Osteoarthritis Diagnosis and Treatment Before Replacement

Osteoarthritis diagnosis is clinical: typical pain on walking, climbing stairs or sitting cross-legged, with definite tenderness along the joint line, almost confirms the disease, and a standing X-ray graded on the Kellgren-Lawrence scale serves as the baseline. Treatment then escalates from physiotherapy and medication to joint injections and joint-preserving surgery, with replacement reserved for patients whose pain and disability persist.

Most patients with osteoarthritis never need a new joint. What they need is an accurate diagnosis and a treatment plan matched to how much the disease is actually costing them in pain and function. Dr. Ramkinkar Jha, an orthopaedic surgeon specialising in joint replacement, bases his approach on one principle: the X-ray describes the joint, but the patient's symptoms decide the treatment. This article follows that principle from the first consultation through medication, injections and the joint-preserving operations that come before replacement. The replacement itself is covered in the complete guide to hip and knee replacement surgery.

What osteoarthritis does to a joint

In osteoarthritis the joint cartilage becomes dehydrated, disorganised, rough and eroded, and that erosion is what causes the pain. Dr. Jha uses the knee as the model, but the same process occurs in every major synovial (freely moving, fluid-lined) joint. The change can be read at four levels.

• On X-ray, the healthy joint keeps its joint space. The arthritic joint shows narrowing of that space, osteophyte formation (bony spurs at the joint margins) and deformity.
• Under the microscope, healthy cartilage has a well-ordered architecture. Arthritic cartilage is dehydrated and disorganised.
• To the naked eye at surgery, healthy cartilage is smooth and glistening. Arthritic cartilage is rough and eroded.
• At the molecular level, a cascade of biochemical events drives the transition. The detail is complex, but the point for clinicians is that osteoarthritis is a change in biochemistry as well as in anatomy.

What causes osteoarthritis

The causes are multifactorial: physical inactivity, obesity, diet, metabolic syndrome and joint injury all contribute to progression.

How osteoarthritis is diagnosed

Osteoarthritis is diagnosed on the clinical picture, with a plain X-ray as the first investigation and the baseline for grading.

The first investigation

When a patient presents with joint pain, the first test is a plain X-ray. For the knee it must be a standing anteroposterior (front-to-back) view, so that the film gives a dynamic picture of the joint under the patient's own body weight rather than a joint at rest.

Kellgren-Lawrence grading of osteoarthritis

The X-ray is then graded on the Kellgren-Lawrence (KL) system from grade 0 to grade 4, none to severe, according to how much joint space has been lost and how much osteophyte formation and deformity is present. KL grading is universal and useful as a baseline. Dr. Jha does not regard it as a gold standard.

The real gold standard

The gold standard is clinical. A patient who describes the typical pain of osteoarthritis (pain on walking, on climbing stairs, on sitting cross-legged) and who has definite tenderness along the joint line almost certainly has the disease. The X-ray then serves as the baseline test, not the arbiter of treatment.

Does the X-ray grade decide who needs knee replacement?

No. Dr. Jha calls the relationship between X-ray grade and the need for surgery a paradox.

• A patient with grade 4 arthritis on X-ray may not be a candidate for replacement. If pain is minimal and responds well to physiotherapy, surgery is not indicated.
• A patient with grade 3 arthritis may be a candidate. If every conservative measure has been tried and the pain has not been relieved, replacement is justified.

The X-ray alone therefore never decides who goes to theatre. Pain, disability and the response to treatment do.

Osteophytes or joint-space loss: what matters on the film

Joint-space reduction is the finding Dr. Jha weights most heavily, because it shows, indirectly, that the articular cartilage has gone, and that loss is irreversible. Asked in the masterclass's live discussion whether osteophytes or joint-space loss carry more weight, he distinguished between the two. For osteophytes, location matters most: when they sit around the weight-bearing zone, or form so-called kissing lesions on opposing surfaces, they are clinically relevant and may be amenable to minimally invasive surgery such as arthroscopy.

Osteoarthritis treatment without surgery

Non-surgical treatment of osteoarthritis rests on physiotherapy and medication, which are the first line of treatment. Once osteoarthritis is confirmed, Dr. Jha takes a comprehensive approach to pain. Treatment escalates through three tiers: non-invasive, less invasive, and invasive (surgical).

Physiotherapy as treatment, not adjunct

Physical therapy is the foundation, delivered through several modalities and aimed at five specific targets:

1. Flexibility.
2. Load management.
3. Neuromuscular control.
4. Muscle strength.
5. Movement efficiency.

Medication for early osteoarthritis

Drug treatment for early osteoarthritis follows a simple sequence. Topical anti-inflammatory preparations come first, particularly for the knee, with oral anti-inflammatory drugs at the lowest effective dose for short periods if needed. Paracetamol has only a small effect, and opioids are not recommended for osteoarthritis because their harms outweigh their modest benefit.

The threshold for moving beyond medical therapy is functional: if pain persists despite medication and physiotherapy, and the patient's activities of daily living are disturbed, the patient becomes a candidate for further intervention.

Joint injections for osteoarthritis: PRP, stem cells, hyaluronic acid and steroids

When moderate arthritis no longer responds to simple medication, Dr. Jha offers four kinds of injection. Each has its own advantages and disadvantages, and he treats the choice as a question of purpose.

Evidence that PRP or stem-cell injections regenerate cartilage remains limited.

Who benefits from joint injections

Every joint can be injected. The question is why. Dr. Jha identifies two main groups who benefit.

• Patients with severe osteoarthritis who are not fit for surgery. For them, injection is pain relief in its own right.
• Patients who are not willing to have an operation in the coming months or years. For them, injection buys time: a pain-free interval until replacement is accepted or becomes unavoidable.

The risk of steroid injections

Corticosteroid injections give excellent pain relief, and that is precisely their risk. A patient who suddenly feels well often believes the joint is cured, returns to high-impact activity, and accelerates the deterioration of the joint. The steroid then takes the blame for damage caused by the rebound in activity. Dr. Jha's remedy is to be explicit before the injection: the patient must understand it is being given for pain relief, not as a cure.

The one complication he highlights for steroid infiltration is infection. An infected joint deteriorates faster, and infection can compromise a patient's suitability for joint replacement later.

Surgery for osteoarthritis before joint replacement

When injections no longer help and arthritis is moderate or severe, three surgical categories remain: arthroscopy, osteotomy and replacement. The first two preserve the patient's own joint, and partial replacement sits between them and a total joint.

Arthroscopy for knee arthritis

Arthroscopy is keyhole surgery inside the joint, performed through small incisions with a camera. In Dr. Jha's practice it is used to:

• wash out the joint and debride it (remove damaged tissue);
• remove loose bodies;
• trim a torn meniscus, the knee's cartilage shock absorber (meniscectomy);
• treat a focal cartilage defect.

It is a daycare procedure: the hospital stay is about a day, and recovery takes two to three weeks. Its place is in joints with mechanical problems such as loose bodies or meniscal tears, or with focal cartilage damage. Current guidelines from NICE and the American Academy of Orthopaedic Surgeons (AAOS) do not recommend arthroscopic washout or debridement for degenerative knee osteoarthritis unless there is a clear mechanical problem such as true locking.

High tibial osteotomy

A high tibial osteotomy cuts and realigns the upper tibia to shift load away from damaged cartilage, and Dr. Jha uses it when the problem is alignment rather than the whole joint. That is often the case when the joint is not badly damaged overall, or only one compartment is involved. A typical X-ray shows arthritis confined to the medial (inner) compartment of the knee, with deformity of the leg as a whole.

In that situation Dr. Jha corrects the deformity rather than replacing anything. The procedure changes both the alignment of the leg and the dynamics of the joint, opening up the overloaded compartment and shifting load away from the damaged cartilage.

Unicondylar (partial) knee replacement

Where osteoarthritis is confined to one compartment, the whole joint does not need to be replaced. A unicondylar (partial) knee replacement resurfaces the medial compartment, for example, and leaves the rest of the knee alone. It is a relatively small operation compared with total joint replacement, and its indication is intermediate to severe osteoarthritis limited to a single compartment.

Beyond this point, with disease across the joint, the remaining option is total replacement. The goals of that operation, who qualifies for it and what follows are set out in the complete guide, and the implants, techniques and difficult cases in complex and revision joint replacement. Related articles are collected on the orthopaedics specialty page.