Download MBBS Orthopaedics PPT 9 Inflammatory Arthritis Lecture Notes

Inflammatory Arthritis-

Rheumatoid Arthritis

--- Content provided by FirstRanker.com ---

Leaning Objective

? Clinical Features of RA
? Investigations
? Diagnosis

--- Content provided by FirstRanker.com ---

? Indications for Surgery in Arthritis
? Various procedures possible
? Rational choice in treatment
Clinical Features

--- Content provided by FirstRanker.com ---

? Chronic multisystem disease of unknown cause.
? persistent inflammatory synovitis
? Peripheral joints in a symmetric distribution
? synovial inflammation causes cartilage destruction and bone

--- Content provided by FirstRanker.com ---

erosions and subsequent changes in joint integrity
Effects of IL-6

? B cell maturation

--- Content provided by FirstRanker.com ---

? Ig,

? rheumatoid factor,

? hypergammaglobulemia

--- Content provided by FirstRanker.com ---

? Hepatocyte stimulus

? acute phase proteins (high ESR)

--- Content provided by FirstRanker.com ---

? decreased albumin synthesis

Course of RA

? Quite variable

--- Content provided by FirstRanker.com ---

mild oligoarticular il ness

relentless progressive

--- Content provided by FirstRanker.com ---

of brief duration with

polyarthritis with marked

minimal joint damagea

--- Content provided by FirstRanker.com ---

functional impairment
Epidemiology

? RA occurs in 0.5-1.0% of the population

--- Content provided by FirstRanker.com ---

? Women affected three times more often than men
? Prevalence increases with age
? Onset most frequent in fourth and fifth decades.

Articular Manifestations

--- Content provided by FirstRanker.com ---

? Typically a symmetric polyarthritis
? Peripheral joints with pain, tender ness, and swelling
? Morning stiffness is common
? PIP and MCP joints frequently involved

--- Content provided by FirstRanker.com ---

? Joint deformities may develop after persistent inflammation.
Systemic

? Fever
? Decreased appetite

--- Content provided by FirstRanker.com ---

? Muscle wasting

Extraarticular Manifestations

? Cutaneous-rheumatoid nodules, vasculitis

--- Content provided by FirstRanker.com ---

? Pulmonary-nodules, interstitial disease.
? Ocular-keratoconjunctivitis sicca, episcleritis, scleritis
? Hematologic-anemia, Felty's syndrome (splenomegaly and

neutropenia)

--- Content provided by FirstRanker.com ---

? Cardiac-pericarditis, myocarditis
? Neurologic-myelopathies secondary to cervical spine disease,

entrapment, vasculitis

--- Content provided by FirstRanker.com ---

EVALUATION

? Hx and physical exam with careful examination of all joints.
? Rheumatoid factor (RF) is present in >66% of pts; its presence

--- Content provided by FirstRanker.com ---

correlates with severe disease, nodules, extraarticular features.

? Antibodies to cyclic citrullinated protein {anti-CCP) have similar

sensitivity but higher specificity than RF

--- Content provided by FirstRanker.com ---

? may be most useful in early RA

? Presence most common in pts with aggressive disease with a tendency for

--- Content provided by FirstRanker.com ---

developing bone erosions.

Other laboratory data

? CBC, ESR.

--- Content provided by FirstRanker.com ---

? Synovial fluid analysis-useful to rule out crystalline disease, infection.
? Radiographs-juxta-articular osteopenia, joint space narrowing,

marginal erosions.

--- Content provided by FirstRanker.com ---

? Chest x-ray should be obtained.
2010 ACR/EULAR Classification Criteria for RA

? JOINT DISTRIBUTION (05)
? SEROLOGY (03)

--- Content provided by FirstRanker.com ---

? SYMPTOM DURATION (01)
? ACUTE PHASE REACTANTS (01)

> 6 ? Definitely RA

--- Content provided by FirstRanker.com ---

JOINT DISTRIBUTION

? 1 large joint 0
? 210 large joints 1
? 13 small joints (large joints not counted) 2

--- Content provided by FirstRanker.com ---

? 410 small joints (large joints not counted). 3
? >10 joints (at least one small joint) 5
SEROLOGY

? Negative RF AND negative ACPA 0

--- Content provided by FirstRanker.com ---

? Low positive RF OR low positive ACPA 2
? High positive RF OR high positive ACPA 3

SYMPTOM DURATION /ACUTE PHASE REACTANTS

--- Content provided by FirstRanker.com ---

? < weeks - 0
? > 6 weeks - 1

? Normal CRP AND normal ESR 0
? Abnormal CRP OR abnormal ESR 1

--- Content provided by FirstRanker.com ---

SURGERY FOR RHEUMATOID ARTHRITIS

Indicated when the disease has progressed to such a stage
? Pain is unrelieved by medication
? Mechanically unstable joint

--- Content provided by FirstRanker.com ---

? Arthroscopic synovectomy/ open synovectomy

? Proximal tibial osteotomy

--- Content provided by FirstRanker.com ---

? Arthrodesis

? Total joint arthroplasty

Goals

--- Content provided by FirstRanker.com ---

? Relieve pain
? Prevent destruction of cartilage or tendon
? Improve function of joints by
? Increasing or decreasing motion

--- Content provided by FirstRanker.com ---

a) Correcting deformity
b) Increasing stability
c) Improving effective muscle forces
Functional Impairment

--- Content provided by FirstRanker.com ---

Class I - Can carry out all usual activities without handicap
Class 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

--- Content provided by FirstRanker.com ---

Class IV -Are largely or completely incapacitated, are bedridden or
confined to a wheelchair, and are limited to little or no self-care.

SYNOVECTOMY- Rheumatoid Arthritis

--- Content provided by FirstRanker.com ---

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

--- Content provided by FirstRanker.com ---

? Refractory to pharmacological agents.

? Open synovectomy

? Arthroscopic synovectomy.

--- Content provided by FirstRanker.com ---

Synovial vil i with nodular lymphocytosis , marked

increase in plasma cells with synovial cell

--- Content provided by FirstRanker.com ---

hyperplasia and hypertrophy

Synovectomy

--- Content provided by FirstRanker.com ---

? Removing the superficial layers of the synovium with a shaver
? Down to a defining plane between the synovium and subsynovial

tissues.

--- Content provided by FirstRanker.com ---

? Smooth shiny fibers of the capsule can be seen
TOTAL JOINT ARTHROPLASTY

? Moderate to severe destruction of cartilage and subchondral bone
? Relieve pain and improve function in most joints

--- Content provided by FirstRanker.com ---

Case 1

? 36 years old
? Seropositive Rheumatoid Arthritis

--- Content provided by FirstRanker.com ---

? CRP 5
? ESR 34 mm
? Unable to walk more than a dozen steps
? Severe restriction of movement
? Received DMARDS for 15 years

--- Content provided by FirstRanker.com ---

What is the appropriate further

Management?

--- Content provided by FirstRanker.com ---

a) Arthroscopic synovectomy
b) Tibio-femoral Fusion
c) Total knee replacement
d) Unicondylar knee replacement

--- Content provided by FirstRanker.com ---

Bl TKR

Total Knee Replacement

--- Content provided by FirstRanker.com ---

Complications may be more frequent in patients with rheumatoid

arthritis than in those with osteoarthrosis because of

--- Content provided by FirstRanker.com ---

? Poor healing of tissue

? Deep wound infections

? Severe flexion contracture

--- Content provided by FirstRanker.com ---

? Severe joint laxity or osteopenia

? Involvement of multiple other joints limiting

--- Content provided by FirstRanker.com ---

rehabilitation.
Pre op radiographs
Post Op after knee replacement

Rheumatoid Arthritis Hip

--- Content provided by FirstRanker.com ---

The following procedures have proved useful
? Synovectomy,
? Arthrodesis
? Total hip arthroplasty

--- Content provided by FirstRanker.com ---

? Resection of the femoral head and neck
SYNOVECTOMY

? Indicated early in the course of juvenile rheumatoid arthritis when

--- Content provided by FirstRanker.com ---

joint destruction is minimal.

? Temporary symptomatic relief and improved function can often be

achieved in careful y selected patients.

--- Content provided by FirstRanker.com ---

RESECTION ARTHROPLASTY

? Severe rheumatoid arthritis of long duration and contractures of

--- Content provided by FirstRanker.com ---

multiple joints are not candidates for hip arthroplasty.

? Rare functional class IV patients -there is no hope for rehabilitation to

an ambulatory status.

--- Content provided by FirstRanker.com ---

? When there is increasing pain and when deformities interfere with

perineal hygiene- Girdlestone resection or neck resection have been

--- Content provided by FirstRanker.com ---

useful


Case 2

--- Content provided by FirstRanker.com ---

? 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

--- Content provided by FirstRanker.com ---

Radiographs


MCQ 2

--- Content provided by FirstRanker.com ---

? Which of the following

radiological feature is not

--- Content provided by FirstRanker.com ---

present?

a) Shentons arch is broken
b) Reduced joint space
c) Protrusio acetabuli

--- Content provided by FirstRanker.com ---

d) Medialization of head

Cemented

THR

--- Content provided by FirstRanker.com ---

UPPER EXTREMITY

? Shoulder- Adduction and internal rotation deformity

--- Content provided by FirstRanker.com ---

? Elbow - flexion deformity of the, limitation of pronation and

supination

? Flexion deformity of the wrist

--- Content provided by FirstRanker.com ---

? Ulnar deviation of the hand, and flexion and ulnar deviation of the

fingers

Treating the affected part with rest usually relieves pain

--- Content provided by FirstRanker.com ---

Loss of function often follows.

Total shoulder Arthroplasty
Elbow

--- Content provided by FirstRanker.com ---

? 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

--- Content provided by FirstRanker.com ---

elbow
? Synovectomy (most often combined with radial head excision)
? Total elbow arthroplasty.
? Often requires a release of the collateral ligaments and complete

--- Content provided by FirstRanker.com ---

capsulotomy to optimize movement after surgery.

? Combined with a resection of proximal radial head to improve

--- Content provided by FirstRanker.com ---

pronation and supination.


Radiographic - Lateral view

--- Content provided by FirstRanker.com ---

TER


MC Q 1 What is the appropriate further

--- Content provided by FirstRanker.com ---

Management?

a) Arthroscopic synovectomy
b) Tibio-femoral Fusion
c) Total knee replacement

--- Content provided by FirstRanker.com ---

d) Unicondylar knee replacement

MCQ 2

? Which of the following

--- Content provided by FirstRanker.com ---

radiological feature is not

present?

--- Content provided by FirstRanker.com ---

a) Shenton's arch is broken
b) Reduced joint space
c) Protrusio acetabuli
d) Medialization of head
Conclusions

--- Content provided by FirstRanker.com ---

? 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

--- Content provided by FirstRanker.com ---

? Joint replacement ? End stage disease

Thank You