Intervention with Stair-like Strategy: Recommendations for Treating Osteoarthritis from Orthopedic Joint Surgeons in Shanghai General Hospital

Osteoarthritis is commonly referred to "bone spurs" and "bone hyperplasia" which has different symptoms in mild, moderate or sever stage. “Regarding different stages, stepped interventions and managements should be implemented accordingly for treatment,” Professor Ma Jinzhong, director of the Orthopedic Center of Shanghai General Hospital, emphasized. 

In recent years, thanks to the application of concepts and patterns such as rapid rehabilitation, pain management, holistic rehabilitation intervention, and robot-assistant surgery，the postoperative rehabilitation can be greatly accelerated even in patients with severe osteoarthritis.

Mild osteoarthritis: positive intervention of "exercise prescription"

Osteoarthritis is a kind of chronic degenerative joint disease closely related to age. Its main changes are the wear of the surface of articular cartilage and secondary bone hyperplasia, also known as "bone spur". In sharp contrast to the huge number of patients, patients generally lack of the correct awareness of osteoarthritis, and often use hearsay "folk remedies" such as "soaked in vinegar" and "stomping heels" for irregular treatment, which worsen the symptoms.

Professor Ma stresses that the purpose of the treatment of osteoarthritis is to reduce or eliminate pain，correct deformity and improve or restore joint function, and then improve the quality of life. The overall treatment principle is to adopt individualized and stepped treatment plan according to different stages of the disease.

The main manifestation of osteoarthritis at early clinical stage is joint stiffness, which is aggravated after fatigue, cold or slight trauma. The pain and stiffness can be quickly relieved after minor activity .Typic Osteoarthritis is commonly referred to "bone spurs" and "bone hyperplasia" which has different symptoms in mild, moderate or sever stage. “Regarding different stages, stepped interventions and managements should be implemented accordingly for treatment,” Professor Ma Jinzhong, director of the Orthopedic Center of Shanghai General Hospital, emphasized. 

In recent years, thanks to the application of concepts and patterns such as rapid rehabilitation, pain management, holistic rehabilitation intervention, and robot-assistant surgery，the postoperative rehabilitation can be greatly accelerated even in patients with severe osteoarthritis. al symptoms are stiffness and pain when getting up in the morning or standing up after sitting for a long time. The symptoms are obvious, and the joint symptoms are reduced or disappeared after movements.

Non-pharmaceutical treatment is the preferred treatment for osteoarthritis at early stage. It is recommended that patients take the correct "exercise prescription"——aerobic exercise such as swimming and cycling to train joint function and muscle strength and it is necessary to pay attention to avoid running, jumping, squatting and climbing stairs for a long time. If the symptoms are obvious, physical therapy such as hyperthermia, hydrotherapy, ultrasound, acupuncture, massage, traction, percutaneous nerve electrical stimulation and other physical therapies can also be used to increase local blood circulation and reduce inflammatory reaction. If necessary, walking sticks, crutches or walking aids can be also employed to reduce the weight-bearing of the affected joints. For varus or valgus deformity associated with osteoarthritis, appropriate orthopedic braces or orthopedic shoes shall be applied to balance the load of each joint surface.

Moderate osteoarthritis: rational drug selection after risk assessment

If the patients do not pay enough attention to the symptoms of osteoarthritis in the early stage and do not treat them in time, the symptoms of osteoarthritis will gradually worsen. At this stage, patients can have an acute attack once every 1-2 years when the joint is slightly swollen or has a small amount of effusion. Sometimes the friction occurs when the joint moves and causes joint dysfunction.

For patients with moderate osteoarthritis, if the drug treatment is ineffective or the pain is obvious, drug treatment can be a choice. Latex, plaster and patch of non-steroidal anti-inflammatory drugs are most common choices for local treatment. External drugs can effectively relieve mild and moderate joint pain, with slight adverse reactions.

For moderate and severe pain, local application can be combined with oral non-steroidal anti-inflammatory drugs. Before taking systemic analgesic drugs, more attention should be paid to assess the risk of potential internal diseases, especially the risks of digestive system and cardiovascular system. Individual treatment and the lowest effective dose are recommended. Avoid excessive use and repeating or overlapping use of similar drugs. If the therapeutic effect of oral medicine is not significant, sodium hyaluronate viscoelastic supplement can be injected into the joint cavity to lubricate the joint and relieve symptoms.

Severe osteoarthritis: individualized minimally invasive surgery

When osteoarthritis develops to a severe degree, the continuous joint pain will get worsen and patients often wake up at night .The joint will be deformed, swollen， dysfunctional and even failing to take care of themselves. At this point, surgical intervention is usually required.

The surgical treatments of osteoarthritis are divided into “joint preservation” surgey and “joint replacement” surgery, both of which can be carried out by minimally invasive surgery to reduce pain and accelerate recovery.

"Joint preservation" surgery includes arthroscopic surgery, unicompartmental knee arthroplasty(UKA), high tibial osteotomy and stem cell therapy. The UKA is designed for the lesions of the medial/lateral single compartment of the knee joint which preserves the knee joint. It can replace the diseased part of bone and cartilage tissue with artificial materials like filling teeth, which can solve the problems of weight-bearing pain and limited movement. As long as the indications are selected properly and the surgical techniques are mature, the clinical effect of UKA can last for decades.

High tibial osteotomy is used for knee osteoarthritis with genu varus or genu valgus deformity. The main purpose of osteotomy is to improve the knee function by correcting the knee axis and increasing the stability of the joint. This knee preservation surgery, with simplified operation and shortened braking time, allows patients to exercise the knee joint earlier afterwards.

Stem cell therapy for osteoarthritis is a new way in recent years. Stem cell therapy can not only preserve their own joints and improve the clinical symptoms of osteoarthritis, but also achieve the repair and regeneration of articular cartilage, providing a new hope for the majority of patients.

"Joint replacement" surgery is also named as "artificial joint replacement surgery". Unlike the previous impression that "joint replacement is major surgery", today's artificial knee replacement and artificial hip replacement can be performed with minimally invasive technology, which not only reduces the pain of patients, but also helps the recovery after surgery. In recent years, the joint surgery department of Shanghai General Hospital has given full play to the construction advantages of the "orthopedic center" of a comprehensive hospital, and applied the concepts of ERAS rapid rehabilitation, pain management, whole-process rehabilitation intervention, robot-assistant surgery to take the lead in carrying out minimally invasive anterior approach hip replacement and MAKO robot-assistant hip replacement in China. Patients can be performed the surgery and discharged from the hospital on the same day.