World Arthritis Day was marked last Monday. Consultant orthopaedic surgeon Alistair Melvyn Pace discusses with Joseph Agius the causes and symptoms of this condition and other joint-related ailments, possible future treatments and how patient services could improve in Malta.

It is estimated that up to 20 per cent of the global population suffers from osteoarthritis. What are its causes and symptoms?

The term ‘osteoarthritis’ comes from the word osteo meaning bone, arthro meaning joint, and ritis meaning inflammation. The condition causes degeneration of the cartilage lining the joints due to wear and tear. It may affect any joint but, most notably, the hip and knee. In fact, these are the joints in the body that are most frequently surgically replaced. A large number of patients have arthritis and have absolutely no symptoms.

There is no correlation between the severity of arthritis on an X-ray and the extent of the symptoms. Osteoarthritis increases with age and as the geriatric population increases as we live longer, the incidence of osteoarthritis will increase in the years to come. This will result in increasing numbers of patients having mobility and functional problems. Lifestyle, obesity and lack of physical activity will also result in increased incidence of this disease.

Osteoarthritis is mostly idiopathic i.e. there is no cause for it although genetic predisposition is important. Having a physical and manual job may accelerate the condition. Infection, fracture of the joint, gout and inflammatory arthritis such as rheumatoid arthritis are also important causes.

What is the difference between osteoarthritis and rheumatoid arthritis and what do the Maltese suffer from most?

There are two main types of arthritis. The first is osteoarthritis which is a wear and tear/degenerative arthritis related to loss of the cartilage lining the joints. The other type is inflammatory arthritis. There are more than 100 types of inflammatory arthritis. The most common type is probably rheumatoid arthritis. Others may include those related to psoriasis, SLE (systemic lupus erythematosus), ankylosing spondylitis and those associated with bowel conditions.

Crystal disease conditions such as gout can also cause inflammatory arthritis. Inflammatory arthritis is most commonly an autoimmune condition where the body attacks its own joints, destroying them. Osteoarthritis is by far the most common arthritis in Malta but there are certainly thousands of patients suffering from inflammatory arthropathy, particularly rheumatoid arthritis.

Do cold and humidity accentuate the symptoms or is this an old wife’s tale? 

Yes, warmth appears to help relieve symptoms of arthritis in most patients. Cold and humidity seems to worsen the symptoms. In fact, in winter, there appears to be a spike of patients in my clinic complaining of joint pains and stiffness. I normally recommend my patients with arthritis to apply warm towels, hot showers and baths. There is no scientific reason for this observation but probably relates to the gateway theory of pain where higher temperatures rise the threshold for feeling pain.

Are people involved in sports and high-impact activities more likely to suffer from joint-related conditions?

As a senior consultant in orthopaedic and trauma surgery, I manage a variety of conditions, which include injuries sustained in sports and high-impact activities. These injuries vary from fractures which occasionally may be challenging to injuries requiring operations or plaster, to soft tissue injuries such as shoulder or elbow dislocations.

I am an upper-limb specialist and during my extensive training in the UK, I have had the opportunity to manage patients with various sports-related injuries. They could require open and keyhole surgery of the shoulder, elbow, wrist and knees.

We are always hearing of new technologies, such as nanotechnology, genetic sequencing and artificial intelligence, that should one day treat and possibly cure various ailments. Are we closer to a paradigm shift in the way we tackle joint-related conditions?

Certainly science has helped to develop more complicated technology to help in the diagnosis, management and treatment of patients. This is an ever-evolving field and some operations we did 15 years ago are today completely obsolete. Today we can reach and treat areas of the bodies we never could do before.

As the geriatric population increases, the incidence of osteoarthritis will increase in the years to come

Minimally invasive surgery has decreased patient post-operative pain and allowed quicker recovery. Computer systems and robotics have also allowed us to develop systems to treat patients individually and specifically rather than using off-the-shelf implants. 

We are a long way away from implementing genetic sequencing and nanotechnology in clinical practice, but the future is promising and developing. I firmly believe in regenerative therapy of joints rather than replacement. This involves using stem cells and PRP − platelet rich plasma − using one’s own cells and blood as well as transplanting cartilage cells. These techniques have shown extremely good results in the patients I treat this way.

Pain is such a difficult sensation or emotion to fathom and rationalise. Do you believe in a holistic approach to pain relief, that includes the psychological dimension of pain, at least until the condition is remedied surgically? 

Certainly, pain is a very subjective unpleasant symptom, very complex and difficult to understand at times. Acute pain developing over hours or weeks is easier to manage but chronic pain, for example back pain, is very challenging and involves a positive approach addressing the psychological issues.

This would involve the participation of a multidisciplinary team and pain specialists. In fact, surgery and medical treatment may play only a small role in the management of these patients.

You have studied and practised your profession for some years in the UK. Does Malta enjoy the same level of expertise, treatment, equipment, etc.?

I have had the privilege of working in over 16 different hospitals, mostly large teaching hospitals in the UK, during my extensive orthopaedic training.

The level of expertise and care in Malta is comparable to that in the UK, despite the limited resources we have as an island. The services provided in the community and main hospital here in Malta are excellent.

In the UK, the health system is run mostly by non-clinically trained managers and personnel unlike in Malta. There is thus more emphasis on cost-saving occasionally to the detriment of health priorities. The private sector also has a great say in the UK with extensive public private work relationship.

How can Malta improve its services to patients suffering from the above-mentioned conditions?

The treatment of patients with osteoarthritis and joint-related conditions must be coordinated through a multidisciplinary approach to allow the patient to receive the best service. This may involve the general practitioner, orthopaedic surgeon, physiotherapist and rheumatologist.

In order to achieve this, GP services should be empowered, and a named patient GP should be the central hub of reference for a particular patient. In this way, there would be no duplication of services and oral and written communication would be improved.

I also believe computerised letters related to patient events, which would be accessible to specialists in the public and private sector, would help improve the service provided to patients.

My view, however, is that there should be more emphasis on the private sector and private health insurance should be encouraged and subsidised by the government to help decrease the burden on the main hospital. 

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