Arthritis & Joint Replacement

Osteoarthritis

What is Osteoarthritis?

Osteoarthritis (OA) is one of the oldest and most common forms of arthritis. Known as the “wear-and- tear” kind of arthritis, OA is a chronic condition characterized by the breakdown of the joint’s cartilage. Cartilage is the part of the joint that cushions the ends of the bones and allows easy movement of joints. The breakdown of cartilage causes the bones to rub against each other, causing stiffness, pain and loss of movement in the joint. Today, an estimated 27 million Americans live with OA. Many different factors may play a role in whether or not you get OA, including age, obesity, injury or overuse and genetics. Your OA could be caused by any one or by a combination of any of these factors.

Taking Charge of Your Arthritis

The most effective way to manage your arthritis is to use a combination of treatments, each of which can help.

Medications

Most people with osteoarthritis will use pain medicine to ease their pain and stiffness. Drugs do not cure arthritis. They should be used to reduce pain so that you can stay active.

Analgesics (pain-relievers) – Analgesics relieve pain without relieving inflammation or swelling. If you are only interested in pain relief, these drugs tend to have fewer side effects. They are recommended for people with mild-to-moderate pain. Examples include acetaminophen (Tylenol), and tramadol (Ultram, Ultracet). We commonly prescribe tramadol, 1 or 2 tablets twice a day as needed for pain. Side effects can include nausea or dizziness, but commonly resolve after a few days.

Topical Analgesics – Topical analgesics include creams or rubs that are applied directly over the painful area. Never use topical analgesics with heat treatments; the combination can cause serious burns. Active ingredients include counterirritants (wintergreen oil, camphor, eucalyptus), which stimulate nerve endings to distract the brain from joint pain; anti-inflammatories, which hamper the activity of prostaglandins, which are chemicals in the body involved in pain and inflammation; and capsaicin, which uses the natural ingredient found in cayenne peppers to relieve pain by depleting a neurotransmitter that sends pain messages to the brain. Prescription strength topical analgesics are the anti-inflammatory gel diclodenac (voltaren gel) applied to the painful joint up to four times daily or lidoderm (pain reliever) 5% patches applied for 12 hours once daily.

Non-steroidal anti-inflammatory drugs (NSAIDs) – NSAIDs reduce inflammation and swelling as well as aid in pain relief and are recommended for people who have moderate-to-severe pain and signs of inflammation associated with OA. Examples of NSAIDs include aspirin, ibuprofen, diclofenac, naproxen, and meloxicam.

NSAIDs are very effective. They do have side effects and need to be monitored. People with difficult to control high blood pressure, stomach ulcers or reflux, diabetes, liver problems or those who take multiple medications should use NSAIDs only rarely and with caution.

If you take NSAIDs regularly, you must check your blood pressure regularly, have screening laboratory tests every 3-6 months, and notify your doctor immediately if you develop any side effects (stomach pain, heartburn, blood in stool, leg swelling).

Cox-2 Drugs – Cox-2 drugs are targeted NSAIDs that don’t cause the stomach irritation associated with traditional NSAIDs. Celexocib (Celebrex) is the only Cox-2 NSAID available.

Steroid Injections – Steroid injections are fast and effective. They are particularly helpful when there is swelling and inflammation. Because steroid injections, when overused, can cause problems with bone and cartilage loss, elevation in blood sugar or tendon and ligament damage, we limit these injections to no more than a couple a year.

Hyaluronan (HA) Injections – Hyaluronan is a natural lubricant present in joint fluid. Arthritis joints have less HA, making them stiff, Replacing HA in the joint, through process called viscosupplementation, can reduce pain and improve motion. There are several different HA products: Synvisc (one injection weekly for three weeks), Synvisc-One (one large injection), Hyalgan (one injection a week for 5 weeks), Euflexxa (one injection weekly for three weeks) and Supartz (one injection weekly for 5 weeks). These injections typically reduce pain by 50% or more, and can be repeated every 6 months. The only serious complication is a rare hypersensitivity reaction, where the joint becomes very swollen and painful. This resolves with a steroid injection. Occasionally, patients will experience a small rash at the site of injection, or 24-48 hours of mild increase in joint pain, both of which will resolve without treatment.

Other drugs – There is some evidence that other medications (such as SAM-e, progabalin/Lyrica, amitriptyline, etc) can help reduce pain in arthritis. These are used in very specific situations. There is research into the use of drugs to reduce OA progression. For example, the antibiotic doxycycline has been shown to reduce the progression of osteoarthritis in middle aged women.

Exercise!

Exercise is the single most important treatment you can pursue. Strong and efficient muscles protect joints and dampen pain. Exercise is the only treatment ever shown to reduce the rate at which arthritis progresses. We suggest you begin your exercise program by seeing a Physical Therapist, who will design for you a customized exercise program.

Orthotics and Braces

Knee orthotics (braces) and shoe inserts can sometimes change the alignment of the leg, reducing joint pain. Commonly used, knee unloader braces can help reduce pain in people with knee varus (bow- legged) or valgus (knock-kneed) malalignment. Sometimes shoe lifts are needed to correct differences in leg lengths.

Alternatives and Natural Supplements

Flavocoxid (Limbrel) – Limbrel is the first prescription supplement designed specifically to safely meet the distinctive nutritional requirements of patients with osteoarthritis. Limbrel contains flavocoxid, a proprietary blend of natural ingredients from phytochemical food source materials. These or similar ingredients can be found in common foods such as soy, peanuts, cauliflower, kale, apples, apricots, cocoa and green tea. Because Limbrel’s ingredients have been derived from natural plant sources, they are not synthetic or artificial. The typical dose is 500 mg twice daily, and Limbrel can take 2-4 we

Glucosamine and Chondroitin Sulfate – These two dietary supplements have been used for years to treat osteoarthritis in dogs and horses and in Europe to treat osteoarthritis in people. Although a recent large study suggested these drugs are no more effective than placebo, some people with milder OA find them helpful at reducing pain. Common side effects include increased intestinal gas and softened stools. Chondroitin can interfere with blood thinners, and glucosamine is related to shellfish, which can trigger allergies in hypersensitive people. Glucosamine can also raise blood sugar in diabetics. These supplements take 6-8 weeks to take effect.

Vitamins – Some research has shown that antioxidants in certain vitamins may help ease certain symptoms of osteoarthritis. In general, vitamins from whole foods are believed to be better absorbed by the body than supplements. Vitamin C has been shown to counteract the wearing away of cartilage in animals with OA. Vitamin E provides some pain relief to people with OA. Vitamin D is the most important vitamin. It may even help prevent OA. One study found that disease progression was faster in people who had a low intake of the vitamin. We suggest a minimum of 1000 IU Vitamin D a day, and more in people with low vitamin D levels.

Diet – There are no specific diets that have been shown to reduce arthritis. Many people believe that diets high in omega-3 fatty acids reduce overall body inflammation and pain.

Acupuncture – Several medical studies have shown that acupuncture can reduce pain in osteoarthritis. Positive effects are usually seen by 6-8 treatment sessions. Acupuncture does not change the rate of progression of arthritis; nor does it build cartilage.

Weight Control

Weight control is particularly important for people with OA. Excess weight directly contributes to the development of osteoarthritis. Weight control not only helps prevent OA, it is an important element in your treatment of the disease as well.

Maintaining your recommended weight or losing weight if you are overweight can lessen your pain by reducing stress on your affected joints. Weight loss specifically helps ease pressure on weight-bearing joints such as the hips, knees, back and feet.

If you are overweight, work with your doctor to devise a weight-loss plan that includes eating fewer calories and increasing physical exercise. Make sure you are getting enough nutrients to keep your body healthy and that the activities you choose don’t harm your joints. See the Exercise and Arthritis and Diet and Nutrition sections for more information.

Avoiding Joint Pain and Damage

You can take steps to protect your joints and manage joint. Listening to your body is the most important thing you can do to take care of yourself. This is where balancing rest and activity really comes into play, because if you plan rest breaks in your day, you may avoid times of acute pain.

Keep active – Too much rest isn’t good for your joints. Even on days when you are tired and stiff, try to do some exercise. By increasing your level of fitness, you will actually have more energy and less pain.

Know when to take breaks – Don’t wait for the physical signals of pain before you rest. Take a 15- minute break each hour to give your body a break from the computer, from standing or sitting too long or from concentrating to long on one task.

Use good body mechanics – Use your palms instead of your fingers when lifting or carry things. Use your larger muscles, rather than smaller ones, to carry things. For example, carry a backpack instead of a purse. Lift with your legs instead of your back. Use good posture, which takes stress off your joints.

Surgery

While most people with osteoarthritis won’t need surgery, when used appropriately, joint replacement surgery can dramatically improve function and eliminate disabling pain. It is considered one of the most effective orthopedic surgeries. Successful joint replacement can transform the life of a person suffering from arthritis.

Arthroscopic Surgery – In this procedure, the surgeon inserts a very thin tube with a light at the end into the joint through a small incision. It is connected to a closed-circuit television and allows the surgeon to see the extent of the damage in the joint. Once there, the doctor can take tissue samples, remove loose cartilage, repair tears, smooth a rough surface or remove diseased synovial tissue. It is most commonly performed on the knee, shoulder and increasingly on the hip.

Joint Replacement Surgery or Arthroplasty – This is the surgical reconstruction or replacement of a joint. Joint replacement surgery involves the removal of the joint, resurfacing and relining of the ends of bones and inserting a prosthetic joint. These surgeries are now performed using smaller incisions and minimally invasive techniques, allowing patients to get up and moving very quickly. Most people now stay in the hospital only 2 or 3 days after surgery. Dedication to physical therapy and exercise is particularly important. Most people are walking the day after surgery, driving after a couple of weeks, and back to work within a month. Joint replacements are estimated to last about 25 years.