Page 94 - ASOP ROT Study Guide

♦ rest and physiotherapy

♦ Analgesia through medication may be used subsequently or in parallel with these measures.

Weight loss: Lower limb joints in particular are subject to large loads which are the result of the leverage
exerted by the muscles around the joints. The resulting joint loads may be several times the body weight they
are supporting. In the hip for example, joint loading during the stance phase of walking can reach about three
times body weight and during activities of greater hip muscle exertion joint loading can reach five times body
weight. (This will be discussed more fully in the Biomechanics module). This means that quite modest
reductions in body weight will result in significant reductions in the total loads being borne by the joint. Also,
weight loss is usually accompanied by a general improvement in well-being which often affects the overall
pain experienced by the patient.

Walking cane: In lower limb joint disease, particularly in the hip, the use of a stick in the opposite hand means
that the shoulder girdle can help in tilting the pelvis and so help in weight bearing. Normally when we walk,
when we have our weight on the right leg, the gluteal muscles on the right side contract to tilt the left side of the
pelvis upward, permitting the left leg to swing forward freely to make contact with the ground. Efficient walking
is highly dependent on the ability of the abductor muscles to carry out this function for every stride. The use of
a stick has the effect of reducing the work required of the weight bearing abductor muscles thereby
dramatically reducing the muscle induced loads on the hip.

Physiotherapy: The role of physiotherapy and rest remains controversial and a balance is required.
Over-exercise cannot in the long term be beneficial but some exercise does relieve stiffness and muscle
spasm and therefore pain. Young sufferers should be advised against excessive unnecessary activity and a
change to a light job is useful if practicable. Total rest is however equally counterproductive, especially in the
elderly where a maintenance of the activities of daily living is essential. Remember that muscles work most
efficiently when they are in regular use. Stretching them in exercises helps them maintain natural tone.
Excessive resting of muscles around a painful joint will make them go into a spasm which is in itself painful
and inhibiting.

2 . 3 . 2 Surgical Options

For most forms of arthritis there are four surgical options:

♦ Nothing
♦ Arthrodesis
♦ Osteotomy
♦ Arthroplasty

Nothing: Doing nothing should always be borne in mind as an option. The patient must be aware that the
benefits of surgery must outweigh the risks. For very disabled patients in a great deal of pain, the option to
take the risks of surgery must be considered. Following a careful and full explanation of the risks and
benefits of surgery by the doctor, the patient can take the decision to undergo surgery. Provided the patient
has a good grasp of the risk: benefit ratio in their particular case, then they may take the lion's share in a
decision to have surgery.

Arthrodesis, or surgical stiffening of a joint in a position of function, is an appropriate operation for a young
person with a painful and limited range of movement in the affected joint. The more attractive option of joint
replacement is not a safe choice for reasons which will be explained later. Essentially, a relatively stiff and
very painful joint is cut out and the remaining raw bone ends are held together either by an external splint or
screws until they heal with a bony bridge. In the hip for example, fusion in thirty degrees of flexion and
some adduction produces pain free functional gait, whilst permitting sitting. It is more acceptable to the male
than to the female as any hip fusion is likely to interfere with female sexual activity. Fusion is not a technically
easy procedure in large joints such as the hip because the bones are difficult to hold together once the joint
has been removed. The operation requires a prolonged recovery period of up to six months, often in a
plaster splint.

The long term disadvantage of arthrodesis is mat it puts stress on the adjacent joints. For example in the hip
this means extra stress on the lumbar spine and knee as well as the opposite hip. However, this problem