Conservative treatment of osteoarthritis

The aim of conservative treatment of arthrosis is to relieve pain, improve functioning, and slow down the progression of the disease. The treatment includes weight reduction, unloading joints, rehabilitation, and pharmacotherapy. If patients do not react adequately to oral medication or if it is not advisable for health reasons, intra-articular injections are a very good treatment option. Intra-articular injections include viscosupplementation with hyaluronic acid, treatment with growth factors in platelet-rich plasma (PRP), and stem cell therapy. Oral joint supplements are only supportive - those are mainly preparations for athletes who want to take care of the health of their excessively overloaded joints.

Osteoarthritis

Osteoarthritis is characterized by a cascade of changes leading to the gradual destruction of the joint structures. The primary site of pathology is the articular cartilage, which, under the influence of various factors, becomes thinned and damaged up to the subchondral bone layer. This leads to secondary inflammation, which causes swelling, aggravates pain, and accelerates the destruction of the joint. Also, the properties of the joint fluid (synovial fluid), which moisturizes and reduces friction between joint surfaces and is a source of nutrients for the articular cartilage, deteriorate. The joint fluid of healthy joints is characterized by a high concentration of hyaluronic acid of high molecular weight, which determines its good lubricity and optimal viscosity. The inflamed synovial membrane produces smaller amounts of hyaluronic acid, which is of reduced molecular weight, and releases inflammatory mediators and enzymes that accelerate the destruction of the articular cartilage.

Are there any drugs for the reconstruction of articular cartilage?

Cartilage tissue loss within the joint surface rarely heals spontaneously, which leads to increased damage and degeneration of the knee or ankle joint. It is, therefore, advisable to stimulate the healing and repair of the articular cartilage using available methods. Articular cartilage is a hyaline cartilage. Every healing and auto-repair process leads to the formation of a slightly different fibrous cartilage. Therefore, there are no medications for articular cartilage that could lead to its regeneration, i.e. restoration of its original vitreous structure. The applied treatment may improve the quality of cartilage, inhibit the inflammatory process, and alleviate pain.

Indications for conservative treatment are slight cartilage damage – 1st and 2nd degree of degenerative changes. The 3rd and 4th degree usually require surgical treatment. In the process of qualifying for a given form of treatment, also taken into account are the location of cartilage damage (loaded or unloaded surface), the biomechanics of the joint, and the health condition of the patient.

Hyaluronic acid injections

How does hyaluronic acid work?

The mechanisms by which hyaluronic acid contributes to the reduction of degenerative pain are not entirely clear. It has been proposed that hyaluronic acid:

• Improves the properties of synovial fluid (viscosity and lubricity),
• Protects the surface of the articular cartilage,
• Inhibits inflammation of the synovial membrane and increases the amount of naturally produced hyaluronic acid,
• Directly interacts with nociceptors (pain receptors), inhibiting pain sensations.

Hyaluronic acid injections

1. Cingal

This preparation is a combination of hyaluronic acid with a strong anti-inflammatory and analgesic steroidal agent. The steroid starts to work 2-3 days after injection and its action lasts for about a month. Simultaneously, during this period, the effects of viscosupplementation with hyaluronic acid appear and last for the next couple of months. Thanks to this, Cingal brings relief from osteoarthritis pain quickly and for a long time.

1. Monovisc

This preparation is a highly concentrated hyaluronic acid viscosupplement, which allows the use of only one injection in the treatment cycle. Monovisc is the only preparation obtained with means of natural bacterial fermentation, which results in high tissue compatibility with the patient’s organism. The greatest benefits of injection are enjoyed by young people with joint injuries, those expecting better joint hydration, and patients who want to quickly return to physical activity.

1. Orthovisc

A preparation with similar properties as Monovisc but intended for multiple injections into the same joint. Orthovisc is a good solution for those who, for financial reasons, prefer a series of injections.

Platelet-rich plasma (PRP)

What is platelet-rich plasma?

Platelet-rich plasma is an innovative treatment method supporting natural tissue regeneration processes. PRP is autologous (derived from the patient’s own blood) plasma containing concentrated platelets and associated growth factors. Platelets are a natural source of growth factors in their natural and biologically determined proportions. The therapeutic effect of platelet-rich plasma is based on the stimulation of physiological processes of tissue healing and the acceleration of regeneration processes.

How do growth factors work?

Plasma factors are signal particles that promote healing and regeneration processes, regulating inflammation, cell proliferation and differentiation, creation of new blood vessels (angiogenesis) and collagen production.

Growth factors are released from alpha granules of the platelets. This process is activated by naturally occurring blood clotting factors, which results in the gradual release of growth factors over a longer period of time, supporting the tissue healing process.

Plasma growth factors include, among others:

• Platelet-derived growth factor (PDGF),
• Transforming growth factor (TGF),
• Vascular-endothelial growth factor (VEGF),
• Fibroblast growth factor (FGF).

Platelet-rich plasma in the treatment of osteoarthritis

Growth factors stimulate the repair processes of cartilage tissue and can lead to the formation of new cartilage cells. 

Advantages of growth factor therapy:

• Autologous therapy (plasma comes from the patient’s own blood) ensures safety due to tissue compatibility (no risk of rejection and side effects), 
• A small amount of blood (10-60 ml) is required, 
• In the administered plasma, 2-8 times the natural platelet concentration is obtained, which increases the effects of treatment. 

Process of PRP preparation

In the Dworska Hospital, we use the TropoCells™ system, which enables precise and safe preparation of platelet-rich plasma. 

The physician or nurse collects a small sample of venous blood from the patient and places it in a sterile test tube. The blood is then centrifuged to separate the red blood cells (erythrocytes) from the plasma. Subsequently, fractions of platelet-poor plasma are separated from platelet-rich plasma with the highest concentration of platelets. The platelet-rich plasma with growth factors is ready for administration 10-20 minutes after centrifugation. 

Which medications should be discontinued before platelet-rich plasma therapy?

Nonsteroidal anti-inflammatory drugs (e.g. ibuprofen) should be discontinued at least 7 days before the planned start of treatment with growth factors. Parallel administration of nerve block injections and anticoagulants is contraindicated. 

Are platelet-rich plasma injections painful?

Platelet-rich plasma with growth factors is administered via intra-articular injections. There is no need to be afraid of this treatment, as it is a standard and safe procedure. During the injection, you may experience a slight twinge caused by the insertion of the needle into the joint. After the treatment, slight discomfort is possible, which passes after a few hours. 

How many treatments with platelet-rich plasma are required for the therapy to be effective?

The number of injections is determined by the orthopaedic surgeon after a thorough assessment of the degenerative changes and individual conditions of the patient. Usually, 2-3 injections made within 6 months are sufficient. 

When are the first effects of platelet-rich plasma therapy noticeable?

The first effects in the form of pain relief are experienced during the first couple of weeks of treatment. During growth factor therapy, it is advisable to continue the rehabilitation in order to maximize the effects of the treatment. 

What are the contraindications to platelet-rich plasma therapy?

Contraindications include blood diseases (e.g. thrombocytopenia), hepatorenal syndrome, viral hepatitis, scleroderma, vascular diseases involving the immune system, and liver failure. 

Orthokine® therapy

Orthokine therapy is used to treat pain that results from persistent inflammation associated with degenerative lesions or post-traumatic damage of joint structures. Orthokine is also used to relieve pain in rheumatoid arthritis and other systemic inflammatory diseases. 

Orthokine therapy is based on the administration of a natural anti-inflammatory protein in a plasma solution prepared from the patient’s own blood. This protein is called interleukin-1 receptor antagonist (IL-1Ra). Interleukin-1 (IL-1) is a signalling protein responsible for stimulating inflammatory processes in the joint. IL-1 concentration increases in response to tissue damage. In the course of osteoarthritis, the ratio between IL-1 and IL-1Ra is disturbed, promoting chronic inflammation and related pain. 

Orthokine therapy enables the administration of the patient’s own anti-inflammatory protein (IL-1Ra) to the affected joint, avoiding foreign substances. The process of preparing a plasma rich in this anti-inflammatory protein includes:

1. Collection of venous blood from the patient, 
2. Incubation of the blood in an incubator (37°C), during which the production of natural anti-inflammatory proteins takes place, 
3. Separation of the serum fraction rich in anti-inflammatory proteins from the blood clot (in a special centrifuge). 

The prepared serum is injected 1-3 times a week. The final frequency of treatments is determined individually by the attending physician. 

Stem cells

Each specialized cell of our body originates from a stem cell. Stem cells have the ability to proliferate and differentiate into all cells of our body, e.g. cells building connective tissue. The sources of stem cells are bone marrow, blood, and adipose tissue. \

In the treatment of cartilage damage or osteoarthritis, the most frequently used is a stem cell concentrate obtained from the patient’s bone marrow. The MSCC (Mesenchymal Stem Cells Concentrate) or BMA (Bone Marrow Aspirate) concentrate is prepared according to a strict procedure, thanks to which it contains several times higher concentrations of stem cells than the bone marrow suspension taken from the patient. 

Stem cell therapy stimulates the formation of new cells, e.g. collagen, which accelerates the regeneration of joint building tissues or extra-articular soft tissues, e.g. muscle tendons. 

Stem cell therapy in orthopaedics

Stem cells are most often used in the following cases:

• initial stages of osteoarthritis (arthrosis), 
• partial damage to the intra-articular ligaments, e.g. the cruciate ligaments of the knee joint, 
• some types of cracks in the meniscus of the knee joint, 
• partial damage to shoulder rotator cuff tendons, 
• repair of ligaments and tendons – stem cells are administered intraoperatively to facilitate healing in a specific area of the tissue. 

Stem cell concentrate preparation process

The first stage involves the collection of the bone marrow from the ala of the ilium. The procedure is performed under anaesthesia, so it is painless for the patient. The syringe into which the bone marrow is collected is equipped with an anticoagulant to prevent clotting. As a rule, a small amount of bone marrow is taken – about 50 ml, which is also sufficient to prepare a suitable stem cell concentrate. 

The bone marrow suspension is transferred to a so-called separator, which is placed in a special device. This device allows for precise obtaining of layers of individual morphotic elements, including layers of concentrated stem cells. The obtained stem cell concentrate (about 6 ml) is then injected into the joint. The duration of the whole procedure takes about 30-40 minutes. 

After stem cell administration

During the first couple of days after surgery, mild pain may occur at the injection site, which is normal. To improve the patient’s comfort, the physician may recommend the use of analgesics (except for non-steroidal anti-inflammatory NSAIDs such as ibuprofen). The injected joint should be unloaded for up to 4 weeks after surgery. At the same time, physiotherapy aimed at improving the biomechanics of the joint and limb function should be carried out.

Over-the-counter joint tablets

The efficacy of joint supplements containing glucosamine sulphate and/or chondroitin sulphate is still under discussion. Advertisements in the media and press suggest that oral use of glucosamine and chondroitin can alleviate the symptoms of osteoarthritis by improving articular cartilage properties.

Glucosamine/chondroitin sulphates belong to the group of proteoglycans, which are components of the cartilage tissue. Their presence determines the proper mechanical resistance of articular cartilage. It has been suggested that joint supplements increase the synthesis of proteoglycans and may thus inhibit the progression of degenerative changes. However, there are no independent long-term clinical trials that would clearly indicate the efficacy of such joint supplements. The pain relief observed in some patients is largely subjective and difficult to measure. Other patients, on the other hand, do not notice any positive effects of glucosamine/chondroitin supplementation. 

It is worth noting that the use of joint supplements makes sense only in the case of very small cartilage lesions (1st-degree degenerative lesions). They can also be used in order to strengthen the cartilage under conditions of increased stress on the joints. Therefore, joint tablets for athletes, who are expecting a chondroprotective effect, are very popular. 

In summary, joint supplements cannot be considered as a stand-alone treatment. They can only be a supplement to other therapies that have been clinically proven to be effective. Joint supplements may also be a form of prophylaxis based on the chondroprotective action of the preparation components. 

Other strategies

1. Physiotherapy

Regular participation in rehabilitation is an obligatory element of the treatment process. Thanks to the use of manual therapy, the capsular ligaments become more flexible, muscle tension is normalized, and thus the biomechanical conditions of the joint are improved. Properly selected exercises improve the ability to actively stabilize the joint and, thus, protect the cartilage against further overloading. 

1. Knee braces

In the case of gonarthrosis /link/, it may be useful to use orthoses that unload a given knee compartment, e.g. an orthosis that inhibits excessive bendiness reduces cartilage overloading on the medial side of the knee joint.

1. Orthotics

Personalized orthotics /link/ correct improper foot positioning and can affect the load on selected areas of the cartilage in the trochlea of the talus.

1. Unloading the joint

Unloading the joint is achieved by:

- body weight reduction (in overweight individuals),

- modification of physical activity – changing from running to cycling or swimming,

- unloading the diseased joint via the use of crutches while walking.

1. Steroid nerve block /link/

Steroid nerve block injections consist of the administration of a strong anti-inflammatory and analgesic drug (steroid). This method is used only if other forms of conservative treatment are unsuccessful.

FAQ

1. Hyaluronic acid injections – are they painful?

During the injection, you may experience a slight discomfort caused by the twinge and the injection of hyaluronic acid into the joint. This discomfort should pass away a few hours after the injection. 

1. What is good for joints? How to rebuild articular cartilage?

Due to the complex multi-layer structure of the joint cartilage, it is not possible to fully rebuild the vitreous cartilage. By using treatment methods from the field of regenerative medicine (platelet-rich plasma PRP, stem cells) it is possible to accelerate the healing and repair processes of the damaged cartilage. Biological treatment is effective only in the case of proper qualification of the patient for the therapy. Intra-articular delivery of platelet-rich plasma or stem cell concentrate is effective only in the treatment of early degenerative lesions and minor damage to the articular cartilage. Advanced forms of degeneration are an indication for surgical treatment. 

1. When are the first effects of platelet-rich plasma PRP therapy noticeable?

The effects of platelet-rich plasma therapy are felt already during the first couple of weeks of treatment and consist of pain relief. During platelet-rich plasma therapy, it is advisable to continue rehabilitation in order to achieve even better treatment results. A prerequisite for successful therapy is that the patient has been properly qualified for PRP injections. 

1. Platelet-rich plasma – how many procedures are necessary to feel improvement?

The number of injections of platelet-rich plasma is determined by the orthopaedic surgeon after a thorough assessment of the degenerative changes and individual conditions of the patient. The majority of patients undergo a therapy in which 2-3 injections are performed within 6 months.