MANAGEMENT OF

To relief pain

Paracetemol (mild to moderate pain)

NSAIDs e.g diclofenac, ibuprofen -if no response to PCM/inflammation features- gastrointestinal (GI) complaints which range from gastritis to ulceration and bleeding are common side effects -pt with GI problem, give together with proton pump inhibitors or COX-2 inhibitors such as celecoxib (fewer side effect)

Tramadol- opiod analgesia ( highly resistant pain)

Topical cream- capsaicin cream-adjunct in hand or knee OA

Glucosamine/chondroitin sulphate- nutritional supplements-symptomatic pain relief + slow progression of OA at early stage, c/I shellfish allergy, caution: worsening DM (monitor blood glucose conc. before rx and periodically thereafter)

Intra-articular injection of steroids-can markedly reduce the swelling of soft tissues and relieve pain-should be used only occasionally, particularly in younger people-adverse side effects e.g accelerate joint degradation, caution if infxn -single injection may be sufficient to relieve OA for several months-the effect lasts for diff. amounts of time in diff. people.

Hyaluronic acid therapy injection e.g Hyalgan® and Synvisc® -viscosupplementation - once a week for three to five weeks- provide pain relief and functional improvement for up to 6 months+ does not cause the side effects of most oral pain relievers- suitable for people who still suffer discomfort after being treated by pain medication, exercise, or physical therapy- expensive

Although no surgical procedure is absolutely indicated or contraindicated for osteoarthritis (OA), certain general aspects are important to consider

-severe pain not responding to conservative rx-limitations in a pt's ability in ADL affecting quality

of life-long-term functional outcome in patients. These factors must be integrated into an overall

evaluation in selecting the appropriate surgical procedure.

A few types of surgical procedures in relation to OA

Arthroscopy- joint debridement to remove interfering osteophyte, cartilage tags and loose bodies

may provide temporary relief from symptoms but does not stop the progression of OA

Arthroscopic view of the removal of cartilaginous loose body.

Osteotomy- used in active pt younger than 60 years who want to continue with reasonable physical activity with mobile jt and most beneficial for significant genu varum or bowleg deformity (mal alignment)

Bone is osteotomized close to the affected joint, and the fragments are then realigned so that a less damaged part of articular surface is exposed to load stress

Osteotomy can lessen the pain, although it can lead to more challenging surgery later if the patient requires arthroplasty

Principle: To redistribute loading forces towards less damaged parts of the joint e.g to shift weight from the damaged cartilage on the medial aspect of the knee to

the healthy lateral aspect of the knee

Arthroplasty- creation of an artificial joint to correct advanced degenerative arthritis and restore integrity and function of the joint.

An excellent treatment in individuals with moderate to severe OA, most reliable, can significantly improve the patient's quality of life, and has results that last the longest (15 years or more).

Candidates are preferably older than 60 years- less likely to need a repeat procedure (revision).

Consists of the surgical removal of joint surface and the insertion of a metal and plastic prosthesis which held in place by cement or bone ingrowth into the porous coating.

HEMIARTHROPLASTY

TOTAL REPLACEMENT

Complications:-Deep vein thrombosis-Infection (most feared cx)-Perforation/# femur/acetabulum esp in v.old,

osteoporotic, previous hip surgery-Heterotropic bone formation-Aseptic loosening-Aggressive osteolysis

Excision Arthroplasty - Girdlestone : resection arthroplasty of the hip-Rarely done these days but are choice after the failure of hip

replacements if there is extensive bone destruction or persistent infection

- The femoral head and neck are excised, leaving a false articulation btwn upper end of femur & side wall of the pelvis

- The ‘jt’ will be unstable but pt can still walk because of local fibrosis and stabilizing effect of powerful surrounding muscle although with marked limp as shortening of the limb ranged from 3 to 11cm, and all patients used a support for walking postoperatively.

Arthrodesis- artificial induction of joint ossification between two bones via surgery

A procedure in which the surfaces of the joint are removed and the bone ends are united- provides pain relief and stability, but the main disadvantage will be the joint cannot bend.

A preferred surgery for some younger individuals who have a single involved joint as mobility in the other joints often will compensate for the loss of movement in the fused joint.

The joints most commonly fused are smaller joints, such as those in

the toes or fingers.

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