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Osteoarthritis
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Osteoarthritis

Osteoarthritis is a disease process that affects the joint as a whole. It can affect any joint in the body but it is most commonly a clinical problem of weight bearing joints such as the hip, and knee, ankle and also the shoulder.

Overall osteoarthritis is a progressive disease that, once it has begun, cannot be stopped. It can be considered a “down-hill” road towards eventually a chronically painful joint that may require joint replacement. Adequate management and treatment short of a total replacement of a joint, however, can influence how fast this road is going to lead us there.

It is also important to understand that osteoarthritis is not an acute injury or a sudden event. An injury or event can set changes in motion inside a joint that may or may not lead to osteoarthritis. If some of these early injuries are treated quickly, they may not or only very slowly lead to osteoarthritis (in those cases it may be possible to repair cartilage or ligaments successfully). If these injuries are missed or only surface late, then the articular cartilage may already be beyond the point of repair.

In the illustration below you can see that a knee joint with no osteoarthritis (Grade 0) can have a cartilage defect (this could be repaired). If this situation is uncorrected and continues to wear on the joint it may lead to further wear (Grade 1+2) and ultimately to a loss of all articular cartilage of the joint and “bone on bone” arthritis. (Grade 3+4)

A word about the different tissues that are affected by osteoarthritis

Cartilage exists at the surface of the ends of the bones and provides joints with a gliding surface and shock absorber during activities of daily living. Osteoarthritis causes the cartilage layer to break down and wear away, exposing raw bone. It also causes changes in the bone underlying the articular cartilage (subchondral bone) and makes this bone stiffer and less adaptable to load. In addition this progressive wear leads to recurrent inflammation of the inner lining of the joint (synovium). This inflammation can cause some of the pain felt with osteoarthritis, and it also produces a lot of fluid in the joint that, in itself, is detrimental to the remaining articular cartilage. If there is a lot of fluid buildup it can lead to cysts that form, often in the back of the knee. These cysts are called a “Baker’s Cyst”.

As a result of the cartilage loss, the progressive wear of the bone and in response to the inflammatory changes there will be additional bone formation along the edges of the joint. These so-called “osteophytes” may be the bodies’ attempt to increase the weight bearing surface of the joint (and thus decrease the maximum load transmitted through the joint) but it is also the main reason for the progressive stiffness that develops during the course of osteoarthritis. Other changes occur throughout the course of this disease that affect the subtlety and flexibility of the joint capsule, the muscle and tendons around the affected joint and contribute to the, often-felt stiffness.

Who gets osteoarthritis?

Osteoarthritis is the most common form of arthritis. Worldwide estimates have indicated that 9.6% of men and 18.0% of women aged >60 years have symptomatic osteoarthritis1.

Generally, osteoarthritis occurs as an accumulation of the wear and tear of the joint, and is more common in older adults. However, osteoarthritis can affect younger adults, primarily as a result of an injury to the joint. Osteoarthritis is more common in men under the age of 45 and more common in women over the age of 45. Other illnesses may also affect the cartilage in joints. An important factor that contributes to the development of osteoarthritis is excessive body weight or participation in recreational or professional activities that overstress certain joints.

An important point to understand is that osteoarthritis has many facets and usually starts with very mild and potentially reversible changes before it progresses to a more definite and ultimately disabling disease. If you and your doctor recognise these changes very early, it may be possible to do a cartilage transplant or another surgical procedure to stave off the further development of disabling osteoarthritis for many years to come. For this reason it is important to seek help from a professional early in order not to miss this window of opportunity.

Cartilage repair and osteoarthritis

Once osteoarthritis is fully established, a cartilage repair is usually not possible any longer because the environment is too harsh for cartilage cells or replacement cartilage to tolerate. However, an isolated cartilage defect and “bone on bone arthritis” lie on opposite ends of the same spectrum. It is therefore often an individual decision where on this spectrum a patient comes to present himself to a physician and depending on the stage of osteoarthritis cartilage repair procedures may or may not be possible.

So it is possible, that a patient displays some very early signs of osteoarthritis that, however, can be addressed (such as very mild joint space narrowing with the loss of a meniscus). In those cases it may be possible to replace articular cartilage and also address the other problem (i.e. meniscus loss) at the same time. It is fair to say, however, that in patients displaying beginning signs of osteoarthritis, cartilage repair is usually more difficult and often involves additional procedures.

I have established osteoarthritis, so what can I do now?

Osteoarthritis is a disease process that affects not only your joints: it can also cause stiffness in the surrounding tendons, ligaments and muscles. This may make it difficult for you to maintain your normal level of activity, and may significantly affect your ability to enjoy life. Exercise is one of the most effective treatments for osteoarthritis. A routine exercise program can decrease joint pain and stiffness, while strengthening the heart. Exercise, when done correctly, has practically no side effects and can be done in a supervised (via physical therapy or fitness training with a professional) or non-supervised fashion in a gym or at home. Your doctor can help you identify exercises that are good for your particular situation.

Exercise, especially when coupled with a proper diet, will also help you with weight control. Every pound of weight you lose through exercise and/or diet will be approximately 5 pounds of weight that your knee does not have to carry! Weight loss should therefore be an important part of your contribution to treat osteoarthritis. A dietitian may help you develop a weight loss program that suits you best.

What can my doctor do to help me?

Many patients with osteoarthritis are afraid that they may need immediate surgery. That is not usually the case. Many non-surgical methods exist that will be available to your doctor to help you live with osteoarthritis, and keep your pain under control while allowing you to be as active as you would like to be.

What treatment options are there that are non-surgical?

There are different medications and tools that your doctor can use to help you return to your normal activities:

Oral Medication:

Acetaminophen

Tylenol (or paracetamol) is very effective for pain control. It does not decrease the inflammation alone and is therefore often combined with anti-inflammatory drugs

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

These drugs are very effective in reducing pain and swelling. Often it is necessary to try different NSAIDs to get the best effect.

Glucosamine & chondroitin sulfate

These drugs are provided as a medical food supplement and may decrease swelling and pain in the joint in some patients; however, they are not effective in everyone.

Medication by injection:

Steroid injections

A one-time injection of a steroid directly into the joint, is a powerful anti-inflammatory agent, and effectively decreases the swelling of an osteoarthritic joint. A single steroid injection can provide relief from symptoms for several months to a year and longer, with little side effects.

Viscosupplementation

These drugs usually are a treatment option if NSAIDS and steroid injections have failed. They act as a lubricant for the joint and can decrease the swelling. Generally, three to five injections may be necessary to complete the treatment

Braces:

Sometimes only one part of the joint may be affected with osteoarthritis. In that case, your doctor may prescribe a brace for you that can decrease the load that your affected joint must bear, and in doing so decrease your pain.

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