A Comprehensive Guide to Osteoarthritis Treatment
The treatment of OA depends on the joint (or joints) involved, the stage of the disorder, the severity of the symptoms, the age of the patient and his or her functional needs. Three observations should be borne in mind (1) symptoms characteristically wax and wane, and pain may subside spontaneously for long periods; (2) some forms of OA actually become less painful with the passage of time and the patient may need no more than reassurance and a prescription for pain killers; (3) at the other extreme, the recognition (from serial x-rays) that the patient has a rapidly progressive type of OA may warrant an early move to reconstructive surgery before bone loss compromises the outcome of any operation.
EARLY OSTEOARTHRITIS TREATMENT
There is, as yet, no drug that can modify the effects of OA. Treatment is, therefore, symptomatic.
The principles are: (1) maintain movement and muscle strength; (2) protect the joint from overload"; (3) relieve pain; and (4) modify daily activities.
Physical therapy The mainstay of treatment in the carly case is physical therapy, which should be directed at maintaining joint mobility and improving muscle strength. The programme can include aerobic exer cise, but care should be taken to avoid activities which increase impact loading. Other measures, such as mas- sage and the application of warmth, may reduce pain but improvement is short-lived and the treatment has to be repeated.
Load reduction Protecting the joint from excessive load may slow down the rate of cartilage loss. It is also effective in relieving pain. Common sense measures such as weight reduction for obese patients, wearing shock-absorbing shoes, avoiding activities like climb ing stairs and using a walking stick are worthwhile.
Analgesic medication Pain relief is important, but not all patients require drug therapy and those who do may not need it all the time. If other measures do not provide symptomatic improvement, patients may respond to a simple analgesic such as paracetamol. If this fails to control pain, a non-steroidal anti-inflammatory preparation may be better.
INTERMEDIATE OSTEOARTHRITIS TREATMENT
Joint debridement (removal of loose bodies, cartilage tags, interfering osteophytes or a torn or impinging acetabular or glenoid labrum) may give some improvement. This may be done either by arthroscopy or by open operation.
If appropriate radiographic images suggest that symptoms are due to localized articular overload arising from joint malalignment (e.g. varus deformity of the knee) or incongruity (eg. acetabular and femoral head dysplasia), a corrective osteotomy may prevent or delay progression of the cartilage damage.
LATE OSTEOARTHRITIS TREATMENT
Progressive joint destruction, with increasing pain, instability and deformity (particularly of one of the weight bearing joints), usually requires reconstructive surgery. Three types of operation have, at different times, held the field: realignment osteotomy, arthroplasty and arthrodesis.
Realignment osteotomy Until the development of joint replacement surgery in the 1970s, realignment osteotomy was widely employed. Refinements in techniques, fixation devices and instrumentation led to acceptable results from operations on the hip and knee, ensuring that this approach has not been completely abandoned. High tibial osteotomy is still considered to be a viable alternative to partial joint replacement for unicompartmental OA of the knee, and intertrochanteric femoral osteotomy is sometimes preferred for young patients with localized destructive OA of the hip. These operations should be done while the joint is still stable and mobile and x-rays show that a major part of the articular surface (the radiographic 'joint space') is preserved. Pain relief is often dramatic and is ascribed to (1) vascular decompression of the subchondral bone, and (2) redistribution of loading forces towards less damaged parts of the joint. After load redistribution, fibrocartilage may grow to cover exposed bone.
Joint replacement in one form or another, is nowadays the procedure of choice for OA in patients with intolerable symptoms, marked loss of function and severe restriction of daily activities. For OA of the hip and knee in middle-aged and older patients, total joint replacement by modern techniques promises improvement lasting for 15 years or longer. Similar operations for the shoulder, elbow and ankle are less successful but techniques are improving year by year. However, joint replacement operations are highly dependent on technical skills, implant design, appropriate instrumentation and postoperative care - requirements that cannot always be met, or may not be cost-effective, in all parts of the world.
Arthrodesis is still a reasonable choice if the stiffness is acceptable and neighbouring joints are not likely to be prejudiced. This is most likely to apply to small joints that are prone to OA, e.g. the carpal and tarsal joints and the large toe metatarsophalangeal joint.
