Treatment of early arthritis: non-operative measures
- Modification of activities and weight reduction
- Ambulatory aids, braces
- Exercises and physiotherapy
- Medications
- Analgesics and NSAIDs
- DMARDs and biological agents
- Neutraceuticals
- Joint injections
- Other modalities: stem cell therapy, cartilage grafting, QMF, etc.
Modification of activities, weight reduction, use of ambulatory aids (like stick or walker) and joint supports (kneecap, unloader braces) give relief in a large number of patients.
Exercises and physiotherapy are important to maintain mobility, preserve muscle strength and prevent progression of deformities. Physical modalities like hot packs, infra-red lamps, ultrasonic massage, etc. also help to some extent. Alternative systems like yoga, acupuncture, ayurvedic massage, etc. also help in the early stages.
If the symptoms are not controlled by these measures, the patient is started on medications – pain-killers (analgesics) and anti-inflammatory drugs like NSAIDs and their congeners.
Patients with inflammatory arthritis need Disease-Modifying Anti-Rheumatic Drugs (DMARDs). Early and aggressive treatment with DMARDs can result in significant long-term improvement. Monoclonal antibodies and other biological agents also have similar benefit. These medications are usually given under the supervision of Rheumatologists.
Nutritional supplements like chondroitin sulphate and glucosamine (neutraceuticals) and other drugs like methyl-sulphonyl methane, esterified fatty acids and diacerin can help in early cases but cannot cure arthritis, or reverse the wear and tear process. They are not beneficial in advanced arthritis. They have no role in inflammatory arthritis.
Viscosupplementation is injection of hyaluronic acid into the joint to lubricate it. It provides relief for a few months. It is not useful in advanced arthritis. There is a risk of hypersensitivity reaction and infection with this procedure. It is not suitable for inflammatory arthritis.
Steroid injection into the joint provides short-term improvement of symptoms. Repeated injections adversely affect the cartilage lining of the joint. There is a risk of infection and other side-effects as well.
Other methods like magnetic therapy (QMF), platelet-rich plasma (PRP), stem cell injections, etc. are being advocated. There is no hard evidence that these offer long-term benefit. They cannot be recommended universally and are considered experimental at present. They are not applicable for inflammatory arthritis.
Treatment of severe arthritis: surgical options
- Arthroscopy (keyhole surgery)
- Osteotomy (realignment)
- Arthrodesis (fusion)
- Resection arthroplasty
- Joint replacement
When arthritis progresses beyond the early stage, non-operative measures do not give any relief. In this situation operative treatment becomes necessary.
Arthroscopic washout:
Arthroscopy has a limited role and is helpful in early arthritis. Unstable tears of the meniscus or inflamed joint lining (synovitis) can be excised. Small cartilage defects can be freshened by chondroplasty and microfracture techniques with variable benefit. Arthroscopy is not effective when arthritis is advanced. It gives partial relief of pain for a variable duration. It does not alter the long-term outcome of the joint..
Certain arthroscopic procedures like mosaicplasty, cartilage grafting and stem cell grafting are appropriate for limited defects in young patients. They are not applicable to arthritis because of the widespread nature of cartilage degeneration and associated mal-alignment, stiffness and deformities.
Osteotomy:
Knee arthritis is associated with deformity in which one half of the joint is overloaded. Osteotomy is an operation to realign the limb and shift the weight-bearing stress from the more affected half of the joint to the less affected half. This unloads the arthritic part of the joint and relieves pain. The pain relief is not complete because there is usually some arthritis in the other half of the joint as well. The joint continues to wear out and eventually joint replacement becomes necessary.
Osteotomy can result in over-correction and change of slope of the tibial surface (these problems have been minimized with newer implants). It causes scarring and shortening of the quadriceps mechanism. These complications make a future knee replacement more difficult. Hence osteotomy is usually reserved for young patients who have severe arthritis and demonstrable mal-alignment. Osteotomy is being done very infrequently nowadays because the results of joint replacement are far better than osteotomy.
Arthrodesis:
Arthrodesis is an operation in which the cartilage lining of the joint surfaces is completely removed and the bones are fused (joined rigidly) to each other. This eliminates movement at the joint and results in a totally stiff (rigid) joint. Arthrodesis is advised for treating arthritis in ankle, subtalar joint, wrist and some joints of the hand and foot. It is especially indicated for young patients and those with physically demanding jobs. When there is bilateral involvement, arthrodesis of a major joint will result in serious restriction of mobility and worsening of load on the opposite side. Patients do not accept arthrodesis for joints like the hip, knee, shoulder and elbow where it has largely been given up. Joint replacement is the preferred mode of treatment for these joints.
Excision or resection arthroplasty:
In this procedure, the worn out surfaces of the joint are removed and a gap is left in place of the joint. This may be filled by a muscle or fascial or artificial (metal, etc) interface, in which case it is called interpositional arthroplasty. Pain relief is partial. Excision of bone ends results in significant shortening (sometimes severe) and a flail (unstable) limb. The functional outcome of these procedures is poor. Excision arthroplasty is advised for base of thumb, toes and, occasionally, the elbow. It is not accepted by patients for the hip or knee joint. It is reserved as a salvage procedure for failed or infected joint replacements.
Joint Replacement (Replacement Arthroplasty):
In this procedure, the worn-out surfaces of the arthritic joint are replaced by artificial bearing surfaces (prosthesis). This provides a lasting relief of pain, restores movements to joints, and corrects any deformities. It leads to a huge improvement in the activity and functional level of the patient. Joint replacement is a reliable and long-lasting procedure that overcomes the disability of arthritis.
Why is joint replacement preferred?
Severe arthritis does not respond to non-operative methods. It requires surgical treatment. Arthroscopic washout, osteotomy, arthrodesis and excision arthroplasty were advised earlier. They do not give full relief of pain and some of them impose serious limitations in terms of movement and function. Joint replacement, on the other hand, gives profound and lasting relief from the pain of arthritis. It restores mobility to previously stiff joints. It also results in the correction of deformities. The functional result after joint replacement is far superior than that of other operations. With the advent of joint replacement the other procedures have been largely given up. After undergoing joint replacement the patient does not need any medications, physiotherapy, etc. for pain relief. He can expect years of active pain-free life.
IN THE PRESS:
Arthritis in the young – my article in the Deccan Herald
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