PTA - Your voice can influence policy decisions

During a recent arthritis conference, I was struck by the absence of arthritis advocates living with post-traumatic arthritis. Ann Qualman, outgoing President of the Canadian Arthritis Patient Alliance (CAPA), agreed that this population is not well-represented and assured me that CAPA, as an advocacy organization of arthritis patients/consumers would welcome such advocates. To improve the quality of life of all people living with arthritis, the voices of those living with post-traumatic osteoarthritis must be heard to ensure that programs and policy decisions are also relevant to them.

Although the term “arthritis” means inflammation of the joints, arthritis can be divided into two main categories: 1) non-inflammatory arthritis (i.e., osteoarthritis (OA)) and 2) inflammatory arthritis (i.e., rheumatoid arthritis (RA)). Although OA is considered a non-inflammatory form of arthritis, there can be a small inflammatory component but it is never as intense as that seen in RA.¹ OA can be further subdivided into two classes based on the cause of the condition: 1) primary or idiopathic OA (no known cause); or 2) secondary OA (known cause). Primary OA, the most common form of arthritis,² is a degenerative disease in which the joint cartilage that serves as a “shock absorber” between our bones gradually wears away. This causes the bones to rub abnormally against one another, resulting in pain and dysfunction in the involved joint. Although the exact cause of primary OA is unknown, it is characterized by an imbalance in the increased destruction of joint cartilage and decreased formation of new bone at the joint surfaces.¹

Unlike primary OA, the cause of secondary OA is known. In fact, there are several well-recognized potential causes of secondary OA, of which one is major joint trauma. Post-traumatic arthritis is caused from blunt, penetrating or repeated trauma or from forced inappropriate motion of the joint or ligament. An intra-articular injury (an injury within a joint), such as a severe fracture or sprain, can cause “bruising” of the articular cartilage when too much pressure is exerted on it. Sometimes the cartilage is ripped away from the bone. If these pieces are not removed surgically, they can float around in the joint causing further damage to the articular cartilage. Or sometimes the articular cartilage is not damaged at the time of injury; rather the trauma changes the way the joint moves, thereby increasing the forces on the articular cartilage. It may take several years for this imbalance to cause cartilage damage. Other than post-traumatic arthritis, the other potential causes of secondary OA can be grouped into three remaining categories: metabolic (e.g., Ehlers-Danlos joint hypermobility syndrome); anatomic (e.g., leg length inequality); and, inflammatory (e.g., septic arthritis).¹

Every year there are approximately 10,000 major trauma cases with an ISS >12 in Canada.³ Of these, about 64% involve an orthopaedic injury. The busiest trauma centre, Sunnybrook & Women’s College Health Science Centre located in Toronto, treats about 10% of these cases. Of the 1048 trauma cases treated between April 1 2004 to March 31 2005, 261 (25%) involved an intra-articular fracture: with 80, 73 and 108 fractures involving the hip, knee and ankle joints, respectively.4 Intra-articular injuries involving the weight-bearing joints of the lower extremities are most often the result of high-energy trauma such as motor vehicle collisions or bad falls.³ These injuries affect individuals during the most productive years of their lives. The typical Canadian trauma patient to sustain these injuries is a 43-year-old male.³ Like primary OA and RA, post-traumatic arthritis can result in severe long-term pain and physical disability. This is a real issue for these young patients who want to get back to work.

A recent study by McKinley et al., found that intra-articular fractures of the lower extremity affect the hip, knee and ankle joints differently.4 The prevalence of post-traumatic arthritis is significant, ranging from approximately 80% in the ankle joint, 60% in the hip joint to 40% in the knee joint.5,6 McKinley suggests that the reason knee joints are more able to tolerate intra-articular fractures is that much of the knee’s stability is provided by the ligaments and the cartilage is very thick compared to the other joints.⁴ Arthrodesis (when the joint is permanently fused) is the mainstay of treatment of end stage arthritis of the foot and ankle. Many with post-traumatic arthritis of the hip and knee eventually need a total joint replacement. Of all primary total hip and knee replacement recipients performed in Canada between May 2001 to March 2002, 4% and 2% were for post-traumatic arthritis, respectively.7 A study done by our group demonstrated that a revision total hip replacement occurs earlier among those with a previous acetabular (hip socket) fracture.⁸

Post-traumatic arthritis is a form of secondary OA. Pathologically, one cannot distinguish secondary OA from primary OA and clinically this is not important, as treatment is generally the same. To those people with post-traumatic arthritis – help make a difference by contributing to the collective voice and influence policy decisions that are relevant to you, while at the same time helping to improve the quality of life of all people living with arthritis.

Cornelia Borkhoff, works with Population Health Sciences Research Institute, The Hospital for Sick Children, Toronto ON and is a Canadian Arthritis Network Trainee

References

1. Dequeker J, Dieppe PA, eds. Disorders of bone cartilage and connective tissue. In: Klippel JH, Dieppe PA, eds. Rheumatology. 2nd ed. London: Mosby, 1998.
2. Lagacé C, Perruccio A, DesMeules M, Badley E. The impact of arthritis on Canadians. In: Health Canada, Arthritis in Canada: an ongoing challenge. Ottawa, ON: Health Canada; 2003: 7-37.
3. Canadian Institute for Health Information (CIHI). National Trauma Registry 2004 Report: Major Injury in Canada (includes 2002 – 2003 data). Ottawa, ON: CIHI; 2004: 7-10.
4. McKinley TO, Rudert MJ, Koos DC, Brown TD. Incongruity versus instability in the etiology of posttraumatic arthritis. Clin Orthop 2004; 423: 44-51.
5. Vallier HA, Nork SE, Benirschke SK, Sangeorzan BJ. Surgical treatment of talar body fractures. J Bone Joint Surg 2004; 86A: 180-92.
6. Honkonen SE. Degenerative arthritis after tibial plateau fractures. J Orthop Trauma 1995; 9: 273-7.
7. Canadian Institute for Health Information (CIHI). Canadian Joint Replacement Registry (CJRR) Bulletin. Surgical and Orthopaedic Implant Information for Total Hip and Total Knee Replacement Procedures Performed in Canada, May 2001-March 2002. Toronto, ON: CIHI, 2002.
8. Borkhoff CM, Zaveri G, Kreder HJ, Jimenez MJ, Waddell JP, Stephen DJG, Tile M. Total hip arthroplasty after previous acetabular fracture: a matched cohort study. Presented at the Canadian Orthopaedic Association Meeting. London, ON, June 2001.