DANIEL R. YANICKO, JR., M.D. – ORTHOPAEDIC SURGEON

ARTHRITIS TREATMENT--NONSURGICAL OPTIONS:

Arthritis comes in many forms. The treatment is similar for the different types of arthritis, but the prognosis varies. 94% of all arthritis is Degenerative Joint Disease (DJD) or Osteoarthritis (OA). The remaining conditions are genetically determined autoimmune inflammatory types of arthritis, such as rheumatoid arthritis, lupus, gout, pseudogout, Reiter’s and Sjögren’s syndrome, or mixed connective tissue disease (MCTD). Osteoarthritis (OA) is an acceleration of the age-related joint surface deterioration (cartilage). It is frequently silent early on with periods of minor joint stiffness or pain. Minor injury later brings out an awareness of morning stiffness and generalized joint pain. This minor injury, though, does not cause the osteoarthritis. DEGENERATIVE JOINT DISEASE (DJD) frequently involves a single joint at first, later progressing to multiple joints. The common joints involved are the back, neck, hips, knees, and hands. Treatment of the various joints include: weight loss, exercise, braces, heel cushions/wedges, medication, injections, and surgery. Bracelets, vitamins, minerals, and other dietary supplements have not known to provide consistent benefit (with the exception of Glucosamine). The following is a progressive list of treatment of DJD as the disease advances. In general, each subsequently category is added to the previous category for overall benefit.

PILLS (MEDICATION):

Tylenol (a mild pain killer);Nonsteroidal Anti-Inflammatories (NSAIDs); and cartilage supplements such asGlucosamine, Methyl-Sulfonyl Methane (MSM), Hyaluronic Acid, and/or Chondroitin can all be used concurrently. Glucosamine and Chondroitin (ground up cartilage building blocks) don’t build cartilage (as manufacturers claim), but may slow down the deterioration process. MSM is reported to stabilize cartilage and slow breakdown especially in more inflammatory arthritis situations. These probably act like an NSAID without the side effects and thus are frequently used first in conjunction with Tylenol. Next, an NSAID medication is added. There are over twenty of these with several subcategories. The anti-inflammatory effect leads to direct and indirect pain relief sometimes within the hour but often reaching peak benefit 4-5 days later. Dose equivalent – potency of the various NSAIDs is basically equal. There are multiple common side effects: 10-20% stomach upset/ulcers, 1% liver and kidney toxicity, platelet and bleeding problems, interference with high blood pressure and Coumadin treatment. All NSAIDs should be taken with a full stomach and stopped for stomach upset. COX-2 inhibitor NSAIDs such as Celebrex produce much less stomach upset and no reported platelet/Coumadin effect, but are not in general any more effective than other NSAIDs. Ibuprofen and Naprosyn are the original and still very effective NSAIDs. Current recommendations are to try one NSAID from four different sub-categories for 7-10 days looking for effect and side effects. Then, allowing the patient to titrate the dose of the best NSAID on a weekly basis looking for the effect of change 4-5 days after change. All NSAIDs eventually lose their effectiveness as the disease advances. Stop all NSAIDs about seven days prior to surgery to reduce bleeding risks.

SHOT (INJECTIONS):

These are more effective than NSAID tablets as they are a more potent anti-inflammatory placed directly where they need to work. Cortisone is still the standard injection to which others are compared. Cortisone shots take one to three days to take effect. Systemically, they are around for six weeks, but the anti-inflammatory effect usually lingers much longer. Cortisone injections have few side effects, but oral cortisones (Prednisone) have far more adverse effects. Cortisone injection side effects include temporary (3-5 days) mild elevation of blood pressure and blood sugars (diabetics must watch their blood sugars closely for five days), palpitations, headache, insomnia, and sunburn-like rash. These shots can be given as needed every 3-6 weeks. There is, though, a maximum on cortisone shots of 3-4 per joint per year.

Another group of new injections are the hyaluronic acids made from rooster combs. They include Synvisc, Orthovisc, Euflexxa, Supartz, and Hyalgan, which are cartilage lubricants in injection form. There are minimal known side effects and some patients get up to 6 months of relief. I find the response to these injections more variable than cortisone. They are far more expensive and require insurance approval. As with NSAIDs, all shots eventually lose their effectiveness as the disease progresses.

DANIEL R. YANICKO, JR., M.D. -- ORTHOPAEDIC SURGEON

ARTHRITIS TREATMENT--SURGICAL OPTIONS:

ARTHROSCOPIC SURGERY includes plica band removal, chondroplasty (cartilage shaving) and bone microfracture/abrasion arthroplasty or cartilage plug techniques. These methods provide reasonable but sometimes variable duration of symptom relief over time. There is also a debatable decrease in the rate of arthritis progression. This is best used as a temporary measure for those too young for total joint replacement.

CARTILAGETRANSPLANTATION for a small isolated cartilage lesion with culture growth of the patient’s own cartilage is now available and shows promise for good, long-term results. Small isolated cartilage lesions are very rare, and as such, these procedures are less commonly used except in very young patients ( 40 years). More common now are cadaver meniscus cartilage transplants with good early and often long-term results. Fresh allograft (human donor) bone cartilage plugs are also an option but with a very restricted patient selection.

OSTEOTOMIES are procedures that transfer the body weightbearing stress to the healthy cartilage. This assumes that the remaining cartilage is healthy and is going to be durable enough to withstand this added stress over time. This frequently produces arthritis of the remaining cartilage over 7-10 years, but is quite useful for younger patients with bowed legs or other angular deformities about the knee or congenital or developmental or degenerative labral hip conditions.

FUSIONS are removal of a joint, getting the joint to heal bone to bone like a fracture. This is a permanent solution for the joint, eliminating pain, but also eliminating all motion. Unfortunately, this transfers the stress of movement to the adjacent joints that accelerate their deterioration over time. The most common joints involved include small fingers and toes, hindfoot, subtalar joints, wrist, ankle and occasionally the knee for chronic infections and hip in traumatic, unilateral very young patients.

UNISPACER: This is a new rendition of an old treatment for knee arthritis from 20+ years ago. Metal wedges shaped like the meniscus (knee cartilage) are placed into the knee during a short-stay hospital procedure. These act like a metal cartilage to realign the knee joint and keep the bones from rubbing together.

TOTAL JOINT REPLACEMENT (partial or complete) is artificial resurfacing of the joint (cartilage replacement). Different joints have different architecture, but the basic idea is the same. Most joint replacements are a metal on plastic articulating surface, but new articulating surfaces are being developed such as ceramics and metal-on-metal. Available for most joints, the more common joint replacements involve the hip, knee and shoulder. Ankle, wrist, elbow, and finger joint replacement can also be done in selected, less active patients. Joint replacement produces consistent pain relief for a majority of patients, but is not a permanent lifetime solution.

In general, most joint replacements are demonstrating at least 15-20+ years of pain relief and improved function; and new developments in component design and materials such as cancellous-structured titanium, hydroxyapatite coating, Zimmer tantalum injection-molded polyethylene hip and knee implants, and highly cross-linked polyethylene plastic liners show promise in early testing and clinical results. As we improve the ability to integrate these prosthetic implants directly into bone and reduce wear up to 90% less than previous implant systems, the longevity of artificial joint replacement could consistently approach 25 years or more. Subsequent failures require revision total joint replacement. Present and future research is taking place now to develop ways to remanufacture and replace worn joints sometime in the future with new hyaline articular cartilage and bone, a true “total joint replacement”.