The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Kevin D. Gross PT, PhD, Boston University Clinical Epidemiology Research and Training Unit, and the Department of Medicine at Boston Medical Center, Boston, MA, U.S.A.
David J. Hunter MBBS, PhD, Boston University Clinical Epidemiology Research and Training Unit, and the Department of Medicine at Boston Medical Center, Boston, MA, U.S.A.

Despite the increasing prevalence of symptomatic knee osteoarthritis, many uncertainties exist pertaining to its management. Many putative risk factors are characterized by excessive loading of vulnerable joint structures. Clinical examination includes assessment of knee function and the influence of modifiable risks such as malalignment, muscle strength, and obesity. Knee braces, footwear, exercises, and dieting are prescribed for the purpose of improving the distribution of loads on the knee, and reducing the likelihood that osteoarthritis (OA) and its symptoms will worsen. In this conservative approach, pharmaceuticals of low toxicity are preferred and given only when other methods fail to achieve functional improvement.
Key words: knee osteoarthritis, mechanical risk factors, nonpharmacologic management, physiotherapy, joint replacement.

Nizar N. Mahomed, MD, ScD, FRCSC
Toronto Western Hospital,
University Health Network,
Assistant Professor, Department of Surgery, University of Toronto,
Toronto, ON.

Gillian Hawker, MD, MSc, FRCSC
Sunnybrook and Women's
College Health Sciences Centre,
Associate Professor,
Department of Medicine,
University of Toronto,
Toronto, ON.

Arthritis is the number one cause of disability in any age group. It is estimated that over half of those over the age of 75 suffer from this condition.^1,2 The prevalence of arthritis increases with age; current estimates indicate that the number of people with arthritis-related disability will double by the year 2020.³ Pain and the loss of physical function result in a reduction in quality of life and a loss of independence for these patients. This in turn causes a significant burden to society in terms of lost productivity and the utilization of health care resources.^4,5 Studies have shown long-term improvement in joint pain, physical functioning and quality of life in patients following total hip and knee replacement.^6,7 Total joint replacement (TJR) is cost-effective and, in some cases, even cost saving.⁸ Currently there are over 35,000 hip and knee replacements performed annually in Canada.

Shechar Dworski, BSc

Osteoarthritis (OA) is common in the elderly, affecting as many as 80% of people aged 55 and over. It is the most common form of arthritis, occurring mostly, but not exclusively, in the elderly. It is also the most common musculoskeletal disease in the elderly. It affects mostly the hands, as well as the major weight bearing joints of the body which are primarily the hips and knees. Please refer to the article on Osteoarthritis: Early Diagnosis Improves Prognosis in the May/June 1999 issue of Geriatrics & Aging for more information on the symptoms and specific aspects of OA. There are several routes one may take to treat OA, as well as many preventive measures. Joint replacement is usually the last step, when all other treatments have been unsuccessful. At this stage of disease, people often have difficulty walking and climbing stairs, and have joint pain at rest and at night. In this case, joint replacement therapy is extremely effective at relieving pain and improving function.

Barry Goldlist, MD, FRCPC, FACP

The most common causes of death in old age are, as expected, cardiovascular disease and cancer. However, for those involved in health care of the elderly, it is no surprise to learn that the elderly consider arthritis the greatest cause of disability. Osteoarthritis, rather than diseases such as rheumatoid arthritis, causes most of the burden of joint disease in old age. The major problems are generally pain and functional limitation. Medical management in the past has generally depended on limitation of activity and intermittent use of analgesics. Often, physicians neglect first principles in dealing with this chronic disease. The patient must be educated about the disease (therapy, exercise, weight reduction, use of assistive devices, etc.), and then the doctor and patient must agree on appropriate goals of therapy. If the patient is expecting total pain relief, and the doctor's goal is only to maintain mobility, neither party will be satisfied. There is much evidence now that excessive rest is harmful in osteoarthritis, and that therapy and exercise can improve function and decrease pain. Currently, regularly administered acetaminophen is the drug of choice for significant pain in osteoarthritis. Non-steroidal anti-inflammatory drugs (NSAIDs) are also beneficial, but their use is limited by side effects that are most prevalent in the elderly. The threshold for regular use of NSAIDs might be lowered as the new generation of more specific COX-2 inhibitors become more widely available. The exact role of other modalities, such as oral glucosamine and injections of hyaluronic acid, is not really clear at the present time.

For severe joint disease, the use of surgical joint replacement has been an incredible development. It is clear, however, that the availability of the procedure is greatly restricted in Canada. It is unclear to me how coronary artery surgery (CABG) has prospered in its availability in comparison to joint replacement surgery. Both are primarily done for quality of life issues, not longevity, and CABG is more easily available despite the fact that the elderly say that their joints are a greater source of impaired functional ability than their hearts. Until joint replacement surgery is more widely available, many of our seniors will continue to suffer unnecessarily.