Frontiers in Arthritis

The pathology of osteoarthritis is extremely complex and multifactorial. Recent technological advances have allowed the identification of specific genes and genetic alterations which have helped to elucidate some intricacies involved in the molecular basis of disease development and progression. Known factors and key recent discoveries in pathogenesis, plus typical gross and histologic pathologic findings are described in this chapter.

Exercise can reduce the risk for osteoarthritis by aiding in the prevention of obesity, joint instability, and muscle weakness. It can also serve as an effective treatment by helping patients manage weight, improve muscular strength, decrease joint stiffness, improve range of motion, increase functionality, and reduce the risk for falls. Before starting an exercise program, patients should obtain a physician’s consent and complete a thorough fitness assessment with an exercise specialist. The exercise program should be progressive, beginning with low-to-moderate intensity exercises followed by gradual increases in intensity. Low impact aerobic training and isometric or isotonic strength training are recommended modes of exercise for effective management of osteoarthritis symptoms. Yoga and tai chi provide low impact exercises and are considered effective therapy options for osteoarthritis symptom management. In addition, water-based exercise programs may improve adherence to an exercise program and be equally effective as land-based exercise for improving gait, functionality and pain. Since exercise adherence is the primary predictor of long-term outcomes in osteoarthritic patients, strategies to improve exercise adherence should be implemented.

Osteoarthritis is a common cause of musculoskeletal disability among the elderly. This can place burdens on society as this becomes more problematic for health care professionals to treat. For years, the management of osteoarthritic symptoms has been limited through the use of non-steroidal. Anti-inflammatory drugs (NSAID) for relief of pain and other debilitating symptoms. Since NSAIDs can cause other adverse side effects, nutritional supplements are being promoted as aids for preventing and reducing symptoms that relate to osteoarthritis without the development of adverse side effects. This chapter reviews the background of osteoarthritis as a degenerative joint disease while also looking at animal studies and human clinical trials that evaluate the effects of various nutritional supplements on joint health.

Osteoarthritis (OA) affects millions of people worldwide. However, there is no consensus on the treatment of OA. Treatments aim to reduce pain and help joint function. But they only improve symptoms in the medium term. Nowadays, we have diverse intra-articular treatments, which aim to get better results. Viscosupplementation and Platelet rich plasma are based on the physiologic relevance of hyaluronic acid in synovial joints, and the effect of platelets in the intra-articular homeostasis respectively. HA is used with good results in young patients with Knee OA grade I-II.

Additionally, there is enough evidence to consider the PRP as a valid and effective treatment to reduce pain and to improve the quality of life of patients with knee OA.

Currently, there is no cure for osteoarthritis (OA). Preliminary treatments focus on symptomatic relief. Initially, patients receive cortisone shots, followed by viscosupplementation in a few weeks. Platelet rich plasma injections are also an option. Surgical options include debridement of joints, osteotomy, arthroscopy, or fusion of the bones. Laboratory studies using rats support the use of amniotic membrane (AM) and chorion membrane (CM) in the regeneration and repair of soft tissues. The potential for CM and AM to moderate osteoarthritis has not been explored in length as yet; however, indirect evidence suggests that they may have advantageous effects on cartilages.

In this chapter, we discuss review cartilage restoration surgery in the setting of early knee osteoarthritis (OA). We introduce an algorithmic approach to determining treatment and discuss procedures including microfracture, autologous matrix-induced chondrogenesis (AMIC®), osteochondral autograft transfer (OATS), osteochondral allografting (OCA), autologous chondrocyte implantation (ACI)/matrixassisted chondrocyte implantation (MACI), and stem cell therapy. These techniques have particular advantages and disadvantages. The authors share their approach and outline the protocol for postoperative rehabilitation.

The use of osteotomy is a method to restore knee alignment and is based on the transfer of weight-bearing forces from the area affected by arthrosis to a healthy region of the knee. This force redistribution is the distinctive aspect of osteotomy when compared to other treatment methods. In the last decades, since the introduction and success of knee arthroplasty, the predominance of osteotomy has gradually declined. Nowadays, the actual necessity of osteotomy, beside as a prophylactic operation, is still debated. However, osteotomy remains a valuable technique, in agreement with precise patient indications.

Total knee replacement is one of the most successful and cost-effective interventions in the modern medicine for the treatment of pain caused by advanced arthritis of the knee. Great advances have been made in the last five decades in the mechanical properties and the design of the knee implants, surgical techniques and prevention of complications. Both cruciate-retaining and sacrificing designs are widely used with the proponents of both the designs. More constrained designs are used in complex primary and in revision cases. Pain affecting the activities of daily living in an elderly person suffering from severe osteoarthritis is the commonest indication for a primary total knee arthroplasty followed by rheumatoid arthritis. Current or recent infection is an absolute contraindication for a knee replacement. Most commonly the procedure is performed through a midline longitudinal incision and a medial parapatellar arthrotomy. Recent advances include computer aided navigation (has shown to improve the component positioning), gender specific knee (better choice of component sizes) and patient specific instrumentation (to improve the accuracy of bone resection). Long term results and cost effectiveness of these techniques remain unproven. Infection (1-3%) is the most common and serious complication followed by thromboembolism, instability, and neurovascular injury.

The main aim of cartilage surgery and hip arthroscopy in the management of early hip arthritis is to avoid conversion to total hip arthroplasty, and the earlier the treatment, the greater is the possibility to achieve this purpose. Several techniques have been proposed, such as microfracture, simple debridement, and autologous chondrocyte implantation-matrix assisted autologous chondrocyte implantation (ACI-MACI) for arthroscopic approach and open ACI-MACI and mosaicplasty for open surgery. Arthroscopic debridement associated with microfracture, depending on the patient’s condition, represents the best choice for the treatment of early stages osteoarthritis (OA) of the hip joint, especially where an associated chondral defect has to be fixed. The cause of OA must be promptly individuated and the cartilage surgery must always be associated (except for degenerative OA) with procedures aimed to fix any other structural defect in order to avoid further degeneration and to improve the outcome of the surgery.

Total hip arthroplasty (THA) has been designated as the Operation of the century. The past 3-4 decades have seen tremendous improvement in the patient outcomes, products and technology that has enabled all these changes to improve the quality of life of our patients with problems of the hip joint. We have reviewed the surgical approaches to the hip joint, the bearing surfaces, implant selection and their problems and complications in this chapter. We have also stated our approach and philosophy to have good outcome of THA.