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Polvi- ja lonkkanivelrikko
Käypä hoito -suositus |  Julkaistu: 25.08.2014   | Tila: voimassa  |  Aihepiiri(t): Fysiatria, Geriatria, Kuntoutus, Ortopedia ja traumatologia, Reumatologia, Työterveyshuolto, Yleislääketiede
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Suomalaisen Lääkäriseuran Duodecimin ja Suomen Ortopediyhdistys ry:n asettama työryhmä
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Polvi- ja lonkkanivelrikko

Käypä hoito
25.8.2014
Suomalaisen Lääkäriseuran Duodecimin ja Suomen Ortopediyhdistys ry:n asettama työryhmä

Opi ja ota käyttöön

Koosteet

Potilaalle

Suosituksen tärkeimmät periaatteet

  • Polvi- ja lonkkanivelrikon tärkeimmät vaaratekijät ovat lihavuus, nivelvammat ja raskas fyysinen työ.
  • Nivelrikon diagnoosi perustuu potilaan kuvaamiin oireisiin, kliinisen tutkimuksen nivellöydöksiin ja radiologisiin löydöksiin.
  • Nivelrikon hoidon tavoitteena ovat kivun hallinta ja lieventäminen sekä toimintakyvyn ylläpito ja parantaminen.
  • Konservatiivisista lääkkeettömistä hoidoista itsehoidon ohjaus, laihduttaminen ylipainoisilla nivelrikkopotilailla ja sopiva terapeuttinen harjoittelu ja liikunta ovat nivelrikon hoidon perusta.
  • Nivelrikon lääkehoito on oireita lievittävää. Parantavaa tai taudin etenemistä estävää lääkehoitoa ei ole.
  • Nivelrikon ensisijainen lääke on parasetamoli. Jos sen teho ei riitä, siirrytään tulehduskipulääkkeisiin. Tällöin tulee ottaa huomioon tulehduskipulääkkeiden haittavaikutukset ja arvioida yksilöllisesti niiden riski. Jos tulehduskipulääkkeiden teho ei riitä, voidaan kokeilla opioideja. Nivelrikkoa voidaan hoitaa myös paikallisesti iholle siveltävillä tulehduskipulääkkeillä ja polvinivelrikkoa myös nivelen sisäisillä glukokortikoidi- ja hyaluronaattiruiskeilla.
  • Tekonivelleikkaus tehdään, jos nivelrikkokipu ei ole muutoin hallittavissa tai potilaalla on olennaisesti toimintakykyyn vaikuttava liikevajaus tai virheasento.
  • Päävastuu nivelrikon diagnostiikasta ja hoidosta on perusterveydenhuollolla ja työterveyshuollolla.

Suosituksen tavoitteet ja rajaukset

  • Suosituksen tavoitteena on
    • yhdenmukaistaa polvi- ja lonkkanivelrikon diagnostiset radiologiset menetelmät ja diagnostiset kriteerit
    • yhtenäistää polvi- ja lonkkanivelrikon konservatiiviset ja operatiiviset hoitokäytännöt
    • vähentää polvi- ja lonkkanivelrikosta aiheutuvaa kipua ja parantaa potilaiden toimintakykyä.
  • Suosituksessa ei käsitellä patellofemoraalinivelen ja nivelrustovaurioiden hoitoa eikä tekonivelpotilaiden seurannan järjestämistä.

Kohderyhmät

  • Suosituksen kohderyhmänä on polvi- ja lonkkanivelrikkopotilaita hoitavat perusterveydenhuollon ja erikoissairaanhoidon työntekijät.

Etiologia ja taudinkuva

Vaaratekijät

Taulukko 1. Lonkkanivelrikon vaaraa lisäävät tekijät.
Vaaratekijä Näytön taso Kirjallisuusviitteet
Ikä «Ikä lisää lonkkanivelrikon vaaraa.»A «Heliövaara M, Mäkelä M, Impivaara O ym. Association of overweight, trauma and workload with coxarthrosis. A health survey of 7,217 persons. Acta Orthop Scand 1993;64:513-8 »15, «Tepper S, Hochberg MC. Factors associated with hip osteoarthritis: data from the First National Health and Nutrition Examination Survey (NHANES-I). Am J Epidemiol 1993;137:1081-8 »16, «Karlson EW, Mandl LA, Aweh GN ym. Total hip replacement due to osteoarthritis: the importance of age, obesity, and other modifiable risk factors. Am J Med 2003;114:93-8 »17
Lihavuus «Lihavuus (BMI gt; 30.0) lisää ilmeisesti lonkkanivelrikon vaaraa.»B «Heliövaara M, Mäkelä M, Impivaara O ym. Association of overweight, trauma and workload with coxarthrosis. A health survey of 7,217 persons. Acta Orthop Scand 1993;64:513-8 »15, «Lievense AM, Bierma-Zeinstra SM, Verhagen AP ym. Influence of obesity on the development of osteoarthritis of the hip: a systematic review. Rheumatology (Oxford) 2002;41:1155-62 »18, «Jiang L, Rong J, Wang Y ym. The relationship between body mass index and hip osteoarthritis: a systematic review and meta-analysis. Joint Bone Spine 2011;78:150-5 »19, «Juhakoski R, Heliövaara M, Impivaara O ym. Risk factors for the development of hip osteoarthritis: a population-based prospective study. Rheumatology (Oxford) 2009;48:83-7 »20
Lonkkavamma «Lonkkavamma saattaa lisätä lonkkanivelrikon vaaraa.»C «Heliövaara M, Mäkelä M, Impivaara O ym. Association of overweight, trauma and workload with coxarthrosis. A health survey of 7,217 persons. Acta Orthop Scand 1993;64:513-8 »15, «Tepper S, Hochberg MC. Factors associated with hip osteoarthritis: data from the First National Health and Nutrition Examination Survey (NHANES-I). Am J Epidemiol 1993;137:1081-8 »16, «Juhakoski R, Heliövaara M, Impivaara O ym. Risk factors for the development of hip osteoarthritis: a population-based prospective study. Rheumatology (Oxford) 2009;48:83-7 »20, «Cooper C, Inskip H, Croft P ym. Individual risk factors for hip osteoarthritis: obesity, hip injury, and physical activity. Am J Epidemiol 1998;147:516-22 »21, «Lau EC, Cooper C, Lam D ym. Factors associated with osteoarthritis of the hip and knee in Hong Kong Chinese: obesity, joint injury, and occupational activities. Am J Epidemiol 2000;152:855-62 »22
Raskas liikunta «Raskas liikunta saattaa lisätä lonkkanivelrikon vaaraa.»C «Lievense AM, Bierma-Zeinstra SM, Verhagen AP ym. Influence of sporting activities on the development of osteoarthritis of the hip: a systematic review. Arthritis Rheum 2003;49:228-36 »23, «Michaëlsson K, Byberg L, Ahlbom A ym. Risk of severe knee and hip osteoarthritis in relation to level of physical exercise: a prospective cohort study of long-distance skiers in Sweden. PLoS One 2011;»24
Raskas fyysinen työ ja painavien taakkojen nosteleminen «Raskas fyysinen työ ja painavien taakkojen nostaminen lisäävät ilmeisesti lonkkanivelrikon vaaraa.»B «Heliövaara M, Mäkelä M, Impivaara O ym. Association of overweight, trauma and workload with coxarthrosis. A health survey of 7,217 persons. Acta Orthop Scand 1993;64:513-8 »15, «Juhakoski R, Heliövaara M, Impivaara O ym. Risk factors for the development of hip osteoarthritis: a population-based prospective study. Rheumatology (Oxford) 2009;48:83-7 »20, «Lievense A, Bierma-Zeinstra S, Verhagen A ym. Influence of work on the development of osteoarthritis of the hip: a systematic review. J Rheumatol 2001;28:2520-8 »25, «Kaila-Kangas L, Arokoski J, Impivaara O ym. Associations of hip osteoarthritis with history of recurrent exposure to manual handling of loads over 20 kg and work participation: a population-based stud»26, «Jensen LK. Hip osteoarthritis: influence of work with heavy lifting, climbing stairs or ladders, or combining kneeling/squatting with heavy lifting. Occup Environ Med 2008;65:6-19 »27
Lonkkanivelen epämuodostumat ja kehityshäiriöt «Lonkkanivelen epämuodostumat ja nivelen kehityshäiriöt lisäävät lonkkanivelrikon vaaraa.»A «Lane NE, Lin P, Christiansen L ym. Association of mild acetabular dysplasia with an increased risk of incident hip osteoarthritis in elderly white women: the study of osteoporotic fractures. Arthritis»28, «Smith RW, Egger P, Coggon D ym. Osteoarthritis of the hip joint and acetabular dysplasia in women. Ann Rheum Dis 1995;54:179-81 »29, «Yrjönen T. Long-term prognosis of Legg-Calvé-Perthes disease: a meta-analysis. J Pediatr Orthop B 1999;8:169-72 »30, «Yrjönen T. Prognosis in Perthes' disease after noncontainment treatment. 106 hips followed for 28-47 years. Acta Orthop Scand 1992;63:523-6 »31, «Jacobsen S, Sonne-Holm S. Hip dysplasia: a significant risk factor for the development of hip osteoarthritis. A cross-sectional survey. Rheumatology (Oxford) 2005;44:211-8 »32, «Reijman M, Hazes JM, Pols HA ym. Acetabular dysplasia predicts incident osteoarthritis of the hip: the Rotterdam study. Arthritis Rheum 2005;52:787-93 »33, «McWilliams DF, Doherty SA, Jenkins WD ym. Mild acetabular dysplasia and risk of osteoarthritis of the hip: a case-control study. Ann Rheum Dis 2010;69:1774-8 »34
Perimä «Perimä näyttää altistavan lonkkanivelrikolle.»B «Valdes AM, Spector TD. Genetic epidemiology of hip and knee osteoarthritis. Nat Rev Rheumatol 2011;7:23-32 »14, «Lanyon P, Muir K, Doherty S ym. Assessment of a genetic contribution to osteoarthritis of the hip: sibling study. BMJ 2000;321:1179-83 »35, «Lanyon P, Muir K, Doherty S ym. Influence of radiographic phenotype on risk of hip osteoarthritis within families. Ann Rheum Dis 2004;63:259-63 »36, «MacGregor AJ, Antoniades L, Matson M ym. The genetic contribution to radiographic hip osteoarthritis in women: results of a classic twin study. Arthritis Rheum 2000;43:2410-6 »37, «Chitnavis J, Sinsheimer JS, Clipsham K ym. Genetic influences in end-stage osteoarthritis. Sibling risks of hip and knee replacement for idiopathic osteoarthritis. J Bone Joint Surg Br 1997;79:660-4 »38
Taulukko 2. Polvinivelrikon vaaraa lisäävät tekijät.
Vaaratekijä Näytön taso Kirjallisuusviitteet
Naissukupuoli «Naisilla on enemmän polvinivelrikkoa kuin miehillä.»A «Blagojevic M, Jinks C, Jeffery A ym. Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis. Osteoarthritis Cartilage 2010;18:24-33 »39, «Srikanth VK, Fryer JL, Zhai G ym. A meta-analysis of sex differences prevalence, incidence and severity of osteoarthritis. Osteoarthritis Cartilage 2005;13:769-81 »40
Ikä «Ikä lisää polvinivelrikon vaaraa.»A «Blagojevic M, Jinks C, Jeffery A ym. Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis. Osteoarthritis Cartilage 2010;18:24-33 »39, «Hart DJ, Doyle DV, Spector TD. Incidence and risk factors for radiographic knee osteoarthritis in middle-aged women: the Chingford Study. Arthritis Rheum 1999;42:17-24 »41, «Anderson JJ, Felson DT. Factors associated with osteoarthritis of the knee in the first national Health and Nutrition Examination Survey (HANES I). Evidence for an association with overweight, race, a»42
Lihavuus «Liikapaino (BMI 25.0–29.9) ja lihavuus (BMI gt; 30.0) lisäävät polvinivelrikon vaaraa.»A «Felson DT, Anderson JJ, Naimark A ym. Obesity and knee osteoarthritis. The Framingham Study. Ann Intern Med 1988;109:18-24 »43, «Cicuttini FM, Baker JR, Spector TD. The association of obesity with osteoarthritis of the hand and knee in women: a twin study. J Rheumatol 1996;23:1221-6 »44, «Felson DT, Zhang Y, Hannan MT ym. Risk factors for incident radiographic knee osteoarthritis in the elderly: the Framingham Study. Arthritis Rheum 1997;40:728-33 »45, «Cooper C, Snow S, McAlindon TE ym. Risk factors for the incidence and progression of radiographic knee osteoarthritis. Arthritis Rheum 2000;43:995-1000 »46, «Jiang L, Tian W, Wang Y ym. Body mass index and susceptibility to knee osteoarthritis: a systematic review and meta-analysis. Joint Bone Spine 2012;79:291-7 »47, «Manninen P, Riihimäki H, Heliövaara M ym. Overweight, gender and knee osteoarthritis. Int J Obes Relat Metab Disord 1996;20:595-7 »48, «Toivanen AT, Heliövaara M, Impivaara O ym. Obesity, physically demanding work and traumatic knee injury are major risk factors for knee osteoarthritis--a population-based study with a follow-up of 22 »49, «Manninen P, Heliövaara M, Riihimäki H ym. Physical workload and the risk of severe knee osteoarthritis. Scand J Work Environ Health 2002;28:25-32 »50, «Muthuri SG, Hui M, Doherty M ym. What if we prevent obesity? Risk reduction in knee osteoarthritis estimated through a meta-analysis of observational studies. Arthritis Care Res (Hoboken) 2011;63:982-»51
Polvivamma «Polvinivelvamma lisää polvinivelrikon vaaraa.»A «Lau EC, Cooper C, Lam D ym. Factors associated with osteoarthritis of the hip and knee in Hong Kong Chinese: obesity, joint injury, and occupational activities. Am J Epidemiol 2000;152:855-62 »22, «Blagojevic M, Jinks C, Jeffery A ym. Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis. Osteoarthritis Cartilage 2010;18:24-33 »39, «Cooper C, Snow S, McAlindon TE ym. Risk factors for the incidence and progression of radiographic knee osteoarthritis. Arthritis Rheum 2000;43:995-1000 »46, «Toivanen AT, Heliövaara M, Impivaara O ym. Obesity, physically demanding work and traumatic knee injury are major risk factors for knee osteoarthritis--a population-based study with a follow-up of 22 »49 «Cooper C, McAlindon T, Snow S ym. Mechanical and constitutional risk factors for symptomatic knee osteoarthritis: differences between medial tibiofemoral and patellofemoral disease. J Rheumatol 1994;2»52, «Wilder FV, Hall BJ, Barrett JP Jr ym. History of acute knee injury and osteoarthritis of the knee: a prospective epidemiological assessment. The Clearwater Osteoarthritis Study. Osteoarthritis Cartila»53, «Davis MA, Ettinger WH, Neuhaus JM ym. The association of knee injury and obesity with unilateral and bilateral osteoarthritis of the knee. Am J Epidemiol 1989;130:278-88 »54, «Muthuri SG, McWilliams DF, Doherty M ym. History of knee injuries and knee osteoarthritis: a meta-analysis of observational studies. Osteoarthritis Cartilage 2011;19:1286-93 »55
Raskas liikunta (joukkue- ja voimalajit) «Tavanomainen vapaa-ajan liikunta ei ilmeisesti lisää polvinivelrikon riskiä, mutta huippu-urheilutasoinen raskas liikunta (joukkue- ja voimalajit) näyttää lisäävän polvinivelrikon vaaraa.»B «Michaëlsson K, Byberg L, Ahlbom A ym. Risk of severe knee and hip osteoarthritis in relation to level of physical exercise: a prospective cohort study of long-distance skiers in Sweden. PLoS One 2011;»24, «McAlindon TE, Wilson PW, Aliabadi P ym. Level of physical activity and the risk of radiographic and symptomatic knee osteoarthritis in the elderly: the Framingham study. Am J Med 1999;106:151-7 »56, «Kujala UM, Kaprio J, Sarna S. Osteoarthritis of weight bearing joints of lower limbs in former élite male athletes. BMJ 1994;308:231-4 »57, «Spector TD, Harris PA, Hart DJ ym. Risk of osteoarthritis associated with long-term weight-bearing sports: a radiologic survey of the hips and knees in female ex-athletes and population controls. Arth»58, «Hannan MT, Felson DT, Anderson JJ ym. Habitual physical activity is not associated with knee osteoarthritis: the Framingham Study. J Rheumatol 1993;20:704-9 »59, «Felson DT, Niu J, Clancy M ym. Effect of recreational physical activities on the development of knee osteoarthritis in older adults of different weights: the Framingham Study. Arthritis Rheum 2007;57:»60, «Chakravarty EF, Hubert HB, Lingala VB ym. Long distance running and knee osteoarthritis. A prospective study. Am J Prev Med 2008;35:133-8 »61
Raskas fyysinen työ ja kyykistelyä vaativa työ «Polvinivelrikon vaara kasvaa raskaassa fyysisessä ja kyykistelyä vaativassa työssä.»B «Toivanen AT, Heliövaara M, Impivaara O ym. Obesity, physically demanding work and traumatic knee injury are major risk factors for knee osteoarthritis--a population-based study with a follow-up of 22 »49, «Manninen P, Heliövaara M, Riihimäki H ym. Physical workload and the risk of severe knee osteoarthritis. Scand J Work Environ Health 2002;28:25-32 »50, «Jensen LK. Knee osteoarthritis: influence of work involving heavy lifting, kneeling, climbing stairs or ladders, or kneeling/squatting combined with heavy lifting. Occup Environ Med 2008;65:72-89 »62, «McWilliams DF, Leeb BF, Muthuri SG ym. Occupational risk factors for osteoarthritis of the knee: a meta-analysis. Osteoarthritis Cartilage 2011;19:829-39 »63
Nivelkierukan poisto «Nivelkierukan poisto saattaa lisätä polvinivelrikon vaaraa.»C «Blagojevic M, Jinks C, Jeffery A ym. Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis. Osteoarthritis Cartilage 2010;18:24-33 »39, «Roos H, Laurén M, Adalberth T ym. Knee osteoarthritis after meniscectomy: prevalence of radiographic changes after twenty-one years, compared with matched controls. Arthritis Rheum 1998;41:687-93 »64, «Andersson-Molina H, Karlsson H, Rockborn P. Arthroscopic partial and total meniscectomy: A long-term follow-up study with matched controls. Arthroscopy 2002;18:183-9 »65, «Englund M, Roos EM, Lohmander LS. Impact of type of meniscal tear on radiographic and symptomatic knee osteoarthritis: a sixteen-year followup of meniscectomy with matched controls. Arthritis Rheum 20»66, «Englund M, Lohmander LS. Risk factors for symptomatic knee osteoarthritis fifteen to twenty-two years after meniscectomy. Arthritis Rheum 2004;50:2811-9 »67, «Papalia R, Del Buono A, Osti L ym. Meniscectomy as a risk factor for knee osteoarthritis: a systematic review. Br Med Bull 2011;99:89-106 »68
Perimä «Perimä näyttää altistavan polvinivelrikolle.»B «Valdes AM, Spector TD. Genetic epidemiology of hip and knee osteoarthritis. Nat Rev Rheumatol 2011;7:23-32 »14, «Chitnavis J, Sinsheimer JS, Clipsham K ym. Genetic influences in end-stage osteoarthritis. Sibling risks of hip and knee replacement for idiopathic osteoarthritis. J Bone Joint Surg Br 1997;79:660-4 »38, «Spector TD, Cicuttini F, Baker J ym. Genetic influences on osteoarthritis in women: a twin study. BMJ 1996;312:940-3 »69, «Neame RL, Muir K, Doherty S ym. Genetic risk of knee osteoarthritis: a sibling study. Ann Rheum Dis 2004;63:1022-7 »70
Polven varus- tai valgusvirheasento «Varus- tai valgusvirheasento ilmeisemmin nopeuttaa polvinivelrikon etenemistä.»B «Cerejo R, Dunlop DD, Cahue S ym. The influence of alignment on risk of knee osteoarthritis progression according to baseline stage of disease. Arthritis Rheum 2002;46:2632-6 »71, «Sharma L, Song J, Felson DT ym. The role of knee alignment in disease progression and functional decline in knee osteoarthritis. JAMA 2001;286:188-95 »72, «Tanamas S, Hanna FS, Cicuttini FM ym. Does knee malalignment increase the risk of development and progression of knee osteoarthritis? A systematic review. Arthritis Rheum 2009;61:459-67 »73, «Sharma L, Song J, Dunlop D ym. Varus and valgus alignment and incident and progressive knee osteoarthritis. Ann Rheum Dis 2010;69:1940-5 »74

Epidemiologia

Diagnostiikka

  • Nivelrikkodiagnoosi perustuu
    • potilaan kuvaamiin oireisiin
    • kliinisen tutkimuksen nivellöydöksiin
    • radiologisiin löydöksiin
    • tarvittaessa tehtäviin erotusdiagnostisiin laboratoriotutkimuksiin.

Anamnestiset oireet

Kliininen tutkimus

Laboratoriolöydökset

Kuvantamistutkimukset

Taulukko 3. Polvinivelrikon röntgenkuvaan perustuva radiologinen Kellgrenin ja Lawrencen luokitus «Kellgren JH. The epidemiology of chronic rheumatism. Atlas of standard radiographs of osteoarthritis. Philadelphia, PA: F.A. Davis G. 2. painos 1963:1-13»109.
Luokka Polvinivelrikko Kuva
1 Mahdollinen nivelraon kaventuminen ja mahdollinen reunaosteofyytti «Mahdollinen nivelraon kaventuminen ja mahdollinen reunaosteofyytti»3
2 Selvät osteofyytit ja mahdollinen nivelraon kaventuminen «Selvät osteofyytit ja mahdollinen nivelraon kaventuminen»4
3 Useita kohtalaisia osteofyyttejä, selvä nivelraon kaventuminen ja jonkin verran skleroosia ja mahdollinen luiden päiden deformiteetti «Useita kohtalaisia osteofyyttejä, selvä nivelraon kaventuminen ja jonkin verran skleroosia ja mahdollinen luiden päiden deformiteetti»5
4 Kookkaita osteofyyttejä, merkittävä nivelraon kaventuminen, vaikea skleroosi ja selvä luiden päiden deformiteetti «Kookkaita osteofyyttejä, merkittävä nivelraon kaventuminen, vaikea skleroosi ja selvä luiden päiden deformiteetti»6
Taulukko 4. Lonkkanivelrikon röntgenkuvaan perustuva radiologinen Kellgrenin ja Lawrencen luokitus «Kellgren JH. The epidemiology of chronic rheumatism. Atlas of standard radiographs of osteoarthritis. Philadelphia, PA: F.A. Davis G. 2. painos 1963:1-13»109.
Luokka Lonkkanivelrikko Kuva
1 Mahdollinen nivelraon kaventuminen ja mahdolliset reisiluun pään osteofyytit «Mahdollinen nivelraon kaventuminen ja mahdolliset reisiluun pään osteofyytit»7
2 Selvä nivelraon kaventuminen, selvät osteofyytit ja lievä skleroosi «Selvä nivelraon kaventuminen, selvät osteofyytit ja lievä skleroosi»8
3 Merkittävä nivelraon kaventuminen, lieviä osteofyyttejä, jonkin verran skleroosia ja kystia sekä reisiluun pään ja lonkkamaljan deformiteetti «Merkittävä nivelraon kaventuminen, lieviä osteofyyttejä, jonkin verran skleroosia ja kystia sekä reisiluun pään ja lonkkamaljan deformiteetti»9
4 Nivelrako hävinnyt, skleroosia ja kystia, merkittävä reisiluun pään ja lonkkamaljan deformiteetti ja isot osteofyytit «Nivelrako hävinnyt, skleroosia ja kystia, merkittävä reisiluun pään ja lonkkamaljan deformiteetti ja isot osteofyytit»10

Erotusdiagnostiikka

Taulukko 5. Lonkkanivelrikon erotusdiagnostiset sairaudet «Nivelreuma [verkkoversio]. Käypä hoito -suositus. Suomalaisen Lääkäriseuran Duodecimin ja Suomen Reumatologiyhdistyksen asettama työryhmä. Helsinki: Suomalainen Lääkäriseura Duodecim 18.9.2009. www.»111, «Orava S, Vasankari T, Helttula I. Urheilijan pakaraperäiset iskiasoireyhtymät. Suom Lääkäril 2003;58:3423-7»112, «Vastamäki M. Alaraajan hermopinteet. Suom Lääkäril 2004;59:2493-8»113, «Huddleston JI, Goodman SB. Huddleston JI, Goodman SB. Hip and knee pain. In book Kelly's Textbook of Rheumatology. Eight edition. (Eds. Firestein GS, Budd RC, Harris Jr ED, McInnes IB, Ruddy S, Sergen»114, «Margo K, Drezner J, Motzkin D. Evaluation and management of hip pain: an algorithmic approach. J Fam Pract 2003;52:607-17 »115, « Aikuisten alaselkäsairaudet [verkkoversio]. Käypä hoito -suositus. Suomalaisen Lääkäriseuran Duodecimin ja Suomen Fysiatriyhdistyksen asettama työryhmä. Helsinki: Suomalainen Lääkäriseura Duodecim »116, « Arokoski JPA. Lonkan ja polven sairaudet. Kirjassa: Fysiatria 4. painos (Toim. Arokoski J, Alaranta H, Pohjolainen T, Salminen J, Viikari-Juntura E), Kustannus Oy Duodecim 2009, s.199-214»117, «Alaraajojen tukkiva valtimotauti [verkkoversio]. Käypä hoito -suositus. Suomalaisen Lääkäriseuran Duodecimin ja Suomen Verisuonikirurgisen Yhdistyksen asettama työryhmä. Helsinki: Suomalainen Lääkä»118, «Lonkkamurtuma [verkkoversio]. Käypä hoito -suositus. Suomalaisen Lääkäriseuran Duodecimin ja Suomen Ortopediyhdistyksen asettama työryhmä. Helsinki: Suomalainen Lääkäriseura Duodecim 10.6.2011. www.»119, « Martell JM, Reider B. Pelvis, hip and thigh. In book: The orthopaedic physical examination. Ed. Reider B. W.B. Sauders Company, Philadelphia 1999, p.159-99»120, «Partanen J, Ojala T, Arokoski JP. Myofaskiaalinen kipuoireyhtymä - lihasjuostekipu. Duodecim 2010;126:1921-9 »121, «Seppänen M, Itälä A, Mäkelä K, Virolainen P. Kivulias lonkka ei aina merkitse artroosia. Suom Lääkäril 2010;65:2185-91»122, «Heikkinen T. Aikuisten nivustyrän diagnostiikka ja hoito. Suom Lääkäril 2009;64:4243-47»123, «Pohjolainen T. Lonkan bursiitit ja insertiitit. Duodecim 2008;124:1988-92 »124, «Hannonen P, Mikkelsson M.M79.0 – mistä fibromyalgiassa on kyse, mitä hoidoksi? Duodecim 2004;120:237-46 »125, «Mäkelä EA. Luutuumorit. Duodecim 2001;117:2205-14 »126, «Isomäki H. Kihti. Duodecim 2001;117:1843-7; quiz 1847, 1861 »127, «Hannu T, Leirisalo-Repo M. Reaktiivinen artriitti. Duodecim 2003;119:837-45 »128, «Hakala M. Selkärankareuma (ankylosoiva spondyliitti). Duodecim 2011;127:357-8 »129.
Lonkkakipujen syitä Sairaus
Tulehdukselliset nivelsairaudet
  1. Nivelreuma
  2. Selkärankareuma
  3. Reaktiivinen (uro- ja enteroartriitti) ja pyogeeninen artriitti
  4. Kihti
Tendiniitit, bursiitit ja lihas-jänneyksikön kiputilat
  1. Iliopsoas-, ja iskiogluteaalibursiitti
  2. Ison sarvennoisen kipuoireyhtymä
  3. Piriformisoireyhtymä
  4. Polymyalgia rheumatica
  5. Lihasrepeämät
  6. Myofaskiaaliset kiputilat
Lonkkanivelen rakenteelliset syyt
  1. Lonkan dysplasian ja luksaation jälkitila
  2. Reisiluun pään avaskulaarinen nekroosi
  3. Osteokondroosi
  4. Lonkkamaljan labrumvaurio
Murtumat
  1. Rasitusmurtumat
  2. Avulsiomurtumat
  3. Lantio- ja lonkkamurtumat
Hermovammat ja hermopinteistä johtuvat kivut ja säteilyoireet
  1. Säteilykipu spinaalistenoosissa ja iskiaksessa
  2. Lantion alueen hermopinteet ja hermovammat
Muut syyt
  1. Ahdas lonkka -oireyhtymä (Femoroacetabular Impingement, FAI)
  2. Valtimoperäiset syyt (aneurysma)
  3. Vatsan ja lantion alueen tuumorit ja syövän etäpesäkkeet
  4. Nivusalueen tyrät
  5. Vatsan elinten tulehdukset
  6. Sakroiliakaalinivelen nivelrikko
  7. Säteilykipu lanneselän diskusdegeneraatiossa ja fasettinivelrikossa
  8. Luukasvaimet
  9. Fibromyalgia
Taulukko 6. Polvinivelrikon erotusdiagnostiset sairaudet «Järvelä T. Kipeä polvi. Duodecim 2005;121:2105-12 »95, «Nivelreuma [verkkoversio]. Käypä hoito -suositus. Suomalaisen Lääkäriseuran Duodecimin ja Suomen Reumatologiyhdistyksen asettama työryhmä. Helsinki: Suomalainen Lääkäriseura Duodecim 18.9.2009. www.»111, «Vastamäki M. Alaraajan hermopinteet. Suom Lääkäril 2004;59:2493-8»113, «Huddleston JI, Goodman SB. Huddleston JI, Goodman SB. Hip and knee pain. In book Kelly's Textbook of Rheumatology. Eight edition. (Eds. Firestein GS, Budd RC, Harris Jr ED, McInnes IB, Ruddy S, Sergen»114, « Aikuisten alaselkäsairaudet [verkkoversio]. Käypä hoito -suositus. Suomalaisen Lääkäriseuran Duodecimin ja Suomen Fysiatriyhdistyksen asettama työryhmä. Helsinki: Suomalainen Lääkäriseura Duodecim »116, « Arokoski JPA. Lonkan ja polven sairaudet. Kirjassa: Fysiatria 4. painos (Toim. Arokoski J, Alaranta H, Pohjolainen T, Salminen J, Viikari-Juntura E), Kustannus Oy Duodecim 2009, s.199-214»117, «Alaraajojen tukkiva valtimotauti [verkkoversio]. Käypä hoito -suositus. Suomalaisen Lääkäriseuran Duodecimin ja Suomen Verisuonikirurgisen Yhdistyksen asettama työryhmä. Helsinki: Suomalainen Lääkä»118, «Partanen J, Ojala T, Arokoski JP. Myofaskiaalinen kipuoireyhtymä - lihasjuostekipu. Duodecim 2010;126:1921-9 »121, «Hannonen P, Mikkelsson M.M79.0 – mistä fibromyalgiassa on kyse, mitä hoidoksi? Duodecim 2004;120:237-46 »125, «Mäkelä EA. Luutuumorit. Duodecim 2001;117:2205-14 »126, «Isomäki H. Kihti. Duodecim 2001;117:1843-7; quiz 1847, 1861 »127, «Hannu T, Leirisalo-Repo M. Reaktiivinen artriitti. Duodecim 2003;119:837-45 »128, «Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: Part II. Differential diagnosis. Am Fam Physician 2003;68:917-22 »130, «Reider B. Knee. In book: The orthopaedic physical examination. Ed. Reider B. W.B. Sauders Company, Philadelphia 1999, p.201-248»131, «Kujala U. Polven rasituskiputilat - käypä diagnostiikka ja hoito. Suom Lääkäril 1999;54:771-5»132.
Polvikipujen syitä Sairaus
Tulehdukselliset nivelsairaudet
  1. Nivelreuma
  2. Reaktiivinen (uro- ja enteroartriitti) ja pyogeeninen artriitti
  3. Kihti
Luu- ja jännevammat
  1. Nivelsidevauriot (eturistiside- sekä mediaali- ja lateraalikollateraaliligamentit)
  2. Rasitusmurtumat
  3. Polvimurtuma
  4. Osgood–Schlatterin tauti
Nivelperäiset syyt
  1. Nivelkierukan repeämä tai kysta
  2. Bakerin kysta
  3. Plica-oireyhtymä
  4. Osteokondroosi
  5. Hemofilia
  6. Osteonekroosi
Tendiniitit ja bursiitit
  1. Tractus iliotibialiksen hankauskipu
  2. Pes anserinuksen bursiitti ja insertiotendiniitti
  3. Prepatellaribursiitti
  4. Hyppääjän polvi
  5. Muut polven alueen tendiniitit ja bursiitit
Rinta-, lanne- ja ristirangan sairaudet
  1. Säteilykipu spinaalistenoosissa ja iskiaksessa
Muut syyt
  1. Luukasvaimet ja syövän etäpesäkkeet
  2. Fibromyalgia
  3. Paikalliset hermovauriot

Diagnostiset määritelmät

Taulukko 7. Polvi- ja lonkkanivelrikon kliinis-radiologinen luokitus «Altman R, Asch E, Bloch D ym. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committe»134, «Altman R, Alarcón G, Appelrouth D ym. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum 1991;34:505-14 »135.
Sairaus Diagnostiset kriteerit
Polvinivelrikko Polvinivelkipu useampina päivinä kuukaudessa
JA
Ainakin yksi seuraavista
  • ikä yli 50 vuoden ikä
  • alle 30 minuuttia kestävä aamujäykkyys
  • kliinisessä tutkimuksessa tuntuva nivelritinä
JA
Polven röntgenkuvassa osteofyyttejä
Lonkkanivelrikko Lonkkanivelkipu useampina päivinä kuukaudessa
JA
Ainakin kaksi seuraavista
  • lasko alle 20 mm/h
  • lonkan röntgenkuvassa osteofyyttejä
  • lonkan röntgenkuvassa nivelraon kaventumia

Nivelrikon ehkäisy

Nivelrikkoriskin pienentämiseksi ehdotettuja toimenpiteitä

Polvi- ja lonkkanivelrikon hoidon pääperiaatteet

Konservatiivinen lääkkeetön hoito

Itsehoidon ohjaus

Laihduttaminen

Terapeuttinen harjoittelu ja liikunta

Manuaalinen terapia

Fysikaalinen terapia

Polvi- ja kenkätuet ja kantakiilaus

Apuvälineet

Asunnon muutostyöt

  • Asunnon muutostöiden tavoitteena on helpottaa itsenäistä liikkumista. Muutostöitä arvioivat fysio- ja toimintaterapeutit ja kuntoutusohjaajat.
  • Suihkujakkara ja pesutilan kaiteet helpottavat peseytymistä. WC-istuimen ja vuoteen korotukset, kynnysten poisto ja tukikaiteet helpottavat itsenäistä liikkumista.

Lääkehoito

Taulukko 8. Tulehduskipulääkkeiden jako COX-1- ja COX-2-selektiivisyyden mukaan.
Epäselektiiviset COX-2-painotteiset COX-2-selektiiviset
  1. Erityislupavalmiste
  2. Aihiolääke, muuttuu elimistössä valdekoksibiksi
ASA Etodolaakki Etorikoksibi
Deksketoprofeeni Meloksikaami Parekoksibi 2
Diklofenaakki Nabumetoni Selekoksibi
Ibuprofeeni Nimesulidi1)
Indometasiini
Ketoprofeeni
Ketorolaakki
Mefenaamihappo
Naprokseeni
Sulindaakki
Tenoksikaami
Tiaprofeeni
Tolfenaamihappo
Taulukko 9. Tulehduskipulääkkeiden mahahaittojen riskitekijät.
Tulehduskipulääkkeiden mahahaittojen riskitekijät
Korkea ikä (yli 65 vuotta)
Aikaisemmin sairastettu ulkus
Suuri tulehduskipulääkkeen annos
Useamman kuin yhden tulehduskipulääkkeen samanaikainen käyttö
Samanaikainen glukokortikoidien käyttö
Samanaikainen antikoagulanttien käyttö
Samanaikainen selektiivisten serotoniinin takaisinoton estäjien (SSRI-lääkkeet) käyttö
Helicobacter pylori -infektio
Yleiskuntoa heikentävät sairaudet

Kirurginen hoito

Artroskopia

Polven osteotomiat

Lonkan osteotomiat

Tekonivelleikkaus

Lonkan ja polven tekonivelleikkausta edeltävä, perioperatiivinen ja leikkauksen jälkeinen ohjaus ja terapeuttinen harjoittelu

Ammatillinen kuntoutus

  • Työ- ja toimintakyky ja kuntoutustarve arvioidaan ensi vaiheessa perusterveydenhuollossa, työterveyshuollossa ja erikoissairaanhoidon kuntoutustutkimusyksiköissä.
    • Kuntoutustarpeen selvityksiä ja kuntoutustutkimuksia tekevät erityisesti erikoissairaanhoidon kuntoutustutkimusyksiköt.
    • Nivelrikkopotilas voidaan lähettää lääkärin B- tai E-lausunnolla myös kuntoutustarvetta ja -mahdollisuuksia selvittävään tutkimukseen Kansaneläkelaitoksen tai työeläkelaitoksen kautta. Tapaturma- ja liikennevakuutustapauksissa potilaat ohjataan Vakuutusalan kuntoutuskeskukseen (VKK).
  • Ammatillisen kuntoutuksen toimenpiteet tulisi käynnistää, jos työkyky ja ansiomahdollisuudet ovat olennaisesti heikentyneet polvi- tai lonkkanivelrikon vuoksi tai on nähtävissä todennäköinen työkyvyttömyyden uhka lähivuosina, vaikka hoidon ja lääkinnällisen kuntoutuksen mahdollisuudet otetaan huomioon. Ammatilliset kuntoutustoimenpiteet tulevat tuolloin harkittaviksi erityisesti silloin, kun potilaan työ vaatii toistuvaa kyykistelyä, nivelen ääriasentoja ja raskaiden taakkojen nostamista.
    • Polvi- ja lonkkanivelrikkopotilaan ammatillinen uudelleenkoulutus tulee kyseeseen erityisesti nuorilla ja keski-ikäisillä.
    • Ikääntyneillä ensisijaisia ammatillisen kuntoutuksen toimenpiteitä ovat työjärjestelyt, työergonomian parantaminen ja työsijoitusratkaisut.
    • Ammatillisen kuntoutuksen kustannuksiin osallistuvat Kansaneläkelaitos, työeläkelaitokset, tapaturma- ja liikennevakuutuslaitokset ja työhallinto.

Hoidon porrastus

  • Päävastuu nivelrikon diagnostiikasta ja erotusdiagnostiikasta on perusterveydenhuollolla ja työterveyshuollolla.
  • Hoito toteutetaan pääosin perusterveydenhuollossa ja työterveyshuollossa.
  • Erotusdiagnostiset ongelmat ja kirurgista hoitoa vaativat tautimuodot kuuluvat erikoissairaanhoitoon ja keskuksiin, joissa on mahdollisuudet erikoistutkimuksiin ja ortopediseen kirurgiseen hoitoon.
    • Potilaat, jotka tuntemattomasta syystä turvonneen nivelen vuoksi tarvitsevat erotusdiagnostiikkaa, lähetetään erikoissairaanhoitoon ensisijaisesti reumatologian poliklinikkaan.

Suomalaisen Lääkäriseuran Duodecimin ja Suomen Ortopediyhdistys ry:n asettama työryhmä

Polvi- ja lonkkanivelrikko -suosituksen historiatiedot «Polvi- ja lonkkanivelrikko, Käypä hoito -suosituksen historiatiedot»6

Puheenjohtaja

Jari Arokoski, LT, fysiatrian dosentti, kliininen opettaja, fysiatrian erikoislääkäri Itä-Suomen yliopiston lääketieteen laitoksen kliininen yksikkö, kirurgia (ml. fysiatria), KYS:n fysiatrian klinikka

Jäsenet

Antti Eskelinen, LT, dosentti, erikoislääkäri, tutkimusjohtaja,Tekonivelsairaala Coxa

Eeva-Eerika Helminen, LL, yleislääketieteen erikoislääkäri, Kuopion sosiaali- ja terveyskeskus

Jyrki Kettunen, TtT, ft, dosentti, yliopettaja, Arcada, Helsinki

Antti Malmivaara, LKT, dosentti, ylilääkäri, Terveyden ja hyvinvoinnin laitoksen terveys- ja sosiaalitalouden yksikkö, Käypä hoito -toimittaja

Ville Mattila, LT, dosentti, ortopedian erikoistuva lääkäri, Käypä hoito -toimittaja

Eeva Moilanen, professori Tampereen yliopiston lääketieteen yksikkö, farmakologia, TAYS

Risto Ojala, LT, dosentti, osastonylilääkäri OYS, kirurgian röntgen

Pekka Paavolainen, LKT, ylilääkäri, professori h.c. Invalidisäätiö

Petri Salo, TtT, ft, Kliinisen fysioterapian asiantuntija, Keski-Suomen sairaanhoitopiiri

Petri Virolainen, LT, dosentti, osastonylilääkäri TYKS:n ortopedian klinikka

Katriina Vuolteenaho, LT, dosentti, Tampereen yliopiston lääketieteen yksikkö, farmakologia, TAYS

Asiantuntijat

Ilkka Kiviranta, LKT, Ortopedian ja traumatologian professori, ylilääkäri, Helsingin yliopisto, HUS

Mika Ulaska, FT, OMT OMT-klinikka; Helsinki

Sidonnaisuudet

Jari Arokoski: Asiantuntijapalkkio (Medicys Ltd), luentopalkkioita (AstraZeneca, MSD, Pfizer, Professio Finland, Mundipharma), osakeomistus (Satucon Oy)

Antti Eskelinen: Asiantuntijapalkkio (DePuy (J&J)), luentopalkkioita (Biomet, DePuy (J&J), Stryker), koulutus- ja kongressimatkoja yritysten tuella (Biomet, DePuy (J&J))

Eeva-Eerika Helminen: Ei sidonnaisuuksia

Jyrki Kettunen: Ei sidonnaisuuksia

Antti Malmivaara: Ei sidonnaisuuksia

Ville Mattila: Ei sidonnaisuuksia

Eeva Moilanen: Asiantuntijapalkkio (Abbott), luentopalkkio (GSK, MSD, Pfizer, Roche, UCB Pharma), osakeomistus (Orion, Tripharma)

Risto Ojala: Ei sidonnaisuuksia

Pekka Paavolainen: Ei sidonnaisuuksia

Petri Salo: Ei sidonnaisuuksia

Petri Virolainen: Asiantuntijapalkkio (Astra-Zeneca, Bayer, Biomet, Boehringer-Ingelheim), luentopalkkioita (Johnson&Johnson, MSD, Stryker), koulutus ja kongressimatkoja yritysten tuella (MSD, Pfizer, Smith&Nephew, Stryker, Zimmer)

Katriina Vuolteenaho: Luentopalkkioita (Schering-Plough, Aducate)

Vastuun rajaus

Käypä hoito -suositukset ovat parhaiden asiantuntijoiden laatimia yhteenvetoja yksittäisten sairauksien diagnostiikan ja hoidon vaikuttavuudesta. Ne eivät korvaa lääkärin tai muun terveydenhuollon ammattilaisen omaa arviota yksittäisen potilaan parhaasta mahdollisesta diagnostiikasta ja hoidosta hoitopäätöksiä tehtäessä.

Tiedonhakukäytäntö

Systemaattinen kirjallisuushaku on hoitosuosituksen perusta. Lue lisää artikkelista khk00007

Kirjallisuutta

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