Ask the Doctors December 2007 Issue

Ask The Doctors: 12/07

I’m 77 and have osteoarthritis in both knees. I’ve taken glucosamine daily for five years and Synvisc once a year in an effort to stave off replacements so I can continue to play tennis once a week. I do not have a lot of pain, only soreness and stiffness. Is there an injection of artificial cartilage available that would make joint replacement unnecessary?

Currently there is no "artificial cartilage" injection available, although injections of cortisone or hyaluronate (Synvisc) have been shown to be effective in relieving osteoarthritis pain and stiffness. A newer therapeutic approach involves removing articular cartilage cells (chondrocytes) from the patient’s joint, expanding them in the laboratory, and implanting them in the damaged areas; however, this requires at least two arthroscopic procedures and appears to work best in younger patients with small, isolated areas of cartilage damage.

If your problems are primarily soreness and stiffness, adding some physical therapy modalities, such as heat, ultrasound, or aquatic therapy, may be beneficial. Topical preparations that are applied to the skin, such as those containing capsaicin or menthol, also may help relieve the soreness and stiffness. You might also consider wearing a neoprene knee brace during activities such as tennis.

What’s your opinion on the effectiveness of TNF-inhibitors for rheumatoid arthritis? If effective, which do you recommend—Remicade, Humira, or Enbrel?

 

For most patients, TNF-inhibitors are extremely effective in controlling RA symptoms (pain and stiffness) and, eventually, the signs (swelling, inflammation) of the disease. They are more effective as adjuncts to more basic treatments, such as methotrexate,

than as a stand-alone treatment. In some cases, they lose effectiveness after providing initial relief, but this is not usually the case. In this situation, switching to a different TNF-inhibitor may provide relief once again.

Remicade (infliximab), Humira (adalimumab), and Enbrel (etanercept) are about equally effective. Since Remicade must be administered intravenously (Enbrel and Humira are administered by injection), it generally would be our third choice among the three.

 

I’ve heard that synovectomy, removing inflamed tissue lining the joint, has been discontinued in recent years because the synovium eventually grows back. But I’ve also heard about synovectomies in which lasers are used that work through the skin. Since there’s no cutting—and therefore no blood loss or risk of infection—it seems safer. But will the synovium grow back, and does the procedure need to be repeated?

Synovectomy does not cure arthritis, but it may relieve symptoms temporarily. Occasionally a synovectomy—often performed arthroscopically—can slow the progress of the disease into adjoining tissues and postpone more radical surgery. Removing the joint lining eliminates the major source of inflammation, and may help preserve cartilage. However, the operation is generally only successful for very early disease in a relatively healthy joint.

Once the cartilage is destroyed, a synovectomy—by any method—isn’t of much help. And although the operation can be repeated, it usually is not that rewarding. Laser synovectomy enjoyed some popularity in the mid-1990s, but it was never tested in large groups of patients and was never shown to be more effective than standard arthroscopic synovectomy.