Treatment Advances Ease Pain, Improve Outlooks
Managing Osteoarthritis
By Jay Pond, M.D.
As the baby-boomer generation ages, osteoarthritis has reached almost epidemic proportions. Almost everyone who lives long enough will suffer from some form of osteoarthritis. It could present in what is most commonly thought of as hip or knee problems; however, osteoarthritis frequently affects the hands, spine, shoulders, and, in fact, almost any joint.
Symptoms include joint pain or aching, often after excessive use but sometimes after limited use. Many people also experience joint stiffness, loss of motion, and loss of strength. Osteoarthritis results from the loss of articular cartilage, or the slippery substance on the end of the bones, resulting in bone-against-bone friction.
There have been multiple advances in the treatment of osteoarthritis. Initial management for all patients should include a lengthy course of non-operative treatment. This means patients should increase their fitness levels, maintain ideal body weights, increase their overall health, maximize joint range of motion, strength and coordination, and optimal management of all medical conditions.
There are multiple medicines used to treat osteoarthritis pain. The most frequently used are non-steroidal, anti-inflammatory drugs such as Ibuprofen and Aleve, which are over-the-counter medications, as well as approximately 20 prescription non-steroidal, anti-inflammatory drugs. Tylenol (acetaminophen) is also an effective medication for the management of pain caused by traumatic arthritis.
Pain Medicines
In more advanced cases, osteoarthritis is managed by narcotic or pain medicines, such as codeine and hydrocodone. Supplements such as glucosamine and chondroitin are also receiving thought with regard to the non-operative management of osteoarthritis. These compounds are considered nutrition for the articular cartilage and may indeed alleviate discomfort from this condition.
Recent studies show that glucosamine and chondroitin are possibly as effective as non-steroidal, anti-inflammatory drugs and acetaminophen with regard to managing this pain. Intra-articular injections of cortisone or hyaluronic acid derivatives such as Synvisc, Hyalgan, and Supartz also may play roles in non-operative treatment.
Functional bracing to realign the extremities and unload some of the forces on the arthritic joint may also help. Orthotics or changes in shoe wear may also change mechanical axis to unload arthritic joints.
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Operations
Operative treatment can take several forms with regard to management of wear-and tear conditions. Arthroscopy, or a “clean-up” operation, is performed with a small TV camera, small shavers, and other tools, has proven effective if a definable degenerative change such as meniscal tear or other specific pathology is identified.
Realignment operations such as cutting the bone, are still utilized but less frequently than in the past. Fusion operations are also intermittently used for joints such as the ankle, fingers, and spine.
Replacement operations are probably the most frequently performed for severe osteoarthritis. These are large operations in which a portion or the entire joint is removed and replaced with mechanical components. Approximately 350,000 joint replacement surgeries are carried out in the United States per year, and this number is increasing.
A complete replacement such as a total knee replacement is a well-accepted treatment for severe arthritis, or for patients who are not responsive to conservative or non-operative treatment. Complete replacements can also occur in almost all joints from the fingers, wrists, elbows, and shoulders to the hips, and ankles. Now even disc replacements are performed successfullt.
Surgery Advances
Recent advances in joint replacement surgery include minimal incision hip surgery and minimally invasive knee surgery for unicondylar or one-sided replacement. These new techniques of older operations allow for faster recovery, lower operative morbidity, less blood loss, and a reduced infection rate. Most patients who experience minimally invasive techniques return more quickly to work and activities of daily living. Their hospital stays are typically shorter, and most patients say their joints feel more like a normal joint than with conventional operative techniques.
The disadvantages of minimally invasive techniques include fewer indications, meaning not all patients qualify for them. The joints requiring replacement must have arthritis that is conducive to minimally invasive techniques. Obese or extremely large patients may not qualify for minimally invasive techniques. These are newer techniques that may indeed have a higher re-operation rate, as they are yet unproven at long-term survival, meaning 15 years.
Unicondylar knee surgery is gaining in popularity. In this procedure, only one joint of the three compartments within the knee (i.e. medial, lateral, and patellofemoral), is replaced. This is typically the medial joint. In this procedure, only the arthritic compartment of the knee is replaced. This procedure is still a significant operative procedure with significant risks and is only indicated for patients who have failed a lengthy non-operative treatment regimen.
The patient selection is critical in the success rate of unicondylar knee replacements. The hospital stay after this procedure is typically one day with rehabilitation also significantly shorter than with a complete knee replacement. Not all patients qualify for unicondylar knee surgery, however. This is determined with extensive counseling and examination by an orthopedic surgeon who is familiar with the techniques of unicondylar knee replacement.
There have been many advances in the treatment of osteoarthritis. It is an exciting time in research and development for this condition. There are many advances to come in the near future with both non-operative and operative techniques for the treatment of osteoarthritis.