OSTEOARTHRITIS: UNDERSTANDING THE PATHOPHYSIOLOGY, GENETICS, AND TREATMENTS: SURGICAL THERAPY

17 Feb
2010

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For now, however, the only definitive treatment for OA is surgical. Such treatment on OA joints should be attempted only if all the non-operative options have been exhausted, and the goal should be to decrease pain and improve mobility. The least extensive treatment is tidal irrigation. It is mostly performed on knee and shoulder joint and involves washing the joint space with large amounts of saline to remove fibrin and debris (usually while performing arthroscopy of the joint). Other surgical options include osteotomy, which is used in mild cases of OA and mostly involves removing painful osteophytes. The most intensive procedure is total joint replacement, which is used in severe cases and is considered to be the definitive treatment. There also is the new and experimental technique of abrasion arthroplasty. This involves stripping the damaged cartilage off of the entire joint surface and allowing it to be replaced by new cartilage. However the new cartilage is weaker and immature. There is no concrete data yet to show that this procedure is effective and further studies are needed.

It should be noted that there are marked racial disparities in the surgical treatment of OA. White men are 3 to 5.1 times more likely than African American men to receive a total knee replace ment. Similar disparity is found in total hip replacements. The differences in access to healthcare were not enough to explain such a disparity. Ibrahim and colleagues surveyed African American and white VA patients with chronic knee or hip pain on their willingness to undergo a total joint replacement. African American patients were found to be less knowledgeable about the procedure, had worse expectations of outcome, and were less willing to undergo a joint replacement surgery if it was needed and recommended by a physician. This difference in willingness was attributed to the worse post surgical expectations. These perceptions could, at least in part, be based on truth. Katz has shown that African American patients are at higher risk of complications from joint replacement therapy.

ALTERNATIVE THERAPIES

There are many alternative therapies for OA, ranging from herbal remedies, to massage therapy, to chiropractic manipulations, to acupuncture. Despite their immense popularity, alternative therapies are still poorly researched and their benefits are unclear due to scarcity of traditional randomized, placebo-controlled, double-blind studies. Institute of Health & Community Studies in Bournemouth, UK, recently conducted a meta analysis of such studies to determine benefits of various herbal therapies for treatment of osteoarthritis. In general, the review showed that all herbal remedies were well tolerated by the patients, without significant side effects. However, overall scarcity of well-designed studies made it difficult to reliably assess efficacy of herbal remedies in treatment of OA. They found sufficient evidence for beneficial effect of avocado/soybean unsaponifiables (ASU) in improving function and decreasing pain. The studies showed 39% improvement with ASU vs. 18% with placebo at the end of trial and 48% improvement with ASU vs. 26% with placebo at a two-month follow-up. Of note: patients with hip OA had significantly greater improvement than patients with knee OA. The reviewers did not find sufficient evidence to prove anti-OA benefit of such herbs as capsaicin topical cream, tipi tea, and Reumalex tablets (a combination of five herbs: guaiacum resin, black cohosh, white willow, sarsaparilla, and poplar bark).

In addition to clinical trials, there is some basic science evidence of benefits of herbal remedies in treatment of OA. Choi et al. have recently showed that the natural product named SKI 306X (a combination of Clematis madshuri-ca, Trichosanthes kirilowii, and Prunella vulgaris) had beneficial effect on cartilage in colla-genase-induced rabbit OA model. SKI 306X inhibited proteoglycan degradation in vitro and protected rabbit joints from OA-like changes in vivo when given prophylactically. buy generic cialis

Some non-pharmacologic alternative medicine modalities, such as acupuncture, T’ai Chi and even application of leeches at periartricular sites have also been found to benefit patients with OA.

CONCLUSION

OA is a serious illness that affects one’s quality of life and could have lethal complications. It is a very common disease and, with the aging population, it is becoming an even greater public health concern. Currently, extensive work is being done to determine the etiology of the disease and refine prevention strategies, as well as to design better medical and surgical treatments that will provide further symptomatic relief, and possibly, stop or reverse the degenerative processes in the joint cartilage. Considering that more and more evidence is coming out about efficacy of alternative therapies in treatment of OA, as well as their safety profile and popularity among general population, a physician should seriously consider including these options in their general treatment plan for OA. canadian pharmacy online

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