Osteoarthritis

The main symptoms of OA are pain, limitation of movements and stiffness of the affected joints. Pain usually starts in the affected joint, occasionally during and after heavy activity, gradually progressing to become obvious with simple activity such as walking then pain becomes continuous even during rest and wakes the patient up from sleep. Occasionally the patient may feel pain in the knee while the pathology is in the hip; this is known as referral pain. Pain may be felt in more than one joint in the body. The patient may also feel that his or her legs are giving away, feeling unstable and not being able to support their body. This is due to loss of cartilage and associate laxity of the ligaments supporting the joint. Stiffness and limitation of movement are very common with OA. The occurrence is gradual; with time the patient will notice that he or she cannot move the joint as well as before, both actively and passively. This may result in joint deformity. Hearing a clicking sound sometimes associated with pain is common.

The main signs of OA are:
* joint swelling,
* limping and
* leg deformity (such as varus or valgus deformities of the knee joint).

Few questions the patient could ask him or herself to assess the severity of the condition if one suspects arthritis.

It is not easy to be objective when assessing your own pain; however here are some questions you can ask yourself to be as accurate as possible.

How severe is your pain?

• The condition is mild when there is no pain or pain is easy to be ignored.
• Mild pain, not affecting activities, may increase with heavy activities and occasionally need to take pain killers for the pain.
• Moderate pain, can be tolerated but have to make concessions to pain, some limitation of activities or work and may require strong pain killers.
• Marked pain, and significant limitation of activities.
• Completely disabled due to pain, pain at rest, bed ridden.

How frequent is the pain?

• Pain is occasional and only with heavy activities.
• Pain is occasional with mild activities such as walking.
• Pain continues all the time even at rest.
• Pain at night preventing sleep or waking up from a sleep.
• Pain location can give an idea about the severity of the condition:
• Pain is superficial under the skin. (For example, on the side of the hip, this means that the condition is something other than arthritis of the hip since hip arthritis pain is usually in the groin and deep.)
• Pain can be pinpointed to one spot. This may indicate that the condition affects a specific part of the joint only.
• Pain is global all over the joint, deep inside and cannot be pinpointed. This may indicate that the disease is advanced.

Other questions about the pain maybe useful such as:

• Is the pain shooting anywhere?
• Is there pain in other joints and pain with certain activities such as walking up hill or down hill?

(This part is easier to asses objectively.)

• How far can you walk?
  - Unlimited
  - Around the mall (30 Minutes) then need to rest
  - Two blocks (10 minutes)
  - Inside the house only
  - Can't walk at all

• Do you walk with a limp?
  - None
  - Slight
  - Moderate
  - Sever
  - Unable to walk

• Do you use a walking aid?
  - None
  - Cane or a stick occasionally
  - Cane or a stick most of the time
  - One crutch
  - Two canes
  - Two crutches
  - Unable to walk

• How easily can you put your socks and shoes?
  - Easily
  - With difficulty
  - Not able to

• Can you get in and out of a public transport or a car?
  - Yes
  - No

• Can you climb stairs?
  - Easily
  - Using a rail
  - With assistance
  - Unable to climb stairs

• Can you sit on a chair?
  - Comfortably on an ordinary chair
  - Can sit on a high chair for 30 minutes
  - Unable to sit comfortably on any chair

(These questions can be answered easily as well.)

• Does the joint swell up?
  - No
  - Yes, occasionally with heavy activity
  - Yes, with any activity
  - The joint is always swollen

• Does your joint get hot?
  - No
  - Yes, occasionally with heavy activity
  - Yes, with any activity
  - The joint is always hot

• Does your joint get red?
  - No
  - Yes, occasionally with heavy activity
  - Yes, with any activity
  - The joint is always red
• Do you hear a click in the joint?
  - Yes
  - No (This may indicate a possible lose body inside the joint associating with the pain.)

• Does your joint lock?
  - No
  - If yes, what do you do to unlock it? (This may give an Idea of possible lose body blocking the movement.)

• Is your Joint stiff?
  - No
  - Yes, only in the morning then it get moving as the day pass
  - Yes, most of the time
  - Yes, all the time

• Does your joint give way on you?
  - No
  - Occasionally
  - Most of the time
  - All the time

As a general rule, if you score high on most of the mentioned questions then you very likely have arthritis and may need surgery.

To confirm the suspected diagnosis of OA, radiological investigation is necessary. Plane X-Ray films are a very useful tool in confirming the diagnosis and quite often it is all that I may ask for. However, in certain circumstances I may ask for further investigations such as MRI scan to outline the soft tissue surrounding the joint, especially if the condition is suspicious of soft tissue disruption like labial tear of the acetabulum or meniscal injury in the knee. I may also request other tests like blood test and electrocardiogram if the plan is to proceed with surgery.

Must I have surgery? Are there any alternative options?

I preserve surgery as a last resource in my line of action. If all other measures failed then I talk about surgical intervention.

What are the conservative or nonsurgical measures?

Non surgical measures include targeting the pain and targeting the joint pathology. For example:

• Modification of activities.
• Using a walking aid.
• Losing weight.
• Physiotherapy, which includes range of movement exercises or strengthening exercises to correct the mal-tracking (for example in the patello-femoral joint).
• Using pain killers and NSAID medications.
• Using cartilage stimulating medications, such as fish oil and glocosaminoglycane.
• More invasive measures such as injection of steroids or lubrication material into the joint.

If all conservative measures fail does that mean I must have joint replacement surgery?

No! There are other operations which may be useful to overt the need of joint replacement or at least delay that for a few years more.

In the case of knees, there are well established operations such as knee arthroscopy (key hole surgery) in which I could do a fair bit in the joint. (For example, remove lose bodies that may be the main reason of pain, repair or debride the torn meniscus cartilage, clean the joint from debris and stimulate new cartilage formation by drilling the subchondral bone.)

Another well known operation in the knee is high tibial osteotomy (HTO) which can be done to transfer the load to the urn affected part of the joint giving more time before the need of joint replacement.

In the hip joint now we are familiar with hip arthroscopy (key hole surgery), this operation has become more popular and the list of indications is expanding. We can use hip arthroscopy for removal of lose bodies from the joint, debride torn laburum, stimulating new cartilage formation by drilling the subchondral surface, cleaning the joint from debris and removal of impinging osteophytes and bony spurs from both the acetabular and femoral sides.

Another operation in the hip joint is open removal of impinging osteophytes, bony spurs and debridement of torn laburnum. This has been significantly replaced nowadays by hip arthroscopy since it can be done through much less scar and in even better exposure to the pathology.