Analysis of the vascular abnormalities of the patients with ankle joint mild osteoarthritis

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Abstract


The vascular factor is one of the leading pathogenesis factors in the formation of ankle joint osteoarthritis. Dystrophic and sclerotic changes in the joint tissues develop as a result of blood flow decrease. These mechanisms understanding will allow to plan treatment and rehabilitation measures, as well as predict and prevent complications. The purpose of the work is to study hemodynamic parameters in the main lower leg arteries of the in patients in follow-up period of mild ankle joint osteoarthritis. Two groups of patients were examined. The first group - 82 patients with mild ankle joint osteoarthritis in the follow-up period (10 years) and the second group - control (healthy) group of 58 people without ankle joint osteoarthritis. Duplex scan of the main lower leg arteries was performed to all the patients. The state of arteries and hemodynamic parameters were evaluated. Excell and STATISTICA 10.0 programs were used for statistical data processing. In patients with follow-up of mild ankle joint osteoarthritis, the diameter of the arteries did not differ from the control group. In patients with mild ankle joint osteoarthritis the thickness of the Intima-media complex in the lower leg arteries and walls pulsation were significantly higher than those in patients of the control group (p <0.05). Analysis of hemodynamic parameters in patients with ankle joint osteoarthritis revealed an increase in the linear velocity of blood flow with a further tendency to normalization and even decrease in the follow-up compared with the control group. Signs of perfusion difficulty that accompanied the development of high blood pressure syndrome in the lower leg arteries were observed in 122 (67.0%) patients, and the signs of perfusion difficulty were bilateral in most of the cases (86.9%). Stenosis, deformation and arteries tortuosity were noted in 22% of patients with ankle joint osteoarthritis. Thus, mild ankle joint osteoarthritis is accompanied by blood flow changes in the form of inadequate perfusion and high-pressure syndrome in the lower leg arteries, which can cause secondary injuries and requires higher attention when selecting treatment and rehabilitation actions.


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The investigations managed in recent decades on the problem of ankle joint osteoarthritis strongly show that vascular factor dominates over the other numerous endogenous and exogenous factors influencing the formation and clinical progression follow-up of this disease [1]. Angiospasm has high importance at the early stage of local vascular pathology development after the traumatic or any other ankle joint damage [2, 3]. Particularly it is defined that infragenicular arteries react on mechanical excitation by unstriated muscles contraction which can be either short or long-termed [4]. Usually these vessels traumatic spasm is bilateral. Large arterial trunks are more affected by this spasm then small arteries. Spasm is mostly apparent in tibial arteries as a result of their tension during the trauma [5]. Vascular spasm of traumatic genesis obligatory influences the joint blood flow speed [6]. This spasm may develop into ischemia with dystrophic and sclerotic processes formation in joint tissue which in many ways defines the particulars of clinical evidence of primary ankle joint osteoarthritis and its delayed follow-up [7, 8]. The investigation of these mechanisms increases the opportunities of complications prognosis and reveals new horizons for treatment and rehabilitation procedures planning. Goal of the research: investigate the hemodynamic indices in long-term period in lower leg arteries in patients with mild ankle joint osteoarthritis. Materials and methods The study included two groups of patients. The firs group - 182 patients at the age of 29-65 y. o. in longterm period with mild ankle joint osteoarthritis (followup 10 years) and the second group - control (healthy) group - 58 people without ankle joint osteoarthritis. To make comparative assessment of lower leg arteries the duplex ultrasonography screening of lower leg arteries was performed for all the patients both with mild ankle joint osteoarthritis in long-term period and in healthy group. The examination was done by standard method of three dimensions scanning using linear (frequency 7MHz) and sectoral (frequency 2.5MHz) sensors of ultrasound system [9]. For the investigation of lower leg arteries state by duplex ultrasonography screening in standard method was evaluated the following parameters: vascular permeability, presence, size and structure intravascular changes, arteries diameter (during systole and diastole with calculation of pulsation rate according to the formula Dsyst / Ddiast), arteria pulsatility index (PI), Intima-Media-Reflex (IMR), their diameter and peak systolic velocity (Vps) [10, 11]. In all quantitative parameters their average value measured in pair segments of contralateral vessels was analyzed. The path of lower leg artery was evaluated (deformation presence or absence, visual appearance, arc, C-shaped tortuosity, S-shaped tortuosity, loopshaped tortuosity), vessel lumen condition to exclude stenosis-occlusive lesion in presence of atheromatous plaque (determining the degree of stenosis by area) [11]. The degree of vessel stenosis was calculated taking into account the area of the vessel and atheromatous plaque area, using the computer of US-scanner according to the formula А(%) = [(А1-А2)/А1] х100%, where A1 - is the greater area and A2 - is the smaller area. Moreover, we took into account the changes and conditionally separated the following models of arteries transformation: no changes, with less than 50% stenosis, with path deformation, coexistent affection (stenosis less than 50% and vascular tortuosity). The cases with stenosis of one or more arteries more than 50% were not included. The scan was performed in patients in supine position. The sensor was placed on the posterior surface of low leg muscles for visualization. The examination was performed using different modes - pulsed Doppler mode (PW-mode), color Doppler coding (CD-mode) and two-dimensional gray-scale sonography (B-mode). In B-mode on both sides were measured: the diameter of the leg artery at its lower third, the intima-media complex thickness in the region of its maximum visual thickening [9]. Excell and STATISTICA 10.0 programs were used for statistical data processing. Results To determine the norm in all control group patients, the diameters of the anterior and posterior tibial arteries of the lower leg were measured, which amounted to 5,77±0,47 mm и 4,91±0,34 mm respectively. The magnitude of vascular wall pulsation of the in the vessels of the lower leg was equal to 1,33±0,13 mm. Quantitative (linear) parameters of blood flow in the lower leg arteries were: for the anterior tibial artery- 67,85±22,1 sm/s; for the posterior tibial artery - 53,19±17,6 sm/s. The ripple index in these arteries ranged from - 2,33±0,6. Vps in the control group for the anterior tibial artery was 72,5±15,8 sm/s, and Vps for the posterior tibial artery 61,9±14,2 sm/s. When studying with the duplex scanning method in patients in the long-term period of mild ankle joint osteoarthritis, the diameter of the arteries did not differ in absolute values from the diameter of the vessels in the control group and corresponded to the anterior tibial artery - 5,67±0,34 mm, to the posterior tibial artery - 4,88±0,48 mm. The thickness of the IMR in lower leg arteries was significantly greater than in control group patients (р<0,05) and rated 1,07±0,21 mm. The wall ripple also exceeded the corresponding values in the control group and amounted to 1,39±0,22 mm (р<0,05). The blood flow in the lower leg arteries linearly did not significantly differ from that in the control group (р>0,05). In terms of absolute values, Vps in the anterior tibial artery was slightly lower than in the control group and amounted to 64.41±12.43 cm/s, in the posterior tibial artery it was slightly higher and was equal to 57,41±13,5 cm/s. PI, which allows us to evaluate the magnitude of peripheral resistance, corresponded to 2.28±0.33 and was unreliably higher than in control group patients. The overwhelming majority of patients in the control group (32 patients - 94.2%) had no intravascular changes and leg arteries disorders (Table 1). Of all the control group patients, only one (2.9%) had a posterior tibial artery deformity the type of S-shaped tortuosity, which, according to the scan, was hemodynamically insignificant. The frequency of deformations, stenosis and tibial arteries combined lesions in patients in the follow-up period of mild ankle joint osteoarthritis Indexes Mild ankle joint osteoarthritis (n= 182) Control group (n=58) р No changes 142 (78,0%) 32 (94,2%) <0,05 Stenosis 6 (3,3%) 1 (2,9%) >0,05 Deformation and tortuosity 34 (18,7%) 1 (2,9%) <0,05 Table 1 Stenosis was revealed in 6 (3,3%) patients with mild ankle joint osteoarthritis, in 34 (18,7%) - deformation and tortuosity were present. Moreover, in 6 of them S-shaped tortuosity of both tibial arteries path of was observed, which was to 3.3% in the group. The analysis of hemodynamic parameters in patients with a mild ankle joint osteoarthritis, compared with those in the control group, showed an increase in linear velocity of blood flow with a further tendency to normalization and even decrease in the long-term period (Table 2). Table 2 Hemodynamic parameters in patients with mild ankle joint osteoarthritis at different follow-up periods in comparison with the control group Hemodynamic Indexes Patient groups P Patients with mild ankle joint osteoarthritis (n=182) Control group (n=58) Follow-up period Acute period Linear velocity of blood flow systolic 76,01±12,91 94,35±12,70 77,03±11,23 P >0,05 Linear velocity of blood flow average 46,81±7,71 61,22±7,79 48,56±6,53 P >0,05 Linear velocity of blood flow diastolic 33,42±7,24 45,16±7,74 35,19±8,29 P >0,05 PI 0,82±0,11 0,79±0,12 0,74±0,21 P <0,05 Signs of perfusion difficulty accompanying the The main hemodynamic parameters in the low development of high blood pressure syndrome in the leg arteries in different periods of mild ankle joint lower leg arteries were observed in 122 (67.0%) patients, osteoarthritis are shown in the table 3. while in the vast majority of cases (106 out of 122 cases, 86.9%), the signs of difficult perfusion were bilateral. Table 3 The main hemodynamic parameters in patients with a mild ankle joint osteoarthritis at different observation times Hemodynamic Indexes in low leg arteries patients with a mild ankle joint osteoarthritis (n=182) Follow-up period Acute period Increased linear velocity of blood flow 52 (28,6%) 136 (75,6%) Normal linear velocity of blood flow 26 (14,3%) 38 (20,0%) Decreased linear velocity of blood flow 104 (57,1%) 8 (4,4%) Increased PI 54 (29,7%) - Normal PI 128 (70,3%) 148 (81,3%) Decreased PI 0 (0%) - Blood flow asymmetry 124 (68,1%) 142 (78,1%) At the time of the examination in the long-term period, in patients with a mild ankle joint osteoarthritis the following blood circulation indices in the lower leg arteries were revealed: in 52 (28.6%), a moderate increase in the average linear velocity of blood flow; 26 (14.3%) had linear velocity of blood flow within normal parameters; in 104 (57.1%) - linear velocity of blood flow was reduced. Moreover, the asymmetry of linear velocity of blood flow did not go beyond the norm in 128 (68.1%) patients. PI was determined within normal limits in 24 (13.2%) patients, in the remaining 158 (86.8%), it significantly exceeded the PI of control group. In all patients with the syndrome of vegetovascular dystonia domination in anamnesis, a significant increase in linear velocity of blood flow in the lower leg arteries was detected, mainly due to diastolic speed. In this group of patients, PI was moderately increased in 54 (29.7%) patients, in 128 (70.5%) - it was within normal limits. PI increase indicated the possible development of the syndrome of high pressure in the lower leg arteries in patients. Hemodynamic parameters in the acute period of mild ankle joint osteoarthritis were obtained by analyzing the primary documentation. The analysis of the examined patient’s primary documentation showed the increase in linear velocity of blood flow in 136 (75.6%), and a decrease in 8 (4.4%) patients during the acute period of ankle joint osteoarthritis. Normal linear velocity of blood flow indicators was determined in 38 (20.0%) cases. Linear velocity of blood flow asymmetry was observed in 142 (78.1%) patients, and normal PI was observed in 148 (81.3%) patients. Discussion Large arteries are known to perform two main functions in the human body. On the one hand, they are an anatomical substrate for ensuring adequate blood flow in various areas of the human body, on the other hand, the continuous pressure gradient between arteries and veins is formed as a result of their discrete work (Nichols W.W.et al., 1998). Both of these functions are interconnected and determine each other. The state of IMR (thickness, echogenicity, degree of differentiation into layers) is the main ultrasound indicator that allows to indirectly assess the presence of structural changes in the vascular wall [12]. In most patients in the long-term period of ankle joint osteoarthritis, a relatively equal increase in the echogenicity of the IMR of the lower leg vessels was observed with a complete or partial loss of its differentiation into layers. Revealed changes can be considered as signs of elastofibrosis and arteriosclerosis [10, 13]. Actually, we measured IMR thickness to make an objective assessment of the degree of its structural changes [11]. Along with the lower leg vessels walls structural changes, their diameters also change, which was observed in our patients. This phenomenon occurrence, apparently, is of a compensatory nature and is aimed at preventing of blood flow volume level decrease. The degree of compensatory dilatation depends both on the way of clinical disease course and on the other factors such as the disease duration and severity [6, 14, 15]. The increased influence of each of them leads to an augmentation in the compensatory dilatation degree, which is consistent with the results of comparisons obtained for the IMR thickness [8]. Thus, according to medical records, a moderate increase in the linear blood flow velocity in the lower leg arteries was noted, with a further tendency towards its normalization, and even decrease, in the majority of patients with mild ankle joint osteoarthritis in the acute period. At the same time, PI changes were directed towards its increase, which indicated the possible development of the increased pressure syndrome in the leg arteries of the patients [10, 11, 16]. The outlined trends were fully confirmed by examination of patients in the long-term period of ankle joint osteoarthritis. Conclusions 1. With a mild ankle joint osteoarthritis, hemodynamic changes are observed in the form of inadequate perfusion and impaired vascular autoregulation, which can cause secondary damage. 2. Due to difficult perfusion, mild ankle joint osteoarthritis develops high pressure syndrome in the lower leg arteries. The linear velocity of blood flow increase tends to normalize and further decrease, and the PI, on the contrary, tends to increase in the long term. 3. Changes in the lower third of the lower leg arteries by the type of deformity, tortuosity and stenosis in the long-term period of mild ankle joint osteoarthritis are 22%, which indicates the requirement to pay more attention in therapeutic and rehabilitation measures selection for this category of patients, due to underestimation of their general condition.

About the authors

A. O. Mombekov

Peoples’ Friendship University of Russia (RUDN University)

Author for correspondence.
Email: galen7@yandex.ru
Moscow, Russian Federation

N. I. Karpovich

Peoples’ Friendship University of Russia (RUDN University)

Email: galen7@yandex.ru
Moscow, Russian Federation

O. A. Dogotar

Peoples’ Friendship University of Russia (RUDN University)

Email: galen7@yandex.ru
Moscow, Russian Federation

A. V. Dergunov

Military Medical Academy named after S.M. Kirov

Email: galen7@yandex.ru
Saint-Petersburg, Russian Federation

N. B. Zagorodnyi

Peoples’ Friendship University of Russia (RUDN University)

Email: galen7@yandex.ru
Moscow, Russian Federation

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Copyright (c) 2020 Mombekov A.O., Karpovich N.I., Dogotar O.A., Dergunov A.V., Zagorodnyi N.B.

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