Conservative treatment includes the following measures:

When patients learn that they have ‘arthritis’, they see wheelchairs. It is essential to dispel this misconception and adopt a positive approach. Osteoarthritis is not a ‘disease’ like rheumatoid arthritis; it is simply a patch of fair wear and tear that will probably get very slowly worse over many years and cause some limitation of activity. Widespread and severe osteoarthritis can be disabling but this is fairly uncommon.

If patients only experience pain during a certain activity they may be able to modify activities to avoid the one that hurts. If a patient with osteoarthritis of the elbow only has pain when clipping the hedge, for example, the simplest solution might be to cut down the hedge or buy an electric hedge-clipper. Similarly, patients with osteoarthritis of the hip who can walk only a few yards are able to cycle for long distances without pain, and a bicycle can solve many of their problems.

These are commonsense solutions that many patients will find without consulting their doctor but they should always be considered before advising operation.

Aids such as sticks, elbow crutches or a walking frame are helpful to patients with osteoarthritis of the lower limbs. A tall chair is better for patients who lack full flexion of the hips and the knees, both of which are necessary to sit in a comfortable or ‘easy’ chair. The same patients are also helped by a high seat when using the lavatory (Fig. 16.5).

Osteoarthritis of the knee or hip can produce real or apparent shortening of the limb. A raise to the heel and sole of the shoe on the shorter side will make good this shortening. Although it will not alter the progress of the disease, the raise will improve the gait and take the strain off other joints and the lumbar spine.

Heat treatment by ice, infrared lamps or short-wave diathermy will often produce relief for many months.

Exercises to increase the power of muscles around osteoarthritic joints are of limited value. It is not possible to ‘compensate’ for worn joints by increasing the strength of the muscles that operate them, any more than it is possible to improve the bodywork of a rusty car by putting in a more powerful engine. It is, however, useful to increase the range of movement in degenerate joints and prevent contractures. Many patients understandably avoid moving their painful joints and function deteriorates; the more painful the joints, the less they are moved, the stiffer they become, the less they are moved, and so on. If the joints are put through their full range of movement every day, function is maintained and stiffness avoided.

Both analgesics and anti-inflammatory drugs are available but many drugs act in both ways.

Non-steroidal anti-inflammatory drugs. NSAIDs include fenamate derivatives such as flurbiprofen, ibuprofen, naproxen and mefenamic acid. These drugs are prostaglandin inhibitors and reduce the inflammatory response of the synovium to articular cartilage debris. Aspirin is also a prostaglandin inhibitor as well as an analgesic and should not be underestimated.

These drugs do not abolish pain but they reduce it effectively. They do not affect the articular surfaces but the response of the synovium to wear particles of articular cartilage is reduced. Some patients learn to take their anti-inflammatory drugs before physical activity; the weekend golfer may take tablets on Saturday morning to reduce the inflammatory response that will be felt on Sunday and Monday.

Almost all NSAIDs cause gastrointestinal problems and should be taken either with food or with milk and biscuits. This gastrointestinal irritation is partly a systemic phenomenon and cannot be avoided by giving the drug parenterally or by suppository, although this can lessen the problem. In the elderly, NSAIDs may cause confusion.

NSAIDs can depress chondrocyte activity and this may cause the disease to progress more rapidly, especially in weight-bearing joints such as the hip. Because of this, NSAIDs should be given intermittently and cautiously, with courses during exacerbations and at important times for the patient, such as golf tournaments.

Analgesics. Simple analgesics such as paracetamol or dihydrocodeine have an analgesic effect only, but reduce the pain caused by raw bone rubbing on raw bone. They do not reduce the synovitis of osteoarthritis. Comparative studies suggest that NSAIDs are more effective than simple analgesics, but in practice the best results may be achieved by a combination of paracetamol with an NSAID.

In some patients with severe osteoarthritis, pain interferes with sleep and the plight of these patients is made worse by perpetual tiredness. Analgesics or anti-inflammatory drugs taken at bedtime, perhaps with a mild hypnotic, can be helpful.

Steroid injections are helpful for areas of extra-articular inflammation, particularly along joint margins or over osteophytes, but intra-articular injections are less effective. The steroid can reduce the intra-articular inflammation but the results are transient and leave the underlying pathology unchanged. Intra-articular steroids are given more often by rheumatologists than surgeons.

Osteophytes are the most obvious radiological abnormality and it is tempting to remove them in the hope that the radiological appearance, and thus the patient, will be restored to normal. Although the osteophytes can be removed, they quickly recur and the benefit from this procedure is transient.

If the osteophytes seriously obstruct joint movement it is reasonable to excise them. Excision of the osteophytes also improves the appearance, which can be important in the hand where the osteophytes around the distal interphalangeal joints may be very unsightly.

Arthrodesis, the fusion of a joint, is one of the oldest operations in orthopaedic surgery and converts a stiff painful joint in bad position into a stiff, painless joint in good position. This is a fair exchange.

Arthrodesis is useful for small joints in the hand, fingers and toes, where the loss of movement in one joint can be disguised by the movement of others. In larger joints the operation has more far-reaching effects. An arthrodesed knee, for example, is good for walking but will not bend when the patient sits down, and creates particular problems when getting out of a car or using a lavatory.

Accordingly, arthrodesis is best suited to degenerative disease affecting a single joint surrounded by joints that are healthy and likely to stay healthy. It is contraindicated in diseases such as rheumatoid arthritis where many joints are involved.

If arthrodesis is carried out, the joint should be fixed in the position of function; i.e. the most useful position. To be sure that the patient will be pleased with the result it is advisable to apply a cast in the proposed position before operation, so that they can use the limb as if it were arthrodesed and assess the likely benefits for themselves.

Osteotomy helps osteoarthritic joints in three ways:

Correcting the deformity reduces the abnormal loads across the joints. This is important in the weight-bearing joints of the lower limb, where the hip, knee and ankle should be one above the other in the same vertical line. Correction of the line of weight-bearing does not ‘cure’ osteoarthritis but can slow the deterioration.

Altering the bone architecture. Cutting across the bone allows some remodelling to occur at the fracture site.

Dividing vessels. Osteotomy divides the medullary cavity of the bone, including the venous channels, and this may have some effect on pain.

Disadvantages of osteotomy. The operation causes considerable discomfort, requires a long period of rehabilitation, and the symptoms can recur. In its favour, the operation does not destroy the joint irreparably, as does an arthrodesis or an arthroplasty, and a second operation is always possible.

Arthroplasty means the creation of a joint; several types are available.

Excision arthroplasty replaces the normal joint with a fibrous ankylosis with less movement and less stability than a normal joint. Excision arthroplasty is therefore unsuitable for weight-bearing joints, but is effective in those that do not bear weight, e.g. the toe.

Disadvantages are that pain can arise in the new ‘joint’ from bone-to-bone contact across the pseudarthrosis and the instability can be distressing to the patient. The advantages are that no foreign material is inserted and the complications of infection and loosening are reduced.

Interposition arthroplasty. The formation of a pseudarthrosis can be encouraged by placing something between the bone ends. Skin, fascia and muscle have all been used but the results are little different from a straightforward excision arthroplasty.

An inert spacer, such as Silastic, can also be used as an interposition material. The results are better but the wear particles of the material can be an irritant and the joint is still unstable.

Mould arthroplasty. A hard material, such as metal, placed between the bone ends can act as a mould to shape a new joint. The idea is simple in principle but in practice the joints become stiff and the bone inside the mould can undergo aseptic necrosis. Cup arthroplasty of the hip was a good example but has now been replaced by total hip replacement.

Replacement arthroplasty. If the worn joint surfaces are removed and replaced by a prosthesis, a stable and painless joint resembling the original can be created. Two types of replacement arthroplasty are in current use:

Salvage of a loose or infected prosthesis is difficult. Excision arthroplasty is always available but is not ideal in weight-bearing joints because so much bone must be removed that later arthrodesis is impossible. In some circumstances amputation may be necessary as a salvage procedure.