Treatment of Osteoarthritis
Treatment consists of a combination of various therapeutic modalities as is indicated in the table below (see also Ref. 2). The initial measures are simple steps such as watching the body weight, improving body mechanics by changing footwear with insoles and supportive shoes or by adding a cane to stabilize the gait. The COX-2 inhibitory drug (brand name: Celebrex) is also useful as it is easier on the stomach. Keep an eye on side-effects of the COX-2 inhibitory medications as one of these drugs (VIOXX) was pulled from the market in October of 2004. The VIOXX link explains this story in detail. However, like the regular anti-inflammatories (brand names: Naprosyn, Voltaren etc.) they are eliminated by the kidney as well. This means that they are toxic to the kidneys when used long-term. This "nephropathy", as it is called, is a serious complication and occurs easier in older patients. It is because of this danger that these medications should only be used intermittently rather than continuously.
| Treatment for osteoarthritis |
| Therapeutic step: |
Reasons behind it: |
| weight normalization |
excessive weight accelerates it |
| stay as active as possible |
prevents joint stiffness |
| proper foot wear, canes etc. |
offloading prevents deterioration |
| rearrange daily living routines |
help with shopping and physical chores helps to reduce load on joints |
| non-steriodal anti-inflammatories |
use only for flare-ups; regular use endangers kidney function |
| physiotherapy treatments |
used for acute flare-ups |
| wax baths, hot tub etc. |
heat has anti-inflammatory effects and improves circulation |
| topicals: heat rub, capsaicin |
helps reduce the pain perception |
| intra-articular hyaluronic acid injection |
helps to replenish lubricant in joint, but is expensive |
| intra-articular corticosteroid injection |
limited to three injections per joint, otherwise leads to cartilage atrophy |
| arthroscopy |
useful for debridement or removal of loose bodies |
| radioisotope synovectomy |
helps some patients with chronic synovitis of large joints |
| joint replacement |
for end-stage osteoarthritis |
Along with these measures physiotherapy treatments are recommended. Many patients find that heat is useful and makes it easier for them to move their affected joints. Such modalities as wax baths or soaking in a hot tub can improve the pain and help improve the ROM for a number of days.
Heat rubs and capsaicin work in a similar fashion as heat. Injections into the knee are something that the physician will on occasion suggest and do. Corticosteroids help via the anti-inflammatory effect and often last 6 to 9 months. Hyaluronic acid (brand name: Synvisc) is usually given as a set of three injection 1 or two weeks apart. The effect, if it works, will last several months up to a year and can then be repeated again. Glucosamine sulfate has been a folk remedy for the past 15 to 20 years and has been well researched.
It has rated in many studies to be almost as powerful as the traditional anti-inflammatory medication, but without the stomach irritating side-effects. Unfortuately these studies were not always well controlled and recently a well controlled study regarding glucosamine and arthritis could not find any significant effect over the placebo effect. There will likely be newer agents developed in future and it might be possible to, for instance, match an injectable agent to what's missing in the affected joint fluid, based on joint fluid analysis. Research in this area has been slow in the past, but one of the products that has come out of it is Synvisc. Perhaps there may be more effective similar medications in future with continued research.
More invasive procedures like arthroscopy can buy time of about 5 years through shaving off of irregularities of the joint surface, removal of foreign bodies and osteophytes. Unfortunately the bits and pieces of the degenerative arthritic surface get shed into the joint space along with broken off osteophytes and get ground down to become "foreign bodies" in physician's lingo. The truth is that this material is not "foreign" at all, but is considered material, which should not be in the joint space. By the fact that it is there, it gets ground down into sand-like material and this only helps to deteriorate the diseased joint surface. When it is removed and flushed out with saline solution, the patient feels often remarkably better, but 5 years later a total joint replacement or fusion surgery might have to be done.
Before a total joint replacement is considered, the physician might consider a radioisotope injection. Yttrium-90 has been used for this purpose and is used by injection into the affected joint. It may work by treating the chronic inflammation of the synovial membrane and modifying the aggressive immune cells that lead to further deterioration of the osteoarthritis. This type of treatment is usually reserved for the rheumatologist in collaboration with a radiation therapist.
Finally, when bone rubs on bone and the patient cannot stand the pain any more, two surgical procedures can be offered: fusion surgery and total joint replacement. Here is what most physicians will do for the more common joints.
| Surgical procedures for end-stage osteoarthritis |
| Location of affected joint: |
surgical procedure: |
| cervical or lumbar spine |
fusion surgery |
| shoulder |
artificial joint replacement, done in University Center |
| wrist |
fusion surgery |
| finger joints |
silastic implants, if this fails fusion surgery |
| hip |
total hip replacement: when socket and hipball are both affected |
| partial hip replacement: when only upper femur and hipball have to be replaced |
| knee |
total knee replacement |
| ankle |
fusion surgery |
| subtalar joint |
subtalar fusion surgery |
| toe joints |
fusion surgery |
These surgical procedures have evolved as they were found to have the best longterm results. For instance, artificial wrist replacements have been done, but they failed miserably on the longterm. This does not mean that sometime in the future there might be a better solution. On the other hand the new total knee replacements with porcelain joint replacements have sofar a 25 to 25 year running time and seem to still last very well. It takes many years of research and follow-up studies to collect such statistics.
We know from comparisons that older people do much better with the longterm success rate of joint replacements, as they are more sedate and therefore less wear and tear forces are at work. The worst longterm outcomes found in athletes as they abuse their implants and loosening is a real problem. When a joint has to be "re-done", there is a much higher risk of complications like infection, lack of healing and loosening. With any big procedure as joints replacements are, there is also a significant risk of clot formation and sudden death from an undiagnosed pulmonary embolus that broke off from one of the large veins in the surgical site. This is more likely to happen after surgery in the lower extremity.
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