Joint Replacement

Osteoarthritis (OA), or degenerative joint disease (DJD), is a form of arthritis characterized by the loss of joint smoothness and range of motion without major joint inflammation. Post-traumatic arthritis is similar to osteoarthritis, but the cause is clearly evident (usually the result of a trauma to the joint sometime in the past).

Osteoarthritis is the most common type of arthritis, affecting over 20 million people in the United States. It probably affects almost every person over age 60 to some degree, but symptoms are often mild.

Signs of osteoarthritis include joint pain and aching, limited range of motion and instability, erosion of the joint's cartilage and formation of bone spurs. Other symptoms include stiffness and roughness on motion; these symptoms are worse after heavy use. OA pathological changes involve both the cartilage and the bones.

If degenerative joint disease is related to abnormalities of cartilage surrounding joints (articular cartilage), it may involve many of the joints of the body. On the other hand, if the degenerative joint disease is caused by an injury, only one joint may be involved. The hips, knees, spine, and shoulders are most commonly involved. This condition may also affect some finger joints, the joint at the base of the thumb, and the joint at the base of the big toe.

In osteoarthritis, the normally smooth cartilage surface softens and becomes pitted and frayed. As the cartilage breaks down, the joint may lose its normal shape. The bone ends thicken and form bony growths, or spurs, where the ligaments and capsule attach to the bone.

Stiffness and joint deformity usually progress slowly without general body symptoms. By contrast, rheumatoid arthritis (RA) usually begins earlier, often developing more suddenly. RA usually affects the same joint on both sides of body (e.g. both knees), causing redness, warmth, and swelling of many joints. RA is often accompanied by a general feeling of sickness, fatigue, weight loss, and fever.

In the hip, OA may produce pain around the groin or in the inner thigh. Some people feel referred pain to the buttocks, the knee or along the side of the thigh. Degenerative joint disease of the hip may cause a limp and may limit range of motion, for example making it difficult to spread the legs.

Degenerative joint disease of the knees may produce pain and stiffness of the knee associated with a grating or catching sensation in the joint when it is moved. It may make it difficult to walk up and down stairs and lumps may be noted particularly along the medial (inner) side of the knee. If the pain prevents you from moving or exercising your knee, the large muscles around the knee area will become weaker.

Degenerative joint disease of the fingers may produce bony lumpiness around the joints of the finger and perhaps pain and stiffness of these joints as well. In the fingers, the breakdown of joint tissue in the fingers causes bony growths (spurs) to form in these joints. If spurs occur in the end joints of the fingers, they are called Heberden's nodes. If they occur in the joints in the middle of the fingers they are called Bouchard's nodes.

Degenerative joint disease of the feet most commonly affects the large joint at the base of the big toe. Stiffness, lumpiness and pain may be associated. Wearing tight shoes and high heels can make this pain worse.

Degenerative joint disease of the spine may produce stiffness of the back and at times, symptoms of pressure on the spinal cord and nerves running through the spine. The latter are particularly important to notice and may include numbness or weakness of the arms or legs, difficulty with controlling the bowel or bladder, loss of balance and pain radiating out the arms or down the legs.

"Wear and tear" is a widely accepted explanation of the cause of OA. It should be noted that OA is the result of an interlocking pathophysiologic malfunction of cartilage and bone metabolism. Interpreting "wear and tear" of the joints in OA from a biomechanic perspective allows patients to understand how OA differs from age-associated degeneration and overuse of the joints. There are ways to reduce the OA "wear and tear" effects which include weight control, muscle strengthening exercises, and increased proprioception accuracy (the ability to feel your joint's position in space).

The effects of degenerative joint disease can often be controlled by a few basic measures, such as diet, exercise, medication, and surgery.

If you have OA, your diet should optimize your body weight so that the joints do not bear large loads which would cause them to wear more quickly. Joints in a person with OA should be protected from rough use, particularly those involving sudden impacts. Canes or walkers may help protect the hip and knee and prevent limping. Physical therapy can help maintain joint ranges of motion, strength and stability. Your doctor may prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) which are also effective in relieving pain.

Surgical treatment for OA may include removing joint spurs, realigning the joint, fusion of the joint, and joint replacement. In the past several years, these operations have become very effective, and many people have benefited from joint reconstruction or replacement.

Rheumatoid arthritis (RA) primarily affects the synovium, the membrane that lines and lubricates a joint. It is the most common form of inflammatory arthritis.

There is no cure for rheumatoid arthritis at present. Until the cause of RA is known, it will not be possible to eliminate the disease entirely. The goals of current treatment methods, therefore, are to relieve pain, reduce inflammation, stop or slow down joint damage, and improve function and patient well-being.

Initial symptoms of rheumatoid arthritis are generally pain and stiffness in the morning and few symptoms with activity. The pain and swelling will usually progress on to obvious joint swelling and the level of stiffness in the morning increases. Other symptoms include fatigue and difficulty sleeping due to joint stiffness.

Rheumatoid arthritis can be distinguished from other forms of arthritis by the location and number of joints involved. The areas affected include the neck, shoulders, elbows, wrists, and hands, especially the joints at the base and middle of the fingers but not the joints at the end of the fingers. In the lower extremities, RA can affect the hips, knees, ankles, and the joints at the base of the toes. RA tends to spare the low back. The joints affected tend to be involved in a symmetrical pattern. That is, if knuckles on the right hand are inflamed, it is likely that knuckles on the left hand will be inflamed as well. This symmetry is not found as often in most other types of arthritis.

Inflamed joints will be warm, swollen, tender, often red, and painful or difficult to move. These physical signs of arthritis are due to inflammation of the lining of joints and tendons in a layer of tissue that is called synovium. The cells of the immune system within the synovium appear active and capable of causing tissue damage. If this inflammation persists or does not respond well to treatment, destruction of nearby cartilage, bone, tendons, and ligaments can follow. This leads to deformity and disability that can be permanent.

Anyone can get rheumatoid arthritis, including children and the elderly. However, the disease usually begins in the young to middle adult years. Among people with RA, women outnumber men by 3 to 1. In the United States, approximately one percent of the population, or 2.5 million people, have rheumatoid arthritis. It occurs in all ethnic groups and in all parts of the world.

The goals of current RA treatment methods are to relieve pain, reduce inflammation, stop or slow down joint damage, and improve function and patient well-being. There is no single standard treatment that applies to all people with RA. The disease may be very different from person to person. Instead, a treatment program should be designed to best meet each person's needs, taking into account how severe the arthritis is, other medical problems, and individual lifestyle and preferences. Often the use of two or more medications at a time, each serving a distinct purpose, is necessary. Some of these medications affect the immune system, making careful monitoring a requirement for treatment.

Treating rheumatoid arthritis usually involves a teamwork approach, using health professionals from different disciplines to help an individual deal with the disease. Treatment most often is directed and coordinated by an arthritis specialist, who is a physician with special training in arthritis and other diseases of the bones, muscles, and joints. Other health professionals, such as physical therapists, occupational therapists, nurses, psychologists, orthopaedic surgeons, and social workers, often play other roles in implementing the treatment plan.

It often is difficult to be patient when suffering from rheumatoid arthritis. People with rheumatoid arthritis might be tempted to try unproven treatments. A treatment that promises "a quick cure" or "miraculous relief" can sound wonderful. But remember, these unproven treatments usually are expensive and will do nothing. The sensational successes advertised are usually illusions. They even may be harmful and often keep people from getting the medical care they really need. For example, magnet therapy has not been proven to work for rheumatoid arthritis. New or alternative treatments should be discussed with your doctor.

Medical management may include the use of non-steroidal antiinflammatory medication, corticosteroids, injectable gold salts (Myochrysine, Solganal), methotrexate (Rheumatrex), hydroxychloroquine (Plaquinil) and antimalarial drugs, Sulfasalazine (Azulfidine), D-Penicillamine (Depend, Cuprimine), and various other immunosuppressive agents.

Physical therapy treatments are helpful for most individuals with rheumatoid arthritis. Physical therapists can teach you how to exercise appropriately for your physical capabilities. They will give you valuable instruction on how best to use heat and cold treatments to reduce joint stiffness and swelling and make movement easier. At times, therapists may use special machines to apply deep heat or electrical stimulation to reduce pain or improve joint mobility.

Therapists construct splints for the hand and wrist and teach people how to best protect and use their joints when they are affected by arthritis. They also show people how to better cope with day-to-day tasks at work and at home, despite limitations that may be caused by RA. Sometimes this includes the use of practical tools and items that help individuals perform their day-to-day activities. It is important to remember that people with RA can and should be able to do most of the normal or usual things everyone else can, except that it takes them a little bit longer to do it.

For individuals with severe joint damage, surgery such as total joint replacement can mean the difference between being dependent on others and independent life at home or in the community. Such procedures are performed by orthopaedic surgeons with special training in joint replacement. The damaged parts of the joints are replaced with metal or plastic components. Some people with RA will benefit from replacement of other joints and from other types of surgery for hand and foot problems caused by the disease. Patients with early rheumatoid arthritis, however, should be placed on a program of medications and therapy before surgery is considered.

Osteonecrosis literally means "death of bone" (osteo = bone, necrosis = death). This condition is often called avascular necrosis. It leads to tiny breaks, and often eventual collapse from within the bone. Osteonecrosis frequently appears in relation to another disease or conditions such as rheumatoid arthritis or alcoholism. The underlying problem of osteonecrosis is a decrease in the blood supply to the affected area. The most common areas affected are the hips, knees, and shoulders, but the elbows, hands and feet also may become involved.

The following groups of people are most at risk for developing this condition:

• People who have a rheumatic disease such as rheumatoid arthritis or systemic lupus erythematosis
• People who are taking high doses of steroids (cortisone-like drugs)
• Alcoholics
• Professional scuba divers who have the bends (a condition brought on by the rapid reduction of air pressure)
• People who have connective tissue disorders, such as Gaucher's disease.

Osteonecrosis of the hip occurs most often between the ages of 30 and 50, and is slightly more frequent in men than in women. Osteonecrosis of the knee occurs most often between the ages of 50 and 60, or much earlier if other risk factors are present. Osteonecrosis of the knee occurs three to four times more often in women than in men. Osteonecrosis often involves more than one joint at a time.

The primary symptom of osteonecrosis is pain. Other symptoms of osteonecrosis include limitation of motion, joint stiffness and muscle spasms.

Symptoms usually begin slowly. In fact, in the earliest stage, there are usually no symptoms at all. Other people may notice that you are limping before you feel any pain. Once symptoms begin, they come and go. If the condition is left untreated, progressive bone damage will often occur. Surgery is usually required to correct the bone damage.

Early diagnosis of osteonecrosis is important in order to lessen the damage to bone. As the condition progresses, the death of bone often leads to changes within the bone and nearby joints so that a routine x-ray shows these changes. All too often, permanent damage has already developed by this point.

Aspirin and the newer nonsteroidal anti-inflammatory medications can help relieve the pain of osteonecrosis. Heating pads, warm baths, and an electric blanket can relieve muscle spasms and pain. Activity modifications and the use of crutches or canes can unload painful joints, and physical therapy can help maintain flexibility. These measures may provide some relief, but do not change the underlying process.

Keep in mind that it is up to you to keep your doctor informed of any increase in pain or decrease in mobility. This way, he or she can work with you to keep you as comfortable and functional as possible.

In later stages, if the area of bone has been severely damaged, joint replacement surgery called arthroplasty is needed to replace the damaged bone.

Twenty-five million Americans have osteoporosis. Fifty thousand people die each year because of complications related to osteoporosis. Yet, most of us know little about protecting ourselves from this disease.

Osteoporosis is a disorder of the bones characterized by decreased bone mass (generalized thinning of the bones), which also decreases bone strength. Because weakened bones are more fragile and more likely to break, people with osteoporosis are at increased risk of fractures, especially fragility fractures (broken bones that happen with little or no trauma). It is not a form of arthritis, although it may cause fractures that, in turn, lead to arthritis.

In the United States, osteoporosis causes more than 1.3 million fractures annually and is much more common in women than in men. The most common first fracture is a wrist fracture, which typically occurs at age 50 to 70 in women. Hip fractures and fractures of the spine (compression fractures) may also occur and are most common in patients who are in their 70s. Particularly when it leads to hip fracture, osteoporosis can cause a great deal of suffering, including an increased risk of institutionalization or death.

Most people with osteoporosis have no symptoms and are totally unaware that they have the problem. One early sign can be a loss of height caused by curvature of the spine (Dowager's hump), which is caused by weakened vertebrae (spine bones). The weakened vertebrae undergo compression fractures — tiny breaks that cause the spine bones to collapse vertically. When this happens, the height of the vertebrae is decreased, and the shape of each single vertebra goes from a normal rectangle to a more triangular form. Although the loss of height caused by compression fractures can sometimes be associated with back pain or aching, more typically it is asymptomatic (causes no symptoms).

When taking your history, your doctor will look for factors that increase your risk of osteoporosis. These risk factors include:

• Being female
• Being age 40 or older
• Being a postmenopausal woman who does not take estrogen replacement medication
• Having a diet low in calcium or an intestinal problem that impairs absorption
• Having an overactive thyroid
• Leading a sedentary lifestyle, with little or no routine exercise
• Being thin
• Taking certain medications, such as prednisone
• Having a certain ethnic background (white people and those of Asian descent are more at risk of osteoporosis than are African-Americans)
• Smoking
• Using alcohol to excess
• Having a family history of osteoporosis
• Having a history of at least one fragility fracture

The diagnosis of osteoporosis should be strongly suspected in any person who has a fragility fracture. It can also be established by a bone density test, or bone densitometry. There are several techniques available to measure bone density. The most complete and accurate method is DEXA (dual- energy X-ray absorptiometry), which is the best for both diagnosing osteoporosis and assessing response to treatment. DEXA is a quick (10 to 15 minutes) and painless test that uses minute amounts of radiation (less than dental X-rays) and is generally done on the spine and hip. DEXA is available at Greater Metropolitan Orthopaedics.

Bone densitometry can diagnose osteoporosis when the condition is asymptomatic and mild and can help lead to treatment that will prevent the condition from getting worse. In people with loss of height or suspicious fractures, bone density tests not only confirm the diagnosis of osteoporosis, they also serve as a baseline for treatment and can be used to follow the response to therapy.

Ask your physician or therapist at Greater Metropolitan Orthopaedics if you are at risk for osteoporosis and if bone densitometry may be indicated.