Foreword | Osteoarthritis: Diagnosis and Medical/Surgical Management

Authors: Moskowitz, Roland W.; Altman, Roy D.; Hochberg, Marc C.; Buckwalter, Joseph A.; GoldberG, Victor M.

Title: Osteoarthritis: Diagnosis and Medical/Surgical Management, 4th Edition

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Foreword

It is a great pleasure to have an opportunity to review and introduce this fourth edition of a really great book on an incredibly important subject osteoarthritis! The book is edited by world authorities in the field of rheumatology but I note with pleasure that several contributing authors are orthopedists, suggesting as we all know that the two specialties are joined together on the altar of the inflamed or damaged joint.

These are modern times in the world and life is in many ways better than it was in the olden days. In the year 1903 the average age of survival was 47 and the patients lives were dominated by tuberculosis, polio, trauma, and an array of cardiac and neurologic disorders that contributed to miserable lives and short survival. By 2003, the mean survival was 30 years longer and the average age until death was 77. Patients have a much better life and in many ways a happier and more productive one. Having said that however, they now have other disorders such as HIV, Alzheimer's, osteoporosis, and multiple sites of osteoarthritis. This last mentioned disorder now dominates the lives of many old people, limits their activities, demands that they take sometimes dangerous medications, use canes, crutches, walkers, or wheelchairs, and in fact have operative procedures that often make them better but not always.

The causes of osteoarthritis are not really well understood. There is no doubt that trauma to a joint is a problem, and certainly the knee joint is most often damaged by what sometimes seem to be minor injuries. Athletes have problems with partial tears of muscles, torn menisci, cruciate ligament injuries, subchondral fractures and, at times, repeated effusions. Older persons who develop osteoporosis may have tiny stress fractures, or may develop abnormal structure based on alteration in joint alignment. Patients with an array of metabolic bone and soft tissue diseases may be prone to cartilage injury or bone problems. These include osteomalacia, hyperparathyroidism, osteonecrosis, and fibrous dysplasia amongst others. We still, however, need to know more about the possible genetic causes or alterations in cartilage structure that may lead to the disease. There is no doubt that chondrocytes and the cartilage matrix change with advancing age, and some of this is related to collagen types, glycosaminoglycan distribution, water content, apoptotic activity, and changes in the aggrecan structure. Perhaps of equal concern is the effect of the synovium and agents such as interleukin-1 on cartilage structure or the possibility of alterations in the subchondral bone structure, which allow damage to the cartilage tidemark.

What a great accomplishment it would be if people could have a reduced frequency and severity of this disease; and if we could find ways of preventing it or reducing its effect and eliminating some of the major impairments that now cause people to be far less functional.

The group of authors presenting chapters in this volume are extraordinary in their commitment to the subject of osteoarthritis, some for many years, and in their ability to write with substance, clarity, and hope. They review the etiology, the pathology, the epidemiology, the biochemistry, and the genetics of the disease and define how these various factors alter and affect the presentation and the patient's fate. Imaging is crucial, particularly using new technology such as that associated with special gadolinium MRIs. The section on treatment is particularly rewarding since it describes in great detail the pharmacologic agents, nonpharmacologic approaches, and intra-articular injection therapies. The final phase is to review the various anatomical sites and the methods of surgical and other treatments currently in use or soon to be introduced.

Of particular importance are the suggestions that the biologic and, more importantly, the genetic approaches to the disease may in the future provide new methods of early diagnosis, genetic predisposition, and ultimately treatment methods that can slow, stabilize, or even eliminate the disease. Biochemical interference with the actions of the MMPs and the interleukins, stabilization of the cell structure, diminution of apoptotic activity, increases in chondrocyte cell division and collagen, and proteoglycan synthesis are really the wave of the future and, according to the chapter authors, are possible and probable with further research. Identification of very early disease by special imaging effects or biologic studies may allow us to introduce earlier treatment protocols which will allow the cartilage to heal and restore the joint to better function.

Of great importance is the rational approach expressed by the authors of the chapters on operative procedures. These are often very effective for a while. It seems logical to assess the competence of these systems by careful evidence-based result analysis and to establish some guidelines for choosing the correct procedure to be performed and best patients to have such surgery.

This is a great book a treasure for the physician and basic scientist and indeed an important contribution to the successful diagnosis and treatment of patients with osteoarthritis. It describes the disease in detail, provides insight into the cause of the problems; but most of all it defines the way we treat it now and, much more importantly, the way we will treat it in the future. There is hope here for new methods, which will make osteoarthritis less of a problem and ultimately will diminish the suffering and disability of mankind.

Henry J. Mankin MD

Former Chief of Orthopaedic Surgery

Massachusetts General Hospital

Edith M. Ashley

Professor of Orthopaedics Emeritus

Harvard Medical School