We all have joint pain. Especially in older people but often there is an arthrosis behind it. This article describes the syndrome of osteoarthritis with its mechanisms of development and typical complaints. Based onOsteoarthritis Exemplary treatment options are shown.
What is osteoarthritis?
The term osteoarthritis (arthrosis deformans) describes a mismatch between the load capacity and the actual load of joints. This causes painful signs of wear over time. The various parts of the joint "do not run smoothly" or are simply overloaded.
Pressure and friction damage the cartilage, which covers the bony articular surfaces like a protective layer. Over time, the cartilage is completely degraded in places or over a large area. Abandoned cartilage particles trigger inflammation of the synovium (synovitis). There are millions of free nerve endings in the periosteum below the cartilage, which makes them highly sensitive. If bone rubs on bones with every movement, it causes severe pain.
Osteoarthritis is a common disease today. About eight to ten million people in Germany suffer from it. Above all, the hip and knee joints (coxarthrosis and gonarthrosis) are affected. But even small joints, for example on the fingers (Bouchard arthritis, Heberden osteoarthritis), can fall ill.
Causes of osteoarthritis
Mainly in old age, but also by inflammatory joint diseases, by congenital misalignments, constant overload or overweight (secondary form) and after accidents (post-traumatic), the degenerative changes in the joints. In the primary or idiopathic form the cause is unknown.
Some medications (certain antibiotics or anticoagulants), hemophilia and elevated levels of uric acid are also suspected of causing cartilage damage. The influence of hormonal and genetic factors on the cartilage structure is still being discussed among experts.
Prevention of osteoarthritis
Unfortunately, there are no concrete preventive measures. Ideal weight, regular exercise and a healthy, balanced diet are generally recommended to reduce joint misfeeding and stress and to support cartilage nutrition. Extreme and contact sports involve a high risk of injury and are therefore critical to rethink.
Following accidents or congenital malocclusion (for example, hip dysplasia, X-legs, or O-legs), specific surgery may help prevent or delay the onset of osteoarthritis. The joint parts are brought into a new - correct - relationship to each other. A supply with an artificial joint replacement (endoprosthesis, see above) can often be omitted or delayed for a long time.
Symptoms of osteoarthritis
The symptoms of osteoarthritis depend on the stage of the disease. At the beginning, one usually only notices a limitation of movement, which mainly exists in the morning (so-called morning stiffness). In addition, there is a pain onset, so a pain that occurs at the beginning of a load and disappears after some time. With the progression of osteoarthritis it comes to pain with every load or movement.
There is a so-called activated osteoarthritis, which corresponds to joint inflammation and fluid accumulation (effusion), all the typical signs of inflammation are recognizable - swelling, redness, overheating, severe pain and restricted mobility.
Diagnosis of osteoarthritis
Responsible for the diagnosis is the orthopedist (specialist in diseases of the musculoskeletal system). He asks about the complaints and checks the appearance of the affected joint. By means of special manipulations he can examine the joint mobility and pain.
For exact diagnosis, radiographs of the joint are generally necessary. Thus, typical changes in the arthrosis can be visualized, for example bone compaction below the cartilage layer (stage I), narrowing of the joint space, unevenness of the articular surfaces and bone attachments (stage II-III), right up to a proper deformation of the joint portions (stage IV) , The complained complaints do not always agree with the findings. The symptoms may be significantly stronger or less pronounced than expected with the respective radiographic findings.
The radiation exposure is low with the currently used, mostly digital, X-ray devices. Sometimes tomographic images (computed tomography / CT with X-rays, magnetic resonance imaging / MRI without X-rays) are also necessary to rule out other causes of the complaints.By blood tests and if necessary the removal of joint fluid (puncture) can be determined, if necessary, whether a rheumatic disease or joint infection exists.
Treatment of osteoarthritis
The one typical therapy for osteoarthritis does not exist. The treatment is based rather on the complaints complained of, the extent of joint changes and the existing limitations in everyday life, work and sports. The therapeutic approaches presented below are primarily valid for all forms of osteoarthritis, but we will look more closely at the treatment of hip osteoarthritis.
Medicines for osteoarthritis
Pain therapy plays an important role in the treatment of osteoarthritis. Although without a healing character, it is usually indispensable given the often severe pain of advanced osteoarthritis. The pain relief can be in the form of ointments, tablets or drops (and rarely patches).
Depending on the intensity of the pain, the following medication groups are recommended or prescribed:
Pain creams are an option for minor ailments or supportive of all other therapeutic approaches. They are available for free in the pharmacy.
To what extent pain creams actually have an effect on osteoarthritis is controversial. Critics complain that the effect would take place as in a placebo (dummy drug) only in the head. According to the motto "If you believe in it, it helps too". It's best to try it for yourself if you feel a positive change from the ointments.
The following active ingredients are often prescribed:
The active ingredient Diclofenac inhibits an endogenous enzyme, cyclooxygenase. This enzyme is significantly involved in inflammatory reactions in the body and thus also in the development of pain.
An approximately cherry-sized amount of Ointment is applied to the intact skin. Depending on the amount of active ingredient in the ointment, the application is made two to three times a day. For information, contact your doctor or the pharmacy or refer to the package leaflet. The active ingredient should be absorbed through the skin and act directly at the site of action - bypassing the gastrointestinal tract - anti-inflammatory and thus pain-relieving. To protect your clothing from stains, you can cover the ointment-wrapped joint with a bandage. This should not constrict or hinder you in your movements.
Examples: Voltaren® Pain gel forte, Diclo-ratiopharm® Pain Relief
Ibuprofen works in a very similar way to diclofenac. Inhibition of cyclooxygenase inhibits the production of certain messengers, prostaglandins, which are responsible for the transmission of pain in the body.
The dissolved Ibuprofen is present in microscopic fragments that migrate into the uppermost layers of the skin. From there, the active ingredient should penetrate directly into the underlying, aching tissue to develop its pain and anti-inflammatory effect. The whole organism is less stressed in this way than when using ibuprofen in tablet form. For the use of gels and ointments, see our explanation under Diclofenac.
Examples: Doc® Pain gel, Proff® Pain Cream
Ibuprofen, Diclofenac & Co: NSAIDs in tablet form
The above anti-inflammatory drugs with analgesic component such as ibuprofen and diclofenac are of course also available as tablets. The active ingredients are also referred to as NSAIDs (non-steroidal anti-inflammatory drugs, ie rheumatism without cortisone). However, this name is misleading because the active ingredients can not only be used in rheumatism.
There are various doses available commercially, in ibuprofen, for example, there are tablets with 200 mg of active ingredient up to 800 mg. The higher-dose tablets are subject to prescription in Germany.
The mechanism of action is based on inhibition of the enzyme cyclooxygenase and consequent inhibition of prostaglandins in the body.
Side effects are mainly gastrointestinal problems including ulcers and bleeding. Therefore, gastric protection should always be prescribed in addition to these medications.
The NSAR at a glance:
Examples: Ibu ratiopharm®, Nurofen®
Examples: Piroxicam AbZ®, Piroxicam Stada®
Examples: Dolormin®, Naproxen AL®
Examples: Aspirin®, Thomapyrin®
Examples: Voltaren® resinate, Diclac®
The active ingredient belongs to the group of so-called Cox-2 inhibitors. This is a group of substances designed to selectively treat inflammation while protecting the gastric mucosa from damage. The latter is often a problem with the other NSAIDs. Nevertheless, the use of celecoxib should only be as short as possible and at a low dose because the dose and duration of treatment increases the risk of cardiovascular disease.
Examples: Celebrex®, Celecoxib TAD®
Like celecoxib, etoricoxib is also a Cox-2 inhibitor. The risk of cardiovascular disease is lower.
Other painkillers without opioid content
The active ingredient blocks certain parts of the pain receptors in the body. The pain transmission is interrupted thereby.
Examples: Novalgin®, Novaminsulfon Lichtenstein®
No anti-inflammatory effect. The analgesic effect is created by inhibiting pain transmission to the brain.
Examples: ben-u-ron®, Paracetamol ratiopharm®
Opioids (painkillers with morphine-like action)
These strong pain killers are partly covered by the Narcotics Act. Since they can severely restrict their ability to react even when used as intended, caution should be exercised when driving or operating machinery. Other side effects may include constipation, euphoria and respiratory disorders. It is important to know that withdrawal from these medications can be extremely difficult.
The opioids at a glance:
An industrially produced weak opioid whose metabolic products inhibit pain perception in the brain. In part, the opioid antagonist Naloxone is added to reduce typical opioid-related side effects.
Examples: Valoron®, Valoron® N
The active ingredient of this weak opioid binds on the one hand to opioid receptors in the brain and acts there similar to certain messengers that inhibit the perception of pain. On the other hand, it inhibits the effects of other endogenous substances that have an effect on pain perception comparable to that of antidepressants.
Examples: Tramal-long®, Tramadol CT®
Strongly effective opioid. It causes the opioid receptors in the brain a similar reduction of pain perception as the body's own substances. In combination with the opioid counterpart Valoron, the risk of constipation as a side effect is reduced.
Also a potent opioid used in chronic pain especially in the form of patches. The patch is stuck on the skin, for example on the upper arm. The body heat provides for the release of the active ingredient, which is absorbed through the skin. After 72 hours, the patch is removed, the next patch is glued to the opposite side.
In contrast to pain creams, which are also applied to the skin, opioid pain plasters act not only locally, but like the other opioids in the central nervous system.
Examples: Durogesic SMAT®, Fentanyl Hexal®
Cartilage-protecting preparations have an anti-inflammatory effect, support cartilage production and inhibit cartilage degradation.
Glucosamine is a component of articular cartilage. Produced industrially, it should be installed in the defective cartilage and "repair" this.
Examples: glucosamine double heart®, Glucosamine taxofit®
The substance produced by cartilage-forming cells helps to protect the cartilage against pressure and impact. When taken as a dietary supplement, it contributes to the health of the cartilage and should prevent signs of wear.
Examples: Abbey® Joint tablets (combination preparation), ArthroLoges® Protect
Herbal remedies for osteoarthritis
Herbal medicines for osteoarthritis usually contain active ingredients with a slightly anti-inflammatory and cartilage-protecting effect. The intake is supportive to all other forms of treatment possible. The onset of action may be delayed in phytopharmaceuticals and will be felt after 2-3 weeks.
- Devil's Claw:
The substances contained in the devil's claw inhibit the production of messengers, which are responsible for cartilage destruction and the development of pain.
Examples: Rivoltan®, Devil's claw dura®
- Willow bark:
It contains substances that are similar to the Aspirin® active ingredient acetylsalicylic acid. The anti-inflammatory and analgesic effect is less.
Examples: Father Severin® Willow bark drops
Medications for use in the joint
If necessary, drugs can also be injected directly into the affected joint. Mainly used are local anesthetics, cortisone, hyaluronic acid for thickening of synovial fluid and homeopathic remedies.
- Local anesthetics:
By blocking the passage of pain-conducting nerve fibers, they inhibit pain transmission to the brain. Commonly used in combination with cortisone preparations. Examples: Naropin®, Xylonest®
Strong anti-inflammatory effect. The consistency of the preparations prevents them from being rapidly absorbed into the blood. Thus, a longer-lasting effect in the inflamed joint is guaranteed.
Examples: Volon A.®, Urbason®
- hyaluronic acid:
Used for filling or thickening of synovial fluid, similar to the oiling of a hinge.
Examples: Hyaluron Hexal®, Ostenil®
- Homeopathic remedies:
The aim of the homeopathic treatment of osteoarthritis is to reduce inflammatory reactions, to reduce pain, to strengthen the cartilage and to improve its regenerative ability and lubricity.
Examples: Traumeel®, Zeel®
Some doctors and naturopaths recommend a self-blood therapy, in which the effect of the body's own anti-inflammatories is used. The patient is bled for this. Anti-inflammatory substances are centrifuged off, frozen and these body-own substances and injected over several weeks in portions into the affected joint.
Physiotherapy and physical therapy
Because of the pain, people with osteoarthritis often unconsciously take a restraint. This will eventually lead to shrinkage of muscles and joint capsule, which may cause further pain. This vicious circle must be interrupted. One approach is physiotherapy or physiotherapy. In doing so, shortened and hardened structures are stretched and made more flexible, possibly with the help of heat. Individually adapted muscle training relieves the affected joints or reduces stress.
In physical therapy, depending on the symptoms, heating or cooling applications are used. With low-frequency current, painkiller and anti-inflammatory agents can also be applied through the skin. The current also provides muscle relaxation and improved circulation in the application area.
Surgery for osteoarthritis
Re-fixing of cartilage fragments
Under certain conditions, cartilage fragments broken by injury can be anchored back to their old position using an arthroscopic technique (keyhole technique). It uses a tissue adhesive, self-resolving pins or special screws. After the procedure, the affected joint is immobilized for six to twelve weeks, so that the fragment can heal in peace.
Transplanting endogenous cartilage (ACT)
A long time mainly applied to the knee joint procedure is the transplantation of own cartilage tissue. This measure is divided into two small operations.
- The first procedure uses keyhole technique to remove a small piece of healthy cartilage from a low-loaded area of the joint. In a special laboratory, the cartilage is grown over a few weeks to a few months. At the end you get a piece of cartilage that is big enough to replace the pathological defect.
- This piece is brought in a second intervention to the affected area and fixed there. This may require a slightly larger skin incision. To safely heal the transplanted cartilage, the leg must be completely relieved with crutches for six weeks.
Another possibility is to apply the cartilage cells taken in the first step to a collagen tissue. In a second, open operation, this biomaterial is placed precisely in the defect and fixed with tissue glue or a few sutures.
Like ACT, microfracturing has long been used mainly on the knee joint. In the process of cartilage damage, tiny holes a few millimeters deep are drilled into the underlying bone. This stimulates the bone marrow to form different stages of development of cartilage cells. These are intended to replace the defect over time with new own cartilage. Relief with crutches for six weeks is recommended. After follow-up examinations of osteoarthritis patients, who performed a microfracture on the hip joint, extensive defect filling (96%) was observed after one and a half years.
In this surgical method, the compacted bone is roughened in a keyhole technique. The resulting small, superficial bleeding stimulates the bone marrow to form fibrocartilage. This overgrows the cartilage defects in the joint within about four weeks. However, fibrocartilage is not as stable as the original cartilage. When combined with abrasion arthroplasty, surgical removal of the cause of osteoarthritis should be performed, if possible.
Endoprosthesis (joint replacement)
The term "prosthesis" is often a specter, because it is associated with the removal of limbs. But do not worry, it has nothing to do with an endoprosthesis. This refers to the replacement of a human joint by an artificial joint (Greek "endo" = inside; "pro" = for; "thesis" = setting, placement).
Depending on the extent of the procedure one speaks of total endoprosthesis (all parts of the joint are replaced) or partial prosthesis (for example, only the femoral head is affected). If it is sufficient to coat the surfaces of the femoral head and acetabulum with a protection, this is called the surface replacement.
The question of whether an endoprosthesis is anchored with or without special bone cement depends on several factors, e.g. of age, sportive or occupational strain, condition of bone and previous operations. Which procedure is suitable for you, the treating physician must decide together with you.
Technique and achievements improved significantly
Previously, the artificial joint replacement had a bad reputation. The procedures took a long time, patients had to stay in bed for a full week and often had severe pain. In addition, material fatigue and abrasion were feared.
Nowadays, there are many advances in the shape and size of the prosthetic parts, the materials, the attachment in the bone and the surgical technique. Due to the increasingly aging society, orthopedic surgeons and accident surgeons in this country have a lot of experience with endoprostheses, and the surgeries are carried out successfully every day in a large number of German clinics.
Artificial hip joint: Procedure before, during and after the operation
The total duration of the hospital stay with the use of an artificial joint is today still about one to two weeks.
In the run-up to the operation, ideally you will already receive a visit from the physiotherapy and learn to walk with crutches ("crutches") as well as the correct sitting down and getting up after the procedure. This can cause painful mistakes.
The insertion of a hip prosthesis takes about one and a half to two hours. Depending on the state of health and individual needs, the procedure can be performed under general or spinal anesthesia. The first night is sometimes spent on the maternity ward, where respiration and cardiovascular function are continuously monitored and can be immediately responded to problems such as pain or the like. Often, however, it is after the procedure for a few hours in the recovery room and then directly back to the station.
How to proceed right after the procedure
Depending on the surgical procedure, you may only lie on your back for a few weeks and place a thick cushion between your legs so that your legs are not accidentally crossed or you turn on your side (the latter can not always be avoided in your sleep). Sometimes it is only allowed to get out of bed over the affected side, sometimes only over the unaffected side. The reason for this is a greater or lesser risk of getting rid of the new hip. The treating physicians, nurses and physiotherapists provide the necessary information and assistance.
The first postoperative day is usually allowed to get up for the first time. This is always accompanied, as pain or circulatory problems can occur after every procedure. The goal is at least a "standing in bed", possibly even a few steps can be run under instructions.
After a few days, you will already see a clear change and become more and more confident and independent when getting up, sitting down and running.
Pain treatment after the operation
The installation of an artificial joint is less painful today than it was 20 years ago. The thigh muscles are less severed today, instead more distended. Nevertheless, it is not completely without pain. However, many clinics are certified as a pain-free hospital. They have special concepts for pain therapy after certain procedures. But also in all other clinics you can get pain medication day and night when needed. Simply contact the nursing staff in good time, because the longer you try to endure the pain, the harder you can get to grips with it.
It is also very important that you do not reduce your drinking. Many sufferers, especially women, do so after the operation. The reason: "The toilet is so difficult!". But if you drastically reduce your drinking and also move little, circulatory problems, thrombosis, pneumonia, urinary tract infections and constipation threaten. All things that you do not want to have and that relativize the discomfort of urinating.
Rehabilitation and follow-up treatment
Let's assume that everything goes according to plan. A few days after the operation, an X-ray inspection takes place, in which the correct position of the prosthesis is checked again. After about 10 days, the threads or staples are removed. If the wound is then completely closed, you may take a shower as usual (unless special "shower patches" have been used previously). After about 12 to 14 days, you are usually allowed to go to rehab or after-treatment (AHB). The application process with your insurance provider (health insurance or pension insurance) is already done during your stay in hospital.
The rehabilitation or follow-up treatment is possible on an outpatient basis near the residence. This is often interesting for younger patients. On the other hand, inpatient rehabilitation offers the advantage of being able to gain a distance and focus entirely on one's own recovery because of the usually further spatial distance from the place of residence. The hotel standard including full board and the omitted daily commutes are often referred to as the reason for deciding on inpatient admission.Prerequisite for both variants is that you can travel longer distances without help and perform the personal care independently. For applications in the water, the wound must be completely closed.
The rehab usually lasts three weeks, but can be extended if necessary. After about three to six months you should be able to master your everyday life as usual.
If nothing unusual happens, such as a fall on the operated hip, you should be able to live well with today's endoprostheses 15-25 years. A later change is therefore not always avoidable. These interventions, especially if the first prosthesis was cemented, are then significantly more extensive.
Prognosis in osteoarthritis
The diagnosis of arthrosis does not necessarily mean that an artificial joint is needed or that one can survive his life only with painkillers. However, you should pay attention to a few things that were mentioned earlier in the text:
- Pay attention to a balanced diet and sufficient exercise.
- Recommended is the consumption of avocado oil. The substances contained in the avocado are said to reduce the risk of suffering cartilage damage by stabilizing the cartilage structure.
- If you are overweight, you are trying to lose weight. The ideal weight can not always be achieved, but every missing kilo relieves the strain on the joints.
- Exercises learned during physiotherapy should be carried out independently at least several times a week.
Everyday life and self-help after the operation
If you already have a joint replacement, the same points per se apply as under prognosis.
- In addition, especially in the first few months after the operation to ensure good muscle.
- Also follow the instructions for getting up and sitting down correctly. The operated leg should not be bent in the groin over 90 degrees, rather less.
- For this purpose, seating with an elevated seating surface and a toilet seat increase are often helpful. The latter can be ordered by the doctor and refer to the medical supply store.
- Good clinics also practice with you the safe entry and exit on the car on both the driver and on the passenger side.
- Sexual activities should not be carried out too wildly in the first few months, especially care should be taken not to spread the legs too far or to overturn them, depending on the doctor's advice.
Osteoarthritis is widespread in Germany. The incidence of illness will increase due to the aging society. Depending on the stage of the disease the symptoms are very different, which makes different therapies necessary. From the over-the-counter pain ointment, which smiles critics rather as a psychological measure, to the artificial joint, there is an enormous range of treatment options available.
Your doctor will check for joint pain, if you have arthritis and discuss with you the currently best treatment for you. You are always free to obtain second and third opinions. With the right therapy, you can also lead a normal life as an osteoarthritis patient, be it with medication or surgery. Even after being treated with an artificial joint replacement, you should be able to lead your life as usual after three to six months.
Authors: Tanja Lodermeier, B.Sc. Health Care Studies & Dr. med. med. Jörg Zorn