Rheumatoid Arthritis

RHEUMATOID ARTHRITIS

Dr. Ashish Gohiya M.S.(Orth.)

Assistant Professor Gandhi Medical College, Bhopal

Introduction • Chronic inflammatory disease. • Waxing & waning course. • Proliferative changes in synovial membrane, periarticular structure, Muscles & perineural sheaths. • Joint destruction. • Ankylosis / Deformity.

Introduction

“It bites the joints, licks all other systems of the body and barks at treating physicians & surgeons”

Pathology • Stage 1: Synovitis. • Inflammatory cell deposition. • Painful, swollen, tender joints.

• Stage 2: Destruction. Chronic synovitis Proteolytic enzymes

pannus

Synovial hyperplasia

Articular cartilage destructiion

• Stage 3: Deformity. Deformity Joint destruction

Tendon Rupture

Capsular stretching

Clinical Features • Chronic, Symmetrical , small joint polyarthritis. • H/O Morning stiffness. • Joint deformity. • Subcutaneous nodule. • Systemic symptoms.

Diagnostic Criteria (Revised criteria of 1987, American College of Rheumatology)

1. Morning stiffness. 2. Arthritis of 3 or more areas. 3. Arthritis of hand joints. 4. Symmetrical Arthritis. 5. Rheumatoid Nodules. 6. Rheumatoid Factor. 7. Radiological changes. {4 of the 7 for at least 6 weeks}

Investigation • Blood tests • Normocytic normochromic anemia. • Rasied ESR.

• Serological test • Rheumatoid factor. • Anti CCP.

• Synovial fluid Analysis • Raised WBC. • Mucin test. • Low sugar.

Rheumatoid Factor • • • •

• NOT DIAGNOSTIC High titers marker of poor prognosis. Present in 60 – 80% Pts of RA. Once positive no need to repeat. Positive RFs –Rheumatological diseases •

RS,SS,SLE,SSc,MCTD,JCA.

–Infections •

TB,leprosy, syphilis, IE,Inf.hepatitis etc.

–Post vaccination –Neoplasms. –Others •

Cirrhosis,DM etc.

Investigation • Radiological • • • •

Juxta articular osteoporosis. Joint destruction. Deformity. Ankylosis.

• CT Scan • MRI

Differential Diagnosis Of Polyarthritis • • • • • • • • •

SLE. Psoriatic arthropathy. Ankylosing Arthropathy. Reiter’s disease. Polyarticular Gout. CPPD. Osteoarthritis. Sarcoidosis. Polymyalgia rheumatica.

Aim Of Treatment • ‘A locally malignant disorder that “metastasizes” in the first 2-3 yrs’. • Induction & maintenance of remission. • Preserve joint function. • Prevent deformity. • Correct deformed joint. • Rehabilitate.

Non Surgical Management • Drug Therapy • • • •

First Line Drug- NSAIDs. Second Line Drug- DMARDs. Third Line Drug- Immunomodulators. Corticosteroids.

• Physiotherapy • Preserve joint mobility & function.

• Splints • Prevent & correct deformities.

• Local steroid injection • For trigger finger and Carpal tunnel syndrome.

Role of DMARDs • Early institution of DMARDs as joint damage starts early. • Early institution of DMARDs reduces use of NSAIDs & their toxicity. • Combination preferred due to different site of action &less toxicity. • Short term low dose corticosteroids (bridge therapy) in combination with DMARDs.

Role of Corticosteroids Indications • • • • • •

During acute & severe flare. Prominent extra-articular features. Bridge therapy. Rheumatoid vasculitis. In elderly. Failure of DMARDs.

Drug Treatment

“NO DRUG HAS GREATER TOXICITY THAN RHEMATOID ARTHRITIS ITSELF”

Prior to Surgery • STOP: • Salycilates – 2 Wk prior to surgery. • NSAIDS – 5 Days prior to surgery.

• If corticosteroids taken for more than 3 Wks in previous 12months, it should be given in pre, intra & post operative period.

Surgery Articular disease • Synovectomy. • Arthroplasty. • Arthrodesis,

Surgery Extra - Articular disease • • • •

Release of nerve entrapment. Release of contractures. Correction of deformities. Tendon repair.

Rheumatoid Hand Deformities can be due to • Tightness of intrinsic muscles.- Intrinsic plus • Adherence of lateral bands in fixed dorsal position.- Swan neck deformity. • Volar subluxation of lateral bands.Boutonniere deformity. • Rupture of long flexor or extensors.

Rheumatoid foot • Fore foot – – – – –

Hallux valgus Dislocation of MTP joint Claw toe Plantar callosities Hammer toe

• Mid foot – Affection of metatarsocuneiform joint & naviculocuneiform joint.

• Hind foot – Heel valgus – Loss of longitudinal arch

Ankle Joint • Synovectomy • Arthrodesis • Arthroplasty

Major Joints Synovectomy • Range of motion preserved but not increased. • Useful in early stages of disease. • Cartilage damage & FFD should be less. • Minimum of 6 month of conservative therapy being ineffective. • In elbow radial head excision should be combined. • In shoulder excision of bursa should be combined.

Major Joints Arthrodesis • Rarely indicated. • For severe U/L joint involvement in young individual.

Major Joints Cemented THR

Arthroplasty • Surgical treatment of choice

TSR

Semiconstrained

Total Condylar TKR