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Arthritis patients used to have two choices. They could live with pain, tempered by dangerous levels of anti-inflammatory drugs. Or they could wait until the pain became unbearable, eventually undergoing artificial joint replacement.
Luckily, kinder treatments are on the horizon. At the Stone Clinic, we focus on biologic-not bionic-alternatives. Supplements and exercise are a first line of defense. But when more invasive methods are necessary, we perform surgery using a paste grafting method to regrow articular cartilage, combined with allograft meniscus replacement.
This procedure-known as biologic knee replacement-is still in its infancy. Nevertheless, we have seen promising results and have helped many patients return to their pre-injury status.
Arthritis Etiology
Osteo and traumatic arthritis are considered degenerative joint diseases. These are not considered inflammatory, as is rheumatoid arthritis. The damage to the joints can be genetic (osteoarthritis) or caused by misalignment or injury. Loss of the knee's shock absorber, called the meniscus cartilage, is a frequent precursor to traumatic arthritis. In addition, tears of the cruciate ligament or medial collateral ligament also can cause knee instability and abnormal mechanics, leading to early wear and tear.
In most cases, the damage in the joint is due primarily to a loss of the articular cartilage covering of the end of the bones. When the cartilage wears off, bone grinds against bone, resulting in small fragments of cartilage scattered around the joint. The fragments irritate the joint and produce swelling. The knee fluid, called synovial fluid, contains enzymes, known as inflammatory cytokines, which accelerate the breakdown of cartilage and cause pain.
Most often, surgeons replace the knee with an artificial one. Joint replacements are effective at removing the pain; in experienced hands, a success rate of more than 90 percent is reported at 10 years. But this approach has limitations. Patients lose range of motion and cannot perform impact sports.
When the artificial implants fail, usually because the cement-fixed components loosen, the revisions are more difficult, with worse outcomes. A major complication of revisions is the considerable bone loss that occurs during removal of the old cemented implants. Survival and success rates of the revision devices are significantly lower than those for the primary total knee replacement. Pain, loss of motion and restricted activities are the primary complaints.
A Nonoperative Approach
Most patients with arthritis benefit from nonoperative methods of joint mobilization and core strengthening. Exercise programs that strengthen the whole body, focusing on the extremities and the core can help diminish the symptoms of OA by strengthening the muscles around the joint. Despite having severe arthritis, many people can delay surgical intervention for years, if they combine strengthening and joint mobilization with a nutrition program to optimize their weight.
In addition, newer generations of drugs and supplements treat the disease of arthritis, not just the symptoms. Glucosamine (minimum of 1,500 mg daily) stimulates cartilage repair, inhibits cartilage breakdown, builds the natural lubricant of the knee (called hyaluronan) and helps hydrate all tissues. An NIH prospective blinded trial (the GAIT study) of glucosamine showed equal effectiveness in pain control to an expensive prescription drug (Celebrex) in patients with moderate to severe arthritis. In those with mild changes, there were no measurable effects.
Glucosamine also may be a natural performance enhancer, promoting faster recovery after intense exercise, with less pain and stiffness. Although glucosamine comes in pills or liquid formulas, we have found the liquid form provides the most efficient method of absorption into the body, and compliance is better among patients.
We also use hyaluronan, a lubricant that is normally found in joints. As we age, we produce less natural joint lubricant. Injections of hyaluronan can lubricate the joint, but pain relief is not long-lasting. However, the injections appear to stimulate the joint-lining cells to produce more natural lubricant, inhibit the enzymes that cause the breakdown of cartilage and keep the active joints healthy and moving smoothly.
When pain management is needed, we prefer to use natural anti-inflammatory medications, such as glucosamine, and newer pain management programs that carry few side effects. These programs include soft-tissue massage, ice massage, electrical stimulation, ultrasound, acupuncture and exercise modifications in combination or individually. Although these measures are helpful, they often only extend the time before more invasive measures are required.
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