Rheumatoid Arthritis
Rheumatoid Arthritis
Rheumatoid Arthritis
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<strong>Rheumatoid</strong> <strong>Arthritis</strong><br />
Dr. C. C. Visser<br />
MBChB MMed (Med Phys)<br />
Diploma in Orthopaedic Medicine<br />
Member of the Society of Orthopaedic Medicine, UK
<strong>Arthritis</strong><br />
OA<br />
Crystal<br />
RA<br />
SpA<br />
CTD<br />
Vasculitis<br />
Primary: DIP<br />
PIP,hip,knee<br />
spine, 1 MTP<br />
Secondary:<br />
Gout<br />
Pseudogout<br />
AS<br />
Psoriatic<br />
Enteropathic<br />
Reactive<br />
SLE<br />
PSS<br />
PM/DM<br />
MCTD<br />
PAN,<br />
Wegeners<br />
Takayasu,<br />
GCA etc<br />
Cartilage<br />
Cartilage<br />
Synovium<br />
Soft tissue<br />
Bone<br />
Synovium<br />
Joints + C-spine<br />
>> Systemic<br />
Synovium<br />
Entheses<br />
Axial + peripheral<br />
joints>> systemic<br />
Synovium<br />
Systemic >><br />
Synovium<br />
Synovium<br />
Systemic >><br />
Synovium<br />
XR<br />
Synovial fluid<br />
XR<br />
Urate level<br />
RF<br />
XR<br />
XR<br />
HLA B27<br />
ANF<br />
ENA<br />
Organ Fx tests<br />
ANCA<br />
Histology<br />
Imaging
<strong>Rheumatoid</strong> arthritis<br />
• Most common form of inflammatory<br />
arthritis<br />
• Affects 1 % of all populations<br />
• Females > males 3:1
<strong>Rheumatoid</strong> <strong>Arthritis</strong><br />
• Wide variation in<br />
– age at onset<br />
– degree of joint involvement<br />
– severity of disease<br />
• Difficult to predict early on who will<br />
develop more severe disease
Effects of RA<br />
• Systemic disease but joint involvement<br />
dominates<br />
• RA affects morbidity and mortality<br />
• RA reduces life expectancy<br />
– males by 7 year<br />
– females by 3 years
Etiology<br />
• Immune mediated chronic inflammation<br />
• Trigger: Environmental<br />
Antigen<br />
Genetic (30%)<br />
Self Antigen<br />
T cell activation<br />
Chronic Inflammation<br />
Lymphoid cells infiltrate synovium<br />
New blood vessels form in synovium<br />
Synovial proliferation<br />
Joint destruction
Mechanisms of joint damage<br />
• Synovial mass stretches joint capsule and<br />
ligaments: joint swelling, instability &<br />
deformity<br />
• Cytokine and proteolytic enzyme rich synovial<br />
fluid destroys cartilage joint space<br />
narrowing on X-rays<br />
• Infiltration of cartilage and later bone by<br />
invading synovium (pannus)<br />
marginal erosions
Onset<br />
• 60% insidious onset of pain, stiffness,<br />
symmetrical swelling of joints especially<br />
small joints<br />
• 20% acute or subacute<br />
• 10% vague aches and pains<br />
• 5% systemic symptoms: fatigue,<br />
malaise, weight loss, low fever, myalgia,<br />
morning stiffness, depression
ACR Classification Criteria<br />
(4/7)<br />
• EMS > 1 hour<br />
• > 3 joint arthritis<br />
• Symmetrical arthritis<br />
• Wrist, MCP, PIP arthritis<br />
• <strong>Rheumatoid</strong> nodules<br />
• <strong>Rheumatoid</strong> factor<br />
• X-ray changes: periarticular<br />
osteopaenia/marginal erosions
Articular involvement
Articular involvement<br />
Any synovial joint can be involved<br />
Also inflammation of synovium in bursae<br />
and tendon sheaths<br />
Can start asymmetrically with only few<br />
joints affected
Articular involvement<br />
• Spreads within months to years to other<br />
joints in symmetrical distribution<br />
• Joint involvement reaches a plateau<br />
after first few years<br />
• Number of joints affected in early<br />
disease related to severity of disease
Hand<br />
• MCP joints<br />
– Synovitis<br />
– Ulnar deviation<br />
• PIP joints<br />
– Synovitis<br />
– Swan neck deformity<br />
– Boutonniere deformity<br />
• Z-deformity of thumb<br />
• Tendons<br />
– Flexor tenosynovitis<br />
– Extensor tenosynovitis<br />
• Poor grip: power and pinch
Wrist<br />
• Synovitis<br />
• Piano key sign (distal radio-ulnar joint)<br />
• Subluxation<br />
• Radial deviation<br />
• Ankylosis<br />
• Carpal tunnel syndrome
Elbow<br />
• Synovitis<br />
• Flexion contracture<br />
• Decreased, painful pronation and<br />
supination<br />
• Olecranon bursitis<br />
• RA nodules
Shoulder<br />
• Subacromial bursitis<br />
• Rotator cuff tendinitis<br />
• Glenohumeral joint arthritis<br />
• Acromio-clavicular arthritis
Foot<br />
•MTP<br />
– Synovitis<br />
– Subluxation with hammer/claw toe and<br />
metatarsalgia<br />
– Bunions<br />
– Bunionettes<br />
– Toe deviation/overriding<br />
• Collapse of medial arch of foot
Ankle/Hindfoot<br />
• Ankle<br />
– Synovitis<br />
– Retrocalcaneal bursitis<br />
• Tenosynovitis/rupture<br />
– Peroneal tendons<br />
– Tibialis posterior<br />
• Subtalar arthritis<br />
– Reduced and painful movement<br />
– Hindfoot valgus
Knee<br />
• Synovitis<br />
• Effusions<br />
• Baker’s cyst +/- rupture<br />
• Instability/ deformity eg valgus deformity<br />
• Flexion contracture
Hip<br />
• <strong>Arthritis</strong> (usually late)<br />
– Pain especially on weight bearing<br />
– Reduced movement<br />
• Trochanteric bursitis
Cervical spine<br />
• Involved in 70% patients with longstanding<br />
RA<br />
• Occipital pain made worse by movement<br />
• Subluxation of C1-2 with compression of<br />
spinal cord during neck flexion<br />
– Significant if >10 mm instability on flexion<br />
– Usually slowly developing myelopathy<br />
• Subaxial subluxation
Serial cervical X-rays in a RA patient
Other joints<br />
• TMJ: reduced mouth opening<br />
• Sternoclavicular<br />
• Crico-arytenoid<br />
• Ossicles of ears
Non-articular manifestations
Non-articular manifestations<br />
• Generalized lymphadenopathy<br />
• Nodules<br />
– 30% patients<br />
– external over areas of pressure<br />
– internally eg lung, heart, gallbladder<br />
– central necrosis with pallisade of<br />
fibroblasts
Non-articular manifestations<br />
• Lungs<br />
– Pleurisy<br />
– Pleural effusions (NB exudate!)<br />
– RA nodules single/multiple (Caplan<br />
syndrome if huge nodules in coal miners)<br />
– Lung fibrosis
Non-articular manifestations<br />
• Heart<br />
– pericarditis, usually asymptomatic, but can<br />
lead to friction rubs / effusions / tamponade<br />
– RA nodules: conduction defects
Non-articular manifestations<br />
• Bone<br />
– Generalized osteoporosis<br />
•Muscle<br />
– Muscle atrophy<br />
– Rarely myositis
Non-articular manifestations<br />
• Skin<br />
– Palmar erythaema<br />
– Digital gangrene (small arteries)<br />
– Nail fold infarcts (small arteries)<br />
– Skin ulcers (medium arteries)<br />
– Purpuric papules (venules)<br />
– Palpable purpura (leukocytoclastic<br />
vasculitis)
Non-articular manifestations<br />
• Eyes<br />
– Secondary Sjögren syndrome<br />
– Episcleritis<br />
– Scleritis<br />
– Scleromalacia perforans
Complications
Complications<br />
• Infections<br />
– More susceptible to any infection (RA,<br />
steroids, MTX)<br />
– ESPECIALLY susceptible to joint<br />
infections<br />
– Always suspect septic arthritis if sudden<br />
increase in symptoms in one joint
Complications<br />
• Felty syndrome<br />
– Splenomegaly and low WBC in RA<br />
• Neurological<br />
– Entrapment neuropathy: CTS, ulnar nerve, tarsal<br />
tunnel syndrome<br />
– Mononeuritis multiplex (RA vasculitis)<br />
– Atlanto-axial subluxation with cord compression
Complications<br />
• Osteoporosis and fractures<br />
–RA<br />
– Immobility<br />
–Steroids<br />
• Amyloidosis<br />
– Rare<br />
– Longstanding disease<br />
– Proteinuria/decreased renal function
Special investigations
Laboratory diagnosis<br />
• <strong>Rheumatoid</strong> factor<br />
• Raised markers of inflammation (ESR/ CRP)<br />
• LFT abnormalities<br />
– Raised ALP<br />
– Raised proteins (polyclonal rise in globulins, often<br />
also low albumin)<br />
• FBC abnormalities:<br />
– Anaemia of chronic disease<br />
– Reactive thrombocytosis
<strong>Rheumatoid</strong> factor<br />
• Antibodies against human IgG Fc<br />
• 1-5% of normal people<br />
• Also in chronic infections<br />
and inflammation eg TB,<br />
endocarditis and liver<br />
cirrhosis
Radiological diagnosis<br />
• Periarticular soft tissue swelling<br />
• Periarticular osteopaenia<br />
• Joint space narrowing<br />
• Marginal joint erosions leading eventually to<br />
complete joint destruction<br />
• Subchondral cysts<br />
• Compressive changes due to collapse of<br />
osteoporotic subchondral bone eg protrusio<br />
acetabuli at hip
Serial X-rays of a knee in RA
Treatment
Multidisciplinary Care<br />
• Rheumatologist<br />
• Orthopaedic Surgeon<br />
• Physiotherapist<br />
• Occupational therapist<br />
• Orthotist<br />
• Psychologist<br />
• Community based support systems<br />
– <strong>Arthritis</strong> Foundation<br />
– Patient Partners<br />
– Support Groups
Medical Treatment<br />
• Greatest and irreversible joint damage<br />
occur early in disease<br />
•Thus: Treat early and aggressively<br />
• No single treatment regimen<br />
consistently halts disease progression
Medical Treatment<br />
Symptomatic:<br />
NSAID’s, paracetamol, opioids, low dose steroids,<br />
atypical analgesics<br />
Intra-articular steroids<br />
Disease modifiers: Slow acting and side effects!<br />
Methotrexate, Chloroquine, Sulphasalazine, D-<br />
penicillamine, gold salts, leflunomide, high<br />
doses steroids, immunosuppressants,<br />
biologicals (anti TNF alpha and IL-1 agents)
Surgical Treatment<br />
• Soft tissue:<br />
– Carpal tunnel release<br />
– Synovectomy<br />
– Tendon transfers<br />
• Joint replacement<br />
• Arthodesis<br />
• Excision arthroplasty eg radial head
Treatment<br />
• Rest vs exercise<br />
• Diet<br />
– Avoid obesity<br />
– “Anti-inflammatory diet”: vegetarian with<br />
omega 3 fatty acids (fatty fish/fish oils)<br />
– Essential fatty acids (evening primrose oil)<br />
– Anti-oxidants?