? Clinical Features of RA
? Investigations
? Diagnosis
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? Indications for Surgery in Arthritis? Various procedures possible
? Rational choice in treatment
Clinical Features
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? Chronic multisystem disease of unknown cause.? persistent inflammatory synovitis
? Peripheral joints in a symmetric distribution
? synovial inflammation causes cartilage destruction and bone
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erosions and subsequent changes in joint integrityEffects of IL-6
? B cell maturation
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? Ig,? rheumatoid factor,
? hypergammaglobulemia
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? Hepatocyte stimulus
? acute phase proteins (high ESR)
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? decreased albumin synthesisCourse of RA
? Quite variable
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mild oligoarticular il ness
relentless progressive
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of brief duration withpolyarthritis with marked
minimal joint damagea
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functional impairment
Epidemiology
? RA occurs in 0.5-1.0% of the population
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? Women affected three times more often than men? Prevalence increases with age
? Onset most frequent in fourth and fifth decades.
Articular Manifestations
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? Typically a symmetric polyarthritis
? Peripheral joints with pain, tender ness, and swelling
? Morning stiffness is common
? PIP and MCP joints frequently involved
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? Joint deformities may develop after persistent inflammation.Systemic
? Fever
? Decreased appetite
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? Muscle wastingExtraarticular Manifestations
? Cutaneous-rheumatoid nodules, vasculitis
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? Pulmonary-nodules, interstitial disease.? Ocular-keratoconjunctivitis sicca, episcleritis, scleritis
? Hematologic-anemia, Felty's syndrome (splenomegaly and
neutropenia)
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? Cardiac-pericarditis, myocarditis
? Neurologic-myelopathies secondary to cervical spine disease,
entrapment, vasculitis
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EVALUATION? Hx and physical exam with careful examination of all joints.
? Rheumatoid factor (RF) is present in >66% of pts; its presence
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correlates with severe disease, nodules, extraarticular features.? Antibodies to cyclic citrullinated protein {anti-CCP) have similar
sensitivity but higher specificity than RF
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? may be most useful in early RA
? Presence most common in pts with aggressive disease with a tendency for
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developing bone erosions.Other laboratory data
? CBC, ESR.
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? Synovial fluid analysis-useful to rule out crystalline disease, infection.? Radiographs-juxta-articular osteopenia, joint space narrowing,
marginal erosions.
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? Chest x-ray should be obtained.2010 ACR/EULAR Classification Criteria for RA
? JOINT DISTRIBUTION (05)
? SEROLOGY (03)
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? SYMPTOM DURATION (01)? ACUTE PHASE REACTANTS (01)
> 6 ? Definitely RA
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JOINT DISTRIBUTION? 1 large joint 0
? 210 large joints 1
? 13 small joints (large joints not counted) 2
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? 410 small joints (large joints not counted). 3? >10 joints (at least one small joint) 5
SEROLOGY
? Negative RF AND negative ACPA 0
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? Low positive RF OR low positive ACPA 2? High positive RF OR high positive ACPA 3
SYMPTOM DURATION /ACUTE PHASE REACTANTS
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? < weeks - 0? > 6 weeks - 1
? Normal CRP AND normal ESR 0
? Abnormal CRP OR abnormal ESR 1
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SURGERY FOR RHEUMATOID ARTHRITISIndicated when the disease has progressed to such a stage
? Pain is unrelieved by medication
? Mechanically unstable joint
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? Arthroscopic synovectomy/ open synovectomy
? Proximal tibial osteotomy
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? Arthrodesis? Total joint arthroplasty
Goals
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? Relieve pain
? Prevent destruction of cartilage or tendon
? Improve function of joints by
? Increasing or decreasing motion
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a) Correcting deformityb) Increasing stability
c) Improving effective muscle forces
Functional Impairment
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Class I - Can carry out all usual activities without handicapClass II - Can perform normal activities despite the handicap of
discomfort or limited motion at one or more joints
Class II -Are limited to few of the duties of their usual occupation or
self-care
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Class IV -Are largely or completely incapacitated, are bedridden orconfined to a wheelchair, and are limited to little or no self-care.
SYNOVECTOMY- Rheumatoid Arthritis
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The procedure consists of? Removing the diseased synovium
? Decreasing the inflammatory mediators and protecting the cartilage.
Indicated in patients with
? minimal structural damage to the joint
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? Refractory to pharmacological agents.? Open synovectomy
? Arthroscopic synovectomy.
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Synovial vil i with nodular lymphocytosis , marked
increase in plasma cells with synovial cell
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hyperplasia and hypertrophy
Synovectomy
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? Removing the superficial layers of the synovium with a shaver? Down to a defining plane between the synovium and subsynovial
tissues.
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? Smooth shiny fibers of the capsule can be seenTOTAL JOINT ARTHROPLASTY
? Moderate to severe destruction of cartilage and subchondral bone
? Relieve pain and improve function in most joints
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Case 1
? 36 years old
? Seropositive Rheumatoid Arthritis
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? CRP 5? ESR 34 mm
? Unable to walk more than a dozen steps
? Severe restriction of movement
? Received DMARDS for 15 years
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What is the appropriate further
Management?
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a) Arthroscopic synovectomy
b) Tibio-femoral Fusion
c) Total knee replacement
d) Unicondylar knee replacement
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Bl TKR
Total Knee Replacement
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Complications may be more frequent in patients with rheumatoid
arthritis than in those with osteoarthrosis because of
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? Poor healing of tissue? Deep wound infections
? Severe flexion contracture
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? Severe joint laxity or osteopenia
? Involvement of multiple other joints limiting
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rehabilitation.Pre op radiographs
Post Op after knee replacement
Rheumatoid Arthritis Hip
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The following procedures have proved useful
? Synovectomy,
? Arthrodesis
? Total hip arthroplasty
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? Resection of the femoral head and neckSYNOVECTOMY
? Indicated early in the course of juvenile rheumatoid arthritis when
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joint destruction is minimal.? Temporary symptomatic relief and improved function can often be
achieved in careful y selected patients.
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RESECTION ARTHROPLASTY
? Severe rheumatoid arthritis of long duration and contractures of
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multiple joints are not candidates for hip arthroplasty.? Rare functional class IV patients -there is no hope for rehabilitation to
an ambulatory status.
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? When there is increasing pain and when deformities interfere with
perineal hygiene- Girdlestone resection or neck resection have been
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usefulCase 2
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? 42 years old? Rheumatoid arthritis for 20 years
? Increasing pain and stiffness right hip for 4 years
? Severe restriction of function and ADA affected
? Flexion deformity 20 degrees adduction deformity 20 degrees
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Radiographs
MCQ 2
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? Which of the following
radiological feature is not
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present?a) Shentons arch is broken
b) Reduced joint space
c) Protrusio acetabuli
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d) Medialization of headCemented
THR
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UPPER EXTREMITY
? Shoulder- Adduction and internal rotation deformity
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? Elbow - flexion deformity of the, limitation of pronation andsupination
? Flexion deformity of the wrist
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? Ulnar deviation of the hand, and flexion and ulnar deviation of thefingers
Treating the affected part with rest usually relieves pain
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Loss of function often follows.Total shoulder Arthroplasty
Elbow
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? Involved in 20% to 50% of patients with rheumatoid arthritis.? The function of the joint may deteriorate
? Compromising activities of daily living and independence.
Surgical procedures for rheumatoid arthritis
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elbow
? Synovectomy (most often combined with radial head excision)
? Total elbow arthroplasty.
? Often requires a release of the collateral ligaments and complete
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capsulotomy to optimize movement after surgery.
? Combined with a resection of proximal radial head to improve
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pronation and supination.Radiographic - Lateral view
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TERMC Q 1 What is the appropriate further
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Management?a) Arthroscopic synovectomy
b) Tibio-femoral Fusion
c) Total knee replacement
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d) Unicondylar knee replacementMCQ 2
? Which of the following
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radiological feature is not
present?
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a) Shenton's arch is brokenb) Reduced joint space
c) Protrusio acetabuli
d) Medialization of head
Conclusions
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? Rh Arth is a multisystem disease
? If not diagnosed early ? Significant damage to joints
? Classical presentation may/May not be present
? Each diagnostic test needs to be understood
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? Joint replacement ? End stage diseaseThank You