Pacientes jóvenes con rodillas viejas

Para aquellas personas que sufren lesiones de rodilla en etapas tempranas de su vida

423

Se ha visto que tienen mayor riesgo de sufrir osteoartrosis (OA – proceso degenerativo) en una edad más joven, que aquellos que no sufrieron ninguna patología.

Podemos estar hablando entonces de “pacientes jóvenes con rodillas viejas”. Los estudios muestran que una articulación lesionada es la causa más frecuente de osteoartrosis (OA) sobre todo de la rodilla, que es la articulación más grande de nuestro organismo, y por lo tanto, más expuesta a los traumas. La lesión de la rodilla es particularmente importante en personas que inician el proceso de la enfermedad.

Se han realizado estudios sobre todo en rodillas de pacientes jóvenes que sufrieron accidentes severos y que perdieron la vida, la edad promedio fue de 35-40 años y se observo que el proceso degenerativo ya había iniciado.
Lo que lleva al paciente con el médico es el dolor, que si después de dos a tres semanas no ha obtenido mejoría acuden para su valoración, sin embargo, hay personas que dejan pasar meses, hasta acudir a la consulta. La principal molestia es el dolor y la incapacidad para la movilidad. A veces llegan a ingerir algún medicamento antiinflamatorio para control de las molestias, sin embargo, la articulación ha empezado a lesionarse.

Las caídas constantes, los golpes contusos sobre las rodillas, los esguinces severos producen lesiones tales como la ruptura del ligamento cruzado anterior (LCA) o lesiones de los meniscos, lesiones de ligamentos o lesiones óseas y estos problemas envejecen la rodilla en cerca de 25 a 30 años, esto quiere decir que, si tienen una rodilla lesionada (estamos hablando de una lesión de moderada a severa) a la edad de 20 años, para los 40 años la rodilla será como la de una persona de 65 años. ¿Increíble? No, desafortunadamente esto está ocurriendo sobre todo ahora con los llamados deportes extremos en donde los traumatismos severos están a la orden del día, como en el barranquismo, bicicroos, bungee o caída libre, carreras de supervivencia, descenso de ríos o hydrospeed, escaladas en solitario, paracaidismo, esquí extremo, kite jumping, free running, snowboard extremo, parapente, descensos forzados con caídas y golpes contra piedras y rocas, amén de los consabidos deportes como el fútbol americano y fútbol soccer, etc. Las lesiones se presentarán más rápido.

Desde hace algunos años se están observando rodillas con diversos grados de OA, en personas de edad que tienen las mismas lesiones de meniscos y ligamentos que aquellos pacientes jóvenes que han acudido al médico por una lesión. Y tenemos que considerar que la artrosis: es un continuo deterioro de la articulación que será más evidente en relación a los traumatismos constantes o lesiones que no se atendieron a tiempo.

Cuando escuchamos las descripciones de pacientes de cómo fue que se lesionaron las rodillas u otra articulación, de cómo se aplicaron una serie de tratamientos que iban desde agua caliente, cremas, remedios caseros, se colocaron una venda o una rodillera elástica, de cómo siguieron caminando o realizando sus labores habituales con: claudicación, limitación de la movilidad, con inflamación, derrame articular y tomando algún medicamento recetado por el vecino o algún dependiente de farmacia. Si pudiéramos ver en una película rápida el cómo se van lesionando las rodillas después de traumas repetidos o enfermedades sistémicas, quedaríamos sorprendidos.

Los empíricos (sobadores) son los elegidos por el mayor número de personas que padecen de una problemática articular, ¿por qué? Por muchas razonas, cobran poco, a veces son certeros en sus diagnósticos, y la gente les tiene confianza. Los médicos especialistas, cobramos caro, a veces nos ayudamos con radiografías, con medicamentos que cuestan mucho dinero; y mejor se prefiere a alguien con menos “especialidad” pero más barato, aunque a veces el tratamiento no sea el adecuado.

Las nuevas investigaciones que se están llevando a cabo dentro de la comunidad científica, son para identificar biomarcadores del proceso de la enfermedad que conduce a la OA después de lesiones de rodilla y finalmente encontrar tratamiento con terapia que retrase o haga más lento el progreso de la enfermedad.

Los medicamentos que existen actualmente como el sulfato de glucosamina, el condroitin sulfato, la diacereína, el hialuronato, el colágeno; son retardadores del desgaste del cartílago. Son hasta el momento el tratamiento a largo plazo, aparte de los antiinflamatorios y analgésicos que se prescriben para un tratamiento sintomático agudo.

Los cambios que se suceden con el tiempo comienzan en diferentes partes del cuerpo y en distintos momentos, varían de una persona a otra y son difíciles de medir con exactitud. Por ejemplo, un paciente se puede quejar de una rodilla y acudir al médico, quien le podría decir que se trata “de la edad” y el propio paciente le contestaría: “doctor la otra rodilla tiene la misma edad y no me duele”. Estas modificaciones suceden a un ritmo especial en cada uno y determinan el envejecimiento biológico, tiene que ver la edad, la genética, la dieta, la actividad, enfermedades agregadas.

Estos cambios se podrían reflejar en los biomarcadores de artrosis. Hasta el momento no existen como tal aunque tenemos a varios, los marcadores inflamatorios junto con otros marcadores biológicos (hormonales, cardiovasculares del SNC, metabolismo) debidamente valorados permiten medir riesgos de mortalidad e intervenir en riesgos potencialmente modificables como sucede con los biomarcadores de resorción y formación ósea, que nos permiten considerar el grado de deterioro de la masa ósea y consecuentemente intervenir terapéuticamente ante la osteopenia u osteoporosis.

Existen biomarcadores de enfermedad cardiovascular, cuyos niveles aportan datos sobre la respuesta inflamatoria del individuo (biomarcadores inflamatorios) y otros sobre los lípidos relacionados con el desarrollo de una ateroesclerosis (biomarcadores lipídicos): proteína C reactiva, fibrinógeno, molécula soluble de adhesión intracelular 1 [ICAM-1], homocisteína, colesterol LDL y HDL, colesterol total, apolipoproteina A-1 y B, lipoproteína (a) y creatinina.

La progresión de la OA es muy lenta, toma muchos años en progresar desde las primeras etapas a la etapa clínica evidente. Las medidas que se están utilizado para identificar las primeras etapas de la enfermedad, tales como los rayos X, la imagen por resonancia magnética o la tomografía por emisión de positrones, nos permiten ver cosas, pero no han sido muy sensibles para determinar en qué momento empieza el proceso destructivo. Por lo que muchos grupos de investigadores están buscando formas para una mejor detección del proceso, la gravedad de la enfermedad y el riesgo de progresión de la misma.
Dentro de las investigaciones de la enfermedad se están analizando, el proceso de destrucción del cartílago más lesión en modelos humanos, la ventaja de estos modelos es que se puede seguir el avance de enfermedad desde el momento que inicia hasta que las lesiones son evidentes.

Se han encontrado que en las etapas tempranas de la enfermedad, hay cambios metabólicos en la articulación como lo reflejan estudios del líquido sinovial. Sin embargo, todavía no se ha identificado ningún biomarcador específico aplicable para uso clínico. Estos estudios se están realizando desde hace casi veinte años, y se están obteniendo algunos datos muy interesantes, y se espera que terminando el año 2020 se vean resultados optimistas.

Los biomarcadores que se están buscando incluyen fragmentos de moléculas de la matriz cartilaginosa tales como colágeno y agrecanasa, marcadores de inflamación de la articulación como citocinas y proteasas que pueden estar activas en la descomposición de dicha matriz. Aunque pudieran surgir otros elementos a considerar, reacciones antígeno-anticuerpo, ingeniería genética, células madre, en fin.
La OA es la más común de las enfermedades articulares que los médicos reumatólogos u ortopedistas estamos viendo día a día. Si somos capaces de entender a la OA desde las primeras etapas, tal vez podamos intervenir de un modo más eficaz, con el paciente tratando de cuidar sus articulaciones y siguiendo las indicaciones, y los médicos protegiendo a las articulaciones con mejores rutinas de ejercicios, con medicamentos menos agresivos y una rehabilitación adecuada ante las lesiones que pueden presentar los pacientes sobre todo los jóvenes.

Dos laboratorios de investigación anunciaron en este 2018, que un estudio en pacientes con dolor de OA, evaluaron la administración subcutánea de tanezumab, un anticuerpo monoclonal humanizado que cumplió todos los fines propuestos. El estudio demostró que los pacientes que recibieron dos dosis de tanezumab separadas por ocho semanas experimentaron una mejoría estadísticamente significativa en el dolor, la función física y la evaluación general de los pacientes de su OA, en comparación con los que recibieron placebo.

Tanezumab es parte de una clase en investigación de analgésicos conocidos como inhibidores del factor de crecimiento nervioso (NGF) y además del dolor por OA, está siendo evaluado para el dolor lumbar crónico (CLBP) y el dolor por cáncer (debido a metástasis óseas). Los resultados se verán en el transcurso de los próximos meses. Aunque el dolor se puede controlar, el daño articular será progresivo.

Así es que amigas, amigos, cuídense esas articulaciones el proceso degenerativo empieza desde temprana edad, la forma en que las usemos y tratemos, nos dará un mejor calidad de vida. Recuerden esto para siempre: el cuerpo humano no perdona, lo que le hagamos, tarde o temprano nos lo va a cobrar y muchas veces, en forma de deformidades, dolor, inflamación, hasta la destrucción articular. De nosotros depende cuidar las articulaciones para el resto de la vida, no hay ofertas de tres por dos, para ir al centro comercial y comprar dos o tres rodillas, columnas o tobillos.

Dr. José Luis Sánchez Mejía.
Ortopedia y Traumatología.

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