— Gwen, Alabama Ordinary osteoarthritis causes the formation of bone spurs (osteophytes), while erosive osteoarthritis causes erosions of the bones and inflammation. Erosive osteoarthritis is a variant of osteoarthritis that occurs in a minority of patients. It affects primarily the middle and end finger joints (called the proximal and distal interphalangeal joints) and the joint at the base of the thumb (first carpometacarpal joint) and causes redness, swelling and pain of the joints. There are several reports that inflammatory and erosive osteoarthritis may progress to rheumatoid arthritis (RA). We’re not sure how or why this happens, but it should be suspected especially if the knuckles (metacarpophalangeal joints), wrists, the feet and other joints become painful and swollen, and there is morning stiffness. It would then be helpful to do a sedimentation rate test (sed rate), a CRP, and a rheumatoid factor test. Neither sed rate nor CRP is elevated in erosive osteoarthritis, but both usually are in rheumatoid arthritis. Rheumatoid factor is positive in 60-80% of adult patients with RA, but not in osteoarthritis. Persons older than 65 may have a low positive rheumatoid factor. Half of patients with RA and negative rheumatoid factor have another antibody positive or anti-CCP. In summary, if the pain and inflammation start affecting more joints than the middle and end joints of the fingers, the diagnosis of erosive osteoarthritis should be reconsidered and RA should be considered or ruled out. The correct diagnosis is extremely important because RA is a systemic illness and requires very vigorous therapy early on, or else joint damage occurs. Q2. I’ve been told that I have degenerative joint disease/osteoarthritis. I’ve had a lot of back, neck, knee, and hip pain. Just recently I had a myelogram on my neck because my arms were giving me a lot of pain, numbness, and tingling. The myelogram showed a significant amount of cervical stenosis in between my sixth and seventh vertebrae and also the fourth and fifth. Is this because of my osteoarthritis and exactly what is cervical stenosis? I am very confused. Cervical stenosis is the narrowing of the cervical spinal canal. The cervical spine is a complicated structure of bones (the vertebrae), disc joints and facet joints between the vertebrae, the spinal cord, and the nerve roots that emanate from the cord. In addition there are ligaments, and a rich component of blood vessels. The cervical canal is a tube inside the cervical spine, where the spinal cord is located. The spinal cord is a continuation of the brain that gives rise to the nerve roots, which combine to form the nerves for our body from the neck down. The spinal cord requires a spinal canal diameter of at least 12 millimeters (about ½ inch). Anything less than 12 mm can result in pressure on the highly sensitive spinal cord. The symptoms that arise depend on the part of the cord that is being pressed and can include pain, numbness, tingling, and muscle weakness. A good way to diagnose the cause of cervical stenosis is via magnetic resonance imaging (MRI). There are at least 3 ways that stenosis of the cervical spinal canal can occur:
A herniated discA central osteophyteA cervical subluxation
A herniated disc is a bulge of the jelly-like center of a disc, which can put pressure on the cervical spinal cord. A herniated disc is not necessarily related to osteoarthritis and can occur in young persons. In some cases there can be more than one herniated disc. A central osteophyte is a bone spur that grows inside the spinal canal and can cause narrowing and put pressure on the cord and the blood vessels that supply it. This type of spinal stenosis is clearly related to osteoarthritis. A cervical subluxation is the slippage of one vertebra onto another due to arthritis and the weakening of ligaments. The most common cause of subluxation is rheumatoid arthritis, and rarely, osteoarthritis. Traumatic injury of the neck can also cause a subluxation. A cervical subluxation causes instability of the neck and is potentially dangerous. Treatment depends on the severity of the stenosis and the severity and extent of symptoms. A soft cervical collar and physical therapy that focuses on strengthening neck muscles and proper head and neck positioning can help. At times intermittent cervical traction may be beneficial. In the most extreme cases, surgery is required to widen the canal In the case of cervical subluxation, surgical fusion is needed to stabilize the cervical spine. Q3. I have severe osteoarthritis plus CPPD. My joints are shot, and I have been having terrible shoulder problems. I’ve been told the shoulder joint is frozen and the cartilage is all but gone. Short of joint replacement, is there any known successful shoulder reconstruction that might offer relief? — H., California I would like to review some facts about CPPD for the benefit of our readers. CPPD stands for calcium pyrophosphate dihydrate, which is a crystal of calcium that is deposited in joint cartilages where it causes arthritis. CPPD arthritis was called pseudogout by Dr. Daniel J. McCarty, who described the arthritis and the crystal, and who was my first mentor in rheumatology. The name pseudogout (false gout) was chosen because at times the condition causes acute, painful arthritis similar to gout. Another name for this condition is chondrocalcinosis, which means “calcium in cartilage.” Chondrocalcinosis commonly accompanies certain diseases: A benign adenoma (growth) of the parathyroid glands that causes increased function (hyperparathyroidism) is seen in 10-18 percent of CPPD patients, who should be checked for it. Patients with reduced function of the thyroid gland (hypothyroidism), Wilson’s disease (abnormality of copper-binding protein), hemochromatosis (abnormal accumulation of iron in the body) or kidney failure have a high chance of developing CPPD disease. CPPD crystals deposit preferentially in the menisci (fibrous cartilage) of the knees, the triangular cartilage of the wrist, and the symphysis pubis (the joint behind the pubic area), but they may occur in any joint cartilage. As stated, CPPD crystals cause joint inflammation, which may vary from very acute to subacute, or chronic. Gradually the joint cartilage deteriorates and becomes thinner, and secondary osteoarthritis (OA) develops. Structures around the joint, such as tendons and ligaments, are also involved in the inflammation and may be damaged or ruptured. Thus, besides joint pain, this damage of the tendons and ligaments, as well as the muscle atrophy (thinning) that can result from pain, causes reduced mobility and function. When the shoulder joint is involved, all of the above occurs, as well as damage and rupture of the rotator cuff tendon and enlargement of the joint by an accumulation of fluid. The rotator cuff tendon is crucial for shoulder motion, so when it is ruptured, shoulder mobility is impaired. Pain can be very severe and persistent. The shoulder can become unstable and sublux (that is, be slightly “out of joint”). Incidentally, this syndrome was also described by Dr. McCarty, in Milwaukee, Wisconsin, and he named it Milwaukee shoulder. Other types of calcium crystals can also be found in such joints. Sometimes, before such shoulder damage occurs that surgery is warranted, lavage (washing) of the joint with sterile saline (the same as intravenous fluid) can rid the joint of a lot of crystals and may help delay the damage. Corticosteroid injections can help reduce the inflammation but do not slow the damage. Joint injections with hyaluronate should be avoided because they have triggered acute attacks of arthritis in several patients. (Hyaluronate is a normal component of the cartilage and of the synovial fluid, and it’s sometimes injected in osteoarthritic joints for pain relief.) As for surgery of the shoulder joint, the best person to give you advice is an orthopedic surgeon who actually performs the procedure. I will summarize here what I know as a rheumatologist. There is not a lot of information about arthroscopic surgery for a patient like you. Arthroscopic surgery is usually helpful for relatively minor problems, such as a loose body (piece of bone or cartilage) in the shoulder joint, or a small tear of the labrum (part of the socket). Arthroscopy, meaning “joint inspection” (from the Greek arthron and scopo), is done by inserting a tube with a light through a small incision, and a tube with an instrument to probe and/or cut through another small incision. In situations of substantial damage to the shoulder, as your question describes, arthroplasty is the most promising solution. The major indication for arthroplasty of the shoulder is persistent and incapacitating pain, either at rest or with activity. Secondary indications are loss of shoulder mobility, stability, and strength, causing interference with the joint or inability to function. There are two types of arthroplasties: total replacement arthroplasty, in which both the socket (glenoid fossa) and the ball (humeral head surface) are replaced, and hemiarthroplasty, in which only the humeral head is replaced. Hemiarthroplasty is chosen when the socket of the joint has not sustained much damage. The replacement socket component is made of high-density polyethylene; the ball component, of an inert metal (titanium or cobalt). There are four types of total shoulder arthroplasty designs: unconstrained, semiconstrained, reversed ball and socket, and constrained. The unconstrained design is the most frequently used; it allows the greatest freedom of motion but has no stability. It is indicated when the rotator cuff mechanism is intact or can be repaired to give dynamic stability to the shoulder. The semiconstrained design has some degree of joint stability and is indicated when a damaged socket can be “cleaned up” surgically and the rotator cuff still functions. The reversed ball and socket design combines some degree of stability with mobility and is chosen when the damaged rotator cuff cannot be repaired. The constrained design has the most inherent joint stability, but offers less mobility and is rarely used today because its components have a high rate of loosening or failure. As you can see, there are several choices; the right one depends on the degree of damage to the joint and surrounding tendons. It is necessary to choose a surgeon who operates mostly or only on the shoulder, and to have your shoulder function and damage assessed carefully before surgery, with imaging and evaluation by physical and occupational therapists. During surgery, the surgeon will assess the mobility of the shoulder, and after surgery, intensive physical therapy and rehabilitation are important so that shoulder function is maximized. Learn more in the Everyday Health Osteoarthritis Center.
