Not the Last Word: Pre-arthritis Syndrome.

Abstract

Do you suffer from pre-arthritis syndrome? You may feel fine, but your joints might be quietly conspiring against you, poised to fail when you least expect it. Arthritis has many risk factors [3]: A history of injury, overuse, smoking, alcohol use or infection; extremes of body mass; certain occupations; and genetic influences, among others. If you can claim more than a few items on that list, perhaps the pre-arthritis syndrome label will suit you well. The specific category of “prearthritis syndrome” is new—I just made it up—but the general designation of accumulated risk factors as a pre-disease syndrome is well established in medicine. For example, the American Diabetes Association [1] classifies people with impaired fasting glucose or impaired glucose tolerance, yet without a single overt symptom of disease, as having “prediabetes syndrome”. Interestingly, diabetes itself is a pre-disease syndrome, as elevated blood sugar can damage the arteries and nerves well before any symptoms appear. It won’t be long, I predict, before a “pre-prediabetes syndromesyndrome” is defined as well. The justification for finding predisease syndromes is the prevention of complications. Diabetes can be silent as it smolders, and prediabetes quieter still. If patients are identified before tissue damage irrevocably takes root, modification of the risk factors might avert clinical problems. Orthopaedics does not traffic much in pre-disease syndromes, but mild developmental dysplasia of the hip (DDH), to name one example, might qualify. Infants whose hips are reduced but can be subluxed will have no symptoms, and unless the hip dislocates, there may be no outward manifestation of the condition as the child is growing, either. Nonetheless, we vigilantly seek and diligently treat DDH in the neonate, all in the name of preventing degeneration later in life. Pre-disease syndrome diagnoses are labels created by doctors. The question is how much predisease should we manufacture. The adage “an ounce of prevention is worth a pound of cure” establishes the value of detection and preemption, that some amount of labeling is laudable, but does not tell us howmuch. After all, an equally famous adage, “a stitch in time saves nine” also establishes the value of prevention, but with an effectiveness ratio only 9/16th (56.3%) as large. More predisease will be created if the threshold defining abnormality is lowered. Metrics that were once “high normal” according to an older criterion would be placed in the abnormal category if the threshold line were to be moved downward. Yet dropping the threshold—what I’ll call defining deviancy up [14]—also runs the risk of medicalizing many people who would benefit more from simply being left alone. Using the definition from the CDC [4], 29.1% of the adult population in the United States is said to experience hypertension (with three-quarters of them taking medications for it). Increase that rate just a bit, and the term “normotensive”, currently used to designate the healthy state, will be obsolete: Abnormal is the new normal. The obvious problem with identifying too much of predisease disease is that there is no natural limit to how A note from the Editor-in-Chief: We are pleased to present to readers of Clinical Orthopaedics and Related Research the next Not the Last Word. The goal of this section is to explore timely and controversial issues that affect how orthopaedic surgery is taught, learned, and practiced. We welcome reader feedback on all of our columns and articles; please send your comments to eic@ clinorthop.org. The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJEConflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of Clinical Orthopaedics and Related Research or The Association of Bone and Joint Surgeons. Joseph Bernstein MD (✉), University of Pennsylvania, 424 Stemmler Hall, Philadelphia, PA 19104, USA, Email: [email protected] J. Bernstein, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA