El cartílago, lo importante de las articulaciones saludables
El cartílago está constituido por 65 a 80% de agua. Las otras sustancias que forman adicionalmente el tejido cartilaginoso son: colágeno, glucoproteínas y los condrocitos.
El colágeno, una proteína fibrosa, es también la base constitutiva de la piel, tendones, huesos y otros tejidos conectivos.
Las glucoproteínas, son una combinación de proteínas y azúcares, y entrelazadas al colágeno forman fibras y forman una red semejante a un tejido. Esto permite al cartílago tener flexibilidad y absorber los traumas.
Los condrocitos son células que forman al cartílago. Ayudan a mantener el crecimiento del mismo y a mantenerlo saludable. Algunas veces, sin embargo, pueden liberar sustancias (enzimas) que destruyen al colágeno y a otras proteínas.
El cartílago, puede describirse como un tejido de tipo conectivo especializado, que está desprovisto de nervios (lo que hace que el cartílago como tal no duela), vasos sanguíneos y de vasos linfáticos. Estos tejidos permiten mover las articulaciones, protegen las terminaciones de los huesos y actúan como soporte ante eventuales traumatismos.
Es posible distinguir tres clases de tejido cartilaginoso: el denominado cartílago hialino, el cartílago fibroso y el cartílago elástico.
El primero de los mencionados es el más frecuente, pudiendo observarse en la estructura nasal, la tráquea, la laringe, los bronquios, las costillas y las puntas articulares óseas. De aspecto blanquecino azuloso, se nutre con el líquido sinovial y presenta pocas fibras. Este tipo de cartílago puede dividirse a su vez en cartílago hialino no articular y en cartílago hialino articular.
El cartílago fibroso (también conocido como fibrocartílago, por su parte, aparece como una combinación que oscila entre el tejido conectivo denso y el ya mencionado cartílago hialino. Se sitúa en los discos localizados entre las vértebras, los bordes de las articulaciones, los discos del grupo articular, los meniscos y en los espacios donde se ubican los tendones y los ligamentos.
El cartílago elástico, por último, se encuentra en la laringe, la trompa de Eustaquio y el oído exterior. Posee una flexibilidad mayor respecto al cartílago hialino y posee una tonalidad amarillenta.
Sabemos entonces que el cartílago tiene tres compuestos: el colágeno, los proteoglicanos y el agua, y vamos a ver como interactúan para hacer del cartílago algo especial. Así nos daremos cuenta porque es tan difícil reemplazar el cartílago por cualquier medio quirúrgico. El colágeno -tipo II- es un colágeno muy particular que es único, que sirve para regenerar, entonces no sólo el colágeno y el tipo de colágeno es muy importante sino también la orientación.
El cartílago es tan especial en su orientación que cuando se introduce un artroscopio parece como si fuera un tejido blando, blanco y plano, pero si hipotéticamente pusiéramos un montón de agujitas en el cartílago, podríamos ver como se separa en partecitas y es como si fueran huellas que tiene cada cartílago, para cada articulación, serían como huellas digitales. Esto refleja las distintas fuerzas que recibe la articulación. Estas huellas se marcan en la articulación con distintos tipos de fuerzas.
La cara superficial de este cartílago si se mira con el microscopio electrónico, es muy áspera, pero al verla por artroscopio o en vivo es muy lisa. Esto mantiene al líquido sinovial y le da una lubricación especial, muy eficiente. El cartílago sobre cartílago es cinco veces más resbaladizo que hielo sobre hielo; o sea que la función de deslizamiento, es perfecta.
Otro factor que tiene que ver es que, el cartílago está agarrado al hueso subcondral (debajo del mismo). Esto es lo que lo mantiene adosado al hueso. En el individuo joven no hay una marca, no hay un nivel de arriba y de abajo, porque en los individuos jóvenes los problemas de cartílago son mayores pero la reparación también es mayor; en cambio en los adultos y mayores hay un nivel y la difusión es nada más desde el líquido sinovial, como resultado se limita y esto evita que se repare tan fácil como en el adolescente.
Otro componente además del colágeno, son los proteoglicanos (proteínas + azúcares). Esto lo que le da elasticidad o rebote al cartílago. Es una molécula grande, con muchas cadenas que son muy hidrofílicas (atraen al agua). Si ustedes miran estas cadenas laterales pueden ver el sulfito de queratina o de condroitina. Las uniones tienen una gran carga negativa y atraen el agua. Al atraer el agua se expanden, y es lo que le da al cartílago su capacidad de rebote o elasticidad y permite mucha absorción de traumas. A medida que absorbe esta agua y se agranda, cuando ustedes se paran y cargan peso, ese agua se corre a otro lugar, permitiendo el efecto de rebote o elástico.
El cartílago normal tiene mucho intercambio de agua, el fibrocartilaginoso o el de reparación no tienen la misma capacidad. Entonces mecánicamente el cartílago de reparación no es tan bueno porque el agua no se mueve para adelante o para los costados libremente.
Los proteoglicanos están concentrados mayormente por el medio y en las capas profundas. Esto es muy importantes ya que le da algunas propiedades particulares al cartílago.
Entre el 70 y el 80 % del peso del cartílago es de agua, que es intercambiable libremente; se puede apretar y hacerla salir o entrar toda. El problema es que a medida que envejecemos perdemos agua en todos los tejidos del cuerpo; entonces al tener menos agua que entre o salga de la articulación, la deformación es más fácil y se llega a la osteoartrosis finalmente. Por eso es que la osteoartrosis no aparece en los jóvenes (salvo un trauma severo de una articulación), sino en los viejos que ya tienen pérdida de agua y están más propensos a los cambios articulares.
Por eso a pesar de tener algún problema degenerativo incipiente, les decimos a los pacientes que tienen que caminar para forzar este intercambio de agua, proteínas, azúcares, al momento del apoyo.
El último componente es el celular. En los individuos jóvenes y maduros las células se dividen y se reparan solas. A medida que envejecemos no tienen estabilidad y entonces nos quedamos con las mismas células que tenemos y sin otras nuevas para mejorarlo, perdiendo así su capacidad de reparación.
Lo que es importante para mantener la salud de la articulación es mantener todos los componentes articulares lo más sanos posible: el agua, el colágeno, los proteoglicanos, pero también la parte mecánica de la articulación tiene que estar bien, sino no funciona la articulación adecuadamente, ya sea postrauma, reciente o de años. Tiene que haber libertad de movimiento, estabilidad, una distribución de carga equitativa, porque no sólo el cartílago debe ser fuerte y que pueda tolerar una cantidad equis de presión.
Esta distribución de la carga, mucha o poca, va a afectar al cartílago. Si usted está en la cama durante seis semanas sin cargarle peso al cartílago, es tan malo como una inestabilidad de articulación. La mayor parte de las veces es el aumento de la carga lo que realmente daña el cartílago. A las células cuando empiezan a lesionarse secretan una enzima que termina rompiendo el cartílago, que se defiende secretando más enzimas y es un círculo vicioso que no termina nunca hasta que el cartílago queda totalmente destruido.
Cuando más temprano se pueda tratar una inestabilidad articular, se podrá reorientar, estabilizar, y será el mejor resultado para el cartílago. ¿Puede corregirse con una cirugía, con un par de plantillas, con una ortesis (bastón, andadera)? Pudiera ser, hay que estudiar muy bien al paciente. Pero si se necesitan algunos suplementos que puedan mejorar el estado del cartílago y que además disminuyan el dolor articular, están:
El Sulfato de Condroitina: (condroitin) es uno de los viscosuplementos (glucosaminoglicano) con macromoléculas formadas por un número elevado de subunidades disacáridas que contienen hexosamina y hexurónico. Estas macromoléculas no existen en estado libre en los tejidos y van asociadas a proteínas, por lo que se llaman proteoglicanos. El condroitin sulfato ayuda a mantener la estructura de los tejidos con gran matriz extracelular como en el cartílago de articulaciones, ligamentos y tendones.
La existencia del grupo sulfato y ácidos urónicos del condroitin, los hace portadores de numerosas cargas negativas y están capacitados para fijar fuertemente los cationes (iones de calcio++) lo que explica su presencia en zonas de osificación. Tiene también una capacidad importante de retención de agua lo que ayuda a proporcionar la capacidad de resistencia compresiva articular.
Por lo que el efecto sobre el cartílago, ayuda a sintetizar proteoglicanos, ácido hialurónico y colágeno y por tanto a reparar la matriz mejorando la estructura dañada. Tiene un efecto antiinflamatorio sobre la COX-2 o las Interleucinas-1b. Sobre la membrana sinovial aumenta la síntesis de ácido hialurónico y reduce el derrame articular. Reduce la actividad catabólica de los condrocitos, e inhibe enzimas proteolíticas como la colagenasa o elastasa.
Estudios realizados confirman que la suplementación con condroitin sulfato y otros viscosuplementos, disminuyen el dolor articular, la inflamación y ayudan a regenerar las estructuras dañadas mejorando la capacidad del cartílago para absorber y distribuir la carga. Los efectos empiezan a notarse al cabo de dos semanas.
El condroitin sulfato no presenta toxicidad y las dosificaciones efectividad son de 800ª 1200mga al día. Las presentaciones van asociadas con sulfato de glucosamina y algunas vitaminas que actúan de forma sinérgica aumentando la efectividad. Es importante tener en cuenta el tipo de condroitin sulfato que se utiliza, algunas formas son más absorbibles que otras, demostrado al utilizar condroitin sulfato de bajo peso molecular.
Glucosamina
Es un monosacárido utilizado como visco suplementación a menudo asociado al condroitin sulfato por su efecto sinérgico. Esta se produce de forma natural en nuestro organismo por los condrocitos, se sintetiza a partir de la Glutamina y Fructuosa fosfato. La suplementación con glucosamina estimula la síntesis de glucosa, aminoglicanos y proteoglicanos necesarios para mantener la función del cartílago articular. Mejora el potencial de difusión de la glucosa y los aminoácidos dentro de la cápsula articular y de la membrana sinovial, lo que provee los sustratos fundamentales al condrocito para sintetizar los proteoglicanos.
La glucosamina tiene tres acciones a nivel articular.
Estimular crecimiento de células del cartílago.
Inhibir la destrucción de proteoglicanos.
Aportar sustratos y ayudar a sintetizar nuevo cartílago.
Podemos encontrar diferentes tipos de glucosamina entre las cuales están: la glucosamina clorhidrato, glucosamina sulfato y la n-acetil glucosamina. La más utilizada en varios estudios clínicos es el sulfato de glucosamina, al administrarla se disocia en glucosamina y iones sulfato que tienen un papel importante en la síntesis de proteoglicanos.
Las dosificaciones efectivas son de 1000 a 1500mg al día. Se ha visto en algunos pacientes diabéticos que la suplementación con glucosamina puede provocar un aumento en la resistencia a la insulina y también interacción con algunos medicamentos que se usan para la diabetes.
Ácido Hialurónico (AH)
Es un polisacárido formado por la combinación de una molécula de n-acetil D-glucosamina y ácido D-glucorónico. Esta muy distribuido en el organismo y se puede encontrar en el cordón umbilical, en la sangre, el líquido sinovial, en la piel y en general, en todo el tejido conjuntivo. El AH tiene propiedades de viscosidad importantes, así como, una baja velocidad de sedimentación, propiedades que lo hacen adecuado para permitir una base deslizante, resistente a la compresión y para dar movilidad a las articulaciones sin que haya fricción.
El AH se utiliza en inyección intra/articular para aumentar la concentración de este en el líquido sinovial que se encuentra en la articulación y mejorar así su viscosidad y elasticidad, sobre todo en problemas de rodilla y cadera. Reduce la inflamación y el dolor. El AH se utiliza en estética para mejorar el estado de la piel ya que estimula la producción de colágeno y como material de relleno.
Se obtiene de la cresta de gallo, aletas de tiburón y en forma sintética, este último no da reacciones de alergia en pacientes que tengan intolerancia a productos como el huevo o pollo, o al pescado.
Antioxidantes:
Los antioxidantes aunque no tienen efecto directo sobre la regeneración del cartílago articular, sí tienen una importante acción antiinflamatoria ya que actúan sobre las interleucinas y citoquinas relacionadas con los procesos inflamatorias. Varios estudios han mostrado elevados niveles de Proteína C reactiva, PCR, en pacientes con artrosis.
Cuando se les ha administrado Antioxidantes, se demostró una disminución de los niveles de PCR hasta de un 70%, además se redujeron niveles sanguíneos de otros componentes que sugieren inflamación aguda como el fibrinógeno que descendió un 37%, las especies reactivas del oxígeno (ROS), que son sustancias pro/oxidantes y radicales libres, que descendieron en un 30%.
Ejemplos de los 10 mejores Antioxidantes:
Melatonina
Té verde
Ácido alfa Lipoico (ALA)
Resveratrol
Glutation
Coenzima Q10
Astaxantina
Beta caroteno
Vitamina E
Vitamina C
Hay algunos compuestos (complementos) que vienen en combinaciones diversas; así es que se escogerá el mejor para el paciente. Y su médico podrá indicarles el mejor para cada uno. Consulte primero a su médico.
Dr. Sánchez Mejía
Ortopedia y Traumatología
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