Osteoarthritis revisited, an update.
Osteoarthritis is the most commonly occurring joint disease affecting more than 30 million in the USA. It is believed to be a degenerative condition involving the articular cartilage and the subchondral bone, an inflammatory reaction producing pain and deformity, rendering at time the patient disabled. There is as well an elevated mortality rate on the fact that many suffering from this disease will develop cardiovascular disease after the age 50. The knee is most often affected followed by hip, shoulder, spine and hands/feet.
This is a disease of aging but female sex, obesity, trauma and anatomical variations may also contribute to Osteoarthritis. It is said that 10% of men and 13% of female over the age of 60 will suffer from Osteoarthritis but in the UK, 25% of patients older than 55 will complaint of pain and discomfort. Athletes involved in sport like soccer, basketball or athlete with ligamentous injury are prone to have the disease. Less commonly, post meniscectomy patients will develop such problem.
Osteoarthritis can be diagnosed by clinical signs and by radiologic changes. In examining an arthritic joint, we may find deformity, joint effusion, instability but more often a loss of the range of motion. Bony crepitation can be felt in presence of osteophytes or a popliteal cyst can be noted. X-Rays will demonstrate joint narrowing, deformity of the condyles with or without the presence of loose bodies. MRI can also detect changes in the environment of the joint pointing at joint effusion and the formation of a popliteal Baker’s cyst. A new method, the T1rho MRI technique has been useful in detecting biochemical changes in the joint
The primary clinical feature of Osteoarthritis is pain with progressive loss of range of motion. Maintaining a healthy weight and a balanced nutrition will prevent the breakdown of the cartilage in facilitating the lubrication of the joint. High impact activities including twisting mode will enhance degenerative changes. It is always better to keep the joints supple and limber through a good exercise program to encourage longevity.
Chondroitin sulfate and Glucosamine effects in protecting the articular surface have been studied for years especially in over weighted female patients older than 55 and has shown significant controversy. European and Canadian studies may have consistently stressed a beneficial effect in using such medications in oral or injectable forms but the American Academy of Orthopedic surgeons has some doubts about the beneficial effects of those medications. A reduction of weight has proven to minimize the risks for Osteoarthritis.
Much has been postulated about visco-supplementation acting against the destruction of the articular surface after attempts at multiple corticosteroid injections. Some claimed deleterious effects of high dosage of corticosteroids on the articular cartilage while small doses may have positive effects probably due to the reduction in the inflammatory reaction. Laboratory markers like Sedimentation rate and C-reactive protein have constantly decreased following a few days and lasting for months after the injection.
Therefore, if any articulation is viewed as an “organ”, advanced degenerative arthritis can basically be considered as an organ failure like for a kidney failure in Diabetes Mellitus or in Hypertensive disease. Different factors may contribute as well to the failure of a joint, including excessive weight, poor nutrition and even genetic factors. One has to remember that managing Osteoarthritis require the expertise of a multi-disciplinary team to address weight loss, active range of motion of the involved joint, muscle strengthening exercises, correction of deformities as well as an adequate nutrition.
It is the proper of a joint to demonstrate changes with age. I wish this review on osteoarthritis will bring awareness on the degenerative process to stimulate the more than 50’s to remain active for the benefit of keeping their joints mobile.
A wide spectrum of interventions is indeed considered in the treatment of patients with knee osteoarthritis from physical therapy and conservative treatment to limited arthroscopic debridement, osteotomy and meniscectomy until consideration to Resurfacing or total joint replacement can be determined upon the severity of the symptoms and the failure of the conservative treatment. Weight loss, bracing, arch support, foot wedges and nutraceuticals including glucosamine and chondroitin sulfate added to systemic anti-inflammatory agent such as nonsteroidal anti-inflammatory drugs, intra-articular steroids or hyaluronic acid are part of a useful armamentarium. Nowadays biologics such as bone marrow concentrate (BMAC) or platelet-rich plasma (PRP) injections are also offered to avoid surgical treatment.
Researchers have claimed that newer viscosupplementation products will become available to affect mechanics, deformability and joint biology. Other firms have already claimed a new hyaluronic acid combined to corticosteroids, recently approved by the FDA providing a better mechanical effect while acting as a shock absorber and lubricant to delay surgical treatment as long as possible. Xu-Cao MD, a researcher at John Hopkins University school of Medicine is offering a new theory about two articular cartilage and subchondral bone proteins called TGF-Beta 1 protein and their inhibitors. One inhibitor linked to the osteoporosis drug Diphosphonate and the other one deriving from an ancient medicinal plant from China used in the treatment of Malaria but known as “halofuginone”. Ongoing clinical trial are now undergoing in China with participant receiving one injection in the subchondral bone or in the joint.
The efficacy of those different approaches remains controversial especially when nutraceuticals, biologic injectable products until recently halofuginone and even limited surgical treatment like arthroscopic debridement and resurfacing are considered. In 2013, an evidence-base clinical guideline published by the American Academy of Orthopedic Surgeons (AAOS) stressed that weight loss, physical rehabilitation and muscle strengthening exercises with the beneficial effect of anti-inflammatory NSAIDs medication and Tramadol were found to be effective in the treatment of Osteoarthritis.
Special considerations should be given to opioid in the recent midst of an epidemic of opioid drug use and misuse among more than 50 million Americans who have received such prescription. The role of the orthopedist in the treatment process is always to help the patient attain improvement in the joint pain and provide a better quality of care. The entire team (Orthopedist, physical Therapist, Primary Care physician, Sport Medicine Specialist and others) play a specific role in improving the symptoms. Patient education through the treatment process and communication will create a better understanding between the patient and his caregivers. Benefits can be assessed through the different steps of the treatment and an overall response can be given in relation to the severity of the joint osteoarthritic process.
The disease of Osteoarthritis is reaching epidemic proportions in the United States of America and the number of knee replacement performed is expected to significantly increase in the next decade. A high prevalence in Obesity affects a third of our adult population (36%) and all physicians recommend conservative therapies to postpone an eventual total knee replacement.
We all want to spend considerable time with a new patient diagnosed with osteoarthritis in explaining the pathophysiology of the disease, the need to lose weight in order to avoid more joint deterioration while keeping an adequate nutrition. Some may choose to consult a bariatric surgeon for weight reduction. I take a habit in discussing any co-morbidity.
More, the patient has to understand that a Total Knee replacement is not always the solution to the problem. Knee replacements are associated to a lower success rate than hip replacements. One has simply to contemplate a recent study done in Philadelphia PA in which more than 60% of patients who underwent Total Knee Replacement, did not meet their expectations. It was stipulated that simply, patients overestimated the possibilities of weight loss and their ability to return to sport activities. It is then very important to set realistic goals and address all expectations.
As stated above, one has to understand that knee arthroplasty does not provide relief to all who undergo such procedure. Many will be dissatisfied because of residual symptoms. A pre-surgical preparation is important to achieve a weight control, in providing a strict diet and an exercise program while co-morbidities are addressed. This will provide better outcome as shown in most studies around the nation. Sometimes it may take one to two years to get ready for the surgical treatment. Many of us may choose to have a contract signed between the patient and the physician to assure that he/she will commit self to the program, rendering both parties responsible. Some patients may be encouraged to look for a second opinion. Physicians as well may consult their colleagues.
In conclusion, Osteoarthritis may be a sign of aging of a joint but it remains a challenge to all clinicians. We hope in a near future to delay or eliminate the degeneration of an articular cartilage. We are encouraged by the new studies performed in Baltimore and in China.
This what I tried to expose in an orthopedic point of view of the disease with the hope that some will discover in this paper, a guideline to their practice, a new way to approach Osteoarthritis. Remember that you must always control the patient’s weight in imposing a balanced nutrition, encourage exercises, provide a relief in the painful outburst with Injections of cortisone or viscosupplement products when needed prior to referring a patient to their orthopedic specialist for further consultation.
Maxime Coles MD
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