What is Arthritis ?
Arthritis is a degenerative condition that occurs due to wear & tear of the articular surfaces of joints. It can be caused by degenerative process (osteoarthritis), inflammatory process (rheumatiod arthritis, ankylosing spondylarthropathy, connective tissue diseases, etc.) or incongruity of joint surfaces (post-traumatic arthritis, avascular necrosis, developmental dysplasia, etc.).
The wear & tear process of arthritis is progressive and continues in spite of treatment. When a large portion of cartilage is worn away it leads to more pain, further reduction of movements and onset of deformities. There is loss of the natural flexibility of the ligaments and capsule giving rise to contractures. The muscles that span across the joint become thin and weak and less flexible. In late stages there is erosion of the bone ends which can become quite severe. In inflammatory arthritis there is significant thinning of the bone as well. The end result is a worn out and painful joint with loss of movements and deformity.
Advanced arthritis imposes serious physical, economic, mental and social burden on the patient and his family.
In the elderly patients, this leads to chronic pain, difficulties in day-to-day activities, loss of independence and poor health due to immobility and lack of exercise.
Young patients with arthritis face the possibility of social isolation, job loss, marital discord and a severely restricted lifestyle.
Impact of arthritis on the patient and family
Physical burden:
Pain: Severe arthritis gives rise to increasing amount of pain. Initially the pain is present during activity but in later stages the patient gets pain at rest as well. In the most severe cases the patient gets pain during sleep (night cries) that severely affects the quality of life.
Limitation of activities: Pain and stiffness interfere with the patient's mobility which leads to increasing physical limitations. Initially sporting and recreational activities get affected. Later on occupational activities become difficult. In severe cases even day-to-day tasks become problematic (activities of daily living).
Loss of independence: This is especially difficult for the elderly patients who live alone.
Poor health - and other hazards:
As a result of limited mobility the general health of patient suffers. Lack of exercise and physical exertion causes weight gain, poor control of diabetes, poor cardiopulmonary fitness, etc.
Pain and deformity result in limping. Limping worsens backache and can exacerbate the symptoms of spondylosis. Arthritis of the hip, in particular, can cause severe mal-alignment of the spine and directly lead to spondylosis. This is especially true with developmental disorders (hip dysplasia).
Patients with arthritis are prone to falling and sustaining injuries. Hip fractures in the elderly are very common and almost always need surgical treatment.
Prolonged use of painkillers can have side-effects on the kidneys (renal impairment) and heart (ischemic heart disease) and cardio-vascular system (sodium retention, hypertension).
Anti-rheumatic medications (DMARDs) cause liver abnormalities, bone marrow depression and immune suppression. If only a single joint is severely affected, rheumatologists recommend treating that joint surgically rather than punish the whole body with DMARDs. In long-standing cases of inflammatory arthritis, the disease becomes burnt out (inactive). These patients have painful joints secondary to the destruction caused by arthritis. In these patients DMARDs do not give any relief. These patients actually benefit from joint replacement.
Adverse effects of steroids: Steroids can cause hypertension, diabetes, osteoporosis, muscular weakness and depressed immunity.
Economic burden:
Patients who are affected by severe arthritis face difficulty in their job especially if it involves physical exertion or prolonged standing or travelling. Frequent leaves also result in loss of earnings and hampers career prospects. Some patients may need a full-time care-giver or nurse.
Social costs:
Pain and limited mobility prevent the patient from participating in an active social life. This leads to isolation from family and friends and inability to take part in social events. In severe cases they need a full-time care-giver which adds to the social burden. Young patients with arthritis face the possibility of social isolation, job loss, marital discord and inability to fulfill familial obligations like taking care of children, elders etc.
Mental costs:
All of the above contribute to a negative mental outlook and depression.
TREATMENT OF ARTHRITIS
Treatment of early arthritis
Modification of activities, weight reduction, use of ambulatory aids (like stick or walker) and joint supports (kneecap, unloader braces)
Exercises and physiotherapy to maintain mobility, preserve muscle strength and prevent progression of deformities
Pain-killers and anti-inflammatory drugs
Disease-Modifying Anti-Rheumatic Drugs (DMARDs), Monoclonal Antibodies and other biological agents. These are given for inflammatory arthritis.
Nutritional supplements like chondroitin sulphate and glucosamine (neutraceuticals) and other drugs like methyl-sulphonyl methane, esterified fatty acids and diacerin. They are not beneficial in advanced arthritis. They have no role in inflammatory arthritis.
Viscosupplementation is injection of hyaluronic acid into the joint to lubricate it. It provides relief for a few months. It is not useful in advanced arthritis. There is a risk of hypersensitivity reaction and infection with this procedure. It is of no use in inflammatory arthritis.
Steroid injection into the joint provides short-term improvement of symptoms. Repeated injections adversely affect the cartilage lining of the joint. There is a risk of infection and other side-effects as well.
Other methods like magnetic therapy (QMF), platelet-rich plasma (PRP) injections, stem cell injections, etc. are being advocated. There is no hard evidence that these offer long-term benefit. They cannot be recommended universally and are considered experimental at present.
Treatment of severe arthritis
When arthritis progresses beyond the early stage, non-operative measures do not give any relief. In this situation operative treatment becomes necessary.
Arthroscopic washout:
Arthroscopy has a limited role in the treatment of arthritis. It gives partial relief of pain for a variable duration. It does not alter the long-term outcome of the joint. Certain arthroscopic reconstructive procedures like mosaicplasty and cartilage stem cell grafting are appropriate for limited defects in young athletes in the setting of sports medicine. They are not applicable to arthritis because of the widespread nature of cartilage degeneration and associated mal-alignment, stiffness and deformities.
Osteotomy:
Knee arthritis is associated with deformity in which one half of the joint is overloaded. Osteotomy is an operation to realign the limb and shift the weight-bearing stress from the more affected half of the joint to the less affected half. This unloads the arthritic part of the joint and relieves pain. The pain relief is not complete because there is usually some arthritis in the other half of the joint as well. The joint continues to wear out and eventually joint replacement becomes necessary.
Osteotomy can result in over-correction (reverse deformity), change of slope of the tibial surface and scarring and shortening of the quadriceps mechanism. These complications make a future knee replacement more difficult. Hence osteotomy is usually reserved for young patients who have severe arthritis and demonstrable mal-alignment. Osteotomy is being done very infrequently nowadays because the results of joint replacement are far better than osteotomy.
Arthrodesis:
Arthrodesis is an operation in which the cartilage lining of the joint surfaces is completely removed and the bones are fused (joined rigidly) to each other. This eliminates movement at the joint and results in a totally stiff (rigid) joint. Arthrodesis is advised for treating arthritis in ankle, subtalar joint, wrist and some joints of the hand and foot. It is especially indicated for young patients and those with physically demanding jobs. When there is bilateral involvement, arthrodesis of a major joint will result in serious restriction of mobility and worsening of load on the opposite side. Patients do not accept arthrodesis for joints like the hip, knee, shoulder and elbow where it has largely been given up. Joint replacement is the preferred mode of treatment for these joints.
Excision or resection arthroplasty:
In this procedure, the worn out surfaces of the joint are removed and a gap is left in place of the joint. This may be filled by a muscle or fascial or artificial (metal, etc) interface, in which case it is called interpositional arthroplasty. Pain relief is partial. Excision of bone ends results in significant shortening (sometimes severe) and a flail (unstable) limb. The functional outcome of these procedures is poor. Excision arthroplasty is advised for base of thumb, toes and, occasionally, the elbow. It is not accepted by patients for the hip or knee joint.
Joint Replacement (Replacement Arthroplasty):
In this procedure, the worn-out surfaces of the arthritic joint are replaced by artificial bearing surfaces (prosthesis). This provides a lasting relief of pain, restores movements to joints, and corrects any deformities. There is no need for any analgesics or any other medications after joint replacements. The prosthesis is designed to mimic the normal movements of the joint as much as possible. This helps in achieving a near-normal function at the operated joint. Certain precautions and lifestyle modifications are advised to improve longevity of the implant. Joint replacement is one of the most successful procedures in medical field and has dramatically improved the lives of millions of patients.
