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 Total Condylar
TKR
Cemented THR
Arthroplasty
• Surgical treatment of
choice

TSR

Semiconstrained