Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
The Aging Skeleton Andrew A. McBeath To cite this article: Andrew A. McBeath (1975) The Aging Skeleton, Postgraduate Medicine, 57:7, 171-175, DOI: 10.1080/00325481.1975.11714086 To link to this article: https://doi.org/10.1080/00325481.1975.11714086
Published online: 07 Jul 2016.
Submit your article to this journal
Article views: 1
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20
Osteoporosis of the bones and degenerative arthritis of the joints can detract from quality of life. Although these diseases cannot be cured, they can frequently be treated sufficiently to allow the patient a more satisfactory life.
THE AGING SKELETON Osteoporosis and Degenerative Arthritis The skeleton and its joints are definitely susceptible to the aging process, but both osteoporosis and degenerative arthritis are treatable to varying degrees.
ANDREW A. McBEATH, MD University of Wisconsin Medical School Madison
Osteoporosis
Osteoporosis affects women four to six times more often than it does men. In the United States, 25 % to 30% of postmenopausal women, or 4 to 6 million women, have this disease.1 lt may be discovered as an incidental radiographie finding, or when fractures of the hip, wrist (Colles type), or vertebrae occur. Osteoporosis is a basic causative factor in many of these fractures. Subtle compression fractures of the thorade and lumbar vertebrae are responsible for the dowager's hump, the increased abdominal skin folds, and the loss of height frequently seen in the elderly stooped female. All these fractures cause various degrees of morbidity, and unfortunately, a fractured hip can still precipitate death. Osteoporosis results from a balanced loss of bone substance, ie, a proportional loss of both the mineral and the protein matrix portions of the bone. This is in contrast to osteomalacia, in which only mineral is decreased. Several different factors are known to cause
Vol. 57 • No. 7 • June 1975 • POSTGRADUATE MEDICINE
osteoporosis, but no one mechanism has been isolated as the cause in elderly females. The hormonal theory of estrogen deficiency has much circumstantial support in that the disease is seen most frequently in postmenopausal females. Osteoporosis can be of early onset and great severity in a woman who has been castrated before menopause. Overt hyperparathyroidism is known to cause osreoporosis, and one group2 feels that mildly elevated levels of parathyroid hormone in association with impaired renal function may be a cause. Increased levels of corticosteroids, either endogenous or exogenous, is a well-known cause of osteoporosis. Disuse of the skeleton as seen in patients with poliomyelitis, forced immobilization, and inactivity is also known to cause osteoporosis. Chalmers and Ho3 found that in cultures in which Adapted from a course on problem solving in clinical geriatries held at the University of Wisconsin-Madison.
171
1 Most people acquire degenerative • arthritis sometime during middle • age. For most the symptoms are • only an aggravation, but for a • few they are a true disability. • the women have a higher level of activity than does the average American woman, elderly women suffer fewer hip fractures. Somé feel that inadequate diet causes osteoporosis and not just osteomalacia. Older people, especially when living alone and feeling or actually being poor, tend to have an inadequate diet. When evaluating patients for osteoporosis, one should include in the history dietary habits, activity level, existence of steroid administration, prior malignant disease, loss of height, and any recent weight loss (likely with multiple myeloma or carcinomatosis). Generalized skeletal tenderness is seen in osteomalacia, multiple myeloma, and carcinomatosis, but not in osteoporosis. Localized tenderness is present after a recent compression fracture. When many compression fractures exist, dorsal kyphosis and increased transverse abdominal skin folds are present. If the history is inconclusive as to height loss, arm-span/height ratios cao be checked. Results of routine laboratory studies are normal in osteoporosis, including complete blood count, sedimentation rate, and calcium, phosphorus, and alkaline phosphatase levels. Alkaline phosphatase may be elevated in the presence of healing fractures. Bence Jones protein determination, or better yet, serum electrophoresis, is done to detect multiple myeloma. Bone biopsy is rarely necessary, but it is an excellent diagnostic procedure. During surgery on a fractured hip, there is no reason not to obtain a biopsy specimen.
172
Radiographs reveal generalized skeletal rarefaction which spares the skull. The cortices are thinned and the vertebrae show increased prominence of the vertical trabeculae and often the loss of height due to compression. Calcification is frequendy seen in the aorta. Determination of calcium and protein levels in a 24-hour urine collection cao be useful in diagnosis. Techniques such as densitometry, photonscan, and resonant frequency exist for relatively precise determinations of bone mineral. Thus, it cao be seen that the main purpose of performing laboratory studies is to exclude conditions other than postmenopausal osteoporosis which might cause rarefaction of bones. Treatment of Osteoporosis
Local complications-Most wrist fractures are treated with closed reduction and cast immobilization. The most frequent problems assodated with these fractures relate to residual joint stiffness. The cast must allow full metacarpophalangeal flexion, and the patient must be encouraged to exercise actively the small finger joints, especially the metacarpophalangeal joints, and the shoulder and elbow joints. Shoulder motion is easily lost. Generally, a short arm cast in elderly patients is sufficient for fracture treatment. This allows elbow motion to be maintained. Exercise must be done many times per day. Despite the local and systemic problems assodated with the operative fixation of hip fractures, this is the procedure of choice for most such fractures. If braces of any sort are used to treat spinal compression fractures, they should be used for as short a time as possible. Prolonged use leads only to further muscle weakness and aggravation of the basic problem. lt is far better for the patient to create her own brace by increasing the muscle tone of the trunk fiexors and extensors by geode isometric exercises. Extension exercises coupled with posture awareness can benefit the kyphosis. General-The daily diet prescribed for a patient with osteoporosis should include adequate calcium, vitamin D, and protein (1,250 mg of calcium; 90 gm of protein; 5,000 units of vita-
POSTGRADUATE MEDICINE • June 1975 • Vol. 57 • No. 7
min D for three months, then 1,000 units). 5 The patient should be encouraged to exercise daily. Walking is the most available exercise. Exercise bas advantages for other body systems as weil. Home-environment counseling is of definite value. In addition to unsteadiness, many senior citizens have sight problems. The homes of many elderly people are poorly lighted, crowded with furniture, and adorned with throw rugs. Attention to these factors can diminish chances of falling and sustaining a fracture. The use of drugs is by far the most controversial modality of treatment for osteoporosis. Because the incidence of osteoporosis bas been found to be less in areas with high fluoride concentration in water, administration of fluoride either alone or in combination with other drugs bas been advocated. 6 Results with sodium fluaride treatment, however, have been inconsistent, and gastrointestinal intolerance bas been a problem. Male hormones may give pain relief but have virilizing effects. Estrogens also relieve symptoms and have been shawn to provide a positive calcium balance; however, the duration of this positive balance is debated. If 1 use estrogen, 1 prescribe a conjugated estrogen, 1.25 mg/ day for 25 days of each month. 7 Other drugs such as phosphate and the diphosphonates are also under investigation for the treatment of osteoporosis. Primary Degenerative Arthritis
Most people acquire degenerative arthritis sometime during middle age. For most the symptoms are only an aggravation, but for a few they are a true disability. Pain is by far the most frequent presenting complaint, but limited motion can also create problems. Arthritic problems are second only ta cardiovascular disease as a cause of invalidism.8 Arthritis is obviously more significant when it affects the weight-bearing joints. Even though we do not know the cause of primary degenerative arthritis (hypertrophie arthritis, osteoarthritis), there is much to offer the patient with this disorder in the way of treat-
Vol. 57 • No. 7 • June 1975 • POSTGRADUATE MEDICINE
ANDREW A. McBEATH Dr. McBeath is associate professor of orthopedie sürgery, University of Wisconsin Medical School, Madison.
ment, bath operatively .and nonoperatively. Good liaison with the patient is essential for successful treatment. The physician must clarify for the patient the difference between degenerative and rheumatoid arthritis. Ali too often the physician sees a few osteophytes or joint-space narrowing on a radiograph and tells the patient arthritis is present. The patient then goes home, waiting for grotesque deformities of the fingers. ln these instances, the mental anguish can become far worse than the initial complaint. lt is essential for the physician to explain to the patient that the symptoms of degenerative arthritis are insidious, the disease is not a sudden crippler, symptoms are usually episodic and related to activity, and while there is a tendency for the disease to get worse slowly, it can, in sorne cases, improve.9 The physician must be positive when advocating nonoperative treatment. If he bas no conviction in nonoperative treatment or does not prescribe any, the patient suffers. How does the physician know whether to pursue operative or nonoperative treatment? The primary consideration is how the complaint affects the daily life of the involved individual. What desired activity is eliminated or restricted by the disease? How severe is the pain? Cornplaint of pain occurring on the 18th fairway should elicit a different response than does cornplaint of severe unremitting night pain or pain necessitating premature retirement. The amount and type of medication being taken can give a clue to severity of pain. Examination of the patient is helpful. The degree and type of limp is significant with lower
173
1
Drugs play an important part in • the nonoperative treatment of • degenerative arthritis. Aspirin • is by far the cheapest, least toxic, • and most effective drug to use. •
extremity arthritis. Restricted range of motion, persistent effusions, marked varus or valgus of the knee, and severe fixed deformities such as flexion of the knee or flexion and adduction of the hip are significant. These deformities and restricted range of motion are indications that nonoperative treatment will probably not work. A radiograph is used mostly for confirmation of disease. The degree of impairment often fails to relate to the degree of involvement visible on radiographs. Treatment of Primary Degenerative Arthritis
N onoperative-since arthritis is not fatal, there is no risk in first attempting nonoperative treatment. Drugs play an important part in the nonoperative treatment of degenerative arthritis. Aspirin is by far the cheapest, least toxic, and most effective drug to use. lt not only is an analgesie and an anti-infl.ammatory drug, but it also has been shown to inhibit the catabolic phase of articular cartilage metabolism.10 The drug should be taken in regular doses to be effective, ie, 2 tablets three to four times a day, not just when symptoms become severe. If aspirin irritates the stomach, it should be taken with food, milk, or water. For acute exacerbations, phenylbutazone is effective. If it is going to be effective, it is so within one week. Occasionally, this drug depresses the white blood cell count. Indomethacin is effective in sorne cases of degenerative joint disease, but 1 find it takes longer to act than phenylbutazone and sorne
174
patients experience unpleasant side effects. Ibuprofen has been found to be effective in some cases in which aspirin is not tolerated, but it is more expensive than aspirin. Rest has a definite place in the treatment of degenerative arthritis. Episodes of pain can be treated with traction for two to three days, or home traction can be used on an intermittent basis for arthritis of the knees or hips. A cane is an underrated deviee in the treatment of lower extremity joint disease. When the cane is used properly in the hand on the side opposite the involved hip, each pound of force applied to the cane relieves the hip of about 7 lb of force. 11 There appear to be many psychologie barriers to the use of a cane and aspirin, especially the cane, even though the risk and expense of using a cane and taking aspirin are far less than those of any operation. Exercise is also important in the treatment of degenerative arthritis. The types used include active range of motion, passive range of motion, progressive resistance exercises, and isometric exercises. Bicycling puts the knees and hips through a range of motion in one plane. The goals of exercise are to nourish the articular cartilage, to maintain range of motion, and to prevent fixed deformities. lt has been shown that in patients in whom permanent flexion or adduction deformities of the hip have been avoided, pain is more likely to disappear spontaneously and not require surgical therapy.9 The severity of the problem in sorne joints can be diminished by exercising the key muscles. In the hip, the extensors and abductors are the most important, in the knee the quadriceps, and in the lower back the abdominal muscles. Operative-The most recent, most publicized surgical procedure for the treatment of degenerative arthritis is total joint replacement. Because of the dramatic results achieved with this operation, other procedures tend to be forgotten. This, 1 feel, is a mistake, as other procedures still have a place in the therapeutic armamentarium. Although total joint replacement is a predictable procedure and has brought relief to many older persons who would not have had the strength and endurance to be rehabilitated by
POSTGRADUATE MEDICINE • June 1975 • Vol. 57 • No. 7
other surgical procedures, it is a major surgical procedure with ali the usual inherent risks. Infection is an especially serious complication, because when it occurs the appliance usually must be removed. Thus, the physician should not perform or recommend total joint replacement indiscriminately. There are a few prophylactic procedures. Evidence continues to mount documenting the value of proximal tibial osteotomy in early degenerative arthritis with varus or valgus deformities at the knee. Osteotomy of the proximal femur has been shown to be of value in early disease when proper criteria are met. Occasionally, arthrodesis of the hip is still used to treat degenerative arthritis, though rarely in elderly individuals. Mold arthroplasty, 1 feel, still has a place in the treatment of hip dis-
ease, especially in younger people. One has a greater chance of success when placing a mold in a hip which has been infected than when inserting a total hip. Comment
W e do not know the cause of either osteoporosis or degenerative arthritis, but both of these diseases are treatable to varying degrees. Neither disease kills; therefore, they do not receive the same attention as do such dramatic killers as heart disease and cancer. Obviously, the best solution is prevention, but before this utopian state cao be reached, we must find the cause. Address reprint requests to Andrew A. McBeath, MD, Division of Orthopedie Surgery, University of Wisconsin Hospitals, 1300 University Ave, Madison, WI 53706.
REFERENCES 1. Jurist J: Persona! communication 2. Berlyne GM, Ben-Ad J, Galinski D, et al: The etiology of osteoporosis. JAMA 229:1904, 1974 3. Chalmers J, Ho KC: Geographical variations in senile osteoporosis: The association with physical activity. J Bone Joint Surg 52-B:667, 1970 4. Nordin BE: Osteomalacia, osteoporosis and calcium deficiency. Clin Orthop 17:235, 1960 5. Stearns G: Persona! communication cited by Hunt DD: Changing concepts in osteoporosis. J Iowa Med Soc 55 :563, 1965 6. Bernstein DS, Sadowsky N, Hegsted DM, et al: Prevalence of osteoporosis in high- and low-iluoride areas in North Dakota. JAMA 198:499, 1966 7. Gordon GS: Post menopausal osteoporosis: Problems of diagnosis and therapy. ln: The Female
8.
9. 10.
11.
Climacteric. New York, Ayerst Laboratories, 1970, vol 1, p 14 Chronic conditions and limitations of activity and mobility, U.S. July 1965-June 1967. Series 10, No. 61, National Center for Health Statistics, US Department of Health, Education, and W elfare. W ashington, DC, 1971 Danielsson LG: Incidence and prognosis of coxarthrosis. Acta Orthop Scand (Suppl) 66:1-114, 1964 Chrisman OD, Snook GA, Wilson TC: The prorecrive effect of aspirin against degeneration of human arricular cartilage. Qin Orthop 84:193, 1972 Blount WP: Don't throw away the cane. J Bone Joint Surg 38-A:695, 1956
ilJ
00
c
ReadySource OON
BOOKS Osteoporosis (Barzel, editor) New York: Grune & Stratton, lnc, 1970 The Bioloay of Detenerative Joint Disuse (Sokoloff) Chicago: University of Chicago Press, 1969 Arthritis and Allied Conditions (Hollander, McCarty, editors) Philadelphia: Lea & Febiger, 1972
Vol. 57 • No. 7 • June 1975 • POSTGRADUATE MEDICINE
OSTEOPOROSIS AND DEGENERATIVE ARTHRITIS
Bone as a Tissue (Rodahl, editor) New York: McGraw-Hill Book Co, 1960
AUDIOVISUALS Orthopedie Problems in tht Altd (tape) (SChmeisser) Source: Audiovisual Division of R. A. Becker, lnc., 299 Park Ave, New York, NY 10017 Cost: $8 For details on how to use ReadySource,- P•le 168.
175
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
The Aging Skeleton Andrew A. McBeath To cite this article: Andrew A. McBeath (1975) The Aging Skeleton, Postgraduate Medicine, 57:7, 171-175, DOI: 10.1080/00325481.1975.11714086 To link to this article: https://doi.org/10.1080/00325481.1975.11714086
Published online: 07 Jul 2016.
Submit your article to this journal
Article views: 1
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20
Osteoporosis of the bones and degenerative arthritis of the joints can detract from quality of life. Although these diseases cannot be cured, they can frequently be treated sufficiently to allow the patient a more satisfactory life.
THE AGING SKELETON Osteoporosis and Degenerative Arthritis The skeleton and its joints are definitely susceptible to the aging process, but both osteoporosis and degenerative arthritis are treatable to varying degrees.
ANDREW A. McBEATH, MD University of Wisconsin Medical School Madison
Osteoporosis
Osteoporosis affects women four to six times more often than it does men. In the United States, 25 % to 30% of postmenopausal women, or 4 to 6 million women, have this disease.1 lt may be discovered as an incidental radiographie finding, or when fractures of the hip, wrist (Colles type), or vertebrae occur. Osteoporosis is a basic causative factor in many of these fractures. Subtle compression fractures of the thorade and lumbar vertebrae are responsible for the dowager's hump, the increased abdominal skin folds, and the loss of height frequently seen in the elderly stooped female. All these fractures cause various degrees of morbidity, and unfortunately, a fractured hip can still precipitate death. Osteoporosis results from a balanced loss of bone substance, ie, a proportional loss of both the mineral and the protein matrix portions of the bone. This is in contrast to osteomalacia, in which only mineral is decreased. Several different factors are known to cause
Vol. 57 • No. 7 • June 1975 • POSTGRADUATE MEDICINE
osteoporosis, but no one mechanism has been isolated as the cause in elderly females. The hormonal theory of estrogen deficiency has much circumstantial support in that the disease is seen most frequently in postmenopausal females. Osteoporosis can be of early onset and great severity in a woman who has been castrated before menopause. Overt hyperparathyroidism is known to cause osreoporosis, and one group2 feels that mildly elevated levels of parathyroid hormone in association with impaired renal function may be a cause. Increased levels of corticosteroids, either endogenous or exogenous, is a well-known cause of osteoporosis. Disuse of the skeleton as seen in patients with poliomyelitis, forced immobilization, and inactivity is also known to cause osteoporosis. Chalmers and Ho3 found that in cultures in which Adapted from a course on problem solving in clinical geriatries held at the University of Wisconsin-Madison.
171
1 Most people acquire degenerative • arthritis sometime during middle • age. For most the symptoms are • only an aggravation, but for a • few they are a true disability. • the women have a higher level of activity than does the average American woman, elderly women suffer fewer hip fractures. Somé feel that inadequate diet causes osteoporosis and not just osteomalacia. Older people, especially when living alone and feeling or actually being poor, tend to have an inadequate diet. When evaluating patients for osteoporosis, one should include in the history dietary habits, activity level, existence of steroid administration, prior malignant disease, loss of height, and any recent weight loss (likely with multiple myeloma or carcinomatosis). Generalized skeletal tenderness is seen in osteomalacia, multiple myeloma, and carcinomatosis, but not in osteoporosis. Localized tenderness is present after a recent compression fracture. When many compression fractures exist, dorsal kyphosis and increased transverse abdominal skin folds are present. If the history is inconclusive as to height loss, arm-span/height ratios cao be checked. Results of routine laboratory studies are normal in osteoporosis, including complete blood count, sedimentation rate, and calcium, phosphorus, and alkaline phosphatase levels. Alkaline phosphatase may be elevated in the presence of healing fractures. Bence Jones protein determination, or better yet, serum electrophoresis, is done to detect multiple myeloma. Bone biopsy is rarely necessary, but it is an excellent diagnostic procedure. During surgery on a fractured hip, there is no reason not to obtain a biopsy specimen.
172
Radiographs reveal generalized skeletal rarefaction which spares the skull. The cortices are thinned and the vertebrae show increased prominence of the vertical trabeculae and often the loss of height due to compression. Calcification is frequendy seen in the aorta. Determination of calcium and protein levels in a 24-hour urine collection cao be useful in diagnosis. Techniques such as densitometry, photonscan, and resonant frequency exist for relatively precise determinations of bone mineral. Thus, it cao be seen that the main purpose of performing laboratory studies is to exclude conditions other than postmenopausal osteoporosis which might cause rarefaction of bones. Treatment of Osteoporosis
Local complications-Most wrist fractures are treated with closed reduction and cast immobilization. The most frequent problems assodated with these fractures relate to residual joint stiffness. The cast must allow full metacarpophalangeal flexion, and the patient must be encouraged to exercise actively the small finger joints, especially the metacarpophalangeal joints, and the shoulder and elbow joints. Shoulder motion is easily lost. Generally, a short arm cast in elderly patients is sufficient for fracture treatment. This allows elbow motion to be maintained. Exercise must be done many times per day. Despite the local and systemic problems assodated with the operative fixation of hip fractures, this is the procedure of choice for most such fractures. If braces of any sort are used to treat spinal compression fractures, they should be used for as short a time as possible. Prolonged use leads only to further muscle weakness and aggravation of the basic problem. lt is far better for the patient to create her own brace by increasing the muscle tone of the trunk fiexors and extensors by geode isometric exercises. Extension exercises coupled with posture awareness can benefit the kyphosis. General-The daily diet prescribed for a patient with osteoporosis should include adequate calcium, vitamin D, and protein (1,250 mg of calcium; 90 gm of protein; 5,000 units of vita-
POSTGRADUATE MEDICINE • June 1975 • Vol. 57 • No. 7
min D for three months, then 1,000 units). 5 The patient should be encouraged to exercise daily. Walking is the most available exercise. Exercise bas advantages for other body systems as weil. Home-environment counseling is of definite value. In addition to unsteadiness, many senior citizens have sight problems. The homes of many elderly people are poorly lighted, crowded with furniture, and adorned with throw rugs. Attention to these factors can diminish chances of falling and sustaining a fracture. The use of drugs is by far the most controversial modality of treatment for osteoporosis. Because the incidence of osteoporosis bas been found to be less in areas with high fluoride concentration in water, administration of fluoride either alone or in combination with other drugs bas been advocated. 6 Results with sodium fluaride treatment, however, have been inconsistent, and gastrointestinal intolerance bas been a problem. Male hormones may give pain relief but have virilizing effects. Estrogens also relieve symptoms and have been shawn to provide a positive calcium balance; however, the duration of this positive balance is debated. If 1 use estrogen, 1 prescribe a conjugated estrogen, 1.25 mg/ day for 25 days of each month. 7 Other drugs such as phosphate and the diphosphonates are also under investigation for the treatment of osteoporosis. Primary Degenerative Arthritis
Most people acquire degenerative arthritis sometime during middle age. For most the symptoms are only an aggravation, but for a few they are a true disability. Pain is by far the most frequent presenting complaint, but limited motion can also create problems. Arthritic problems are second only ta cardiovascular disease as a cause of invalidism.8 Arthritis is obviously more significant when it affects the weight-bearing joints. Even though we do not know the cause of primary degenerative arthritis (hypertrophie arthritis, osteoarthritis), there is much to offer the patient with this disorder in the way of treat-
Vol. 57 • No. 7 • June 1975 • POSTGRADUATE MEDICINE
ANDREW A. McBEATH Dr. McBeath is associate professor of orthopedie sürgery, University of Wisconsin Medical School, Madison.
ment, bath operatively .and nonoperatively. Good liaison with the patient is essential for successful treatment. The physician must clarify for the patient the difference between degenerative and rheumatoid arthritis. Ali too often the physician sees a few osteophytes or joint-space narrowing on a radiograph and tells the patient arthritis is present. The patient then goes home, waiting for grotesque deformities of the fingers. ln these instances, the mental anguish can become far worse than the initial complaint. lt is essential for the physician to explain to the patient that the symptoms of degenerative arthritis are insidious, the disease is not a sudden crippler, symptoms are usually episodic and related to activity, and while there is a tendency for the disease to get worse slowly, it can, in sorne cases, improve.9 The physician must be positive when advocating nonoperative treatment. If he bas no conviction in nonoperative treatment or does not prescribe any, the patient suffers. How does the physician know whether to pursue operative or nonoperative treatment? The primary consideration is how the complaint affects the daily life of the involved individual. What desired activity is eliminated or restricted by the disease? How severe is the pain? Cornplaint of pain occurring on the 18th fairway should elicit a different response than does cornplaint of severe unremitting night pain or pain necessitating premature retirement. The amount and type of medication being taken can give a clue to severity of pain. Examination of the patient is helpful. The degree and type of limp is significant with lower
173
1
Drugs play an important part in • the nonoperative treatment of • degenerative arthritis. Aspirin • is by far the cheapest, least toxic, • and most effective drug to use. •
extremity arthritis. Restricted range of motion, persistent effusions, marked varus or valgus of the knee, and severe fixed deformities such as flexion of the knee or flexion and adduction of the hip are significant. These deformities and restricted range of motion are indications that nonoperative treatment will probably not work. A radiograph is used mostly for confirmation of disease. The degree of impairment often fails to relate to the degree of involvement visible on radiographs. Treatment of Primary Degenerative Arthritis
N onoperative-since arthritis is not fatal, there is no risk in first attempting nonoperative treatment. Drugs play an important part in the nonoperative treatment of degenerative arthritis. Aspirin is by far the cheapest, least toxic, and most effective drug to use. lt not only is an analgesie and an anti-infl.ammatory drug, but it also has been shown to inhibit the catabolic phase of articular cartilage metabolism.10 The drug should be taken in regular doses to be effective, ie, 2 tablets three to four times a day, not just when symptoms become severe. If aspirin irritates the stomach, it should be taken with food, milk, or water. For acute exacerbations, phenylbutazone is effective. If it is going to be effective, it is so within one week. Occasionally, this drug depresses the white blood cell count. Indomethacin is effective in sorne cases of degenerative joint disease, but 1 find it takes longer to act than phenylbutazone and sorne
174
patients experience unpleasant side effects. Ibuprofen has been found to be effective in some cases in which aspirin is not tolerated, but it is more expensive than aspirin. Rest has a definite place in the treatment of degenerative arthritis. Episodes of pain can be treated with traction for two to three days, or home traction can be used on an intermittent basis for arthritis of the knees or hips. A cane is an underrated deviee in the treatment of lower extremity joint disease. When the cane is used properly in the hand on the side opposite the involved hip, each pound of force applied to the cane relieves the hip of about 7 lb of force. 11 There appear to be many psychologie barriers to the use of a cane and aspirin, especially the cane, even though the risk and expense of using a cane and taking aspirin are far less than those of any operation. Exercise is also important in the treatment of degenerative arthritis. The types used include active range of motion, passive range of motion, progressive resistance exercises, and isometric exercises. Bicycling puts the knees and hips through a range of motion in one plane. The goals of exercise are to nourish the articular cartilage, to maintain range of motion, and to prevent fixed deformities. lt has been shown that in patients in whom permanent flexion or adduction deformities of the hip have been avoided, pain is more likely to disappear spontaneously and not require surgical therapy.9 The severity of the problem in sorne joints can be diminished by exercising the key muscles. In the hip, the extensors and abductors are the most important, in the knee the quadriceps, and in the lower back the abdominal muscles. Operative-The most recent, most publicized surgical procedure for the treatment of degenerative arthritis is total joint replacement. Because of the dramatic results achieved with this operation, other procedures tend to be forgotten. This, 1 feel, is a mistake, as other procedures still have a place in the therapeutic armamentarium. Although total joint replacement is a predictable procedure and has brought relief to many older persons who would not have had the strength and endurance to be rehabilitated by
POSTGRADUATE MEDICINE • June 1975 • Vol. 57 • No. 7
other surgical procedures, it is a major surgical procedure with ali the usual inherent risks. Infection is an especially serious complication, because when it occurs the appliance usually must be removed. Thus, the physician should not perform or recommend total joint replacement indiscriminately. There are a few prophylactic procedures. Evidence continues to mount documenting the value of proximal tibial osteotomy in early degenerative arthritis with varus or valgus deformities at the knee. Osteotomy of the proximal femur has been shown to be of value in early disease when proper criteria are met. Occasionally, arthrodesis of the hip is still used to treat degenerative arthritis, though rarely in elderly individuals. Mold arthroplasty, 1 feel, still has a place in the treatment of hip dis-
ease, especially in younger people. One has a greater chance of success when placing a mold in a hip which has been infected than when inserting a total hip. Comment
W e do not know the cause of either osteoporosis or degenerative arthritis, but both of these diseases are treatable to varying degrees. Neither disease kills; therefore, they do not receive the same attention as do such dramatic killers as heart disease and cancer. Obviously, the best solution is prevention, but before this utopian state cao be reached, we must find the cause. Address reprint requests to Andrew A. McBeath, MD, Division of Orthopedie Surgery, University of Wisconsin Hospitals, 1300 University Ave, Madison, WI 53706.
REFERENCES 1. Jurist J: Persona! communication 2. Berlyne GM, Ben-Ad J, Galinski D, et al: The etiology of osteoporosis. JAMA 229:1904, 1974 3. Chalmers J, Ho KC: Geographical variations in senile osteoporosis: The association with physical activity. J Bone Joint Surg 52-B:667, 1970 4. Nordin BE: Osteomalacia, osteoporosis and calcium deficiency. Clin Orthop 17:235, 1960 5. Stearns G: Persona! communication cited by Hunt DD: Changing concepts in osteoporosis. J Iowa Med Soc 55 :563, 1965 6. Bernstein DS, Sadowsky N, Hegsted DM, et al: Prevalence of osteoporosis in high- and low-iluoride areas in North Dakota. JAMA 198:499, 1966 7. Gordon GS: Post menopausal osteoporosis: Problems of diagnosis and therapy. ln: The Female
8.
9. 10.
11.
Climacteric. New York, Ayerst Laboratories, 1970, vol 1, p 14 Chronic conditions and limitations of activity and mobility, U.S. July 1965-June 1967. Series 10, No. 61, National Center for Health Statistics, US Department of Health, Education, and W elfare. W ashington, DC, 1971 Danielsson LG: Incidence and prognosis of coxarthrosis. Acta Orthop Scand (Suppl) 66:1-114, 1964 Chrisman OD, Snook GA, Wilson TC: The prorecrive effect of aspirin against degeneration of human arricular cartilage. Qin Orthop 84:193, 1972 Blount WP: Don't throw away the cane. J Bone Joint Surg 38-A:695, 1956
ilJ
00
c
ReadySource OON
BOOKS Osteoporosis (Barzel, editor) New York: Grune & Stratton, lnc, 1970 The Bioloay of Detenerative Joint Disuse (Sokoloff) Chicago: University of Chicago Press, 1969 Arthritis and Allied Conditions (Hollander, McCarty, editors) Philadelphia: Lea & Febiger, 1972
Vol. 57 • No. 7 • June 1975 • POSTGRADUATE MEDICINE
OSTEOPOROSIS AND DEGENERATIVE ARTHRITIS
Bone as a Tissue (Rodahl, editor) New York: McGraw-Hill Book Co, 1960
AUDIOVISUALS Orthopedie Problems in tht Altd (tape) (SChmeisser) Source: Audiovisual Division of R. A. Becker, lnc., 299 Park Ave, New York, NY 10017 Cost: $8 For details on how to use ReadySource,- P•le 168.
175
