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. One such alternative over-the-counter
method is the use of supplemental collagen (see http://www.cr2000collagen.com/). 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 are 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. Alternative
Medicine Approach to Treatment of Osteoarthritis: As I have briefly
mentioned under this link,
there is more to the development of osteoarthritis than just the aging process.
Often a number of hormones are out of balance, which leads to a dysbalance of
bone and cartilage build-up versus breakdown. Anti-aging medicine checks this
out and uses bio-identical hormones to replace what is missing. This has to be
individualized for each patient. Dr. Thierry Hertoghe and Dr. Ron Rothenberg mentioned
in several lectures at a medical conference in Las Vegas (December 2011, Ref.
9) that it is an overconsumption of refined sugar and carbohydrates that leads
to excessive insulin production and subsequent hormone dysbalance. The omega-3/omega-6
ratio is also changed due to a relative lack of omega-3 fatty acids in the diet
resulting in a premature breakdown of the hyaline cartilage in the joints. Along
with the hormone replacement proper nutrition, detoxification, exercise and adequate
sleep are also needed. Here is a link to a summary where I have described a hormone
replacement program for women and men. | 
