Joint Replacements & Osteoarthritis

Osteoarthritis is a condition that causes joints to become painful and stiff. 

It's the most common type of arthritis.

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Symptoms of osteoarthritis

The main symptoms of osteoarthritis are joint pain and stiffness, and problems moving the joint. Some people also have symptoms such as: - swelling - tenderness - grating or crackling sound when moving the affected joints

The severity of osteoarthritis symptoms can vary greatly from person to person, and between different affected joints.

For some people, the symptoms can be mild and may come and go. Other people can experience more continuous and severe problems which make it difficult to carry out everyday activities.

Almost any joint can be affected by osteoarthritis, but the condition most often causes problems in the knees, hips and small joints of the hands.

You should see your GP if you have persistent symptoms of osteoarthritis so they can confirm the diagnosis and prescribe any necessary treatment.

Read more about the symptoms of osteoarthritis.

Causes of osteoarthritis

As part of normal life, your joints are exposed to a constant low level of damage. In most cases, your body repairs the damage itself and you do not experience any symptoms.

But in osteoarthritis, the protective cartilage on the ends of your bones breaks down, causing pain, swelling and problems moving the joint. Bony growths can develop, and the area can become red and swollen.

The exact cause is not known, but several things are thought to increase your risk of developing osteoarthritis, including:

  • joint injury – overusing your joint when it has not had enough time to heal after an injury or operation
  • other conditions (secondary arthritis) – osteoarthritis can happen in joints severely damaged by a previous or existing condition, such as rheumatoid arthritis or gout
  • age – your risk of developing the condition increases as you get older.
  • family history – osteoarthritis may run in families, although studies have not identified a single gene responsible
  • obesity – being obese puts excess strain on your joints, particularly those that bear most of your weight, such as your knees and hips
  • being a woman – osteoarthristis is more common in women than men.

Diagnosing osteoarthritis

To help determine whether you have osteoarthritis, a GP will first ask you about your symptoms and examine your joints.

A GP may suspect osteoarthritis if:

  • you're aged 45 or older
  • you have joint pain that gets worse the more you use your joints
  • the stiffness in your joints is not there in the mornings, or lasts less than 30 minutes

If your symptoms are slightly different, this may indicate another joint condition. For example, prolonged joint stiffness in the morning can be a sign of rheumatoid arthritis.

Further tests – such as X-rays or blood tests – are not usually necessary, but may be used to rule out other possible causes, such as rheumatoid arthritis or a fractured bone.

Treating osteoarthritis

Osteoarthritis is a long-term condition and cannot be cured, but it doesn't necessarily get any worse over time and it can sometimes gradually improve. A number of treatments are also available to reduce the symptoms.

Mild symptoms can sometimes be managed with simple measures including:

  • Regular exercise
  • Losing weight if you're overweight, 
  • standard BMI should be between 20 - 24
  • wearing suitable footwear
  • using special devices to reduce the strain on your joints like brace, sticks, walkers during your everyday activities

If your symptoms are more severe, you may need additional treatments such as painkillers and a structured exercise plan with a physiotherapist.

In a small number of cases, where these treatments haven't helped or the damage to the joints is particularly severe, surgery may be done to repair, strengthen or replace a damaged joint.

Find out more about treating osteoarthritis.



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Pain relief medicines


   

Sometimes a combination of therapies, such as painkillers, exercise and assistive devices or surgery, may be needed to help control your pain.

The type of painkiller a GP may recommend for you will depend on the severity of your pain and other conditions or health problems you have. The main medications used are below.

Paracetamol

If you have pain caused by osteoarthritis, a GP may suggest taking paracetamol to begin with. You can buy this at supermarkets or pharmacies. It's best to take it regularly rather than waiting until your pain becomes unbearable.

When taking paracetamol, always use the dose a GP recommends and do not exceed the maximum dose stated on the pack.

Find out more about paracetamol.

Non-steroidal anti-inflammatory drugs (NSAIDs)

If paracetamol does not effectively control the pain of osteoarthritis, a GP may prescribe a non-steroidal anti-inflammatory drug (NSAID).

NSAIDs are painkillers that work by reducing inflammation.

Some NSAIDs are available as creams (topical NSAIDs) that you apply directly to the affected joints. Some topical NSAIDs are available without a prescription. They can be particularly effective if you have osteoarthritis in your knees or hands. As well as helping to ease pain, they can also help reduce any swelling in your joints.

Your doctor will discuss with you the type of NSAID you should take and the benefits and risks associated with it.

NSAID tablets may be needed if paracetamol and topical NSAIDs are not easing the pain. They may not be suitable for people with certain conditions, such as asthma, a stomach ulcer or angina, or if you have had a heart attack or stroke. If you're taking low-dose aspirin, ask your GP whether you should use a NSAID.

If your GP recommends or prescribes an NSAID to be taken by mouth, they'll usually also prescribe a medicine called a proton pump inhibitor (PPI) to take at the same time. NSAIDs can break down the lining in your stomach that protects it against stomach acid. PPIs reduce the amount of acid produced by the stomach, reducing the risk of damage to your stomach lining.

Opioids

Opioids, such as codeine, are another type of painkiller that may ease your pain if paracetamol does not work. Opioids can help relieve severe pain, but can also cause side effects such as drowsiness, nausea and constipation.

Codeine is combined with paracetamol in common medicines such as co-codamol.

If you need to take an opioid regularly, your GP may prescribe a laxative to take alongside it to prevent constipation.

Capsaicin cream

A GP may prescribe capsaicin cream if you have osteoarthritis in your hands or knees and topical NSAIDs have not been effective in easing your pain.

Capsaicin cream works by blocking the nerves that send pain messages in the treated area. You may have to use it for a while before it has an effect. You should experience some pain relief within the first 2 weeks of using the cream, but it may take up to a month for the treatment to be fully effective.

Apply a pea-size amount of capsaicin cream to your affected joints up to 4 times a day, but not more often than every 4 hours. Do not use capsaicin cream on broken or inflamed skin and always wash your hands after applying it.

Be careful not to get any capsaicin cream on delicate areas, such as your eyes, mouth, nose and genitals. Capsaicin is made from chillies, so if you get it on sensitive areas of your body, it's likely to be very painful for a few hours. However, it will not cause any damage.

You may notice a burning sensation on your skin after applying capsaicin cream. This is nothing to worry about, and the more you use it, the less it should happen. But avoid using too much cream or having a hot bath or shower before or after applying it, because it can make the burning sensation worse.

Steroid injections

Steroids are a type of medication that contain manmade versions of the hormone cortisol, and are sometimes used to treat particularly painful musculoskeletal problems.

Some people with osteoarthritis may be offered steroid injections when other treatments haven't worked.

The injection will be made directly into the affected area. You may be given a local anaesthetic first to numb the area and reduce the pain.

Steroid injections work quickly and can ease pain for several weeks or months.

Supportive treatments

In addition to lifestyle changes and medicines, you may benefit from a number of supportive treatments that can help reduce your pain and make everyday tasks easier.

Transcutaneous electrical nerve stimulation (TENS)

Transcutaneous electrical nerve stimulation (TENS) uses a machine that sends electrical impulses through sticky patches, called electrodes, attached to the skin. This may help ease the pain caused by your osteoarthritis by numbing the nerve endings in your spinal cord which control pain.

Treatment with TENS is usually arranged by a physiotherapist or doctor, who can advise you on the strength of the pulses and how long your treatment should last.

Hot or cold packs

Applying hot or cold packs to the joints can relieve the pain and symptoms of osteoarthritis in some people. A hot-water bottle filled with either hot or cold water and applied to the affected area can be very effective in reducing pain.

Special hot and cold packs that can either be cooled in the freezer or heated in a microwave are also available, and work in a similar way.

Assistive devices

If osteoarthritis is causing mobility problems or making it difficult to do everyday tasks, several devices could help. Your GP may refer you to a physiotherapist or an occupational therapist for specialist help and advice.

If you have osteoarthritis in your lower limbs, such as your hips, knees or feet, your physiotherapist or occupational therapist may suggest special footwear or insoles for your shoes.

Footwear with shock-absorbing soles can help relieve some of the pressure on the joints in your legs as you walk. Special insoles may help spread your weight more evenly. Leg braces and supports also work in the same way.

If you have osteoarthritis in your hip or knee that affects your mobility, you may need to use a walking aid, such as a stick or cane. Hold it on the opposite side of your body to your affected leg so that it takes some of your weight.

A splint (a piece of rigid material used to provide support to a joint or bone) can also be useful if you need to rest a painful joint. Your physiotherapist can provide you with a splint and give you advice on how to use it correctly.

If your hands are affected by osteoarthritis, you may also need assistance with hand-operated tasks, such as turning on a tap. Special devices, such as tap turners, can make performing these tasks more manageable. Your occupational therapist can give you help and advice about using assistive devices in your home or workplace.

Manual therapy

Not using your joints can cause your muscles to waste and may increase stiffness caused by osteoarthritis. Manual therapy is a technique where a physiotherapist uses their hands to stretch, mobilise and massage the body tissues to keep your joints supple and flexible.

Find out more about physiotherapy.

Surgery

Surgery for osteoarthritis is only needed in a small number of cases where other treatments haven't been effective or where one of your joints is severely damaged.

If you need surgery for osteoarthritis, your GP will refer you to an orthopaedic surgeon. Having surgery for osteoarthritis may greatly improve your symptoms, mobility and quality of life.

However, surgery cannot be guaranteed to get rid of your symptoms altogether, and you may still experience pain and stiffness from your condition.

There are several different types of surgery for osteoarthritis.

Joint replacement

Joint replacement, also known as an arthroplasty, is most commonly done to replace hip and knee joints.

During an arthroplasty, your surgeon will remove your affected joint and replace it with an artificial joint (prosthesis) made of special plastics and metal. An artificial joint can last for up to 20 years, although it may eventually need to be replaced.

There's also a newer type of joint replacement surgery called resurfacing. This uses only metal components and may be more suitable for younger patients. Your surgeon will discuss with you the type of surgery that would be best.

Find out more about hip replacement and knee replacement.

Joint fusing

If joint replacement is not suitable for you, your surgeon may suggest an operation to fuse your joint in a permanent position, known as an arthrodesis.

This means your joint will be stronger and much less painful, although you will no longer be able to move it.

Osteotomies, High tibia Osteotomies....Adding or removing some bone around a joint

If you have osteoarthritis in your knees but you're not suitable for knee replacement surgery, you may be able to have an operation called an osteotomy. This involves your surgeon adding or removing a small section of bone either above or below your knee joint.

This helps realign your knee so your weight is no longer focused on the damaged part of your knee. An osteotomy can relieve symptoms of osteoarthritis, although you may still need knee replacement surgery eventually.



Does glucosamine really help joint pain? Ans - NO




With such a massive global market, there's plenty of money being made by big companies - and that's problem number one. 

Commercially funded trials of products are a well-known issue in medicine, and in the case of glucosamine studies it seems that those that are commercially funded turn out to be more likely to show a positive result than those done independently.

Even putting aside industry-funded studies, though, there have been a lot of decent trials done on various forms of glucosamine compared with pretty much anything you might consider an alternative - painkillers, exercise, other drugs... and placebo.

In the group that were given exercises to do, 80% reported the same reduction in pain. So, the exercises were much more effective than the supplement Glucosamine.

If you've got sore joints, then, you might as well save yourself some money - about half the time a sugar pill will make you feel better, but if you actually want the best chance of making a difference, then Phil's exercises are the way to go. Nothing beats them in studies - and they're free.

As Phil explains: "A lot of the pain is coming from the tendons and structures around the joint. If you have trouble getting out of a chair, or trouble undoing a jar, you're at risk of joint pain because your muscles are weak."

The exercises strengthen those muscles and take the strain off your joints. No need for glucosamine.


Intra-Articular Hylan G-F 20 Hyaluronic Acid Injection Compared with Corticosteroid in Knee Osteoarthritis

http://jbjs.org/content/98/11/885?ijkey=c9efea41637339c95b172d9f2cf5aa68f80a9967&keytype2=tf_ipsecsha

A Double-Blind, Randomized Controlled Trial, Nattapol Tammachote, MD, MSc; Supakit Kanitnate, MD; Thanasak Yakumpor, MD; Phonthakorn Panichkul, MD; J Bone Joint Surg Am, 2016 Jun 01; 98 (11): 885 -892

Conclusions: Steroid Triamcinolone acetonide provided better pain control and better knee functional improvement and range of motion compared with Hyaluronic Acid Injection hylan G-F 20 at the 6-month follow-up.


Why ‘new’ knee isn’t the final answer

http://health.economictimes.indiatimes.com/news/diagnostics/why-new-knee-isnt-the-final-answer/58993555

“Nearly 30-35% of knee replacements conducted in the country are unnecessary. At AIIMS, we have been holding awareness programmes to educate patients about the need to focus more on lifestyle modification than surgeries,” said Dr C S Yadav, professor of orthopaedics, AIIMS.


Physiotherapy help........ if unable to follow correct exercises

Sometimes advice or treatment from a physiotherapist is helpful. For example:

  • For advice on which exercises to do to strengthen the muscles above the knee (quadriceps) if you have OA of the knee. Strengthening the 'quads' has been shown to improve symptoms caused by OA of the knee.
  • For advice on how to keep active and fit.
  • For advice on shoes insoles, knee braces, taping to the knee, and how to use walking aids properly (to make sure you have one of the correct height).


Complementary and alternative therapies

Some people with osteoarthritis try complementary or alternative therapies – such as acupuncture and aromatherapy – and find them helpful.

However, there's a lack of medical evidence to suggest they're effective and they generally are not recommended by the National Institute for Health and Care Excellence (NICE).

Nutritional supplements

A number of nutritional supplements have been used to treat osteoarthritis in the past, including chondroitin and glucosamine.

No longer prescribe chondroitin and glucosamine on the NHS because there’s no strong evidence that they are effective as a treatment.

Generally, supplements can be expensive and NICE recommends that they should not routinely be offered on the NHS. 

Rubefacients

Rubefacients are available as gels and creams that produce a warm, reddening effect on your skin when you rub them in. 

Several rubefacients have been used to treat joint pain caused by osteoarthritis.

However, research has shown that rubefacients have little effect in improving the symptoms of osteoarthritis and NICE therefore does not recommend their use.

Living with osteoarthritis

As osteoarthritis is a long-term condition, it's important you receive support to help you cope with any issues such as reduced mobility, and advice on any necessary financial support.

Some people may find it helpful to talk to their GP or others who are living with osteoarthritis, as there may be questions or worries you want to share.

Find out more about living with osteoarthritis.

Preventing osteoarthritis

It's not possible to prevent osteoarthritis altogether. However, you may be able to minimise your risk of developing the condition by avoiding injury and living a healthy lifestyle.

Exercise

Avoid exercise that puts strain on your joints and forces them to bear an excessive load, such as running and weight training. Instead, try exercises such as swimming and cycling, where the strain on your joints is more controlled.

Try to do at least 150 minutes of moderate aerobic activity (such as cycling or fast walking) every week, plus strength exercises on 2 or more days each week that work the major muscle groups, to keep yourself generally healthy.

Find out more about health and fitness, including tips on simple exercises you can do at home.

Posture

It can also help to maintain good posture at all times and avoid staying in the same position for too long.

If you work at a desk, make sure your chair is at the correct height, and take regular breaks to move around.

Find out more about common posture mistakes and fixes.

Losing weight

Being overweight or obese increases the strain on your joints and your risk of developing osteoarthritis. If you're overweight, losing weight may help lower your chances of developing the condition.

Use the healthy weight calculator to find out whether you're overweight or obese.



Knee replacement

Knee replacement surgery (arthroplasty) is a common operation that involves replacing a damaged, worn or diseased knee with an artificial joint.

Adults of any age can be considered for a knee replacement, although most are carried out on people between the ages of 60 and 80.

A smaller operation called a partial knee replacement tends to be performed on younger people aged between 55 and 64 where the artificial joint is expected to need redoing within 10 years.

When a knee replacement is needed

Knee replacement surgery is usually necessary when the knee joint is worn or damaged so that your mobility is reduced and you are in pain even while resting.

The most common reason for knee replacement surgery is osteoarthritis. Other health conditions that cause knee damage include:

  • rheumatoid arthritis
  • haemophilia
  • gout
  • disorders that cause unusual bone growth
  • death of bone in the knee joint following blood supply problems
  • knee injury
  • knee deformity with pain and loss of cartilage

Who is offered knee replacement surgery

A knee replacement is major surgery, so is normally only recommended if other treatments, such as physiotherapy or steroid injections, have not reduced pain or improved mobility.

You may be offered knee replacement surgery if:

  • you have severe pain, swelling and stiffness in your knee joint and your mobility is reduced
  • your knee pain is so severe that it interferes with your quality of life and sleep
  • everyday tasks, such as shopping or getting out of the bath, are difficult or impossible
  • you're feeling depressed because of the pain and lack of mobility
  • you cannot work or have a social life

You'll also need to be well enough to cope with both a major operation and the rehabilitation afterwards.

Types of knee replacement surgery

There are 2 main types of surgery:

  • total knee replacement – both sides of your knee joint are replaced
  • partial (half) knee replacement – only 1 side of your joint is replaced in a smaller operation with a shorter hospital stay and recovery period

Other surgery options

There are other types of surgery which are an alternative to knee replacement, but results are often not as good in the long term. Your doctor will discuss the best treatment option with you. Other types of surgery may include:

  • arthroscopic washout and debridement – a tiny telescope (arthroscope) is inserted into the knee, which is then washed out with saline to clear any bits of bone or cartilage
  • osteotomy – the surgeon cuts the shin bone and realigns it so that your weight is no longer carried by the damaged part of the knee
  • mosaicplasty – a keyhole operation that involves transferring plugs of hard cartilage, together with some underlying bone from another part of your knee, to repair the damaged surface

Preparing for knee replacement surgery

Before you go into hospital, find out as much as you can about what's involved in your operation. Your hospital should provide written information or videos.

Stay as active as you can. Strengthening the muscles around your knee will aid your recovery. If you can, continue to do gentle exercise, such as walking and swimming, in the weeks and months before your operation. You can be referred to a physiotherapist, who will give you helpful exercises.

Read about preparing for surgery, including information on travel arrangements, what to bring with you and attending a pre-operative assessment.

Recovering from knee replacement surgery

You'll usually be in hospital for 3 to 5 days, but recovery times can vary. 

Once you're able to be discharged, your hospital will give you advice about looking after your knee at home. You'll need to use a frame or crutches at first and a physiotherapist will teach you exercises to help strengthen your knee.

Most people can stop using walking aids around 6 weeks after surgery, and start driving after 6 to 8 weeks. 

Full recovery can take up to 2 years as scar tissue heals and your muscles are restored by exercise. A very small amount of people will continue to have some pain after 2 years.

Risks of knee replacement surgery

Knee replacement surgery is a common operation and most people do not have complications. However, as with any operation, there are risks as well as benefits.

Complications are rare but can include:

  • stiffness of the knee
  • infection of the wound
  • infection of the joint replacement, needing further surgery 
  • unexpected bleeding into the knee joint
  • ligament, artery or nerve damage in the area around the knee joint
  • deep vein thrombosis (DVT)
  • persistent pain in the knee
  • a break in the bone around the knee replacement during or after the operation

In some cases, the new knee joint may not be completely stable and further surgery may be needed to correct it.


Hip replacement

A hip replacement is a common type of surgery where a damaged hip joint is replaced with an artificial one (known as a prosthesis).

Adults of any age can be considered for a hip replacement, although most are carried out on people between the ages of 60 and 80.

A modern artificial hip joint is designed to last for at least 15 years. Most people experience a significant reduction in pain and some improvement in their range of movement.

When a hip replacement is needed

Hip replacement surgery is usually necessary when the hip joint is worn or damaged to the extent that your mobility is reduced and you experience pain even while resting.

The most common reason for hip replacement surgery is osteoarthritis. Other conditions that can cause hip joint damage include:

Who is offered hip replacement surgery

A hip replacement is major surgery, so is normally only recommended if other treatments, such as physiotherapy or steroid injections, haven't helped reduce pain or improve mobility.

You may be offered hip replacement surgery if:

  • you have severe pain, swelling and stiffness in your hip joint and your mobility is reduced
  • your hip pain is so severe that it interferes with your quality of life and sleep
  • everyday tasks, such as shopping or getting out of the bath, are difficult or impossible
  • you're feeling depressed because of the pain and lack of mobility
  • you can't work or have a normal social life

You'll also need to be well enough to cope with both a major operation and the rehabilitation afterwards.

How hip replacement surgery is performed

A hip replacement can be carried out under a general anaesthetic (where you're asleep during the procedure) or an epidural (where the lower body is numbed).

The surgeon makes an incision into the hip, removes the damaged hip joint and replaces it with an artificial joint made of a metal alloy or, in some cases, ceramic.

The surgery usually takes around 60-90 minutes to complete.

Read about how a hip replacement is performed.

Alternative surgery

There is an alternative type of surgery to hip replacement, known as hip resurfacing. This involves removing the damaged surfaces of the bones inside the hip joint and replacing them with a metal surface.

An advantage to this approach is that it removes less bone. However, it may not be suitable for:

  • adults over the age of 65 years – bones tend to weaken as a person becomes older
  • women who have gone through the menopause – one of the side effects of the menopause is that the bones can become weakened and brittle (osteoporosis)

Resurfacing is much less popular now due to concerns about the metal surface causing damage to soft tissues around the hip. 

Your surgeon should be able to tell you if you could be a suitable candidate for hip resurfacing.

Preparing for hip replacement surgery

Before you go into hospital, find out as much as you can about what's involved in your operation. Your hospital should provide written information or videos.

Stay as active as you can. Strengthening the muscles around your hip will aid your recovery. If you can, continue to take gentle exercise, such as walking and swimming, in the weeks and months before your operation.

You may be referred to a physiotherapist, who will give you helpful exercises.

Read about preparing for surgery, including information on travel arrangements, what to bring with you and attending a pre-operative assessment.

Recovering from hip replacement surgery

The rehabilitation process after surgery can be a demanding time and requires commitment.

After the operation you'll need a walking aid, such as a frame or crutches, to help support you.

You may also be enrolled on an exercise programme that's designed to help you regain and then improve the use of your new hip joint.

It’s usually possible to return to light activities or office-based work within around 6 weeks. However, everyone recovers differently and it’s best to speak to your doctor or physiotherapist about when to return to normal activities.

Read about recovering from hip replacement surgery.

Risks of hip replacement surgery

Complications of a hip replacement can include:

  • hip dislocation
  • infection at the site of the surgery
  • injuries to the blood vessels or nerves
  • a fracture
  • differences in leg length

However, the risk of serious complications is low – estimated to be less than 1 in a 100.

There's also the risk that an artificial hip joint can wear out earlier than expected or go wrong in some way. Some people may require revision surgery to repair or replace the joint.

Read about the risks of a hip replacement.

Metal-on-metal implants

There have been cases of some metal-on-metal (MoM) hip replacements wearing sooner than would be expected, causing deterioration in the bone and tissue around the hip. There are also concerns that they could leak traces of metal into the bloodstream.

The Medicines and Healthcare products Regulatory Agency (MHRA) has issued new guidelines that certain types of MoM devices should be checked every year while the implant is in place. This is so any potential complications can be picked up early.

If you're concerned about your hip replacement, contact your GP or orthopaedic surgeon. They can give you a record of the type of hip replacement you have and tell you if any follow-up is required.

You should also see your doctor if you have:

  • pain in the groin, hip or leg
  • swelling at or near the hip joint
  • a limp, or problems walking
  • grinding or clunking from the hip

These symptoms don't necessarily mean your device is failing, but they do need investigating.

Any changes in your general health should also be reported, including:

  • chest pain or shortness of breath
  • numbness, weakness, change in vision or hearing
  • fatigue, feeling cold, weight gain
  • change in urination habits

https://www.nhs.uk/conditions/knee-replacement/

https://www.nhs.uk/conditions/hip-replacement/

https://www.nhs.uk/conditions/osteoarthritis/

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