharidosis

6. Simple chondropathy

• articular chondromatosis
• osteochondritis dissecting

7. Endocrine-metabolic chondropathy:

• diabetes
• chondrokalcinosis
• ochronoz and others

8. Osteopathy

• Paget's disease
• aseptic necrosis

Iii. Intervertebral disc degeneration (dyscartrosis)

IV. Dysmetabolic and gyroestrousia arthropathy

V. Acromegalic arthropathy

Vi. Chondromalacia patella

Disadvantages of SIR classification:

• no indication of lesion location
• intervertebral disc degeneration is not osteoarthritis
• points IV-VI relate to secondary osteoarthritis (point II)

[14], [15], [16], [17], [18], [19], [20], [21], [22], [23]

Clinical classification of osteoarthritis

I. Pathogenetic variants

1. Primary (idiopathic)
2. Secondary (due to dysplasia, injuries, static disorders, hypermobility of the joints, arthritis, etc.)

Ii. Clinical forms

1. Polyosteoarthrosis: nodular, nodular
2. Oligoosteoartroz
3. Monoarthrosis
4. In combination with spinal osteoarthritis, spondyloarthrosis

Iii. Preferred localization

1. Interphalangeal joints (Heberden, Bouchard nodules)

1. Hip joints (coxarthrosis)
2. Knee joints (gonarthrosis)
3. Other joints

Iv. X-ray stage (according to Kellgren JH and Lawrence JS): I, II, III, IV

V. Sinovit

1. There is
2. Missing

Vi. Functional ability of the patient

1. Disability is temporarily limited (FN * -1)
2. Disability lost (FN-2)
3. Needs external care (FN-3).

* FN - functional failure.

The diagnosis of osteoarthritis should contain an indication of which joint is affected, the area of its greatest lesion (for example, the medial or lateral part of the knee joint), the presence of synovitis and the degree of impairment of joint function and necessarily the lesion of the knee and hip joints - the X-ray stage.

This classification is most suited to use for the formulation of the diagnosis. However, in our opinion, there are some drawbacks in it, in particular, the division of the PAD into nodular and non-nodular forms (as indicated above), there is no separation of osteoarthritis of the knee joint into sections, only a nodular variant is given for osteoarthritis of the hands.

Taking into account the advantages and disadvantages of the above classifications, a classification of osteoarthrosis of the Association of Rheumatology of Ukraine (AGC) was created, which we recommend as a working one. AGC (2000)

[24], [25], [26], [27], [28], [29], [30], [31]

Working classification of osteoarthritis

Pathogenetic variants

I. Idiopathic (primary)

Ii. Secondary

Clinical forms

1. Monosteoarthrosis (damage to one joint)
2. Oligosteoarthrosis (lesion of two or more joints, but not more than two groups of joints)
3. Polyosteoarthrosis (damage of three groups of joints and more)

Localization

1. Knee Joint:

• osteoarthritis of the medial part of the tibiofemoral part
• osteoarthritis of the lateral part of the tibiofemoral part
• osteoarthritis of the patellofemoral part

2. Hip joint

• eccentric (upper)
• concentric (axial, medial)
• diffuse (coxae senilis)

3. Brushes:

• nodules of Geberden and Bouchard (knot form)
• erosive osteoarthritis of the interphalangeal joints (non-nodular form)
• osteoarthritis of the carpometacarpal joint of the first finger
• osteoarthritis of the other joints of the hands

4. Spine

• apophysial joints

5. Feet:

• hallux valgus
• rigid tow
• osteoarthritis of the other joints of the foot

6. Other localizations

Sionovite

1. With synovitis
2. Without a son

X-ray stage (PC) * (no Kellgren JH and Lawrence JS)

0, I, II, III, IV. The functional ability of the patient

1. Disability temporarily limited (FN-1)
2. Disability lost (FN-2)
3. Needs care (FN-3)

* For OA of the knee, hip and wrist joints, it is necessary to indicate PC

Examples of wording diagnoses

1. Secondary monoosteoarthritis of the left knee joint (medial tibiofemoral and patellofemoral departments) with synovitis. RS-PFN-1.
2. Primary oligosteoarthrosis with lesions of the left hip joint (concentric), PC-III, both knee joints (lateral tibiofemoral departments), PC-II. Synovitis of the right knee joint. FN-1.
3. Primary polyosteoarthrosis with damage to the joints of the hands (Heberden nodes), PC-III, left knee joint (lateral tibiofemoral section), PC-III and right hip joint (diffuse), PC-IV. Synovitis of the left knee and distal interphalangeal joints. FN-1.
4. Primary polyosteoarthrosis with lesions of the proximal and distal interphalangeal joints of the hands (erosive form), PC - III, carpal-metacarpal joint of the first finger of the left hand with synovitis, the metatarsophalangeal joint of the right toe (hallux valgus) with the synovitis, right hip joint of the right foot and synovitis ), PC - IV and cervical spine. FN-2.

[32], [33], [34], [35], [36], [37]

Classification criteria for osteoarthritis

The classification criteria are a kind of diagnostic search algorithm. However, when diagnosing a disease, including OA, one should not rely only on classification criteria. It must be remembered that the main area of their use is not a routine clinical practice, but clinical research - compliance with classification criteria is one of the reasons for including a patient in a study.

[38], [39], [40]

Osteoarthritis of the hands (according to Altaian RD et al., 1990)

1. Pain, stiffness or stiffness in the hands, most often during the day during the past month and
2. Tight thickening of two joints or more * and
3. Less than three swollen metacarpophalangeal joints, or
   • hard thickening of two distal interphalangeal joints or more or
   • wrong position of one or more joints *.

* Distal interphalangeal joints of II and III fingers; proximal interphalangeal joints of II and III fingers; carpometacarpal joints of both hands. Sensitivity is 93%, specificity - 97%.

[41], [42], [43]

Coxarthrosis (by Altman RD et al., 1991)

Clinical symptoms

1. Pain in the hip joint
2. internal rotation less than 15 degrees
3. ESR less than 45 mm / h (with normal ESR - hip flexion is less than 115 degrees)
4. internal rotation less than 15 degrees
5. pain with internal rotation
6. morning stiffness less than 60 min
7. age over 50

Sensitivity is 86%, specificity is 75%.

Clinical and radiological symptoms

Pain in the hip joint and at least 2 of the 3 following symptoms:

• ESR less than 20 mm / h
• radiologically - osteophytes (femoral head or acetabulum)
• X-ray - narrowing of the joint space (top, lateral and / or medial).

Sensitivity - 89%, specificity - 91%.

[44], [45], [46], [47]

Gonarthrosis (according to Altman RD et al., 1986)

1. Knee pain
2. crepitus during most days of the previous month and
3. morning stiffness with active movement less than 30 minutes and
4. age over 37 years or
5. crepitus and
6. morning stiffness less than 30 min and
7. bone deformity (bloating).
8. lack of crepitation and
9. bone deformation.

Sensitivity - 89%, specificity - 88%.

Clinical and radiological symptoms

1. Knee pain during the previous month, most often during the day, and
2. Osteophytes or
3. synovial fluid typical for osteoarthritis (light, viscous, cell count less than 2000 / ml; if there is no information about synovial fluid, then age younger than 40 years is taken into account instead) and
4. morning stiffness less than 30 min and
5. crepitus during active movements.

Sensitivity - 94%, specificity - 88%.

[48], [49], [50], [51], [52], [53], [54]

Criteria for the diagnosis of osteoarthritis (Benevolenskaya LI et al., 1993)

Clinical criteria:

1. Joint pain that occurs at the end of the day and / or in the first half of the night.
2. Joint pain that occurs after mechanical stress and decreases at rest.
3. Deformity of the joints due to bone overgrowths (including Heberden and Bouchard nodules).

X-ray criteria:

1. The narrowing of the joint space.
2. Osteosclerosis.
3. Osteophytosis.

Note. Criteria 1-2 are basic, criterion 3 is optional. For the diagnosis of osteoarthritis, the presence of the first two clinical and radiological criteria is mandatory.

[55], [56], [57], [58], [59], [60], [61], [62]