Question 1

Symptoms of Osteoarthritis:

Accepted Answer

Osteoarthritis is a medical term used to describe general wear and tear of a joint associated aging but not necessarily old age alone. Common symptoms are activity related pain and progressive stiffness in the joint. The onset of symptoms can vary from one individual to another, in other words symptoms and the onset of arthritis can start as early as 40 or maybe as late as 80. Although symptoms generally correlate with arthritic changes on the x-rays, the level of symptoms experienced can vary based on the pain sensitivity and other factors such as activity. Additionally, the symptoms can also be heightened by pain associated with the soft tissues in and around the joint.

Question 2

What is inflammatory arthritis:

Accepted Answer

Conditions such as rheumatoid arthritis or Psoriasis where body mounts an immune or inflammatory response to own cells. Joints are ivolved due to extensive inflammation in and around the joint, in other words the joints are secondarily affected, this is referred to as inflammatory arthritis.
 
Inflammatory symptoms are typically worse at night and aching in nature.

Question 3

Structure and Mechanics of the Joint:

Accepted Answer

The bones are the basic block works of the body forming the skeleton. Joints are the pivot points for the limbs to move about from. The ends of the bones in the joint are covered by strong cartilage namely, ‘articular cartilage’ to help frictionless movements. This is often further facilitated by additional cartilages such as a ‘meniscus’ in the knee. The joints are held together by a very strong capsular tissue and capsular ligaments and further strengthened by ligaments inside the joint, such as ‘ligamentum teres’ in the hip and ‘cruciate ligaments’ in knee; and outside the joint, ‘ileofemoral ligament’ in the hip and ‘collateral ligaments’ in the knee. Muscles are the pulleys for the limbs, they are attached to the bone by becoming tendons.
 
This structure is then controlled through a very complex nervous system controlled by the brain, with various sensors for pain, pressure, position and force, in and outside the joint via sensory nerves, and muscles contractions via motor nerves. These nerves originate from the spine and travel down to respective sensors and motor units in the muscle.

Question 4

Joint Pain and Soft Tissue Pain:

Accepted Answer

What may appear to be pain that is from an arthritic joint alone can be a due to combination of factors such as pain from a worn arthritic joint, pain from surrounding soft tissues such as joint capsule, ligaments, tendson and muscles. The success of a joint replacement therefore depends on whether or not most of the pain is from the worn arthritic joint alone, this however may be difficult to establish and identify before surgery especially in the presence of very painful arthritic joint.

Question 5

What is Referred Pain and Radiating Pain:

Accepted Answer

Occasionally the pain may be extrinsic or outside the joint but felt as from the joint, this is called ‘referred pain’. The brain essentially confuses origin of pain from one structure to the other. For example, the Hip pain can be sometimes felt as Knee pain, as sensations around both joints are carried by the same sensory nerve.
 
Radiating pain is the pain that starts at a point usually above and travells down, typically back pain down to outside of the hip or along the leg due to arthritic small joints or facet joints in the lower back. Similarly neck pain down the shoulder and arm. Best example being Sciatica.

Question 6

Can arthritis be self-limiting:

Accepted Answer

Arthritis is a progressive condition. The natural course is one that of gradual deterioration. After an initial painful period, the symptoms can settle and remain settled for a long period before gradually getting worse. The symptoms can also be intermittent. The speed at which the joint deteriorates and the amount of pain that one experiences can vary enormously from one person to another.

Question 7

What is conservative management of arthritis:

Accepted Answer

This is essentially non-operative management of arthritis. To begin with avoiding excessive activities, especially impact loading activities such as running, controlling weight, taking painkillers and anti-inflammatories. These often improve symptoms to enable day to day activities without significant pain.
 
Short course of anti-inflammatories for a few weeks often help to settle the inflammation and therefore pain. Significant inflammation in the is often sensed as night pain, just like a tooth ache.
 
Its better to try nonoperative management as it may control and settle initial excerbation of sysmptoms, which may remain settled even after stopping medication for a long time.

Question 8

Side effects associated with medication:

Accepted Answer

Unfortunately, all medicines carry a degree of side effects, this needs to be weighed against the benefits The simplest analgesia is Paracetamol which is a weak painkiller. One is restricted to a total of 8 tablets (4gms a day). Paracetamol does carry a risk of liver damage. Prolonged used without discussion with your GP is not advisable as with any other medication.
 
In the early stages of arthritis when there is quite a lot of inflammation from wear debris in the joint, anti-inflammatories do work very well. There are a variety of anti-inflammatories. Common side effects associated with anti-inflammatories are gastric irritation (heart burn), prolonged use can result in kidney and heart damage, therefore prolonged use without medical supervision is not advisable. If you suffer from any of these conditions you must avoid taking them without medical supervision.

Question 9

Arthritis and Anti-inflammatories:

Accepted Answer

In inflammatory arthritis like Rheumatoid Arthritis, controlling the inflammation has a positive effect in delaying or slowing down the process of wear and tear and deformities of the joint.
 
The same can be extrapolated to the initial stages of arthritis, where the pain is mainly due to inflammatory response to wear debris from a wearing joint due to aging. This inflammation although often settles with time, excessive inflammation can secondarily damage the joint as in inflammatory arthropathy. Therefore, a course of anti-inflammatories for a period until symptoms remain settled will have a significant benefit in not only controlling the symptom but possibly avoiding aggressive wear in the joint.

Question 10

How do I decide whether I am ready for a joint replacement?

Accepted Answer

The simple answer is when the symptoms are directly attributable to arthritis of the joint, all of the non-operative measures have been exhausted, X-rays reveal corresponding changes and you have reached a point where a reasonable expectation of a quality of life is significant affected.
 
In choosing surrgery one has to weigh up benefits against the risks, this decision is individual and therefore variable. Several factors such as the efffect of pain, limitation of function, age, preogression of arthritis and expectations on quality of life affect this decision. 
 
Generally speaking surgery remains the last choice in treatment of arthritis.

Question 11

I have been told there are different types and ways I can have Hip replacement?

Accepted Answer

True:
There are different approaches to the hip joint, This is largely dependent upon surgeon's training. Almost all of these will involve cutting through skin, and some form of tendon and some instances part of the muscle. Every approach has its benefits and risks. One has to balance the benefits against the risks.
 
Having tried all of the various approaches to the hip joint over the years, I routinely use what is referred as the 'posterior approach', this allows minimal cutting through skin (minimal incision surgery), good exposure and visualisation, lends itself to difficult complex scenarios, future surgeries and carries minimal risk. It is argued that the risk of dislocation is marginally higher, however with your help and care, this can be virually eliminated.
 
Frequently asked question is regarding 'resurfacing of the hip', firstly this is a metal on metal hip and secondly not an intermediate procedure, in other words it is form of hip replcement. advanatges are that the bearing surfaces are larger, closer to anatmy and therefore theoretically near normal function. Being a metal on metal hip it carries issues and concerns regarding metal debris and metallosis. Although it has its place in certain circumstances, it is unsuitable in most due to benefits not necessarily outweighing the risks!. I no longer offer this in my practice.
 
The issue of exposure is less in knee replacement. However the debate is about Partial Vs Total Knee replacment. Although a selected group will benefits from partial knee replacment, the main beneifit being a better range of movement and stability when rest of the knee and ligamants are intact, the failure rate howver is higher and also they may not always address all of the pain if the arthritis affecs more than one part of the knee. Debate is ongoing.

Question 12

Can I have 'Enhanced Recovery' or 'Daycase Surgery'?

Accepted Answer

Almost all hospital and surgeons have adopted "enhanced or accelerated recovery". It essentially allows you to feel well soon after surgery. These changes are brought about by changes largely to anaesthetic practices and pain management and also to the surgical techniques. Pre-education is a huge component of this process.
 
The main advantage is it allows you to go home to your familier surroundings sooner from hospital. It is not to be confused with early healing, healing is slow process over the months. 
 
If you were able to go home the same day it is referred to as 'Day case Hip replacement'.  Although this is possible in a younger able bodies person, this may be difficult in less physical able and a person with medical issues as some of the issues may not be apparent or arise till a couple of days later and home may not be a suitable place.

General Information