ARHRITIS - OSTEO (DEGENERATIVE)

DIAGNOSTIC CRITERIA

Definition : A degenerative joint condition with loss of articular cartilage leading to pain and deformity.

1. Most common of all joint diseases especially occurring in the elderly, and presents without systemic manifestations. Could be Primary idiopathic or Secondary to congenital, anatomic, metabolic ( Wilson’s disease), post-infective, and post-traumatic causes among others.
2. Joints commonly affected are knees, hips (presenting with pain in groin ,over greater trochanter, buttock, or medial aspect of knee), cervical (c 6-7) and lumbar spine (L3-S1) (lumbar spinal stenosis), and terminal interphalangeal joints (uncommon in India).
3. Progressive loss of articular cartilage with minimal reactive changes of inflammation, and new bone formation at the joint margins.
4. Pain brought on by effort, and relieved by rest, decreased range of motion without much tenderness.
5. X-ray shows narrowed joint space, osteophytes, dense subchondral bone and cyst formation.

Prognosis: Many show phasic symptoms. Tends to be progressive with pain occurring even at rest, cpitus on movement, effusions, and full thickness loss of cartilage, and much disability especially hen weight bearing joints are involved. No mortality due to disease per se but drugs like NSAIDs could cause major problems.

MANAGEMENT

General Principles:

1. As cut-patient with constant review ensuring activity, proper exercises, weight reduction, and minimal consumption of drugs. Stress importance of non-pharmacologic therapy, try to restrict drug therapy to periods of exacerbation of pain.
2. Mefenemic Acid (250 mgs qid ). Specific Cox-2 inhibitors like celecoxib (100-200 mg bid) or Rofecoxib (12.5—25 mg od, could give 50 mg/od for 5 days in acute pain ) cause less gastro-duodenal upset.
3. Glucosamine sulfate (1500 mg daily) with or without chondroitin sulphate (200 mgm tid) found effective in many cases in relieving pain and may help regenerate cartilage. Course for 60 days followed by maintenance phase of 500 to 1000 mgms daily. Takes 2-3 weeks for clinical improvement to occur. Is contra-indicated in patients allergic to sea food.
4. Hyaluronic acid and its derivatives are injected directly into the knee joint to supplement natural acid in the synovial fluid.
5. Judicious use of local lntra-articular injection of steroids! Limit to 2-3 times in a year.
6. Avoid systemic steroids, and narcotic analgesics.
7. Calcium supplements and anabolic steroids for the elderly.

General Measures

1. Adequate rest as dictated by severity of symptoms.
2. Graded proper exercises.
3. Heat and other Physical therapy. Local Rubefacient creams. Capsaicin cream for smaller hand joints and NSAID ointments.
4. Corrective shoes, collars, supports, and straps as suitable, with physiatrist’s advice.
5. Protection of joint from overuse-with crutches, elastic knee support, walkers, crutches.
6. Elderly might need Calcium supplements! Anabolic steroids.
7. Surgical measures - Total Hip/Knee replacement in gross impairment with constant pain. Any associated Lumbar spinal stenosis may need extensive decompression laminectomy for relief of symptoms. Good results in expdrt surgical hands.
8. Arthroscopic Surgery in trained hands for - Osteotomy, debridement, removal of loose bodies
9. Laminectomy and spinal fusion for spinal Osteo Arthritis.

Patient teaching

1. Reassurance on absence of any systemic background illness.
2. Impress on possibility of much disability by neglecting non-pharmacologic measures like exercise, weight reduction, use of corrective gadgets, walking stick, etc.
3. Hazards of NSAIDs abuse (often resorted to, as an alternative ‘easy way out’).
4. To learn to avoid drugs for minimal degrees of pain or discomfort like a ‘little stiffness in the ,,mornings’.

Follow UP

1. At regular intervals to ensure compliance on physical measures, non-abuse of NSAIDs. To assess range of movement of joints, and functional status at every visit.
2. To watch out for GI blood loss (stool for occult blood), renal and cardiac side-effects after NSAIDs, especially in elderly patients.

Prevention

Weight reduction.

Regular exercises! walking / Yoga I Corrective gadgets for Congenital or Acquired deformities.