MBBS, MS(Ortho), MRCS(Eng), MRCS(Ire), MRCPS(Glasgow)
May 18, 2015
As we grow older aches and pains are something that we expect. But for some they are rather a burden which has a bad impact on their quality of life. Arthritis affects all ages. There are more than 1000 different types of arthritis. Among these osteoarthritis is the most common. According to the World Health Organization it is one of the 10 most disabling diseases in the world affecting people of countries like India where agriculture is the main occupation. Researchers have predicted that by 2015 arthritis will be the most common problem in the country.
Osteoarthritis or osteoarthrosis also known as degenerative arthritis, is a disease of the weight bearing joints, caused mainly due to an ageing process. People beyond the age of 60 years are most commonly affected by this condition. As per global statistics 18% of women over the age of 60 suffer from this condition compared to 9.6% of men.
Occasionally, it may occur in younger people as well, due to trauma to the joint. The hip joint, knee joint and the joints of the thumb are most prone to this disease. It is an incapacitating condition which hampers mobility of the patients thus leading to a non productive life.
Osteoarthritis should not be confused with other forms of arthritis like rheumatoid arthritis (VAATA), psoriatic arthritis and gouty arthritis. The latter conditions are caused by inflammation of the joints, unlike osteoarthritis which is a progressive mechanical joint disease associated with old age. This differentiation is very important as the treatment of these conditions is very different.
Osteoarthritis is of two types:
Primary: There is no exact cause for this. It is seen in older age groups and in weight bearing joints like the hip and knee. Usually joints of both sides are affected, one side more than the other. Obesity is a predisposing factor. There is no hereditary preponderance. People involved in heavy labour are mainly affected.
Secondary: Due to a predisposing factor like trauma, fractures or infection of the joint. Usually one joint is involved and it occurs at a relatively younger age, when compared to primary osteoarthritis.
Pathology: Normally all weight bearing joints consist of bones which are covered with articulate cartilage. This cartilage is healthy in younger people and not sensitive to pain. It's basic function is to protect the underlying pain sensitive bones from coming into contact with each other, something like " a cushion between the joints ".
Osteoarthritis is a disease which causes this cartilage (cushion) to wear off, thus exposing the bony surfaces which rub against each other producing pain.
Pain is the most important symptom. In the early stages pain typically occurs following weight bearing and on walking for a long time. It's more severe while climbing stairs or squatting. It is typically relieved by rest and pain killers.
However in the later and severe stages the pain worsens, thus hampering the movement of the patient. In most severe cases pain is present even at rest.
Pain can also referred to the neighboring joints.
Eg: osteoarthritis of the hip can present as knee pain.
Restriction of mobility: It occurs due to pain and stiffness. Initially the person might not be able to walk long distances, but as severity increases he might not be able to move around, even well within his home. The range of movement of the joint also reduces gradually.
Crepitus: The patient usually complains of "click" like sound on moving the joint which is due to the "loose bodies " formed within the joint due to the disease process.
Swelling and redness: This might occur occasionally. But is not as severe as the swelling that occurs in other forms of inflammatory arthritis.
X rays are the gold standard to diagnose this condition. The X rays are usually taken in the standing position, from the front and sides.
Normal X ray
X ray with osteoarthritis
A. Showing decreased space between the bones showing wear and tear of the joint
C. Loose bodies
MRI might be occasionally required to see the condition of the cartilage.
"Prevention is the best cure" is a common saying and is true to this condition as well. However one must understand that the process of the joints wearing off is a normal age related process and it cannot be completely avoided. However the extent to which the joint wears off can definitely be controlled.
The following measures would help to protect our joints:
1) Weight reduction: Obesity being an important factor contributing to this disease, weight reduction becomes paramount in avoiding this condition. Though conditions like diabetes and binge eating have no direct bearing on this condition, as they predispose to weight gain, they must be controlled.
2) Activity modification: Activities like climbing and getting down stairs, sitting cross legged, squatting should be avoided whenever possible. Western toilets should be preferred. Walking and jogging should be done using soft footwear and on jogging tracks whenever possible. While jogging, Concrete surfaces should be avoided.
3) Exercises: These are prescribed so that the muscles of the limb become strong so as to reduce the workload on the joints. Light exercises like yoga and swimming are preferred.
There are no medications to reverse the damage that has already occurred in the joint. However medications do help in reducing pain and protecting the joint from wearing off further, to a certain extent.
1) Pain killers: These are prescribed in acute painful episodes. They provide immediate pain relief. However their action is temporary and long term continuous usage is discouraged as they can cause kidney damage and acidity problems.
2) Drugs to protect the cartilage: They help to prevent disease progression.
Commonly used drugs that protect the cartilage are diacerin, glucosamine, pro, collagen peptides.
3) Injections into the joint: Hyaluronate injections into the joint are advised in mild to moderate cases, which improve the lubrication within the joint. These injections are given once a week for 3-5 weeks, depending on the severity. There is a yearly injection available as well, which is expensive.
Surgical treatment: In moderate to severe conditions where the patient depends on pain killers on a regular basis to relieve the pain surgery is indicated.
1) Arthroscopy and debridement: This is done in moderate cases. This is a key hole surgery, where very small surgical wounds are made over the knee. Joint is washed thoroughly with surgical fluid. Following surgery, patient has considerable relief from pain. However it provides temporary relief, usually lasting for around 4-6 months.This surgery is relatively inexpensive and minimally invasive.
2) Osteotomy: This is a protective surgery that is done in mild to moderate cases, in order to prevent the condition from progressing. This is a bone surgery in which the bone us straightened and is fixed with a "plate". The patient needs to walk with a crutch without bearing weight on the operated limb, for 6 weeks following surgery.
3) Total knee replacement: This is done in advanced cases. Following this surgery the patient would have significant pain relief and a reasonably good range of joint movement. The patient can walk around independently. However squatting is discouraged following this surgery, as it would damage the implant. The patient requires physiotherapy and exercises for 4-6 weeks following surgery to attain the best possible result.
With the advances in the field of medicine, life expectancy has improved. Hence many people around the world will continue to develop age related arthritis. Preventive measures are well worth taking. A regular check up and early specialized treatment would go a long way in improving ones quality of life.
Dr Vivian Roshan D' Almeida
MBBS, MS(Ortho), MRCS(Eng), MRCS(Ire), MRCPS(Glasgow),
Fellow in Knee Surgery, Arthroscopy & Sports Medicine(USA., South Korea)
Consultant Orthopaedic, Knee & Arthroscopy Surgeon,
Ortho 1 Speciality Clinic.