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Osteoarthritis of the hand

The EULAR ( European League Against Rheumatism ) issued recommendations in 2006 for the treatment of Osteoarthritis of the hand. They refer to rhizo-Osteoarthritis and Osteoarthritis of the fingers.

The best approach combines pharmacological treatments with non-pharmacological treatments. However, the choice of treatments remains difficult due to the absence of good quality clinical trials and the low level of testing.

It is necessary, above all, to specify the patient's complaint to know if it refers more to the aesthetic repercussion, pain or disability. Individual treatment and self-management by the patient are paramount.

Non-pharmacological treatments, including ergotherapy, reeducation, the use of technical aids (orthosis or splints) occupy an important place in the recommendations.



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Non-pharmacological treatments

Re-education
The aim of reeducation is to limit joint tensions and maintain joint mobility.
Several techniques are used, such as analgesic massage, thermotherapy, ultrasound and gymnastics. It is important to fight joint stiffness through reeducation, since once installed, it is irreversible.

The local application of heat (hot bandages or paraffin wax) and ultrasound can provide antialgia in a short period, and are proposed before the exercises.

Ergotherapy
Ergonomic measures have to be taken. The patient must be advised to practice "joint savings". For example, you can write with a large diameter ballpoint pen, modify instruments that require a fine grip, etc.

Technical support orthosis thumb

Technical help
The splints can prevent stiffness in bad position, particularly at long fingers. At the level of the thumb, the fight against deformation is also important. It must be early, since progressive degradation of the joint results in an adductus thumb, a loss of mobility and an often important functional discomfort. The latter is aggravated by the atrophy of the thenar eminence against which you have to fight doing exercises.

The thumb orthosis stabilizes the thumb in the function position. It has an orthopedic function against deformation, but it is also analgesic. It can be worn continuously during acute painful periods, or only at night, outside of crises, when the pains are less disabling.

In practice, the orthoses molded to measure in the patient, allow a better adaptation, especially in case of rigidity already installed. Good compliance depends on a good tolerance of the orthosis by the patient.
Pharmacological treatments

With regard to pharmacological treatments, it is necessary to favor the molecule with the best benefit / risk ratio and to re-evaluate the indication regularly.

Local treatments are still preferable to systemic treatments.

Local treatments
Topical NSAIDs can be used with a good symptomatic effect.

Paracetamol
Paracetamol is the reference analgesic since it is effective and has a very good tolerance. You can take up to 3 grams a day.

NSAID and Coxibs orally
NSAIDs should be reserved as a 2nd option in case of failure of paracetamol and / or in case of inflammatory access.
They should always be prescribed and used at the lowest effective dose and for the shortest possible time.

• The choice of an NSAID should be made taking into account its safety profile and the individual risk factors of the patient.
• There is no need to prescribe conventional NSAIDs or coxibs in case of an evolutive peptic ulcer or gastro-intestinal bleeding, a history of digestive bleeding or perforation during NSAID treatment.
• NSAIDs are susceptible to induce an acute IR, it is necessary to remain particularly attentive with patients treated with diuretics, which present a risk of hypovolemia or impaired renal function.
• In patients suffering from confirmed ischemic heart disease, peripheral arterial disease and / or history of stroke (including transient ischemic attack), coxibs are contraindicated and non-selective anti-inflammatory drugs should be used with caution.

Infiltrations of corticosteroids
During painful accesses, intra-articular corticosteroid infiltrations may be proposed to patients. Eventually they can be radio-guided, as access to the joint is often difficult, due to joint pinching and the presence of osteophytes.

Surgical treatments

In case of persistent painful symptoms or a handicap with deformation despite optimal medical treatment, surgical treatment may be considered.

Joint excision consists of a resection of the osteophytic protrusions. This intervention does not modify the osteoarthritic evolution and allows pain and joint discomfort to persist. This surgery is carried out more on a psychological basis.

Digital centering osteotomies can help in the case of particularly disturbed off-center joints.

Arthrodesis aims to fuse the joint in a position of function. It allows a good relief and a centering, but it entails a loss of mobility.

It may be interesting for the distal interphalangeal.

The arthroplasties are used for the proximal interphalangeal ones, since at this level a conservation of the mobility is indispensable.

In the particular case of rhizo-osteoarthritis, there are 3 surgical possibilities:

•     trapezectomy,
•     the escafotrapezoidal arthrodesis,
•     the trapezometacarpal prostheses.

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How to treat osteoarthritis of the knee

How is osteoarthritis of the knee treated?

Your doctor will recommend therapies to help relieve pain. Your doctor can tell you that:

•     Rest your knee or avoid activities that make your pain worse.
•     Put ice on the knee for 20 to 30 minutes a few times a day, to reduce inflammation and relieve pain.
•     Take an over-the-counter medication, such as acetaminophen (one brand: Tylenol) or ibuprofen (one brand: Motrin).
•     Do physical therapy or certain exercises to help strengthen the muscles that surround the joint.

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Are there other options?

Yes. If oral medications and physical therapy do not help the knee enough, your doctor may consider giving you an injection of pain medication (called an anesthetic). This can stop the pain for days to weeks. Adding another medication (called a corticosteroid) to the anesthetic can prevent pain and inflammation for longer. If this does not help enough, your doctor may talk to you about surgery or injections of hyaluronic acid.
What are hyaluronic acid injections?

Some of the hyaluronic acid is already in the joint fluid. In people who have osteoarthritis, hyaluronic acid becomes less thick. When this happens, there is not enough hyaluronic acid to protect the joint. Injections can introduce more hyaluronic acid into the knee joint to help protect it.

Injections of hyaluronic acid may relieve pain more than oral medications. These injections can help the pain go away for 6 months to a year and, sometimes, longer. Unfortunately, these injections do not help all people.

Hyaluronic acid injections are also expensive, but many health insurance programs cover them. It is possible that hyaluronic acid injections are an option for you. Your doctor will talk with you about the advantages and disadvantages of hyaluronic acid injections and whether they are right for you.

What happens with the surgery?

Sometimes osteoarthritis of the knee is so intense that surgery is required to relieve the symptoms. Surgical options include:

•     Arthroscopy is performed with a small endoscope (or camera) that is inserted through the tiny cuts made by a surgeon in the knee. With the endoscope, the surgeon can see the degree of severity of the damage that osteoarthritis has caused in the knee. With other small instruments, the surgeon can remove the damaged parts of the knee joint (this is called debridement), and clean or purge the joint to remove any loose part (called washing or irrigation) that may be causing pain. . Arthroscopy is not suitable for all people and can only provide temporary pain relief or delay the need for other surgeries.
•     Osteotomy is a surgery that re-locates or reshapes the bones of the knee where osteoarthritis has caused damage. This procedure can only be done when only one area or one side of the knee is damaged. This procedure changes the position or alignment of the knee so that the weight is removed from the damaged area. This procedure restores movement in the knee and relieves pain. However, it is possible that people who underwent an osteotomy will need knee replacement surgery in the future.
•     Arthroplasty is also called joint or knee replacement therapy. A surgeon removes the part of the knee damaged by osteoarthritis and replaces it with an artificial joint made of metals and plastic. In this procedure, all or part of the knee joint can be replaced. Although the recovery may take a long time depending on the magnitude of the surgery, the results of the arthroplasty are often successful. Knee replacement therapy can help put an end to your pain and improve or restore movement of the knee.

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High costs and social problems due to lack of treatment of osteoarthritis

It is estimated that 0.4% of GDP in Mexico is destined for the attention of musculoskeletal diseases. Osteoarthritis (OA) is one of the main causes of disability after 40 years of age.

Therefore, multimodal treatment that includes pharmacological and non-pharmacological measures, from the more traditional such as analgesics and the most recent such as viscosupplementation, is important, noted the Mexican Initiative for Patients with Osteoarthritis and Rheumatoid Arthritis (IMPACTAR).



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At the press conference to announce the actions of IMPACTAR to celebrate the World Day for Rheumatic Diseases, Dr. Fernando Torres Roldán, President of the Mexican College of Orthopedics and Traumatology (CMOT), said that the prevalence of osteoarthritis, and in general of this group of ailments, has as a consequence physical, social and economic problems, both within the family and for health institutions. " By 2050 it is expected that the number of people over 60 will triple, since Mexico ranks sixth in terms of aging ."

OA is a chronic inflammatory condition that causes degeneration in the joints, mainly of the hip, hands, knees, lower back (back) and neck. It is estimated that it affects approximately 2.5 million people in Mexico, with a prevalence of 10.5% of the population and this is due to wear in the upper layer of cartilage that generates friction between the bones of the joint. It manifests clinically in pain, swelling and loss of movement.

It is estimated that rheumatic diseases diminish up to seven healthy years and in women the reduction is up to 13 years. These are problems that derive from total or partial disability caused by these diseases, because they generate high economic costs, due to the type of specialized care that includes the use of orthopedic devices and rehabilitation therapies, as well as the payment of subsidies and disability pensions. There lies the importance of adequately treating patients with options that slow the progression of the disease and provide them with quality of life, said Dr. Torres Roldán.

The specialist said that the management of patients with OA has evolved both from the diagnostic and therapeutic point of view, due to scientific advances on pharmacological interventions increasingly effective and safe to improve joint function and reduce pain caused by the deterioration of joints in patients. " There are new treatment patterns, such as viscosupplementation, which consists of the infiltration of a viscous and elastic substance with properties similar to those of synovial fluid in healthy patients, which have favorably contributed to optimizing the condition of the affected joint, especially on the knees".

In addition to the presentation of these new treatment patterns obtained through various studies and the research protocol carried out by the Initiative, the IMPACTAR race was announced, aimed at raising awareness about joint care, mainly in the knees. "We call on society in general to join in the race to be held on October 17, in the second section of Bosque de Chapultepec, to offer information about these diseases and the impact of the lack of timely diagnosis and treatment, as well as as in the quality of life of patients .

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What is osteoatritis and how can it be managed?

Osteoarthritis

There are more than 100 types of arthritis and the most common is called osteoarthritis. It is a degenerative condition of the joints and can vary in severity from a mild to very severe disabling pain.

It usually begins with the rupture of the flexible tissue of the joint known as cartilage and can cause stiffness or immobility of the joints. Many people can develop osteoarthritis: men and women, the elderly and even children. It is more common for osteoarthritis to affect the knees, hips, spine, and hands.

Many people suffer from arthritis - including men and women, the elderly and even children. There are more than 100 types of arthritis and the most common is called osteoarthritis.



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Osteoarthritis: a degenerative disease of the joints

Osteoarthritis begins with the rupture or degeneration of the joints between the bones of the body. The flexible tissue, known as cartilage, provides a cushion where the bones meet and prevents them from rubbing against each other when moving. The cartilage, as well as any other shock absorber, can begin to wear out over the years and the use of the joints and as this happens, the preventive mattress between the bones of the body decreases. 10

Osteoarthritis can:

•     Affect many joints, such as hands, knees, hips and spine.
•     Worsen over time, which can cause the break between cartilage and bone. The bones may begin to rub against each other and wear or damage. This can result in persistent pain.
•     Cause joint pain and stiffness. These symptoms may get worse after resting or not moving the joint for a while.
•     Limit the movement and flexibility of the joints, since the affected joints can not bend easily or in their full range of mobility.
•     Causing chronic pain and severe disability in extreme cases and can affect normal day-to-day activities such as walking, climbing stairs or opening jars.

Risk factors for osteoarthritis

Age is a factor of osteoarthritis. People usually develop osteoarthritis from age 40 and up.

Osteoarthritis is more common and severe in women, especially in the knees and hands. eleven

Preventing osteoarthritis is not always possible due to multiple factors that contribute to its development:

•     Joint injuries can increase the risk of developing osteoatritis in the future (for example, tennis elbow). Be careful not to overwork a damaged or painful joint and try to avoid repetitive or excessive movements of the joints. eleven
•     Being overweight or obese can contribute to the development of osteoarthritis. Excessive weight overloads the joints, particularly in the knees and hips and can result in knee and back pain. eleven
•     Treatment options for mild to moderate osteoarthritis include over-the-counter pain relievers or heat therapies to reduce pain. The medical guides recommend acetaminophen as the analgesic to treat joint pain.
•     Physical therapies that include exercising, staying active, losing weight and maintaining a positive attitude can also help manage osteoarthritis.

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Causes, symptoms and treatments for Osteoarthritis

Osteoarthritis

There are more than 100 types of arthritis and the most common is called osteoarthritis. It is a degenerative condition of the joints and can vary in severity from a mild to very severe disabling pain.

It usually begins with the rupture of the flexible tissue of the joint known as cartilage and can cause stiffness or immobility of the joints. Many people can develop osteoarthritis: men and women, the elderly and even children. It is more common for osteoarthritis to affect the knees, hips, spine, and hands .



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CAUSES OF OSTEOATRITIS

Commonly, osteoatritis results from the rupture of flexible joint tissue, known as cartilage. Healthy cartilage allows bones to slide smoothly over each other during movement. But when the cartilage is damaged or worn, the bones rub against each other, causing pain, swelling and loss of joint mobility.

SYMPTOMS OF OSTEOARTHRITIS

The main symptom of osteoarthritis is joint pain. This can vary from a mild and uncomfortable pain to a severe and disabling pain. Most of the time, this pain appears when using the joint and disappears with time, when resting.

As osteoarthritis progresses, pain may persist when resting and even appear at night when sleeping. Osteoarthritis can cause joint stiffness, hindering the flexibility and the total range of motion of the joints.

TREATMENT FOR OSTEOARTHRITIS

Some of the most important treatments for osteoarthritis are simply a change in attitude and lifestyle. Physical activity and movement, for example, can improve joint mobility and reduce pain. Similarly, changing the diet to help maintain an ideal weight can relieve pressure on many joints.

Because osteoarthritis is a progressive condition, specific treatments for pain relief are usually needed, such as:

•     Analgesics such as acetaminophen
•     Creams, gels and ointments that can be applied to the skin to help reduce inflammation of the joint
•     Supplements such as glucosamine
•     NSAIDs that may require a prescription

If you have osteoarthritis, ask your doctor about treatment options. You can also consider the recommendation of other health professionals such as pharmacists, physiotherapists or nutritionists .

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Osteoarthritis of the knee

Knee osteoarthritis (OA) is one of the main health problems worldwide due to its high prevalence and associated costs. The available knowledge shows that the inflammatory component is fundamental in the development of this condition, abandoning the concept that OA is a purely degenerative disease. In this paper we will review, based on the available literature, the epidemiology and the risk factors involved, the new physiopathological knowledge, the clinical confrontation and the available medical and surgical treatments of this condition.

Introduction

Osteoarthritis is one of the main health problems worldwide due to its high prevalence, being considered the most common cause of permanent disability in people over 65 years of age in the countries in which it has been studied. greater frequency of this disease at the level of the knees 1-3 . OA was classically defined as an articular degenerative condition characterized by progressive loss of articular cartilage, marginal bone hypertrophy (osteophytes) and changes in the synovial membrane 2,4,5 , however today it is recognized that in this disease there is a gene pattern and proteomic inflammatory characteristics similar to that found in diseases as diverse as rheumatoid arthritis or metabolic syndrome 6-10 , so that currently recognizes the inflammatory component as a fundamental part. In this paper we will review the current confrontation of knee OA based on the reports available in the literature.



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Epidemiology and risk factors

In order to determine the exact prevalence of knee OA, the definition of the disease used, the diagnosis method (clinical and / or imaging) and the affected joint are fundamental, and therefore the available data are diverse. Despite this, it is described that more than 50% of the population over 65 years of age presents some type of OA, with the knee joint being the most affected, with an incidence of 240 / 100,000 people / year.

Given that OA develops progressively over time, and that in 50% of patients the symptoms do not correlate with radiological alterations, it is essential to know which risk factors are associated with this condition and which are not. Among the recognized risk factors are age and female sex, while the genetic component has a low association with knee OA, unlike what occurs in other joints, such as the hip or hands 12 . Alterations in weight have been consistently related to knee OA, describing a relative risk of 2 for overweight people and 2.96 for obese people 13 . New systemic risk factors have been recognized in recent years highlighting the metabolic syndrome; the presence of 2 of its components causes a risk of knee OA of 2.3 times, while with 3 or more components the risk rises to 9.8 times 6 .

While physical activity has not been identified as a risk factor for the onset or progression of knee OA, 14 prior articular injuries are recognized as capable of conditioning the development of joint degenerative phenomenon. Special emphasis should be given to menisectomy greater than 30% and rupture of the anterior cruciate ligament (ACL), which condition a relative risk of the order of 7 14 and 5 times 15 respectively, producing an early posttraumatic OA (between 10-15 years of the original lesion); This is especially relevant in ACL injuries, since the surgical reconstruction of this does not reduce the risk of OA.

Pathophysiology of osteoarthritis

Without a doubt this is one of the issues that has generated a high number of research in recent years, because the final understanding of the phenomena involved would generate prevention strategies for the development of OA.

Classically, knee OA has been considered as a purely mechanical condition, with capital importance given to joint overloads associated with shaft alterations (mainly knees), traumatic injuries and multiligamentary instabilities. However, OA is currently recognized as a multifactorial disease where several noxious individuals are able to generate and perpetuate the damage to the articular cartilage, with the subsequent response of the synovial membrane and subchondral bone 11 . In this way, when the extracellular condral matrix (MEC) is compromised, a decrease in the water retention capacity is generated, losing the tissue resistance, resilience and elasticity against compression 16,17 , increasing the damage of the surrounding tissue. Due to the low rate of cell turnover and the poor reparative capacity of the cartilage, it can not compensate for the damage suffered, eventually generating the phenomenon of OA.

Regardless of the original cause of the damage, the fibroblasts of the synovial membrane respond by secreting various cytokines and inflammatory factors (IL-1, TNF-α, TGF-β, IL-8, GRO-α, among others). These inflammatory factors remain present in the joint, independent of the corrective treatment of the original cause of chondral damage (ligament stabilization, reduction of fractures, correction of axes, etc.), being able to maintain the progression of joint damage 9,18-21 . The inadequate response of the subchondral bone replaces the hyaline cartilage with fibrocartilage constituted mainly by type I collagen, which gives it a lower mechanical capacity 4,22,23 at the same time as a process of hypertrophy of the subchondral bone, characterized by angiogenesis with penetration of the neovessels in the deep layer of articular cartilage and chondral apoptosis followed by mineralization of the MEC 18,24 , which is clinically appreciated with the formation of osteophytes, geodes and decreased joint space.

Clinical confrontation, diagnosis and classification

OA of the knee is a condition whose diagnosis is eminently clinical based on the patient's signs and symptoms, the risk factors and the alterations present in the physical examination. The classic presentation of this condition is in patients over 50 years of age with chronic pain of mechanical characteristics, which is greater when initiating movements, and may subsequently decrease associated with joint stiffness greater than 30 min and joint deformity with loss of joint ranges, crepitus and effusion. However, there is a wide range of presentation of this table, not requiring all of it to make the diagnosis, so that clinical suspicion is essential, especially in patients who have the risk factors described. For the diagnosis of precision, specific criteria have been described, highlighting those of the American College of Rheumatology 25 ( Table 1 ). However, from the practical point of view these criteria are mainly used in the development of research studies.


Once diagnosed, the OA must be classified as primary or idiopathic (in balloon they correspond to 70% of knee OA) or secondary 11 , which is fundamental for the therapeutic approach in relation to the presence of other conditions susceptible to treating specifically . It is important to remember that there is no direct correlation between the degree of radiological joint deterioration and the clinical presentation of patients, 26 although it is advisable to have a basic study of rays in all patients. It is essential to obtain radiographs of good technical quality, recommending a basic study in anteroposterior, lateral, axial projection of the patella and Rosenberg ( Figure 1 ). It seems fundamental to emphasize the importance of this last projection, since it is the one that has the best correlation with the reduction of the thickness of the articular cartilage, especially in the medial compartment 27 . Radiologically, knee OA is classified in 5 grades as described by Kellgren-Lawrence ( Table 2 ) 28 , and there are other classifications described, such as Ahlback. Currently, in patients with arthritic joint pain and a negative or nonspecific radiological study, our challenge is to associate a second-line study such as magnetic resonance or arthro-CAT to adequately evaluate the characteristics of articular cartilage, soft structures periarticular and rule out other differential diagnoses (avascular necrosis). The techniques and sequences currently used in magnetic resonance imaging, such as T2 mapping, dGEMRIC or T1rho, allow to obtain quantitative information of the present chondral damage and to adequately differentiate generalized disorders of the joint (OA) with focal chondral or osteochondral lesions, which can be confronted in a specific way with highly satisfactory results 29 .


Conservative treatment alternatives

It is fundamental to understand that even today's knowledge there is no conservative treatment of OA demonstrated as capable of stopping or slowing the progression of its progression. There are a series of interventions that have been postulated as effective for the reduction of symptomatology and functional improvement, presenting solid evidence of its usefulness in weight reduction 30 and low-impact aerobic physical activity in water and floor associated with joint physiotherapy ( [TENS] exercises of joint ranges, open chain fortifications) 31 .

In relation to the available pharmacological treatments, it is essential to differentiate between those that have a clearly analgesic purpose and those that are proposed as chondroprotectors or modulators of the disease ( Figure 2 ). Within the first group of medicines we find:

• - Paracetamol (acetaminophen): analgesic without potent anti-inflammatory effects, it is considered as the 1st line drug in the treatment of knee OA, its safety being proven in long-term use 32 .
• - Non-steroidal anti-inflammatories (NSAIDs): drugs that, through the inhibition of COX enzymes, control the inflammatory process and the cascade of pain. They have been shown to be more effective than placebo and paracetamol in the treatment of pain, function and rigidity. The current recommendations are its use in patients who do not respond to paracetamol, since they have potential deleterious effects in its long-term use 33 .
• - Intra-articular corticosteroids (CIA): antiinflammatory agents historically used for OA due to its ability to reduce the inflammatory phenomenon, and through this decrease the symptomatology. Studies in animals have shown that low doses of CIA normalize the synthesis of proteoglycans and reduce chondral damage. However, when evaluating clinical use, the CIA have only shown a beneficial effect in the short term for pain relief (one week after treatment), compared to placebo, but in the long term it does not show beneficial effects and could even induce a increase in chondral damage and increase the risk of joint infection 34,35 . Our current confrontation does not recommend the use of these compounds in clinical practice, except in the cases of transient synovitis associated with joint effusion in patients diagnosed with previous OA.

Within the second group of drugs (postulated as chondroprotectors or disease modifiers) include:

• - Glucosamine (GA) and chondroitin sulfate (CS): compounds that participate in the formation of MEC proteoglycan synthesis. Both medications are administered orally. According to the available evidence, they may have a limited role in the symptomatic treatment of OA, but there are no studies that consistently demonstrate the modification of the progression of the disease 36,37 . Our current confrontation does not recommend the use of these compounds in clinical practice.
• - Unsaponifiable waste medicines: these drugs have demonstrated in vitro the ability to inhibit interleukin-1 and to stimulate the synthetic activity of articular chondrocytes. However, there are conflicting reports in relation to its usefulness in reducing or stopping the progression of the arthritic phenomenon 38 . Due to biological logic and basic science studies, our current approach includes its use with caution 39 .
• - Nutraceuticals: Among the "natural" therapeutic alternatives with possible antiarthritic effects, numerous nutraceutical compounds stand out, which share antioxidant capacities among their effects. In vitro studies have been reported in which interesting effects are shown in relation to improving the articular cartilage environment, mainly by the stimulation of anabolic metabolic pathways. Resveratrol and green tea, which have been evaluated in OA models. These polyphenols inhibit intracellular signaling pathways that stimulate proinflammatory effects capable of inducing chondral damage, a mechanism by which they could be useful 40 . They have not entered into our current therapeutic scheme due to the lack of better quality studies.
• - Hyaluronic acid (HA): unsulfated glycosaminoglycan found in large quantities in the MEC and the joint fluid. It is produced mainly by chondrocytes, synoviocytes and fibroblasts. Its function is to capture water molecules, giving it elasticity and thus contributing to the distribution function of the load of the joints. It has lubricating, mechanical barrier, anti-inflammatory, analgesic and chondroprotective effects demonstrated by in vitro and in vivo studies, promoting chondral proliferation and the synthesis of ECM components. The available evidence indicates that intra-articular HA is effective in approximately 60% of patients with knee OA in generating symptomatic improvement 41,42 . There are several treatment schemes (single injection versus repeated lower dose cycles), but it is accepted that the treatment can be repeated every 6 months. It is a good therapeutic alternative, its high cost being a limiting factor for its massive use.
• - Platelet rich plasma: natural source of cytokines obtained from platelets, which store more than 60 growth factors in their α-granules, which are subsequently released into the extracellular environment regulating different biological processes. In relation to knee OA, there is evidence that symptomatically it has better results than HA in patients with OA, 43,44 however its high cost complicates its use in current clinical practice.

Alternatives of surgical treatments

Surgical treatments for knee OA are recommended mainly in 2 clinical contexts: in those patients with unicompartmental OA and alteration of axis in which a surgical intervention (osteotomy or unicompartmental prosthesis) manage to improve the symptomatology and the anatomical alteration, being able to diminish the progression to a generalized degenerative joint phenomenon; The other group of patients with surgical indication are those with failure of conservative treatment, either due to pain progression or decreased joint function, mainly loss of range of motion ( Figure 2 ).

In relation to the non-prosthetic surgical techniques available for knee OA, arthroscopic grooming (associated with meniscal and / or chondral regularization techniques) and osteotomies are described. In the studies in which OA arthroscopy has been evaluated, limited symptomatic improvement and similar rates of arthroplasty have been demonstrated in medium-term follow-ups, 45 which is why in patients over 50 years of age we advise against this alternative and recommend treatment prosthetic. The osteotomies, whose objective lies in the correction of axes and in the discharge of the affected compartment, were widely used between 1970 and 1990 as a treatment for OA, with patients benefiting most from those with a unicompartmental commitment and considering themselves an alternative to prostheses. partial, with similar functional results according to the available evidence and recommended for those patients who wish to remain active from the sporting point of view, and with warning of the eventuality of progression of the arthritic phenomenon to the other compartments 46 .

Prosthetic alternatives are currently the most accepted solution in the international literature for knee OA. At the international level there is an increase of 170% in knee prostheses in the last decade, with a total knee prosthesis rate of 8.7 per 1,000 inhabitants, with a higher incidence in female patients (1, 5: 1). On the other hand, the duration of the prosthesis has improved considerably over the course of history, reaching revision rates of less than 10% in follow-ups at 15 years, a period with excellent functional results. 47 These epidemiological changes have begun to be seen in our country with a progressive increase in rates of knee arthroplasties in recent years. The main reported complications of these surgical interventions correspond to infection (< 1%) and aseptic loosening of the implant (< one%). There are different advances in recent years in prosthetic designs, among which it is convenient to point out the fixation of the components (cemented / uncemented), the improvement of the interface between these prosthetic components (high density polyethylene), specific designs by sex and even patient-specific, variations from surgical techniques with bone references to ligamentary references, etc., all of which have generated better results in the medium-term follow-up, with no long-term results to be recorded. The specific type of prosthesis to be used should be evaluated patient to patient to obtain the best functional result with the longest possible duration of in situ arthroplasty.
conclusion

OA of the knee is a highly prevalent disease, with great associated social and economic costs. Current knowledge indicates that this condition is multifactorial, abandoning the concept of pure degenerative disease and recognizing the importance of the inflammatory component. The confrontation is fundamentally clinical, with a basic image study. The currently available conservative treatments have not shown utility in decreasing the progression of the disease. Surgical alternatives are the treatment of choice for OA in definitive stages, being safe procedures, with low complication rates and a durability close to 90% in long-term follow-up.

Conflict of interests

The authors declare that they have no conflicts of interest.

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There are modifying drugs in osteoarthritis

Osteoarthritis is a disease with great epidemiological, social and economic impact on health systems. Its treatment has focused on reducing pain and joint inflammation; In recent years, a series of drugs has appeared on the market that, in in vitro studies, show mechanisms of action that could have a disease-modifying effect, since they reduce the proinflammatory cytokines and the metalloproteinases involved in the degradation of the matrix. of cartilage and have an effect on chondrocyte antiapoptotic mechanisms. Clinical studies have shown efficacy against pain and improvement of joint function; Some studies have shown that there is no loss of joint space evaluated by conventional radiography with longitudinal follow-up of patients. The mechanisms of action in vitro that these new drugs have and the clinical evidence of their usefulness in the symptoms as well as their potential modifying effect of the natural history of osteoarthritis are discussed.



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The osteoarthritis is a disease with high epidemiological, social, and economic impact in health systems. Its treatment has been focused on diminishing pain and inflammation joint; in last years there has appeared on the market a series of drugs that, in studies in vitro show mechanisms of action that might have a modifying effect of disease, since they diminish the proinflammatory cytokines and metalloproteinases involved in degradation of cartilage matrix and it have effect in anti-apoptotics mechanisms in chondrocyte. Clinical studies have showed efficacy against pain and improving joint function; some studies have shown that there is no loss of joint space by conventional x-ray with longitudinal follow-up of patients. We describe new in vitro action mechanisms of theses new drugs and the clinical evidence of their efficacy in symptoms and potentially modifying the natural history of osteoarthritis.

Introduction

Osteoarthritis (OA) is recognized as the most prevalent joint disease in the world. It is estimated that in the United States about 20 million people are affected by this disease and within the next 2 decades this figure will double 1.2 . The prevalence of knee OA has been estimated in 18-25% of men in Eastern Europe, 24-40% of women aged 60-79 in the Netherlands 3 and 28-34% in Spain 4 In Mexico, in a national health survey, it was estimated that 26% of the Mexican population has some symptom of rheumatic disease; in general, the knee is the most affected lower joint (16%) and its prevalence increases to 35% in the eighth decade of life 5 .

Currently there are new drugs that have been used as drugs that improve the symptoms of OA, although there are data from some controlled clinical studies that could have a role as OA modifying drugs (DMOAD).

Glucosamine

Glucosamine is a glycoprotein that serves as a substrate for the biosynthesis of glycosaminoglycan chains and cartilage aggrecans 6 .

In vitro studies

In chondrocytes and synovial cells it has been shown that glucosamine sulphate (SG) reduces the production of prostaglandin E 2 and interferes in the binding of nuclear factor kB with DNA 7,8 . In chondrocytes isolated from rat cartilage, an inhibition of up to 73% of the expression of proinflammatory cytokines secondary to the administration of interleukin (IL) 1b has been demonstrated, but at supraphysiological doses 9 . In a recently published study evaluating chondrogenesis in mesenchymal stem cells (MSCs), osteoarthritic and normal human chondrocytes stimulated with and without IL-1b treated with different doses of SG, they observed that at high doses the production of IL-1b regulating the expression of type II collagen and aggrecans and inhibited the production of cartilage-degrading enzymes such as matrix metalloproteinase (MMP), 13 both in chondrocytes and CMMs that were in chondrogenesis 10 . In chondrocytes isolated from areas of irregular defibrillated cartilage of femoral heads, it was observed that with the administration of SG (50-500 mmol) adhesion to fibronectin was restored (altered situation in chondrocytes with OA) 11 . The main problem with in vitro studies is the high doses (0.50-140 mmol) of SG used in the majority, which are not achieved with the recommended administration of 1,500 mg of SG in patients with OA. 12

Clinical studies

Few controlled clinical studies have evaluated the possible modifying action of OA of glucosamine. In 2001, Reginster et al 13 published a study that included 212 patients with knee OA who randomly received SG at 1,500 mg / day or placebo for 3 years. Anteroposterior radiographs of the knees were performed in full standing position. At 3 years, patients who received placebo had a decrease in joint space (AED) of 0.31 mm (95% confidence interval [CI], 0.48 to 0.13) versus a non-significant AED in the group with SG of 0.66 mm (0.22 to 0.09 mm, p = 0.043). The authors then pointed out a possible effect of SG as a disease-modifying drug 13 . In 2002, Pavelka et al 14 conducted a study, similar to that of Reginster et al, in which they included 202 patients with knee OA. The placebo group had a progressive AED of 0.19 (95% CI, 0.29 to 0.09) mm after 3 years. Conversely, there was no change in the group with OS (0.04 mm, 95% CI, 0.06 to 0.14 mm) with significant difference between the two groups (p = 0.001). Fewer patients treated with SG had severe AED defined as> 0.5 mm: 5 and 14% (p = 0.05) 14 .

We are currently awaiting the results of the 24-month study subgroup of the Glucosamine / Chondroitin Arthritis Intervention Trial (GAIT), carried out by the National Institutes of Health of the United States, which will measure the volume of cartilage with magnetic resonance . In the first analysis of GAIT 15 to 24 weeks, there was no improvement in knee OA pain in the glucosamine group compared to the placebo group. In a subanalysis that categorized the pain at the beginning of the study, it was found that the combination of glucosamine and coindritin may have an effect in reducing pain in patients with greater pain at the beginning of the study. In this research, glucosamine hydrochloride was used and the similarity or difference of these two preparations is not known at the moment.

Chondroitin sulfate

Chondroitin sulfate (CS) belongs to the family of heteropolysaccharides called glycosaminoglycans (GAG).

In vitro and animal studies

In 1998, Bassleer et al 16 found that CS increases the production of proteoglycans, but in the presence of IL-1b inhibits the effects of CS in pro teoglycans, type II collagen and prostaglandin E 2 , which indicates that CS It has anabolic effects by increasing the synthesis of proteoglycans and anticatabolics by inhibiting IL-1. Uebelhart et al 17 , in a study in rabbits, found that in animals that did not receive CS the synthesis of proteoglycans was reduced.

Clinical studies

Most clinical studies with CS evaluate its symptomatic effect in OA 18-20 . Few studies have evaluated its disease-modifying effect. In 2004, in a study that evaluated the intermittent administration of CS at 800 mg / day for two periods of 3 months in 1 year against placebo, significant differences were found in favor of CS in reducing pain and improving joint function of the knee and preserve the joint space observed on radiographs, indicating a modulating effect of the disease. In addition to the prolonged effect of this drug 21 . However, at 2 years there were no differences in the improvement of knee pain and function in OA, but there was a difference in assessing the progression of the disease and a lower decrease in AD was observed in the chest radiographs in the group of CS 22 . The cartilage structure modifying properties of CS were also evaluated in a double-blind, placebo-controlled study, which included 119 patients with OA of the hand interphalange. The CS did not prevent the development of OA in the joints without previous involvement, but it reduced the risk of worsening of the joints with OA at the beginning of the study. 29.4% of the subjects treated with placebo developed frank erosive OA, against 8.8% of the patients treated with CS 23 .

Unsaponified oils of avocado and soy

Since the 1970s, unsaponified avocado and soybean oils (ANSAS) have been studied in different types of connective tissue diseases 24,25 .

In vitro studies

The anti-catabolic action of ANSAS and the anabolic action have been described. In culture of chondrocytes with OA inhibition of the production of MMP-3, IL-6, IL-8, NO and prostaglandin E 2 (PGE 2 ) is observed. They are all dependent on IL-1. In bovine articular chondrocytes, ANSAS stimulates the expression of the transforming growth factor b2 and the plasminogen activating inhibitor 1 26 .

Clinical studies

Only one study showed potential DMOAD effect in patients with hip OA evaluated with radiographs for 2 years; found that ANSAS reduced the progression of the disease in the subgroup of patients who had a greater degree of narrowing of the EA 27 .

Diacerein

Diacerein is a derivative of anthraquinone. The active metabolite of diacerein is the rhein, which has similarities in its chemical structure with tetracyclines. Both anti-inflammatory effects have been attributed to inhibit IL-1 and anabolic effects by promoting the production of TGFβ.

In vitro studies

Diacerein suppresses the expression of IL-1 in human chondrocytes with OA 28 and synovial cells 29 . One of the conclusions reached is that the altered production of IL-1 is secondary to the inhibition of the IL-1 conversion enzyme (ECI). By blocking the cascade of IL-1-dependent molecules, the production of NO, stromeliesin 1, collagenase and pro-inflammatory IL-6, IL-8, IL-18 30 is inhibited. In addition to the inhibition of catabolic molecules, there has been an increase in the production of GAG and collagen secondary to the increased production of TGFβ in chondrocytes treated with diacerein.

Clinical studies

There is only one study with diacerein that evaluates its possible modifying effect of OA. It is a randomized, double-blind, placebo-controlled study with 3-year follow-up. We included 507 patients with primary hip OA who received diacerein (50 mg twice daily) or placebo. The joint space was measured on pelvic radiographs every year. The percentage of radiological progression, defined by a loss of joint space of $ 0.5 mm, was significantly lower in patients receiving diacerein than in patients on placebo (47.3% and 62.3%, p = 0.007). 32

Intra-articular hyaluronic acid

Hyaluronic acid (HA) is a normal component of synovial fluid and an important glycoprotein in joint homeostasis 33 . The fact that the molecular weight and viscosity of AH are decreased in OA led to the hypothesis that the intraarticular application of AH would restore the viscoeslasticity of the synovial fluid and promote its endogenous synthesis and, consequently, the stiffness and pain in OA. would improve 34 . There are presentations with low (0.5-2 MDa) and high molecular weight (6-7 MDa).

In vitro studies

It has been observed that the treatment of human articular cartilage with 800 kDa of sodium hyaluronate inhibits the stimulation of IL-1b and of three degrading enzymes, MMP-1, MMP-3 and MMP-13, possibly through the interaction between the AH and CD44 in chondrocytes 35 . In rabbits with a cruciate lesion of the ligament, HA injections inhibited histopathologically cartilage degradation and apoptosis 36 . In different types of experimental animal models (meniscocectomy, cross-ligament injury) inhibition of cartilage degeneration has been seen 37,38 . Weekly intraarticular sodium AH (5 in total) after partial or total meniscocectomy improves collagen repair compared to saline 39 .

Clinical studies

Several works have studied the modifying effect of AH OA, but only 2 have a minimum duration of 1 year. In one of them, chondral lesions were evaluated by arthroscopy. We included 36 patients who received 3 sets of intra-articular injections in the knee. At one year of follow-up, there was less progression of the joint lesion than in the placebo group 40 . There is another study that included 408 patients with knee OA to whom intraarticular AH was applied 3 times a week every 4 months or saline. Digital radiographs of the knee with corporal load were evaluated. A total of 319 patients completed the study, but only 273 x-rays were obtained both at the beginning and at the end of the study. For the statistical analysis, two groups of patients (less severe OA and severe OA) were made based on the average width of the EA at the time of inclusion, and it was found that those who had more severe disease had lower loss of joint space at baseline. the placebo group 41 .

Conclusions

Currently there are different treatments with some scientific evidence of potential effect as modifiers of OA. The one that has done it with greater consistency until now is glucosamine and coindritin. It should be mentioned that these studies have been carried out with controlled formulas, that is, they are prepared by recognized commercial brands and are regulated by the corresponding health systems, and the medicines sold in different parts of the world, specifically in America. as "food supplements" have not shown such effects. There is still a long way to go to stop the loss and regeneration of cartilage in a sustained manner and there are several problems that we face, from the heterogeneity of the OA to the measurements used to evaluate the cartilage. The path towards an adequate real treatment of OA has only recently begun; We need to see if this is the right one or we will have to change course or even take a path.

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Electromagnetic fields for the treatment of osteoarthritis

A review of the effect of electromagnetic fields on osteoarthritis was performed. We found nine studies with 636 patients.

Background: What is osteoarthritis and what are electromagnetic fields?

Osteoarthritis is the most common form of arthritis and can affect the hands, hips, shoulders and knees. In osteoarthritis, the cartilage that protects the end of the bones is broken, causing pain and inflammation.

An electromagnetic field is the invisible force that attracts things to magnets. This invisible attraction can be created by an electrical current that can affect the cartilage around the joints. In osteoarthritis, electromagnetic fields are a kind of treatment that uses electric currents to apply to the skin around the joints. Small machines or pads can be used to apply electromagnetic fields to the entire body or to certain joints. The treatment can be done by a doctor or a physiotherapist and some machines can be used at home.



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Characteristics of the studies

After searching all relevant studies until October 2013, we found nine studies that examined the effect of treatment with electromagnetic fields compared to a sham or false treatment in 636 adults with osteoarthritis for four to 26 weeks.

Key results

Pain (on a scale of 0 to 100, higher scores mean worse or more intense pain)

• - Electromagnetic fields probably relieve pain in osteoarthritis.
• - Patients who received treatment with electromagnetic fields experienced pain relief of 15 points more compared to patients who received sham treatment (15% improvement).
• - Patients who received treatment with electromagnetic fields rated pain as 26 points lower on a scale of 0 to 100.
• - Patients who received sham treatment rated pain as 11 points lower on a scale of 0 to 100.

Physical function

• - Electromagnetic fields can improve physical function, but this finding may have happened by chance.

Health and general welfare

• - Electromagnetic fields probably do not achieve changes in health and general well-being.

Side effects

• - Electromagnetic fields probably do not change as to whether patients have side effects or interrupt treatment due to side effects, but this finding may have happened by chance.

There is no accurate information about side effects and complications. The above is particularly true for infrequent but serious side effects. Possible side effects may include rash and aggravation of pain.

Changes in x-rays

There was no information available about whether electromagnetic fields cause some improvement in the joint with osteoarthritis on an x-ray.

Quality of the evidence

• - Electromagnetic fields probably improve pain and do not achieve changes in general health and well-being or side effects. These results may change with additional research studies.
• - Electromagnetic fields can improve physical function. The above is very likely to change with additional research studies.

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Thermotherapy for the treatment of osteoarthritis

TO WHAT EXTENT DOES THERMOTHERAPY WORK FOR THE TREATMENT OF KNEE OSTEOARTHRITIS AND WHAT SECURITY CAN IT PROVIDE?

To answer this question, the scientists found and analyzed three studies. More than 170 patients with osteoarthritis continued to take their medication, but used hot pouches, hydrocolloid bags, ice packs or hot packs, with or without massage, or did not receive treatment. The quality of the studies was poor although this Cochrane review provides the best evidence available to date.



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What is thermotherapy and how can it help patients with knee osteoarthritis?
Osteoarthritis (OA) is one of the most common forms of arthritis and can affect the hands, hips, shoulders and knees. In OA, the cartilage that protects the end of the bones is broken, causing pain and inflammation. Thermotherapy is the application of heat or cold in the joints to improve the symptoms of osteoarthritis and can be done with bags, cloths, wax, etc. Heat can act to improve circulation and relax muscles, while cold can numb the painful area, reduce inflammation, contract blood vessels and block nerve impulses to the joint. Thermotherapy can be applied in rehabilitation programs or in the patient's home.

To what extent does thermotherapy work?
One study showed that applying ice massages for 20 minutes, five days a week for two weeks, improved leg muscle strength, knee range of motion, and decreased walking time by 50 feet compared to none treatment.

Another study showed that the application of ice packs three times a week for three weeks improved the pain as well as the non-application of a treatment.

Another study showed that applying hydrocolloid bags ten times for 20 minutes reduced inflammation more than any treatment. Hot bags during the same time had the same effect on inflammation as no treatment.

What security can it provide?
In the studies, no side effects were reported, but in general, studies argue that thermotherapy is safe when applied with care.

What is the conclusion?
Due to the small number of patients included in the studies and the poor methodological quality, it is not possible to draw solid conclusions. There is "silver" level evidence that ice massage could be used to improve
range of motion, knee strength and function in patients with knee osteoarthritis. Hydrocolloid bags can be used to reduce inflammation.

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Treatment of osteoarthritis

Most successful osteoarthritis treatment programs involve a combination of treatments tailored to the needs, lifestyle and health of the patient.
The four objectives for the treatment of osteoarthritis are:

•     Control pain.
•     Improve the function of the joints.
•     Maintain a normal body weight
•     Achieve a healthy lifestyle

Treatment approaches for osteoarthritis include:

•     Exercise.
•     Weight control.
•     Rest and relief of stress in the joints.
•     Pain relief techniques without drugs and alternative therapies.
•     Medications to control pain.
•     Surgery.

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Exercise

Research shows that exercise is one of the best treatments for osteoarthritis.

Exercise can improve mood and perspective, decrease pain, increase flexibility, strengthen the heart and improve blood flow and maintain weight.

Exercise is also cheap and if done correctly, has few negative side effects. The amount and type of prescribed exercise will depend on the parties involved, the stability of the joints and whether an articulation replacement has been made.

Walking, swimming, and doing water aerobics are some popular types of exercise for people with osteoarthritis.

Your doctor and / or physiotherapist can recommend certain types of exercise depending on your specific situation.

You can use the exercises to stay strong and flexible, improve your cardiovascular status, extend the range of movement of the joints and reduce your weight.
The following types of exercise are part of a well-balanced treatment plan:

•     Strengthening exercises : These exercises strengthen the muscles that support the joints affected by arthritis. They can be done with weights or with exercise bands and with low cost devices that add resistance.
•     Aerobic activities: These are exercises like brisk walking or low impact aerobics that make your heart pump and can keep your lungs and circulatory system in shape.
•     Activities for the range of movement: These keep the joints flexible.
•     Balance and agility exercises: These help to maintain skills for daily life.

Ask your doctor or physiotherapist what exercises are best for you. Ask for guidelines on the exercise to be performed when a joint is sore or if inflammation is present.

Also, check if you should:

    Use drugs to relieve pain, such as analgesics or anti-inflammatories (non-steroidal anti-inflammatory drugs) to make exercise easier.
    Use ice after exercising.

Weight control

If you are overweight or obese, you should try to lose weight.

Weight loss can reduce stress on weight bearing joints, limit the appearance of more injuries, increase mobility and reduce the risk of associated health problems.

A nutritionist can help you develop healthy eating habits. A healthy diet and regular exercise help reduce weight.

Rest and relief of tension in the joints

Treatment plans include scheduled rest.

You must learn to recognize your body's signals and know when to stop or slow down. This will avoid the pain caused by excessive exertion.

Although pain can make it difficult to fall asleep, getting enough sleep is important for managing the pain of osteoarthritis.

If you have trouble sleeping, relaxation techniques, stress reduction and biofeedback may help, as well as the timing of medications to provide maximum pain relief at night. If joint pain interferes with your ability to sleep or rest, consult your doctor.

Some people find relief with footwear and special insoles that can reduce pain or with the use of canes to relieve pressure on aching joints.

They can use splints or braces to provide additional support to the joints and / or keep them in the correct position during sleep or activity. The splints should be used only for limited periods of time, because the joints and muscles need to be exercised to avoid stiffness and weakness.

If you need a splint, an occupational therapist or a doctor can help you get a properly adjusted one.

Relief of non-pharmacological pain and alternative therapies

People with osteoarthritis can find many non-pharmacological ways to relieve pain.

Hot and cold

Heat or cold (or a combination of the two) can be useful for joint pain.

The heat can be applied in different ways (hot towels, hot packs or a hot bath or shower) to increase blood flow and relieve pain and stiffness.

In some cases, cold compresses (ice packs or frozen vegetables wrapped in a towel) reduce inflammation and may relieve pain or numb the painful area.

Transcutaneous electrical nerve stimulation

Transcutaneous electrical nerve stimulation is a technique that uses a small electronic device to direct soft electrical impulses to the nerve endings that lie under the skin in the painful area. TENS can relieve some of the pain of osteoarthritis. It seems to work by blocking pain messages to the brain and by modifying the perception of pain.

Massage

A massage therapist will massage the aching muscles. This can increase blood flow and heat a stressed area. However, joints with stressed arthritis are sensitive, so the therapist must be familiar with the problems of the disease.

Acupuncture

When conventional medical treatment does not provide sufficient pain relief, people are more likely to try complementary and alternative therapies for the treatment of osteoarthritis.

Some people have found pain relief through acupuncture, a practice in which a licensed acupuncture therapist inserts fine needles at specific points on the skin.

Scientists believe that needles stimulate the release of natural chemicals that relieve pain produced by the nervous system.

Nutritional supplements

Nutritional supplements, such as glucosamine and chondroitin sulfate have been reported to improve the symptoms of people with osteoarthritis, as well as certain vitamins. It is unknown if these could change the course of the disease.


Medications for pain control

Doctors prescribe medications to eliminate or reduce pain and improve functioning.

Doctors consider a number of factors when choosing medications for their patients with osteoarthritis.

These include:

•     The intensity of pain
•     Potential side effects of medications
•     Medical history (other health problems that have or are at risk of suffering)
•     Other medications you are taking.

Because some medications can interact with each other and certain health problems can put you at higher risk of side effects it is important to talk about your medications and your health history with your doctor before you start taking any new medication, and see your doctor regularly while you are taking medication.

By working together, you and your doctor can find the medication that best alleviates your pain with the least risk of side effects.
The following types of medications are commonly used in the treatment of osteoarthritis:

•     Over-the-Counter Pain Relievers: Oral analgesics such as acetaminophen are often a primary approach to relieving pain in people with osteoarthritis.
•     Nonsteroidal anti-inflammatory drugs (NSAIDs): are a great class of medicines useful against pain and inflammation. Aspirin, ibuprofen, naproxen and naproxen sodium are examples of NSAIDs. They are often the first type of medication used. All NSAIDs work in a similar way by blocking substances called prostaglandins that contribute to inflammation and pain. However, each NSAID is a different chemical, and each one has a slightly different effect on the body.
•     Agents of action or narcotics: Tramadol is a synthetic prescription opioid analgesic that is sometimes prescribed when over-the-counter medications do not provide enough relief. It works through the central nervous system to achieve its effects. Tramadol carries risks that do not exist with paracetamol and NSAIDs, including the potential for addiction. Mild narcotic analgesics containing analgesics such as codeine or hydrocodone are usually effective against the pain of osteoarthritis. Due to concerns about the potential for physical and psychological dependence of these medications, doctors usually reserve them for short-term use.
•     Corticosteroids : Corticosteroids are potent anti-inflammatory hormones created naturally in the body or made by man for use as a medication. They can be injected into the affected joints to temporarily relieve pain. This is a short-term measure, usually not recommended for more than two to four treatments per year. Oral corticosteroids are not usually used to treat osteoarthritis.
•     Hyaluronic Acid Substitutes: Sometimes called viscosupplements, hyaluronic acid substitutes are designed to replace a normal component of the joint involved in joint lubrication and nutrition. Depending on the product your doctor prescribes, it is given in a series of three to five injections. These products are approved only for osteoarthritis of the knee.
•     Other medications: Doctors may prescribe other medications for osteoarthritis. These include topical creams to relieve pain and sprays that are applied directly to the skin on the painful joints. They contain ingredients that work in one of three different ways:
•         By stimulating the nerve endings to distract the brain's attention from pain in the joints.
•         By the depletion of the amount of a neurotransmitter called substance P that sends pain messages to the brain.
•         By blocking chemicals called prostaglandins that cause pain and inflammation.

Because most medications used to treat osteoarthritis have side effects it is important to learn as much as possible about the medications you are taking, even those that are available without a prescription.

Certain health problems and daily habits can increase the risk of side effects of NSAIDs. These include a history of peptic ulcers or bleeding from the digestive tract, the use of oral corticosteroids or anticoagulants (blood thinners), smoking and alcohol consumption.

There are steps you can take to help reduce the risk of side effects associated with NSAIDs. These include taking medications with food and avoiding stomach irritants, such as alcohol, tobacco and caffeine.

In some cases, it may help to take other medications along with an NSAID to coat the stomach or block the stomach acids. Although these measures can help, they are not always fully effective.

Questions to ask your doctor or pharmacist about medications

•     How often should I take this medicine?
•     Should I take this medication with food or between meals?
•     What are the side effects ?
•     Should I take this medication with other prescription medications?
•     Is this medication safe considering other medical conditions that I have?

Surgery

For many people, surgery helps relieve the pain and disability of osteoarthritis.

Surgery can be done to achieve one or more of the following:

•     The removal of loose pieces of bone and cartilage from the joint if they are causing symptoms of buckling or blockage (arthroscopic debridement).
•     Repositioning of the bones (osteotomy).
•     Resurfacing of bones.

Surgeons can replace the affected joints with artificial joints called prostheses. These joints can be made of metal alloys, high density plastic, and ceramic material.

Some prostheses are attached to bone surfaces with special cements. Others have porous surfaces and rely on the growth of bone on that surface (a process called biological fixation) to keep them in place.

Artificial joints can last 10 to 15 years or more. Surgeons choose the design and prosthetic components according to their patient's weight, sex, age, activity level, and other medical conditions.

Advances in joint replacement in recent years have included the ability in some cases to replace only the damaged part of the knee joint, leaving undamaged parts of the joint intact, and the ability to perform hip replacement through smaller incisions.

The decision to use surgery depends on several factors, including age, patient's occupation, level of disability, pain intensity, and the degree to which arthritis interferes with your lifestyle.

After surgery and rehabilitation the patient usually feels less pain and swelling and can move more easily.

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Treatments of osteoarthritis

The effective administration of osteoarthritis involves a combination of lifestyle modifications and medical treatment. In severe cases, surgery can also offer a convenient solution.

Modification of the way of life

Lifestyle choices are important to consider when managing osteoarthritic symptoms, determined as small changes can make a noticeable difference to the severity of symptoms.

Excess weight is known to aggravate symptoms and being obese is a widely validated cause of this condition. This is mostly due to the extra pressure that is applied in the extra weight joints.

As a consequence, taking dimensions of losing weight should be included in the management plan of each fat or obese individual who suffers from osteoarthritis. It has been shown to decrease pain, reduce rigidity and perfect the joint function, which leads to less need for pharmaceutical administration.



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Moderate exercise should also be done at least three times per week for those with affected joints of the elbow and easel. This has been found to benefit individuals in terms of pain and function.

Physical therapy

Treating osteoarthritis symptoms with physical therapy and massage therapies may offer beneficial relief of symptoms, although the overall effectiveness of these treatments has not been determined.

Functional, step and balance training is recommended to help perfect sense, balance and positioning forces. This is determined useful for those individuals who have lower extremity arthritis, leading to a higher risk of falls in the elderly and the resulting fractures.

Elbow braces can offer an advantage to users in helping maintain control and reduce pain. Side wedge insoles, however, have not been shown to offer a useful advantage for osteoarthritis.

To help in relieving stiffness, heat management may prove to offer an advantage, and cold therapy can help manage spasms and muscle pain.

Oral medications

Simple analgesias are usually the first line option for the administration of pain associated with osteoarthritis.

Paracetamol is associated with fewer side effects, making it the preferred treatment for mild pain moderation for this reason. It can often offer a convenient form of pain relief and has a good insurance profile with long-term use.

NSAIDS such as ibuprofen, aspirin and naproxen may also prove beneficial to help in the relief of osteoarthritis pain, particularly for more severe pain. When NSAIDS are used for extended periods of time, however, they are associated with a higher risk of gastrointestinal complications such as ulcers and cardiovascular risk of stroke and heart attack. As a consequence, they must be used appropriately and, as much as possible, steps must be taken to manage this risk.

As an example, taking an antacid with an NSAID has been shown to help reduce the risk of gastrointestinal ulceration. In addition, it is important that patients are aware of the signs of possible complications, such as abdominal pain and black stools. In case complications occur, then they will be equipped to seek immediate medical attention.

Selective COX-2 inhibitors such as celecoxib are another class of NSAIDS that are associated with a lower risk of gastrointestinal effects but the increased risk of myocardial infarction. As a result, they can prove a good option for individuals who are determined to be susceptible to gastrointestinal effects.

As a second line option, oral opioids can offer a solution. The convenience of this treatment is not without obstruction and is recommended only when the first line treatments are not suitable for the individual. They have been shown to offer a small advantage but are associated only with more severe comparable side effects.

Other medications

NSAIDS such as diclofenac can also be formulated in a topical gel that will be applied directly to the affected area. This offers the advantage of reduced risk of gastrointestinal effects, although it may produce a mild skin reaction in some people.

There is transdermal opioid pain and medical options of topical capsaicin available, although the effectiveness of these is controversial.

Hydrocortisone injections can offer short-term pain relief that can last from a few weeks to a few months. Rich injections of platelet plasma may have a role, as they seem to improve common function, but they have no effect on pain and are also associated with important risks.

Injections of hyaluronic acid are not recommended, as they do not offer substantial improvement but are associated with harmful effects.

Alternative remedy

The available evidence of dietary supplements and natural treatments is limited and, as a consequence, recommendations for their use are often not understood.

Glucosamine is thought to offer an advantage based on the role it plays in joint cartilage. Although it appears to be safe, effectiveness is controversial and recent masts have not found it to be more beneficial than placebo. It is possible that glucosamine sulfate is more effective than glucosamine hydrochloride, although both offer modest benefits. According to the International Society of Osteoarthritis Research, glucosamine should be stopped if no effect is observed after six months.

Some other alternative medications that may prove useful include:

•     Phytodolor
•     The same
•     SKI 306X (chinese herbal remedy)
•     The cat hook
•     Avocado and soy
•     Boswellia serrated

The following may also be beneficial but is supported by fewer tests:

•     Herbal preparations of Ayurvedic (Articulin F and Eazmov)
•     Collagen
•     The hook of the devil
•     Duhuo Jisheng pale (Chinese herbal remedy)
•     Fish liver oil
•     Ginger
•     Gitadyl
•     Omega-3 fatty acids
•     Reumalax
•     Stinging nettle
•     Turmeric
•     Vitamins A, C and E
•     Vitamin K
•     Willow bark

Acupuncture has been associated with a relief of modest pain, although the significance of this is uncertain, as the long-term benefits are small.

Electro stimulation techniques such as TEN have been used historically, despite a lack of evidence to prove their effectiveness.

Surgery

For severe cases of osteoarthritis, surgery may offer an alternative solution. Joint surgery of arthroplasty or repairing a surface can help and the common replacement of elbows and trestles can be clinically effective. In the long term, it also offers a low-cost solution.

The osteotomy can help people suffering from osteoarthritis of the elbow even if the tests are limited. Arthroscopic surgery, on the other hand, is not associated with perfected results.