Osteoarthrits

Joint Arthritis/Inflammation

What is the osteoarthritis and what problems occur?

Osteoarthritis is essentially wear and tear arthritis. This is different to rheumatoid arthritis (or other types of inflammatory arthritis which are generalised body wide problems ahere the boby’s defence mechanisms attack the patients own joints. (Problems in rheumatoid arthritis are described in the section on inflammatory arthropathy/rheumatoid arthritis). Osteoarthritis (OA) tends to be confined to one or two joints although some patients have a widespread tendency to it. Moreover in anyone middle aged or beyond there will be mild changes of wear and tear arthritis if looked fro carefully but most people are not troubled significantly.

Osteoarthritis is either primary i.e. occurring for no obvious reason or secondary i.e. occurring due to an underlying cause. The most common cause of secondary arthritis is previous injury particularly a fracture (break) into the joint (intra-articular). Some joints are prone to an inherited type of arthritis specific to those joints particularly the end joints of the fingers (DIP joints).

Patients typically present in middle age and later (40yo and onwards) with gradually increasing stiffness/pain/deformity. There may be a family history of joint arthritis (especially finger DIP joints). The pain and stiffness may run together or one or other may predominate. Sometime the symptoms will come on quite quickly following a sudden injury which may be quite mild but then tips the joint over from being potentially symptomatic to being symptomatic. The symptoms may increase giving marked disability due to restricted movement and pain both at night and in the day. Some patients developed significant deformity particularly in old age although may well not have much pain and not be too troubled. The commonest problem is stiffness with or without pain.

Why does it occur?

Normal joints are lined with articular cartilage and lubricated with a little bit of fluid that is continually renewed. Either due to general wear and tear, an inherited tendency or a structural abnormality in a joint such as a previous fracture (break) or operation the lining of the joint thins and may wear away leading to bone rubbing on bone. This is not necessarily painful but may be. The joint tries to protect itself by forming a little more new bone at the edges and producing more joint fluid. These lead to stiffness and swelling.

What happens if nothing is done?

(This is referred to as the natural history i.e. what happens if Nature runs its own course.)

Some people’s symptoms resolve particularly their pain especially if the activities that cause pain are avoided. Many people are left with some long-term stiffness particularly a lack of full straightening (extension). Some patients develop more pain and stiffness with time. They may develop marked pain and increasing disability in their hand affecting both dexterity and grip strength.

Making the diagnosis

The Hand specialist who sees the patient will ask questions about their symptoms, when they started, how they progressed, what treatment (if any) they have had and other questions relevant to the problems. They will then examine the patient looking at the wrists and hands. Stressing i.e. pushing on the affected joint is usually painful. It is necessary to demonstrate some tenderness to confirm the site of the symptoms but this should not be too painful.

What test(s) might be performed?

Tests (also known medically as Investigations) include X-rays, scans, blood tests and particularly in the hand electrical tests (known as EMGs or Neurophysiology). These may be used to help make or confirm a diagnosis after a patient has described their symptoms and been examined.

The diagnosis is usually obvious after listening to and examining a patient. Typically an X-ray is requested on the same day to delineate the extent of joint damage, although the X-ray findings do not correlate well with the symptoms with some patients having few X-ray changes but marked symptoms and vice versa.

Treatment:

What are the non-operative treatments?

Treatment should start with non-operative options. These will depend upon the specific diagnoses. In general the steps are to reduce pain and then try to improve the joint movement. If pain is settled some patients will be satisfied even without any gain in movement.

Pain: The first step is activity modification which the patient may well already have tried. Pain killers (analgesics) particularly anti-inflammatory analgesics, such as Ibuprofen (Nurofen) and Diclofenac (Voltarol) can be very helpful for the pain. These can be applied as a gel, massaging the area, or taken orally, assuming there is no history of indigestion. A splint for certain activities can also be of value. A splint on the end of the finger may prevent it being knocked during certain activities and can rest the joint. If these measures are insufficient then a steroid injection would usually be recommended. An injection is given of a long-acting steroid, such as Depomedrone or Triamcinolone, with some local anaesthetic into the joint at the bottom of the thumb.  The body naturally produces steroids to help dampen down inflammation. This appears to be one of the actions at this site.  Success cannot be guaranteed but in 70-80% of patients there is some significant benefit.  How long this lasts is unpredictable.  Some people only have a few weeks or months of benefit.  Others may have years or even life-long benefit such that they do not require further treatment, although may still have some mild on-going symptoms.  If one injection provides only short term benefit then it may well be repeated.  Patients often ask how many injections can be given.  There is no set rule about this. Typically, however, a second injection will work a little less well than the first (although this is not inevitable).  By the time three injections have been given, if this is over a shortish period, i.e. less than 1 year, then it is unlikely further injections will be successful and most surgeons would recommend an alternative approach. There are risks. The biggest risk is of failure. There are risks of some pain for a few days, although that is usually minimised by taking pain-killers, starting while the area is still numb from the local anaesthetic.  In theory there is a risk of infection, but this seems very rare and has not occurred in our Practice in over 10 years.  The main other risk is some thinning of the skin. This can present with some pallor and a little less bulk at the site and occasionally an increased tendency to bleeding if the area is knocked.  This is not common with this injection but is common with some other injections.  If it does occur then that is a relative contra-indication to further injections, i.e. the patient’s surgeon would probably decide not to go ahead with further injections because of the risks of further local damage. If these interventions fail then surgery may well be required depending upon the patients symptoms. In general whilst pain persist then efforts to improve movement will have limited success.

Movement: It used to be thought that with efforts to regain movement the patient had to suffer a bit: “no pain no gain”. This is probably counter productive in most cases. Rather the ket is long slow gentle stretches. Ideally these should be performed for 5 mins in each direction (feeling the stretch but without pain) once an hour. In practical terms most people mange 5-6 times a day. Stretches can be helped by splints especially for wearing at night where there is an opportunity for prolonged gentle stretching

Even with optimal non-surgical treatment many patients will require surgical treatment if they are troubled enough.

What are the operative (surgical) options?

The joints can be “cleaned out” (called debridement) usually with release of any contracted joint capsule/ligaments. Mostly this is done as an open procedure but for the larger joints – wrist and elbow – this can sometimes be performed arthroscopically (key hole surgery). The clean out may not be sufficient and at the same time or later a joint replacement may be performed. The results of joint replacement are good but not as good as for hip and knee joints (for specific details see relevant information sheets).

What does the operation involve?

The main operations for osteoarthritis are: joint debridement or with more severe disease; joint replacement (arthroplasty); or joint fusion (arthrodesis):

Joint debridement is the first step in a joint replacement so the second is simply an extension of the first. Debridement means cleaning out of the area in this case of abnormal bone and inflammatory tissue. This aims to reduce pain and allow more movement, and hopefully prevent any progression of the disease process.

Joint replacement (arthroplasty): The joint is opened up and cleaned out. If the joint cartilage is suuficiently worn the surgeon may replace the joint. Traditionally a silicone rubber spacer was used for the finger joints.  This gives reasonable results and is still used but in an effort to improve the results newer anatomical joint replacements are used made of pyrocarbon a carbon composite, long used in heart valves, or metal and plastic replacements like those used in other joints. At the end of the operation the deep tissues are closed and the skin is then stitched up usually with absorbable stitches. A supportive dressing/plaster of Paris is applied and the patient’s arm elevated.

Joint fusion: This is not really used for the elbow or the finger MP joints (first joints of the finger) but is for other wrist and finger joints. The operation bliterates the joint creating a solid bony link between the bones. This is stable, usually painless and reasonably functional. The surgeon makes a cut over the back of the joint. The joint is opened up and cleaned out. The thickened bone ends are trimmed to bone tissue with better healing tendencies. The bones are fixed together with a screw(s) or wire construct. At the end of the operation the deep tissues are closed and the skin is then stitched up usually with absorbable stitches. A supportive dressing/plaster of Paris is applied and the patient’s arm elevated.

The total time in hospital for finger joint surgery and for arthroscopic elbow or wrist surgery is usually 4-6 hours. For open elbow or wrist surgery the time in hospital is 1-4 days.

What happens in the next few weeks?

The care of the hand in the post-operative period is very important in helping to ensure a good result. Initially the aims are comfort and elevation. These are met by keeping the hand up (elevated) especially in the first few days and by use of a long acting local anaesthetic (Bupivicaine). The local anaesthetic lasts at least 12 hours and sometimes 48 hours. Patients should start taking painkillers before the pain starts i.e. on return home and for at least 24 hours from there. This way most of our patients report little or any pain.

The patient is typically reviewed in clinic  in the first 2 weeks following the operation.  Typically dissolvable stitches are used so they should not require to be removed. A splint may be provided by the physiotherapists particularly following joint replacement. Careful follow up is required to ensure a successful result with good relief of pain and a good range of movement.

Most of the movement gained following surgery occurs in the first 6 weeks and this time must be used productively to ensure a good result. The key is regular long gentle stretches both into straightening and into bending. Ideally these should be performed for 5 mins in each direction (feeling the stretch but without pain) once an hour. In practical terms most people mange 5-6 times a day. Elevation and icing the elbow also help reduce swelling and thus pain and improve movement.

Most patients can drive after a 2-3 weeks.  Most patients return to work in 5-6 weeks, but this varies with occupation; heavy manual work usually takes about 3 months if ever. The wound should be massaged by the patient 3 times a day with a bland soft cream for 3 months once the wound is well healed (typically after 2 weeks). This reduces the scar sensitivity which can be a nuisance. If this is marked a Physio may be organised to help reduce the scar tenderness but this is rarely required. Patients should avoid pressing heavy use of the hand for a good 3 months from surgery.

What are the results of the operation?

At least 85% of patients in studies say they have a good or excellent result following this operation, with relief of the pain and a reasonable range of movement (except in fusions where the aims are pain relief and atability). The long-term results of the newer joint replacements are not known.  The silicone rubber ones tend to last reasonably well in the fingers but the joints become stiffer with time.

Are there any risks?

All interventions in medicine have risks. In general the larger the operation the greater the risks. For osteoarthritis surgery the risks include:

  • The scar may be tender, in about 20% of patients. This usually improves with scar massage, over 3 months.
  • Aching at the site may last for several months
  • Grip strength can also take some months to return to normal.
  • Stiffness may occur in particular in the fingers. This is usually short-term and only infrequently requires physiotherapy. But it is very important that it is resolved quickly to avoid permanent stiffness. This occurs rarely but can do associated with CRPS (see below)
  • Numbness can occur around the scar but this rarely causes any functional problems.
  • Wound infections occur in about 1% of cases. These usually quickly resolve with antibiotics.
  • For joint replacement there is a risk of long-term joint replacement failure requiring reoperation.
  • For joint fusion there is a risk of failure to achieve bone to bone union of to gain union with some malalignment. Either may (but not of necessity) require reoperation.
  • Chronic Regional Pain Syndrome “CRPS”. This is a rare but serious complication, with no known cause or proven treatment.  The nerves in the hand “over-react”, causing swelling, pain, discolouration and stiffness, which improve very slowly.
  • Any operation can have unforeseen consequences and leave a patient worse than before surgery.