Joints are constantly used during a lifetime of activity. Worn out cells are efficiently replaced. If the rate of repair falls below the rate of damage, painful degenerative osteoarthritis sets in. This generally occurs earlier in overweight individuals, smokers and those with complicating medical illnesses such as diabetes.
Around 75 per cent of the population over the age of 65 has X-ray evidence of osteoarthritis in the hips or knees. Such people may complain of stiffness, especially after a period of inactivity. There may be difficulty in standing up, stepping and walking. The gait may be waddling and abnormal. There may be dull ache or a sharp, stabbing radiating pain. The knees may be obviously deformed and bent. Balance becomes a problem and frequent falls may occur.
Lifestyle modifications are required for the management of osteoarthritis, and this may include cessation of smoking, treatment of underlying diseases and weight loss.
A common misconception is that exercise will “wear out” an osteoarthritic joint. Low-impact exercises such as walking and cycling are actually beneficial. Physiotherapists can teach effective quadriceps-strengthening exercises (for the knees) and hip motion exercises. These increase flexibility. Strengthening the muscles surrounding an affected joint helps to hold the bones in place, reduces pain and maintains mobility. Exercises must be performed every day for them to be effective. If discontinued, accrued benefit disappears in three days. Patients who participate in exercise programmes have less pain and depression and improve faster than those who rely on medications alone.
Topical application of creams and ointments containing capsaicin (an extract of green pepper), applied four times daily, provide excellent pain relief.
Many patients with osteoarthritis of the hip and knee are more comfortable if they wear slippers with good shock-absorbing properties.
Canes are an excellent aid when held on the unaffected side of the body. For maximum effectiveness, the top of the cane’s handle should reach the patient’s wrist crease (when the patient is standing with arms straight down). Such canes can reduce hip and knee weight bearing by 20 to 30 per cent.
If the person is still incapacitated, medications can be used. In older individuals, dosage has to be carefully monitored to prevent kidney or liver damage.
Paracetamol is the probably the safest drug. It provides excellent pain relief. Non Steroidal Anti-Inflammatory Drugs (NSAIDs) such as ibubrufen or diclofenac can be used for a short time. The “Cox” group, which includes celecoxib, is also effective.
Anecdotal evidence suggests that “food supplements” such as glucosamine sulphate and chondroitin sulphate are safe and effective in patients with osteoarthritis. Actual studies, however, have not demonstrated any proven benefit.
If there is pain and disability despite these simple measures, affected joints can be injected with steroids or hyaluronic acid analogues.
Surgical intervention is also an option. The joint can be viewed, lavaged and debrided through an arthroscope.
Hips and knees can now be replaced. This should be considered if there is severe persistent pain, loss of motion, inability to stand or climb stairs, deformity and if all other therapies have failed. Earlier, replacement was an option reserved primarily for severely affected adults over 60 years. The artificial joints were heavy and maladroit, and the surgery was long and complicated. But now, research has converted the clumsy, original hinge joint into an engineering marvel. Lightweight biocompatible and durable materials such as plastic, titanium and stainless steel are now used. They resist corrosion, degradation and wear. Surgeons no longer need to make 12-inch incisions to replace the joints. Keyhole surgery is possible.
Replacement surgery is successful in more than 90 per cent of patients. Age is no bar to this procedure though it is marginally riskier in older people with other complicating illnesses. (Britain ’s Queen Mother underwent the surgery at the age of 95, and survived for six years after that). If the surgery is performed in active, younger individuals, the replaced joint itself can get worn out after 15 or 20 years, requiring a second surgery.
Physiotherapy speeds recovery and strengthens the muscles supporting the new joint, enabling rapid mobilisation. Within a few days, sitting up or even supported walking with crutches or a walker is possible. Eventually, within a month, unsupported walking is possible.
Squatting is not possible after replacement surgery. High-impact activities such as running are better avoided but swimming, walking and cycling are possible.
Two joints should not be operated simultaneously. There should be least a month’s gap in between surgeries.
Walking is an essential function for all age groups. Effortless walking requires coordination and unhindered functioning of the bones and joints involved. Replacement surgery does this, giving patients a new lease of life.
Dr Gita Mathai is a paediatrician with a family practice at Vellore. If you have any questions on health issues please write to [email protected]