11. Osteoarthritis

Definition
Osteoarthritis is the most common joint disorder. The chronic disease causes the cushioning (cartilage) between the bone joints to wear away, leading to pain and stiffness. It can also cause new pieces of bone, called bone spurs, to grow around the joints.

Alternative Names
Hypertrophic osteoarthritis; Osteoarthrosis; Degenerative joint disease; DJD; OA; Arthritis - osteoarthritis

Causes, incidence, and risk factors
Most of the time, the cause of osteoarthritis (OA) is unknown. It is primarily related to aging. However, metabolic, genetic, chemical, and mechanical factors can play a role in its development.
The symptoms of osteoarthritis usually appear in middle age and are present in almost everyone by the age of 70. Before the age of 55, the condition occurs equally in both sexes. However, after 55 it is more common in women.
The cartilage of the affected joint becomes rough and wears down (degenerates). As the disease gets worse, the cartilage disappears and the bone rubs on bone. Bony spurs usually develop around the joint.
OA is classified as primary or secondary. Primary OA occurs without any type of injury or identifiable cause. Secondary OA is osteroarthritis due to another disease or underlying condition. The most common causes of secondary OA are metabolic conditions, such as acromegaly, problems with anatomy (for example, being bow-legged), injury, or inflammatory disorders like septic arthritis.

Symptoms

• gradual and subtle onset of deep aching joint pain
• worse after exercise or weight bearing
• often relieved by rest
• joint swelling
• limited movement
• morning stiffness
• grating of the joint with motion
• joint pain in rainy weather

Note: There may be no symptoms.

Signs and tests
A physical exam can show limited range of motion, grating of a joint with motion, joint swelling, and tenderness.
An x-ray of affected joints will show loss of the joint space, and in advanced cases, wearing down of the ends of the bone and bone spurs.

Treatment
The goals of treatment are to relieve pain, maintain or improve joint mobility, increase the strength of the joints, and minimize the disabling affects of the disease. The specific treatment depends on which joints are involved.

MEDICATIONS
The most common type of medication used to treat osteoarthritis are nonsteroidal, anti-inflammatory drugs (NSAIDs). They are common pain relievers that reduce pain and swelling. Types include aspirin, ibuprofen (Motrin, Advil, Nuprin), and naproxen (Aleve, Naprosyn, Naprelan, Anaprox).

Although NSAIDs work well, long-term use of these drugs can cause stomach problems, such as ulcers and bleeding. In April 2005, the FDA asked manufacturers of NSAIDs to include a warning label on their product that alerts users of an increased risk for cardiovascular events (heart attacks and strokes) and gastrointestinal bleeding.

Other medications used to treat OA include:

• COX-2 inhibitors (coxibs). Coxibs block an inflammation-promoting enzyme called COX-2. This class of drugs was initially believed to work as well as traditional NSAIDs, but with fewer stomach problems. However, numerous reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Rofecoxib (Vioxx) and valdecoxib (Bextra) have been withdrawn from the U.S. market following reports of heart attacks in some patients taking the drugs. Celecoxib (Celebrex) was still available at the time of this report, but labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest duration possible. Patients should ask their doctor whether the drug is appropriate and safe for them.


• Steroids. These medications are injected directly into the joint. They may also be used to reduce inflammation and pain.


• Supplements. Many people are helped by over-the-counter remedies like glucosamine and chondroitin sulfate. There is some evidence that these supplements are helpful in controlling pain, although they do not appear to grow new cartilage.


• Artificial joint fluid (Synvisc, Hyalgan). These medications can be injected into the knee, They may relieve pain for up to six months.

LIFESTYLE CHANGES
Exercise helps maintain joint and overall mobility. Ask your health care provider to recommend an appropriate home exercise routine. Water exercises, such as swimming, are especially helpful.
Heat and cold treatments, protection of the joints, the use of self-help devices and rest are all recommended.
Good nutrition and careful weight control are also important. Weight loss for overweight individuals will reduce the strain placed on the knee and ankle joints.

PHYSICAL THERAPY
Physical therapy can be useful to improve muscle strength and the motion at stiff joints. Therapists have many techniques for treating osteoarthritis. If therapy does not make you feel better after 3-6 weeks, then it will likely will not work at all.

BRACES
Splints and braces can sometimes support weakened joints. Some prevent the joint from moving; while others allow some movement. You should use a brace only when your doctor or therapist recommends one. The incorrect use of a brace can cause joint damage, stiffness, and pain.

SURGERY
Surgery to replace or repair damaged joints may be needed in severe, debilitating cases. Surgical options include:

• Arthroplasty (total or partial replacement of the deteriorated joint with an artificial joint -- see knee arthroplasty, hip arthroplasty)


• Arthroscopic surgery to trim torn and damaged cartilage and wash out the joint


• For some younger patents with arthritis, cartilage restoration is a surgical option to replace the damaged or missing cartilage


• Osteotomy (change in the alignment of a bone to relieve stress on the bone or joint)


• Arthrodesis (surgical fusion of bones, usually in the spine)

Expectations (prognosis)

• Movement may become very limited. Treatment generally improves function. OA is the leading cause of disability in industrialized nations.


Complications

• Decreased ability to walk


• Decreased ability to perform activities of daily living, such as personal hygiene, house chores, or cooking


• Adverse reactions to drugs used for treatment


• Surgical complications

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