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Osteoarthritis - Curing The Incurable

Osteoarthritis in india

What is Osteoarthritis?

According to the Centers for Disease Control (CDC), approximately 26 million U.S. citizens suffer from a form of arthritis, and the most common form affecting the population is osteoarthritis (OA), which accounts for more than 25% of the cases globally. Osteoarthritis is a chronic, degenerative clinical syndrome of gradual loss of articular cartilage accompanied with joint pain and limitation of joint mobility due to bone hypertrophy. In relation to impact on health and quality of life, it ranks fourth in women and eighth in men in western countries; and in relation to physical disability, it ranks second only to cardiovascular disease. It is estimated that 10% to 15% of adults over 60 years, and more than 80% of people over 75 years, are affected with some form of osteoarthritis, which is becoming an increasingly important disease due to the increase in ageing population.  Osteoarthritis is a multifactorial disease and little is known about its mechanism for widespread distribution.  Generally, it is defined based onthe radiologic features. Reckoning the expenses of diagnosis, therapy for the primary disease and the side effects, and lost life efficiency, it has emerged as one of the expensive and debilitating diseases in the world.

Causes of Osteoarthritis

  • Genetics:Familial osteoarthritis is caused due to a mutation in the type II collagen COL2A1 gene (localized on chromosome 12), which causes not only cartilage dysplasia but also a severe form of OA with defective collagen. Onset promptly follows cessation of growth.  Familial form can also occur due to chronic abnormalities of growth plate development and bone growth, leading to altered congruity of articulating surfaces. Diseases which adversely affect the deposition of cartilage matrix such as hemochromatosis, ochronosis or alkaptonuria, and which cause disturbance in cartilage metabolism, also demonstrate osteoarthritis changes.
  • Age: It is the most common risk factor associated with osteoarthritis. According to Framingham study, 27% of those aged 63 to 70 displayed radiographic evidence of knee osteoarthritis, which increased to 44% in the group of over 80 years. Numerous factors, such as altered gait, weakness of muscles, changes in proprioception and body weight, can contribute to the age-related degeneration in the pattern and magnitude of stress exerted on the joint cartilage. Lack of neuromuscular control most likely contributes to the loss of normal attenuation of body weight-bearing forces during walking. Aging cells show elevated oxidative stress that promotes cell senescence and alters mitochondrial function. Another hallmark of aging chondrocytes is reduced repair response, partially due to alteration of the receptor expression pattern. 
  • Obesity: It is a well-defined risk factor involving excessive joint loading as well as systemic metabolic changes that include low-grade chronic inflammation. In this respect, obesity is regarded as the number one preventable risk factor for osteoarthritis. Obese patients are more prone to develop OA at a comparative early age and present with more severe symptoms. They are at higher risk to develop infections and pose with more technical difficulties in surgically treating them for joint replacement.  Evolutionary adaptations to the upright posture by humans have redistributed preponderant loading forces to new sites, predisposing to an increased risk for development of OA in hips, knees, bunion joints, and the lumbar spine.
  • Trauma: Damage of the cartilage due to trauma, impact injuries, abnormal joint loading and excessive wear, or as part of an aging process, can lead to changes in the composition, structure, and material properties of the tissue. These alterations can compromise the ability of cartilage to function and survive in the strenuous mechanical environment normally found in load-bearing joints. Joint injury and subsequent joint instability and abnormal loading, from loss of ligamental or meniscal support, overexercise or abnormal joint use; are significant risk factors for osteoarthritis. Patients with history of knee injury have shown a 5-6 fold increased risk of osteoarthritis.Trauma-related sport injuries can cause damage to the bone, cartilage, ligament, and meniscus, which negatively affects joint stabilization. Studies have also found a significant relationship between occupational kneelingand repetitive use of joints during work as in dockers and miners; and osteoarthritis.

Signs and symptoms of Osteoarthritis

  • General: Pain, stiffness, gelling, crepitus, bony enlargement, limited range of motion, malalignment, pain and stiffness in the affected joint, which is exacerbated with activity and relieved by rest. Swelling may be due to bony deformity such as osteophyte formation, or due to an effusion caused by synovial fluid accumulation.
  • Hand osteoarthritis: Pain on range of motion, hypertrophic changes at distal and proximal interphalangeal joints with medial and lateral deviation, tenderness over carpometacarpal joint of thumb, squaring of the base of the hand.
  • Shoulder osteoarthritis: Pain on range of motion, limitation of range of motion, crepitus on range of motion.
  • Knee osteoarthritis: Pain on range of motion, joint effusion, crepitus on range of motion, patellofemoral joint symptoms worse on the stairs than on the flat,valgus or varusdeformity with medial compartment disease, Baker’s (popliteal) cysts, tenderness of the pes anserine bursa.
  • Hip osteoarthritis: Pain on range of motion, typically groin pain, but may present in buttocks, less so in knee or below knee; limitation of range of motion, flexion contractures and Trendelenberg sign may be present.
  • Foot osteoarthritis: Pain on ambulation, especially at first metatarsophalangeal joint, limited range of motion of first metatarsophalangeal joint, hallux rigidus, hallux valgus deformity.
  • Cervical spine: Local spine pain, muscle spasm, limited motion both lateral flexion and extension, sensory loss or muscle weakness or nerve atrophy along its distribution, cervical myelopathy with long tract signs, bladder dysfunction.
  • Lumbar spine: The most common site of involvementis L3 to L5. local pain and muscle spasm, buttock pain, limited extension, radicular pattern with pain, sensory and motor changes nerve along its distribution; spinal stenosis causes pseudoclaudication type pain (back/leg pain on standing and walking relieved by sitting).
  • Temporomandibular joint (TMJ):  Osteoarthritis accounts for 8% to12% of patients treated for TMJ pain, limited mandibular motion,decrease in oral opening and lateral movement and mandibular protrusion, crepitus and tenderness of the medial and lateral pterygoid muscles, facial pain, headache, impairedhearing, tinnitus, and dizziness likely related to irritation of the facial or auriculotemporal nerve.

Diagnosis of Osteoarthritis

  • Case history: As osteoarthritis is primarily a clinical diagnosis, in most of the cases general physicians can make the diagnosis on the basis of patients’ history and physical examination.
  • Radiography: Radiographs are a cost effective technique that aids in diagnosis. Changes seen on plain radiographs are localized loss of joint space, eburnation of bone; presence of osteophytes at the sites of revascularization of remaining cartilage, subchondral cysts formation due to synovial fluid intrusion, collaose of weakened bony trabaculae, subchondral sclerosis, intra-articular osseous bodies, deformity and malalignment of capsular and ligamentous structures. Plain radiography is not a good measure of disease progression as it is based on measures of joint space narrowing, which occurs at <0.1 mm per year, hence difficult to measure accurately.
  • Magnetic resonance imaging (MRI): It has been the imaging method of choice for evaluating internal derangements of the knee and other joints. MRI is ideally suited for imaging arthritic joints, as it is capable of quantifying a variety of compositional and functional parameters of articular tissues relevant to the degenerative process and osteoarthritis. MRI’s unparalleled tissue contrast enables it to directly examine all components of a joint simultaneously hence evaluate the joint as a whole organ and quantify cartilage loss. MRI has unique ability to identify very early changes associated with cartilage degeneration, and to quantify subtle morphological and compositional variations in different articular tissues over time. It is recommended in assessing ligament and meniscal tears in the knee. 
  • Ultrasonography (US): It utilizes the principle of the ability of sound waves to produce an image as they reflectfrom matter to the source of origin. Ultrasound is reliable in measuring cartilage thickness, identifying focal chondral defects,detecting effusions and synovial hypertrophy. It can detect bone irregularity and erosions, osteophytes, subchondral bone cysts, decreased joint space, and subluxation of joint surfaces. 
  • Computed Tomography (CT): It utilizes x-ray images and then digitally creates two- or three-dimensional cross-sectional images of the structures. It is predominantly used to define calcified tissues which are not well visualized with MRI, such as trabecular bone and osteophytes.CT has been shown to demonstrate knee joint anatomical structures with high accuracy without contrast medium and have also been found to be reliable in detecting pathology at the knee including fluid, meniscal changes, ligamentous injury, or intra-articular bodies.
  • Scintigraphy: It involves the injection of a radioisotope tracer,technetium-99m labeled bisphosphonate, into the vascular system, which is subsequently taken up into the bone, and delayed imaging of the body can detect regional localization of the tracer in skeletal tissue. Increased osteoblastic activity is demonstrated as an area of increased uptake of tracer, while reduced or absent flow of blood as in case of an infarction, is depicted as an area of decreased tracer localization. Scintigraphy of the knee has been found to be more specific at depicting compartment disease, which is exhibited as a generalized increased uptake in the medial compartment.
  • Biochemical markers: Studies have found these markers to be reliable and sensitive to quantitative variations as they are increasingly tissue and process specific of osteoarthritic changes. Biochemical markers of significance in osteoarthritis are; cartilage oligomeric matrix protein (COMP) which may be used as a marker of cartilage destruction; C-reactive protein, hyaluronan, YKL-40, and metalloproteases which may used as a parameter of synovial inflammation; pyridinoline and bone sialoprotein which may be used as a marker of bone turnover. 
  • Laboratory assessment of synovial fluid: Synovial fluid in primary osteoarthritis is considered to be non-inflammatory. Changes may be seen in case of inflammatory synovitis such as; increased volume of joint fluid, normal or decreased viscosity, mild but significant pleocytosis, a modest elevation in synovial fluid protein, and an increase in mean total white blood cell count.

Types of Osteoarthritis

  • Primary or Idiopathic osteoarthritis: depending on the joints involved it could be Peripheral (single or multiple), Interphalangeal (distal interphalangeal,proximal interphalangeal), Small joints (e.g., first carpometacarpal, first metacarpophalangeal), Large joints (e.g., hip, knee)
  • Spine osteoarthritis are of two types: Apophyseal and Intervertebral 
  • Variant subsets are: Erosive inflammatory osteoarthritis, Generalized osteoarthritis, Chondromalacia patellae, Diffuse idiopathic skeletal hyperostosis (DISH, ankylosing hyperostosis)
  • Secondary osteoarthritis: depending on etiology, the types are: Traumatic, Acute and Chronic occurring due to occupation, sports, obesity
  • Systemic metabolic diseases predisposing to osteoarthritis are: Ochronosis (alkaptonuria), Hemochromatosis, Wilson disease, Kashin-Beck disease
  • Endocrine disorders predisposing to osteoarthritis are: Acromegaly, Hyperparathyroidism, Diabetes mellitus
  • Neuropathic disorders associated with osteoarthritis or Charcot joints are: tabesdorsalis, diabetes mellitus, intra-articular steroid overuse
  • Familial osteoarthritis is seen associated with skeletal dysplasias such as multiple epiphyseal dysplasia, spondyloepiphyseal dysplasia

Stages in Osteoarthritis of knee

  • Stage 1- Minor: minor wear & tear with minute growth of bone spur at the end of the knee joints, little or no pain or discomfort.
  • Stage 2- Mild: diagnostic images joint space show more bone spurs, joint space might appear normal, symptoms of joint pain, feeling of stiffness around the knee joint, particularly when sitting for an extended period or after rising in the morning or following a workout, proteolytic breakdown of the cartilage matrix bymetalloproteinases.
  • Stage 3- Moderate: evident erosion of the cartilage surface between bones, minimized gap between the bones due to fibrillation, increase in growth of bone spurs producing a rough surgace, release of proteoglycan and collagen fragments into the synovial fluid, apparent joint inflammation leading to pain while walking, running, squatting, extending or kneeling, joint stiffness and often popping or snapping sounds when walking.
  • Stage 4- Severe: substantial diminution in joint space causing the cartilage to wear off, stimulating a chronic inflammatory response, deceasing synovial fluid , subsequently leading to joint stiffness, excruciating pain and discomfort while walking or moving the jointwhich makes even everyday chores, a challenge, increased destruction of cartilage by synovial metalloproteinases, cytokines and TNF.

Treatment of Osteoarthritis

  • Weight loss and exercise: Being overweight is the single most important potentially modifiable risk factor for the development of osteoarthritis involving the lower limbs. Exercise is the single most important intervention. Inactivity of the joint due osteoarthritic pain causes reduction in muscle bulk surrounding the joint, eventuallydestabilizing it, and increasing the risk of obesity. Exercise is essential to build muscle strength and endurance, improve flexibility and range joint motion, and enhance aerobic activity.Stretching exercises, muscle strengthening exercises, mobility training such as ambulation, elevations, stairs, assistive device trials, are recommended.
  • Intra-synovial therapy: After aspiration o fluid, the joint space is injected with intra-articular steroid suspension that suppresses inflammationand provides the most effective relief for the longest period of time. It is used as an adjunctive therapy for one or two joints not responsive to other systemic therapy, or to facilitate a rehabilitative and physical therapy program or orthopedic corrective procedures, or to prevent capsular and ligamentous laxity, and to bring about a medical synovectomy.
  • Osteotomy: It is one of the earliest procedures to be used in the surgical management of osteoarthritis. If joint malalignment is present, with resultant abnormal force distribution, an osteotomy to realign the joint in a more normal configuration will correct the abnormal mechanical loads causing progression of the disease.
  • Débridement: In this method irregular joint surfaces are smoothed and the loose bodies are removed along with inflamed synovium. For acase to be considered for debridement, joint malalignment should not be present or it should be correctedvia an osteotomy. A functional range of motion is mandatory.
  • Arthrodesis (Fusion): Osteoarthritis of the cervical or lumbar spine which is unresponsive to medical management, requires fusion of the involved segments, combined with decompression of the neutral elements. These local intercarpal fusions are extremely helpful in controlling the pain and instability associated with carpal osteoarthritis, without completely sacrificing wrist motion and function.
  • Arthroplasty:It is indicated in cases presenting severe pain and disability. To obtain better results, appropriate bone stock and muscle power should be present. Types of arthroplasty are: excisional, partial, or total replacement. Procedure of arthoplasty involves the use of biologic substitutes, like polymethylmethacrylate,which is used as a fixative between the metallic or plastic implant and the bone, and subsequently to resurface confined destroyed articular surfaces in the knee joint.

Complications associated with Surgery

  • Infection: Septic arthritis is quite rare and warrants prompt treatment.
  • Bleeding: Blood clots formed deep in the vein can cause pain and swelling
  • Mobility: Rarely the joint may become mobile, loose and wear down leading to subsequent injury

Am I good candidate for Osteoarthritis Surgery?

A young osteoarthritic patient experiencing activity pain, mild to moderate joint deformity, sparing the articular cartilage and with functional range of motion, is indicated for osteotomy. A young patient with little joint deformity but a well-defined osteoarthritic lesion is indicated for surgical debridement. A young, active and heavy patient with involvement of a single joint is advised spinal arthrodesis as an adjunct to decompression procedures. A patient with significant pain and deformity, functional loss with restricted range of motion or joint disability is advised a total joint replacement.

Recovery time and aftercare

Days of hospitalization depend on the procedure and vary from one to three days. Osteotomy has a recovery period of usually 3 months for knee and 6 to 12 months for hip osteoarthritis, and relief of pain usually improved function. Recovery following debridement is variable and depends on the extent of procedure, and functional improvement is seen but may be for a shorter time. Arthrodesis shows significant improvement in pain and excellent functional improvement depending on the joint. Total joint replacement shows significant, consistent and durable improvement in pain with significant functional improvement.

Success rate of Osteoarthritis treatment

Hip arthroplasty has shown a 10 year survival rate of 96%, while total knee arthroplasty 98%. Total joint replacement has shown a clinical success for 10 to 15 years.

Benefits of Osteoarthritis treatment

  • Relief from pain and anxiety
  • Gain in functional activity
  • Reduced need for task assistance
  • Stabilization of joint
  • Psychological benefit

Cost comparisons:

Debridement is least expensive, Arthrodesis and Osteotomy are moderately expensive, and total joint replacement is the most expensive surgical treatment for osteoarthritis. Biomaterials used for injection cost approximately $185 and arthocentesis may cost up to $60. Total knee replacement surgery cost most affordable in India on the implant material.  To know the cost of Total Knee Replacement Surgery

Why choose MedcureIndia?

Osteoarthritis is a debilitating disease which makes its treatment quite challenging. Here at MedcureIndia, we not only provide you with the conventional treatment options but also assist you through the complementary and alternative medical approach. Patient education regarding dietary supplements, exercise program and functional care of the joint is provided so that the patient can lead an assistance-freelife. 

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