• osteoarthritis
• treatment

In the 1950s and early 60s Sir John Charnley succeeded in developing components for total hip arthroplasty and demonstrated the remarkable success that could be achieved with this procedure in patients with osteoarthritis (OA). Charnley’s adaptation of polymethylmethacylate as a fixation interface between the metallic or plastic implant and the bone served as a major advance in the surgical treatment of severe OA.^1,2 Development of total knee arthroplasty followed. The materials and surgical techniques have improved steadily so that both of these procedures are associated with a high level of patient satisfaction. Most patients with OA of the hip or knee who undergo total joint arthroplasty experience clinically significant improvement in joint pain, function, and quality of life.^3,4

Recommendation of total joint arthroplasty for the patient with OA, however, is tantamount to an acknowledgement of the failure of medical management. The surgical procedure is often performed after the patient has experienced years, or even decades, of pain and disability. Among all the pharmacological and non-pharmacological interventions promoted for treatment of OA in the half century since Charnley directed his attention to replacement of the arthritic hip, none approximates the effectiveness of arthroplasty.

The 1963 edition of the Cecil-Loeb textbook of medicine,⁵ in discussing the treatment of OA, noted: “Analgesics, particularly salicylates, are useful in controlling the symptoms of osteoarthritis. Phenylbutazone is sometimes helpful when salicylates have failed, but the potential toxic reactions rarely justify its use in such a mild disorder. Systemic corticosteroid treatment is not recommended for osteoarthritis. Intra-articular injections of hydrocortisone acetate ... may be helpful for joints which fail to respond to simpler measures.”

Despite enormous increases in our understanding of pain mechanisms and of the metabolism, biochemistry, and molecular biology of articular …