Category Archives: Non-steroidal anti-inflammmatory Drugs

These medicines are used often to treat arthritis symptoms.

Can rheumatoid arthritis kill you?

Here is an email question I received recently…

“I have been in search of a very important question, can you die from RA?  It is listed on a death certificate of a person I know that did not have an autopsy and there were no doctors present when this person died. The person had RA but I am not convinced that this is true and heard you can NOT die from RA alone.  I would appreciate any information you could offer.”

Actually, this is a very interesting question because it brings up an important issue.

Rheumatoid arthritis (RA) is the most common form of inflammatory arthritis, affecting more than 2 million Americans.  It is a systemic autoimmune disease that can affect virtually any organ system.

What is not appreciated by many people, including physicians, is that RA has been associated with a significant mortality risk.

It has been estimated from a number of studies that uncontrolled or poorly controlled RA can shorten life span by ten to fifteen years. Despite the many treatment advances made in recent years, early mortality from rheumatoid arthritis remains a significant concern.

So why is that?

The answer lies in the chronic inflammation caused by the RA. The inflammation sets up an autoimmune situation that is perpetually turned on.  Essentially there is no “off-switch.”

Elegant studies done by Dr. Gerald Weissman and colleagues at the New York University School of Medicine implicate chronic gingival inflammation as the underlying trigger.

In any event, this chronic inflammation leads to early atherosclerotic cardiovascular disease. Heart attacks and strokes are the end result.  While this affects all patients, the effect seems to be most pronounced in women.

Some investigations have provided evidence that aggressive intervention with disease modifying anti-rheumatic drugs (DMARDS) and biologic agents may reverse the tendency to early heart attack and stroke.

Another cause of early death can be lung involvement leading to fibrosis and destruction of lung tissue.

Early crippling and disability is rarely seen nowadays.  However, in the past, this too was a significant cause of early death.

Rheumatoid vasculitis is a devastating complication of RA.  This problem occurs as a result of inflammation of blood vessel walls.  The inflammation causes closure of blood vessels to major organs and that obviously can cause major problems.  Immunosuppressive therapy has had mixed results as far as resolution of the problem.  Occasionally, high dose steroids and biologics have been used with some modicum of success.

This discussion would not be complete without a mention of early death related to treatment.  Non-steroidal anti-inflammatory drugs (NSAIDS) used to treat pain and inflammation can cause stomach ulcers, gastrointestinal bleeding, as well as liver and kidney damage.

Disease-modifying drugs such as methotrexate used to slow disease progression may also present problems.  And biologic therapies, even though they have revolutionized our approach to RA, because of their profound effects on the immune system, can also cause complications leading to death.

Nonetheless, when RA is treated appropriately, the benefits of therapy, I think, outweigh the negatives.

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What are my options for shoulder pain?

The shoulder has the honor of being is the largest, most complex, and most mobile joint in the body.  And it is this reason that makes it the most vulnerable to overuse.

The shoulder consists of three bones: the humerus (upper arm bone), clavicle (collarbone), and scapula (shoulder blade).

The rotator cuff muscles and tendons are responsible for movement and stabilization of the shoulder.

In addition, there are other muscles and a complex array of ligaments that also serve to ensure stability.

Another tendon, the biceps tendon, originates from the glenoid (the cup of the shoulder blade where the humerus sits) and extends down the humerus.  It is responsible for certain arm and shoulder movements.

The ironic fact is that a patient who complains of shoulder pain may have nothing wrong with the shoulder!shoulder-pain

For example, many medical conditions such as gall bladder disease, pneumonia, and ectopic pregnancies can present with shoulder pain.  Also, neck conditions often cause referred pain to the shoulder.  Patients with heart disease who are experiencing a heart attack may complain of pain in the left shoulder and arm.

Shoulder ailments fall into three major groups.  The first is trauma.  An example may be a skier who falls on an extended arm.  The impact can drive the head of the arm bone into the socket and cause damage to the cartilage, the bone, as well as the rotator cuff tendons. If the ligaments are stretched or torn, the shoulder can dislocate.  While the shoulder can be “relocated”, once dislocation occurs, the patient is at increased risk for another dislocation. Significant impact can cause damage to the cartilage that cushions the head of the femur as well as the “cup” of the scapula.  This cup is referred to as the glenoid.  The glenoid also has a lip of tougher cartilage that can be torn with impact injuries.

Trauma, if significant enough, can cause dislocation of the joint joining the collar bone to the shoulder blade. The common term for this is a “separated shoulder.”

A related but different type of ailment is wear and tear.  Because so many of the structures that permit shoulder movement and provide stability are made of connective tissue, it stands to reason that over time, they can begin to wear out.  And that is exactly what happens.  Tendons- the ropes that connect muscles to bone-, ligaments, and bursae (fluid filled sacks that cushion joint movement) all are prone to injury as a result of overuse.

When this occurs, conditions such as tendinopathy (previously known as tendonitis), bursitis, and ligament strain ensue.

While inflammation may be present, the overwhelming problem is tissue breakdown.

The last ailment that affects the shoulder is arthritis.  The three bones that make up the shoulder interact with each other at two specific points.  At these two points, there is a joint where two bones whose ends are covered with cartilage articulate.  The two joints are the glenohumeral joint- the joint that joins the shoulder blade and the humerus and the acromioclavicular joint that joins the collarbone to the shoulder blade.

Arthritis at these two areas can develop as a result of systemic disease such as rheumatoid arthritis or as a result of wear and tear- osteoarthritis.

The treatment of shoulder disorders depends upon both the underlying problem as well as the amount of patient discomfort and the impact on quality of life.

For traumatic disorder where there is obvious tissue disruption, surgery is usually required.  The type of surgery will be up to both the surgeon as well as to the individual who has the problem. The shoulder is a complex joint so it’s important to ensure whoever works on the shoulder is an expert.

For most wear and tear problems, non-steroidal anti-inflammatory medicines (NSAIDS) are sometimes, but not always, helpful. Ice and rest also can be useful.

Patients may require a steroid injection. For people who don’t respond to medicines, injections, and physical therapy, surgery may be an option. Ultrasound guidance is important.

Regenerative medicine techniques can be used for shoulder issues.  An example would be a procedure called percutaneous needle tenotomy which can be used to treat rotator cuff tendinopathy and tears.

In this procedure, a small needle is introduced using local anesthetic and ultrasound guidance. The needle is used to irritate the tendons of the rotator cuff and induce inflammation. Then, platelet-rich plasma, obtained from the patient’s whole blood is injected into the area where the tendons have been irritated. Ultrasound guidance here is mandatory. Platelets are cells in the blood that contain many growth and healing factors. This stimulates the production of new strong tendon tissue.

Another example of a regenerative medicine technique is the use of autologous stem cells (a patient’s own stem cells) for glenohumeral arthritis.

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Rheumatoid arthritis drugs… which ones are friendly to the heart and which ones aren’t!

Rheumatoid arthritis (RA) is a chronic, autoimmune systemic disease which affects approximately two million Americans. While the symptoms that bring the patient to the doctor are the joint swelling and pain, the area of most concern may not be the joints.  It is well established that cardiovascular risk is markedly increased in RA and in fact it is this complication that shortens lifespan by between ten to fifteen years.

A number of clinical studies have retrospectively examined the relationship between certain medications and the risk of cardiovascular events.  The report card has provided some real surprises.heart-attack_0

For example, methotrexate, the workhorse disease modifying anti-rheumatic drug (DMARD) of choice reduces cardiovascular mortality by almost 70 per cent. The mechanism is felt to be due to a reduction of atherosclerotic plaque formation as well as increased clearance of foam cells (Solomon DH, et al. Circulation 2003; 11: 1303-1307).

The other major player in the treatment of RA is the TNF inhibitor group.  These are used in more than 50 per cent of RA patients in the US. These drugs apparently reduce the risk of cardiovascular events by almost 50 per cent (Gonzalaz A, et al. Ann Rheum Dis. 2008; 67: 64-69). Why this occurs is still not clearly understood.

Steroids have been used to treat RA since the early 1950’s.  Steroids have been shown to worsen cardiovascular risk because of their effects on both blood pressure as well as blood glucose.  Steroid use in RA has been associated with increased carotid plaque formation as well as increased arterial stiffness.  So what dose is a safe dose?  The answer is still unknown.

Non-steroidal anti-inflammatory drugs (NSAIDS) raise blood pressure.  Randomized clinical trials have shown that cardiovascular risk is associated with COX-2 inhibitors but also with non-selective COX drugs also.  The upshot? All NSAIDS regardless of class, are associated with increased cardiovascular risk.

Hydroxychloroquine, a drug often used to treat mild RA, is associated with a decrease in diabetes and may also improve lipid status.  Actemra increases lipid profile but the long term effects are still unknown.  Leflunomide (Arava) increases blood pressure.  The eventual effects are still a subject of conjecture.

So what about aspirin?  This medication is used for cardiovascular prophylaxis.  In higher doses it also has anti-inflammatory effects although these are limited by the potential gastrointestinal side effects known to be caused by high dose aspirin. It is well known that other NSAIDS should not be used in patients taking aspirin for cardiovascular prophylaxis since they blunt that effect.

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“Ooohhh, My Aching Knee!” Insider Secrets on How You Can Get Relief Quickly and Easily!

When your knee hurts, getting relief is all that’s on your mind. Getting the right relief, though, depends on knowing what’s wrong. The correct diagnosis will lead to the correct treatment.

Know Your Knee!knee-arthritis

The knee is the largest joint in the body. It’s also one of the most complicated. The knee joint is made up of four bones that are connected by muscles, ligaments, and tendons. The femur (large thigh bone) interacts with the two shin bones, the tibia (the larger one) located towards the inside and the fibula (the smaller one) located towards the outside. Where the femur meets the tibia is termed the joint line. The patella, (the knee cap) is the bone that sits in the front of the knee. It slides up and down in a groove in the lower part of the femur (the femoral groove) as the knee bends and straightens.

Ligaments are the strong rope-like structures that help connect bones and provide stability. In the knee, there are four major ligaments. On the inner (medial) aspect of the knee is the medial collateral ligament (MCL) and on the outer (lateral) aspect of the knee is the lateral collateral ligament (LCL). The other two main ligaments are found in the center of the knee. These ligaments are called the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). They are called cruciate ligaments because the ACL crosses in front of the PCL. Other smaller ligaments help hold the patella in place in the center of the femoral groove.

Two structures called menisci sit between the femur and the tibia. These structures act as cushions or shock absorbers. They also help provide stability for the knee. The menisci are made of a tough material called fibrocartilage. There is a medial meniscus and a lateral meniscus. When either meniscus is damaged it is called a “torn cartilage”.

There is another type of cartilage in the knee called hyaline cartilage. This cartilage is a smooth shiny material that covers the bones in the knee joint. In the knee, hyaline cartilage covers the ends of the femur, the femoral groove, the top of the tibia and the underside of the patella. Hyaline cartilage allows the knee bones to move easily as the knee bends and straightens.

Tendons connect muscles to bone. The large quadriceps muscles on the front of the thigh attach to the top of the patella via the quadriceps tendon. This tendon inserts on the patella and then continues down to form the rope-like patellar tendon. The patellar tendon in turn, attaches to the front of the tibia. The hamstring muscles on the back of the thigh attach to the tibia at the back of the knee. The quadriceps muscles are the muscles that straighten the knee. The hamstring muscles are the main muscles that bend the knee.

Bursae are small fluid filled sacs that decrease the friction between two tissues. Bursae also protect bony structures. There are many different bursae around the knee but the ones that are most important are the prepatellar bursa in front of the knee cap, the infrapatellar bursa just below the kneecap, the anserine bursa, just below the joint line and to the inner side of the tibia, and the semimembranous bursa in the back of the knee. Normally, a bursa has very little fluid in it but if it becomes irritated it can fill with fluid and become very large.

Is it bursitis… or tendonitis…or arthritis?

Tendonitis generally affects either the quadriceps tendon or patellar tendon. Repetitive jumping or trauma may set off tendonitis. The pain is felt in the front of the knee and there is tenderness as well as swelling involving the tendon. With patellar tendonitis, the infrapatellar bursa will often be inflamed also. Treatment involves rest, ice, and anti-inflammatory medication. Injections are rarely used. Physical therapy with ultrasound and iontopheresis may help.

Bursitis pain is common. The prepatellar bursa may become inflamed particularly in patients who spend a lot of time on their knees (carpet layers). The bursa will become swollen. The major concern here is to make sure the bursa is not infected. The bursa should be aspirated (fluid withdrawn by needle) by a specialist. The fluid should be cultured. If there is no infection, the bursitis may be treated with anti-jnflammatory medicines, ice, and physical therapy. Knee pads should be worn to prevent a recurrence once the initial bursitis is cleared up.

Anserine bursitis often occurs in overweight people who also have osteoarthritis of the knee. Pain and some swelling is noted in the anserine bursa. Treatment consists of steroid injection, ice, physical therapy, and weight loss.

The semimembranous bursa can be affected when a patient has fluid in the knee (a knee effusion). The fluid will push backwards and the bursa will become filled with fluid and cause a sensation of fullness and tightness in the back of the knee. This is called a Baker’s cyst. If the bursa ruptures, the fluid will dissect down into the calf. The danger here is that it may look like a blood clot in the calf. A venogram and ultrasound test will help differentiate a ruptured Baker’s cyst from a blood clot. The Baker’s cyst is treated with aspiration of the fluid from the knee along with steroid injection, ice, and elevation of the leg.

Knock out knee arthritis… simple steps you can take!

Younger people who have pain in the front of the knee have what is called patellofemoral syndrome (PFS). Two major conditions cause PFS. The first is chondromalacia patella. This is a condition where the cartilage on the underside of the knee cap softens and is particularly common in young women. Another cause of pain behind the knee cap in younger people may be a patella that doesn’t track normally in the femoral groove. For both chondromalacia as well as a poorly tracking patella, special exercises, taping, and anti-inflammatory medicines may be helpful. If the patellar tracking becomes a significant problem despite conservative measures, surgery is need.

While many types of arthritis may affect the knee, osteoarthritis is the most common. Osteoarthritis usually affects the joint between the femur and tibia in the medial (inner) compartment of the knee. Osteoarthritis may also involve the joint between the femur and tibia on the outer side of the knee as well as the joint between the femur and patella. Why osteoarthritis develops is still being scrutinized carefully. It seems to consist of a complex interaction of genetics, mechanical factors, and immune system involvement. The immune system attacks the joint through a combination of degradative enzymes and inflammatory chemical messengers called cytokines.

Patients will sometimes feel a sensation of rubbing or grinding. The knee will become stiff if the patient sits for any length of time. With local inflammation, the patient may experience pain at night and get relief from sleeping with a pillow between the knees. Occasionally, locking and clicking may be noticed. Patients with osteoarthritis may also tear the fibrocartilage cushions (menisci) in the knee more easily than people without osteoarthritis.

So how is the arthritis treated? An obvious place to start is weight reduction for patients who carry around too many pounds.

Strengthening exercises for the knee are also useful for many people. These should be done under the supervision of a physician or physical therapist.

Other therapies include ice, anti inflammatory medicines, and occasionally steroid injections. Glucosamine and chondroitin supplements may be helpful. A word of caution… make sure the preparation you buy is pure and contains what the label says it does. The supplement industry is unregulated… so buyer beware!

Injections of the knee with viscosupplements – lubricants- are particularly useful for many patients. Special braces may help to unload the part of the joint that is affected.

Arthroscopic techniques may be beneficial in special circumstances. Occasionally, a surgical procedure called an osteotomy, where a wedge of bone is removed from the tibia to “even things out,” may be recommended. Joint replacement surgery is required for end stage knee arthritis.

Research is being done to develop medicines that will slow down the rate of cartilage loss. Targets for these new therapies include the destructive enzymes and/or cytokines that degrade cartilage. It is hoped that by inhibiting these enzymes and cytokines and by boosting the ability of cartilage to repair itself, that therapies designed to actually reverse osteoarthritis may be created. These are referred to as disease-modifying osteoarthritis drugs or “DMOADs.” Genetic markers may identify high risk patients who need more aggressive therapies.

Newer compounds that are injected into the knee and provide healing as well as lubrication are also being developed. And finally, less invasive surgical techniques are also being looked at. Recent technological advances in “mini” knee replacement look very promising.

The technology that will revolutionize our approach to knee osteoarthritis is the use of mesenchymal stem cells.  These are stem cells derived from “non-blood” tissues such as fat, bone marrow, or even the lining of the joint. Studies in both animals as well as humans have shown great potential for these cells to regenerate cartilage.

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Know about aspirin resistance?

Many people who take aspirin for prophylaxis against heart attack and stroke have been found to not respond.  Why is that?  Well, the answer is simple.

Elizabeth Mechatie writing in Rheumatology News reported on a study showing that aspirin resistance is actually not resistance at all.  It is due to the enteric coating that many aspirin preparations have.  This phenomenon is called “pseudoresistance.”  When patients who were initially thought to be resistant were switched from enteric coated tablets to plain aspirin, the resistance disappeared.aspirin

One other note: patients who take prophylactic aspirin have the effect of the aspirin blunted if they take non-steroidal anti-inflammatory drugs for conditions such as arthritis.

The exception is Celebrex.

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How to work out a stiff neck

Everyone, at one time or other, has had a stiff neck.  How do you deal with it?

The cervical spine consists of 7 block-shaped bones called vertebrae.  They are stacked, one upon the other forming the spinal column.

The neck vertebrae have two major functions

•To bear the weight of the head

•To protect the spinal cord or spinal nerve roots inside the spinal column

Each vertebra has bony projections called “processes” that are sites for the attachment of ligaments and muscles that help stabilize and move the spine.

Between each vertebra are cushions, called discs. Each disc has a soft jelly-like center called the nucleus pulposus, which is surrounded by a tough fibrous outer envelope called the annulus fibrosis.

Each vertebrae has areas for the attachment of muscles.

In the neck there are a series of ligaments that are important for stability of the vertebral column.

stiff-neckA stiff neck occurs when there is either a muscle strain or there is damage to the ligaments.  Muscle strains can be due to injury or to prolonged abnormal positioning. An example of injury might be trauma to the muscles during athletic events.

Abnormal positioning is a more common occurrence. This happens when one holds their head in one position for too long a period of time.  Sitting at the computer or driving long distances are two situations where this occurs. Another example is when a person wakes up with a stiff neck because of sleeping in a weird position.

The interspinous ligaments at C5-7 are also prone to tear following neck injuries. The interspinous ligaments are slack when the head and neck are in the upright position.

During hyperextension of the head (when the head is bent backward), the ligaments slacken

In hyperflexion (head is bent forward,) the cervical interspinous ligaments are tightened and they are vulnerable to tears at the tips of the spinous processes.

The classic injury to the interspinous ligaments occurs with rear-end automobile whiplash incidents.

The ligaments at the tips of the spinous processes are mixed with the fibers of the long ligaments of the neck, which are attached to the  base of the skull.

Fibers of the trapezius muscle also blend with these ligaments. This is why  neck injuries may produce symptoms of pain and tightness in the head and shoulder muscles.

If there is no history of trauma, a stiff neck is usually a result of muscle tightness.  Moist heat applied for twenty minutes two to three times a day, neck support during sleep using a curved pillow, and a soft cervical collar worn for two to three days can be helpful.  Non-steroidal-anti-inflammatory drugs and muscle relaxants can also be beneficial.

If symptoms don’t resolve, then a visit to the physician is advised.  Physical therapy modalities such as electrical stimulation and ultrasound can help with pain resolution. Gentle stretches and range-of-motion exercises may be prescribed.

With a history of trauma, then the treatment approach is different.  A visit to the doctor is recommended to make sure there is no significant damage to the neck. Imaging procedures such as MRI may be done before treatment is instituted. Pain resolution may take a long time with significant muscle injury or damage to the interspinous ligaments. This is particularly true if there is underlying osteoarthritis affecting the neck.

Helpful treatment modalities for more severe problems can include acupuncture, chiropractic, prolotherapy, Botox, and massage.

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What are the approaches to treatment of osteoarthritis of the knee?

There are multiple treatment approaches for osteoarthritis (OA) of the knee.

osteoarthritis-knee-2The most important to start with is weight loss and patient education.  Without these, other therapies won’t work.

Analgesics such as acetaminophen may work for mild disease and non-steroidal anti-inflammatory drugs(NSAIDS) can be used for more symptomatic disease. The use of the latter category of drug needs to be tempered with the knowledge that potential gastrointestinal and cardiovascular side-effects are associated with these medicines.  Topical NSAIDS may be safer.

Alternative therapies such ass glucosamine/chondroitin, acupuncture, and so on, serve a complementary role.

Exercise and physical therapy, and, if necessary, braces, orthotics, and other assistive devices may be helpful.

Injections of glucocorticoids and viscosupplements can provide significant palliative relief.

Guided mesenchymal stem cell layering is a technique that can provide symptomatic relief, potentially regrow cartilage, and delay the need for surgery.

Total knee replacement is to be considered for patients with end-stage disease.

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Lumbar spinal stenosis: the masquerader

One of the most common problems encountered by rheumatologists is lumbar spinal-stenosisspinal stenosis.  This is a condition where arthritis and disc disease in the low back narrows the central canal that the spinal cord occupies.  As a result there is pressure placed on the spinal cord leading to many confusing symptoms.

Typically occurring in people past the age of 65, most will have back pain that radiates into the buttocks and upper thighs. The pain is worse with standing and walking and relieved by sitting.  Patients will often exhibit a waddling gait and have an abnormal sensory exam during the physical.

MRI scanning can help confirm the diagnosis.  Typically, the exam will show mri-spinal-stenosisarthritis in the facet joints, bulging of the intervertebral discs, and enlargement of the ligamentum flavum, the thick ligament that runs lengthwise down the spinal canal.

Other conditions can make the diagnosis difficult.  These include osteoarthritis of the hip, mechanical back pain, hip bursitis, and vascular narrowing.  The latter also causes aching in the legs with walking. The difference can be made by having the patient ride a bike.  With vascular claudication, the pain will return.  With spinal stenosis, the pain will not.

Treatment is highly dependent on the individual patient. While exercise and non-steroidal anti-inflammatory drugs may relieve some symptoms, they are difficult for many older patients with spinal stenosis to tolerate.  Epidural injections of steroids sometimes are helpful.  Many patients will require decompression surgery.

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Acute liver injury due to Limbrel

A recent study in the Annals of Internal Medicine described 4 patients out of 877 enrolled in the study who had signs and symptoms of acute liver injury due to limbrel  taking the medical food, Limbrel, for osteoarthritis.  Liver function abnormalities were substantial but resolved within 3 to 12 weeks of drug discontinuation. The fact that something is a “food” or “natural” doesn’t make it 100% safe.

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What can be done about osteoarthritis?

Osteoarthritis (OA) is the most common form of arthritis and affects approximately 28 million Americans.  While it has been viewed as a “wear and tear” phenomenon, it has become quite clear that it is a disease that is multifactorial in its development.

It is not a benign disease because, in addition to the pain, OA leads to functional disability.

The joint is a dynamic structure where anabolic (building) activities are counterbalanced by catabolic (destructive) activities.

With OA, the catabolic activities gradually overtake the anabolic ones. While there are attempts at repair, these attempts are dysfunctional , leading to the formation of bony spurs, called osteophytes.osteoarthritis-knee

There are three major risk factors for the development of osteoarthritis.  They are genetic (usually a family history is prominent), constitutional (obesity in the case of OA of the knee, and aging), and finally local components (injury and ligamentous laxity).

Cartilage consists of cells called chondrocytes that sit inside a “soup”, a matrix, which consists of collagen and proteoglycans.cartilage_1

The development of osteoarthritis starts with an initial injury to cartilage.

The injury may trigger an inflammatory response leading to the synthesis of cartilage matrix degrading enzymes, produced by chondrocytes. Over time, the catabolic activities override anabolic activities and abnormal repair mechanisms lead to the formation of osteophytes, while cartilage continues to degrade.

The treatment for osteoarthritis is primarily symptomatic.  Analgesics (pain nsaidsrelievers), non-steroidal-anti-inflammatory drugs (NSAIDS), weight loss, exercise, assistive devices such as wedge insoles, braces, canes, walkers, and such. Injection of glucocorticoids and viscosupplements (lubricants viscosupplementderived either from rooster combs or from bacteria) may also be helpful.

knee-joint-replacement-surgeryEventually patients will require surgery in the form of joint replacement. Joint replacement surgery has come a long way, but there are still concerns about them.  The first is the possibility of a surgical complication such as blood clot or infection.  The second issue is the finite lifespan of the prosthesis.  They usually last 10 to 15 years but this is a function of activity and joint replacement patients do have restrictions on their activity level.  Persistent pain due to particle induced inflammation can also be a problem.

Finally, the chance of faulty prosthetic devices such as the recent  Johnson & Johnson metal-on-metal hip debacle, makes the choice of total joint replacement less attractive.

Recent developments in stem cell technology may provide an alternative to joint replacement.

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