by Hope Starkman, MD
Osteoarthritis is the most common form of human joint disease. Although it is uncommon prior to the age of forty, its prevalence rapidly rises thereafter. Most people over the age of seventy have osteoarthritis in at least one joint. The risks for the development of osteoarthritis include increasing age, female sex (especially involving the knees and hands), race, genetic predisposition and prior history of trauma or surgery, congenital dysplasias or repetitive use. There are metabolic conditions such as hemochromatosis (excessive iron accumulation) and other storage disorders that can lead to early osteoarthritis. Inflammatory disorders can lead to secondary osteoarthritis, as well.
Osteoarthritis is more of a wear and tear condition of cartilage than it is a disease of bone. A good way to describe osteoarthritis is like the wear and tear of a gasket/padding between two pieces of metal. This makes the friction between the bones more likely which results in pain, dysfunction, and ultimately destruction. Sometime the body’s response is to produce extra joint fluid called an effusion, which in theory should act like amniotic fluid to protect the surrounding tissues but in reality causes distension of the joint, accumulation of inflammatory cells and chemicals and further joint pain and destruction.
Osteoarthritis is different than inflammatory or rheumatoid type arthritis in several ways. Firstly it is a productive disorder where bone spurs from sometimes rather than an inflammatory disorder where bone loss or erosions occur (except in the case of erosive or inflammatory osteoarthritis). The pain and stiffness from osteoarthritis tends to be worse at the end of the day rather than in the morning. Morning stiffness is more common with rheumatoid arthritis or inflammatory arthritis and with osteoarthritis the stiffness at all in the morning lasts only a few minutes rather than hours. There more use of the joints in osteoarthritis, the worse the pain.
When the physician examines a join with osteoarthritis what is generally found is swelling, tenderness, warmth, creaking with movement (crepitus) and restricted range of motion. Muscles surrounding the joints can often atrophy, like the thigh muscles (quadriceps) with osteoarthritis of the knee. Atrophy can lead to weakness. For example patients with knee osteoarthritis and quadriceps weakness report difficultly standing from a seated position and difficulty climbing stairs, getting up from a seat and in and out of their cars.
Blood tests in patients with osteoarthritis are usually normal unless other conditions coexist. Radiographs( X rays) can show joint space narrowing due to cartilage loss between the bones, spurs called osteophytes, cystic changes, thinking of the bone near the joints called sclerosis which appear white on radiographs, loss of bone volume and proper alignment and fusion of the bones so that the joint is ultimately obliterated. Fluid aspirated from an osteoarthritis affected joint is generally noninflammatory and contains less than 200 white blood cells or at least less than 2000 white blood cells. The fluid is clear and yellow and has the consistence of oil.
Osteoarthritis can coexist in the same joint with other forms of arthritis including gout, rheumatoid arthritis and pseudo gout (calcium pyrophosphate crystals. Having more than one condition at the same time in the same joint may make analysis of fluid taken from the joint more difficult.
There are many different types of treatment available for osteoarthritis and a lot of the choices depend on the patient, their prior experiences, the tolerance to specific treatments, co morbid/coexisting conditions, insurance formularies, expense of treatments and the development of a team based plan between the physician and their patient.
Analgesics such as Tylenol may be used as first line agents. Nonsteroidal anti-inflammatory agents can also be tried like ibuprofen, Naprosyn, Relafen, Meloxicam in patients without renal, gastrointestinal, hepatic, hematologic or bleeding disorders. Patients on Coumadin or other blood thinners should not take these medications and both can severely interfere with platelet function and increase the risk of bleeding. Patients need to communicate with their physician about possible other conditions and other medications they are taking which can affect these choices. Also patients should make sure that their physicians communicate with one another so treatment can be coordinated and specifically tailored to each patient.
Topical analgesics, like lidoderm patches may be used over affected joints when pain is localized. Over the counter topical agents may be helpful in some patients as well. Topical Voltaren gel®, a topical nonsteroidal anti-inflammatory agent (NSAID) may also be helpful in some patients that cannot tolerate oral NSAIDS due to gastrointestinal problems.
Steroid injections may be useful on occasion when one or few joints are affected i.e. one knee or one shoulder. Repeat injections into the same area frequently are never recommended. Injections with viscosupplementation liquids (considered devises and not medications by the FDA) can be helpful as well when more conservative measures have failed. Some of these viscosupplementation liquids are Hyalgan®, Synvisc®, Orthovisc®, Supartz®.
Exercise, physical therapy, ultrasound, the use of TENS units, acupuncture, biofeedback, weight reduction to help larger weight bearing osteoarthritis affected joints are all treatment options. Bracing, splinting, elastic supports are helpful sometimes as well.
When all of the former conservative measures are not successful, surgery remains an option. Occasionally arthroscopic surgery alone can be helpful, but more often than not treatment failure with the above more conservative approaches suggests the need for evaluation by an orthopedic surgeon and total or partial joint replacement. Joint replacement surgery has come a long way over the years and minimally invasive techniques are currently available. The coordination of this form of treatment between the patient’s internist, rheumatologist and orthopedic surgeon is crucial. Prior to surgery, there are several things that must occur including the discontinuation of any medications that can increase the risk of bleeding. Medical clearance by the internist or primary care physician is critical as well so that optimal results with the least complications are possible.
In conclusion, osteoarthritis is a disorder that affects almost all of us at some point in our lives. Many things can be done to treat, prevent and improve outcomes in patients with osteoarthritis.