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Arthritis

Osteoarthritis is one of the most common rheumatic diseases in this arthritis, artritis. Actually, for most rheumatologists it may not be the biggest part of their practice -probably rheumatoid arthritis is - because often these patients have mild disease or it’s treated either by the primary care physician or they end up going directly to the orthopedic surgeon who can, in some instances, cure the disease. It’s a slowly progressive, usually polyarticular disease, involving certain joints. Usually weight-bearing joints and certain joints in the hand, especially the DIP joints, PIP joints and also the first carpometacarpal or CMC joint. This is a woman who actually had giant cell arteritis and I was following her for that and she really never complained about any articular manifestations, unless her associated polymyalgia rheumatica flared up. So she had had these little nodules, Heberden’s nodes, for a number of years, thought they were ugly but other than that didn’t seem to care too much about them.

Of course osteoarthritis can occur secondarily to other diseases. Trauma. Someone who had a broken hip or a torn anterior cruciate ligament may be predisposed to develop osteoarthritis in that joint later. Inflammation, either chronic inflammation as in rheumatoid disease or acute inflammation, as in a patient with septic arthritis that just didn’t respond well or get treated adequately. Again, metabolic factors, AVN, avascular necrosis, sometimes by the time you see the patient you can’t tell what the cause was in a single joint, but maybe they have a history of AVN in another joint. Of course if you follow a patient with AVN that is very early in the course and you don’t operate right away.

Probably about 60 million people have x-ray evidence of osteoarthritis in this county. Any country that has a significant older population, it’s a significant problem. Obviously if you go to a country where the average life span is 45, I don’t think osteoarthritis is going to be on the top of their list of things to treat. But in this country it is a very significant medical problem. It’s not life-threatening.

I just want to review a few things that can help you identify what is more likely a structural disease, like osteoarthritis. Generally symptoms with use, gradually progressive course and also no systemic symptoms. That’s what the patients will tell you, "If you can make my back better, if you can make my knee better, I’m going to be very happy." Of course, that’s the challenge. Whereas an inflammatory disease, like rheumatoid arthritis, morning stiffness and systemic symptoms - particularly fatigue - are very typical. And I think that those are two things that you can remember in taking a history in any type of rheumatic problem, they will help separate chronic inflammatory versus pure articular structural diseases. The morning stiffness and fatigue. On examination, osteoarthritis generally involves joints in the hands and these weight-bearing joints.

Going into the treatment of osteoarthritis, again there is no cure, but there is quite a bit that we can do for these patients. A lot of things can be very helpful for a patient. The patients that have pain but good function of the joints, meaning that they have the symptoms of pain with use, but you examine their knee and they have good range of motion, good stability, then if you control the pain their function should improve because it’s the pain that is limiting their function. So things like analgesics, acetaminophen, Darvon, sometimes even a little Tylenol with codeine can be helpful. Non-steroidal antiinflammatory drugs can be useful because they do have analgesic effects. And some patients do have a little bit of inflammation and that might help to control that. But remember, this is an older group of patients and sometimes non-steroidal antiinflammatory drugs.

Intraarticular sodium hyaluronate. how many of you have used this or heard of this? Synvisc or Hyalgan? I’ve only used it a couple of times. One patient that I just finished a course, seemed to like it, the other patient I haven’t seen back yet. These are injections of basically sodium hyaluronate which is purified from chickens, the comb of the rooster, which is like pure hyaluronic acid or hyaluronan if you will.

Physical therapy: two very simple things that you can do in your office is show your patient how to do what we call, "straight leg raising" exercises which are isometric exercises, to help strengthen the quadriceps. There have been some studies showing that patients with osteoarthritis have a very subtle but documentable weakness of these quadriceps muscle. They are not going to complain, "I can’t do this, or I can’t do that" and if you were just to do your gross muscle testing in the office you probably wouldn’t pick it up.

The other thing that is helpful is using one of these Neoprene sleeves or like an ACE bandage that you pull up and it goes right over the knee. When you talk to patients who have osteoarthritis of the knee, a very common complaint is "It doesn’t hurt so much. It feels like it’s going to give out" or "It’s unsteady" or "The pain is in the back of the knee." They won’t describe what you think they should describe and I think that a lot of what they are describing is this abnormal proprioception but it’s just not gross enough - especially for me with my neurological exam - to be able to detect anything. What has been actually shown in studies is that if you have something on the skin, it improves proprioception.

Lastly, orthopedic surgery. In general we are talking about joint replacement. In a patient with knee involvement, that is uni-compartmental, meaning that it is medial or lateral compartment with a normal patellofemoral joint, especially in someone who is younger, you can consider what they call a "high tibial osteotomy." Some orthopedic surgeons may not be very comfortable doing that because it’s not a commonly done procedure. Probably an orthopedic surgeon who does only knee replacements is going to be someone who does this with any frequency. What they do is take a wedge of bone out to open up the joint space that narrowed. In effect it helps to correct any angular deformity.

A couple of things; using things like a cane is very helpful. You have a patient with arthritis in one knee or one hip, and these aren’t just for osteoarthritis, this is a general rule. Every patient that I’ve ever seen that came in with their own cane uses it incorrectly. Most of the time they use it on the wrong side. All the time it’s too long. A couple of very simple rules, you can prescribe a cane. Usually I prescribe an aluminum adjustable cane. Or if they have a wooden one, if they have someone who can use a saw at home, then I’ll mark off the length at which they saw it. Of course, then the cane can’t be used for someone taller in the family a few years later. But an adjustable aluminum cane is not expensive and you just unscrew it and push the button, and it goes up and down within a certain range.