I was browsing Technorati, since I try to keep in touch with arthritis postings this way, and ran across the following:

There is nothing we can do ….

I don’t know if i should laugh or cry ……. getting straight to the point, i have fully blown Osteo-arthritis, the Orthapeadic Surgeon said i have the knees of a 70 year old and there is absolutely nothing they can do to help me.

I am 49 years old, when i am 60 i will need to have both knees replaced and possibly my hips too. In the meantime he can ‘wash out my knees’, which is keyhole surgery to suck out all the chipped and loose pieces of bone that are floating around in my knees to make life more comfortable. They can only do this twice. I have to suffer the pain and discomfort to the pitch of ‘ i can’t take any more’ and then they will do the knee wash. My next appointment is in six months time but in the meantime he is organising physio for me.

I can’t believe i will not get off these crutches, they are now part of my life and the thought that i am going to get worse…… i just can’t believe it ……. i can’t comprehend it …….it has not sunk in…….did he really mean me?

There are a few things that concern me about this post:

First, if this orthopedic surgeon truly said that this woman has “the knees of a 70 year old” then in my humble opinion this surgeon is a boob. Osteoarthritis (OA) is not an inevitable consequence of aging. It is certainly true that the older you get, the more likely you are to have OA, but there are plenty of elderly out there without significant OA. My 84 year old father has no significant OA. So this comment (once again, if it is accurate) is just silly.

Second and along similar lines, the degree of radiograpic OA does not necessarily correlate with pain. There are people out there with severe radiographic OA and little pain, and others with mild radiographic OA who have severe pain. Don’t rely on the X-ray to determine how severe your disease is.

Third, let’s address the statement, “there is absolutely nothing they can do to help me.” In a word, BOLLOCKS! Let’s make sure we differentiate two important points here.

A: In terms of ‘curing’ OA, this statement is mostly true. We don’t understand what causes OA. The initiating event is not known. We understand a few things that make it worse, especially excess weight and mal-alignment of the (knee) joint. (A lot of this pertains to knee OA which is the best-studied kind.) But we can’t make it go away; once it’s there, it’s there and it is likely to progress though there is no way to predict how fast.

B: But in terms of what we can do to help people with OA, there is a lot we can do or at least try. This woman was referred for physiotherapy (physical therapy for those of us in the States) which is a very good start. There are two related goals here. First, to start an activity program to help control excess weight, and second a strengthening program to help stabilize the muscles around the knee joint which can be effective both in slowing disease progression (OK, this is a little controversial but I’ll go with it for now) and in relieving symptoms.

Other ways of trying to relieve pain include medications like acetaminophen (aka paracetamol in the UK, aka Tylenol) and non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Motrin) and naproxen (Alleve). These can also be effective in some patients.

There’s more. Injection of steroids into the joint (“cortisone”) can be effective in relieving pain for weeks or months in some patients. I’m personally not a believer in other injections (agents that supposedly increase the viscosity of joint fluid) but some patients seem to think they help.

Bracing is an under-utilized mode of therapy. As I said above, the alignment of the knee can play a role in perpetuating/worsening the disease, and may also be a source of pain. Using braces to change the alignment of the joint can be helpful.

[Note that I haven’t mentioned glucosamine and chondroitin here – please see my previous posts about these agents: Parts One and Two. Part Three. Part Four.]

So I take issue with saying that “there is absolutely nothing they can do to help.” There are many things that can be done, both to relieve pain and to slow the course of the disease.

Fourth, let’s briefly examine “wash[ing] out [the] knees.” This is called arthroscopic surgery and it involves putting a small instrument into the joint through a small hole in the skin and ‘cleaning out’ loose bodies, excess cartilage, torn menisci, etc. by either ‘rinsing out’ the joint with saline fluid (lavage) or cutting out excess stuff (‘debridement’).

Guess what? There is a very good randomized controlled trial of arthroscopic surgery in knee OA. The verdict? It doesn’t work. Here’s the abstract from the New England Journal of Medicine, July 11, 2002:

Background Many patients report symptomatic relief after undergoing arthroscopy of the knee for osteoarthritis, but it is unclear how the procedure achieves this result. We conducted a randomized, placebo-controlled trial to evaluate the efficacy of arthroscopy for osteoarthritis of the knee.

Methods A total of 180 patients with osteoarthritis of the knee were randomly assigned to receive arthroscopic débridement, arthroscopic lavage, or placebo surgery. Patients in the placebo group received skin incisions and underwent a simulated débridement without insertion of the arthroscope. Patients and assessors of outcome were blinded to the treatment-group assignment. Outcomes were assessed at multiple points over a 24-month period with the use of five self-reported scores — three on scales for pain and two on scales for function — and one objective test of walking and stair climbing. A total of 165 patients completed the trial.

Results At no point did either of the intervention groups report less pain or better function than the placebo group. [My emphasis] For example, mean (±SD) scores on the Knee-Specific Pain Scale (range, 0 to 100, with higher scores indicating more severe pain) were similar in the placebo, lavage, and débridement groups: 48.9±21.9, 54.8±19.8, and 51.7±22.4, respectively, at one year (P=0.14 for the comparison between placebo and lavage; P=0.51 for the comparison between placebo and débridement) and 51.6±23.7, 53.7±23.7, and 51.4±23.2, respectively, at two years (P=0.64 and P=0.96, respectively). Furthermore, the 95 percent confidence intervals for the differences between the placebo group and the intervention groups exclude any clinically meaningful difference.

Conclusions In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure [My emphasis again].

You don’t have to understand the whole abstract to understand that conclusion.

Finally, let’s get to joint replacement. It’s great. In most cases, people trade in their old, worn, painful knee (or hip) for a brand new one. As long as they really participate in rehabilitation after surgery, they usually do very well. Most of the patients I see who have had joints replaced are very happy about it. (However, I advise getting any joint replacement surgery done in a ‘high volume’ center that does lots and lots of them. There are surgeons who do nothing but knee replacements, and because of this they tend to do them better and have fewer complications.)

So the reason I wanted to write about this post is for the very reason that it perpetuates a lot of misconceptions that need to be corrected. This woman does not have to be despondent. She has a disease that can be treated effectively.

However, she probably would benefit from consultation with a rheumatologist. (This is NOT just a plug for my specialty!) Please don’t get me wrong, surgeons are good guys and do a very important job, but when it comes to mangement of OA they often think in terms of “surgery or no surgery” and many (not all) are not up to date on medical (non-surgical) management of this disease. Rheumatologists are (or at least should be). This woman might get a lot out of a rheumatologist. And if not, and if she’s in that much pain, then maybe it’s time to replace the joint, and that’s OK.

So Single Girl, please don’t despair! There are things that can be done!

For more information, please see the links to left.

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