Originally published in GP BUZZ.
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At the time of publishing, Lai Choon Hin was a Senior Consultant in the Orthopaedic Sugery Department of Tan Tock Seng Hospital.
Arthritis is a painful disease that can affect any age, but usually occurs late in life. Understand more about the symptoms and effective treatment options for better outcomes and quality of life.
WHAT IS ARTHRITIS?
Arthritis is the result of wear and tear of the joint cartilage. The common cause is normal wear and tear with ageing. Arthritis can also be accelerated in the following situations:
Intra-articular injuries sustained in road traffic accidents, sports and injuries.
Inflammatory Diseases. For example, Rheumatoid Arthritis, Systemic lupus erythematosus (SLE) and other Autoimmune Diseases.
Joint Infections.
Excessive joint loading from overuse in sports, heavy manual work and obesity.
The most commonly affected weight joint for arthritis is the knee followed by the hip. The shoulder and elbow are affected in trauma and throwing sports as well as in inflammatory diseases.
SYMPTOMS OF ARTHRITIS
1. Pain
Initially, pain occurs at the end of the day and after prolonged walking and weight bearing. As the arthritis and wear of the articular cartilage progresses, the pain becomes more intense and occurs with shorter periods of weight bearing.
2. Stiffness
Early morning stiffness is a common presentation and patients find difficulty getting out of bed or out of a chair, squatting and climbing stairs after prolonged sitting due to loss of cartilage and joint lubrication. The most commonly affected weight joint for arthritis is the knee followed by the hip. The shoulder and elbow are affected in trauma and throwing sports as well as in inflammatory diseases.
3. Deformity
The commonest deformity in arthritis of the knees is bowed legs (genu varum) deformity. In rheumatoid arthritis, the deformity is usually a knock-knee (genu valgum) deformity, or a wind-swept deformity where one knee is in varus and the other knee in valgus deformity.
DIAGNOSIS
A careful examination of a patient's medical history to elucidate the type of arthritis is important prior to giving treatment. Inflammatory arthritis can be distinguished from primary osteoarthritis with a history of fever, rashes, multiple symmetrical joints involvement and systemic symptoms. History of accidents and sports injuries accounts for arthritis in the younger patients. Excessive wear and tear is seen in patients who are extremely overweight or who participate in extreme sports.
A physical examination will reveal the degree of deformity, loss of motion and leg-length discrepancy. Assessment of neurovascular status of the limb is essential in pre-operative planning. X-rays of the joint in question with long-leg films are also needed.
In early cases of arthritis where there is severe pain but little radiographic evidence of arthritis, MRI imaging will be helpful to diagnose early osteonecrosis as well as to evaluate for degenerative meniscal tears which can occur with minimal trauma in the elderly.
TREATMENT OPTIONS
1. Joint Replacement Surgery
Joint replacement surgery has been very successful in treating severe arthritis of the hip, knee, shoulder, elbow and ankle joints. The survivorship of modern hip and knee replacements is 90% over 15 to 20 years.
New methods to improve the longevity of the knee replacement surgery include computer-aided navigation surgery and use of patient-specific jigs during surgery to improve the leg alignment. Robotic surgery has also been introduced to improve the precision and accuracy of the bone cuts in both hip and knee replacement surgeries.
Newer materials like trabecular metal for improved bone ingrowth of prosthetic components have been developed. These are used together with highly cross-linked polyethylene and ceramic bearings to prolong the longevity of the implanted joints.
2. Arthroscopic Surgery
Arthroscopic surgery has been extensively employed for treatment of early and moderate arthritis to remove degenerate meniscal tears and loose bodies. In younger patients with small chondral lesion of less than 3cm2 in size, chondroplasty with microfracture and cartilage implantation has produced good clinical results with pain relief and reconstitution of the cartilage. Arthroscopic ligament reconstruction and meniscal repair restore the normal biokinetics of the injured knee to prevent the development and progress of arthritis.
In the hip, arthroscopic surgery repairs labral tears and remove bone deformities of the femoral neck which caused hip impingement leading to arthritis.
3. Osteotomies
Osteotomies have a role in early hip and knee arthritis where there is significant hip dysplasia or knee deformity. For a patient with varus deformity of the knee, the tibia can be osteotomised to correct the alignment of the leg. As in joint replacement surgery, this can be rendered more accurately with computer-aided navigation.
Acetabular dysplasia can be corrected with periacetabular osteotomy to correct the uncovering of the femoral head with or without femoral osteotomy. Open acetabular labral repairs and treatment of the cam or pincer causes of hip impingement can successfully prevent the development and progression of arthritis in patients experiencing hip impingement.
4. Medication
Paracetamol is the safest analgesia for arthritis with the least side-effects. NSAIDS and Cox2 inhibitors have more potent analgesic and anti-inflammatory effects but have side-effects on the heart, kidney and stomach. Glucosamine with or without Chondrotin has been prescribed with varying results.
5. Intra-articular Viscosupplementation Hyaluronic acid injection
The injuection is useful in early to moderate arthritis and can give pain relief for up to a year in 70% of patients. It acts as a joint lubricant and nutrition for the cartilage.
6. Weight-loss and Lifestyle Changes
The role of weight-loss and lifestyle changes to treat arthritis have not often been emphasised in the consultation room. A person with arthritis should be advised to lose weight, avoid running on the roads or participating in cross-country runs and change to low- impact exercises such as cycling, swimming and walking. An elliptical cross trainer can also be used in the gym as opposed to running on the treadmill. Avoid using the stairs and squatting. Elevators and escalators should be used where possible.
In conclusion, advances and improvement in the treatment of osteoarthritis has enabled the arthritic patient to lead a healthy and active lifestyle. OPBUZZ
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