Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Orthopaedics PPT 9 Inflammatory Arthritis Lecture Notes
Inflammatory Arthritis-
Rheumatoid Arthritis
Leaning Objective
? Clinical Features of RA
? Investigations
? Diagnosis
? Indications for Surgery in Arthritis
? Various procedures possible
? Rational choice in treatment
Clinical Features
? Chronic multisystem disease of unknown cause.
? persistent inflammatory synovitis
? Peripheral joints in a symmetric distribution
? synovial inflammation causes cartilage destruction and bone
erosions and subsequent changes in joint integrity
Effects of IL-6
? B cell maturation
? Ig,
? rheumatoid factor,
? hypergammaglobulemia
? Hepatocyte stimulus
? acute phase proteins (high ESR)
? decreased albumin synthesis
Course of RA
? Quite variable
mild oligoarticular il ness
relentless progressive
of brief duration with
polyarthritis with marked
minimal joint damagea
functional impairment
Epidemiology
? RA occurs in 0.5-1.0% of the population
? Women affected three times more often than men
? Prevalence increases with age
? Onset most frequent in fourth and fifth decades.
Articular Manifestations
? Typically a symmetric polyarthritis
? Peripheral joints with pain, tender ness, and swelling
? Morning stiffness is common
? PIP and MCP joints frequently involved
? Joint deformities may develop after persistent inflammation.
Systemic
? Fever
? Decreased appetite
? Muscle wasting
Extraarticular Manifestations
? Cutaneous-rheumatoid nodules, vasculitis
? Pulmonary-nodules, interstitial disease.
? Ocular-keratoconjunctivitis sicca, episcleritis, scleritis
? Hematologic-anemia, Felty's syndrome (splenomegaly and
neutropenia)
? Cardiac-pericarditis, myocarditis
? Neurologic-myelopathies secondary to cervical spine disease,
entrapment, vasculitis
EVALUATION
? Hx and physical exam with careful examination of all joints.
? Rheumatoid factor (RF) is present in >66% of pts; its presence
correlates with severe disease, nodules, extraarticular features.
? Antibodies to cyclic citrullinated protein {anti-CCP) have similar
sensitivity but higher specificity than RF
? may be most useful in early RA
? Presence most common in pts with aggressive disease with a tendency for
developing bone erosions.
Other laboratory data
? CBC, ESR.
? Synovial fluid analysis-useful to rule out crystalline disease, infection.
? Radiographs-juxta-articular osteopenia, joint space narrowing,
marginal erosions.
? Chest x-ray should be obtained.
2010 ACR/EULAR Classification Criteria for RA
? JOINT DISTRIBUTION (05)
? SEROLOGY (03)
? SYMPTOM DURATION (01)
? ACUTE PHASE REACTANTS (01)
> 6 ? Definitely RA
JOINT DISTRIBUTION
? 1 large joint 0
? 210 large joints 1
? 13 small joints (large joints not counted) 2
? 410 small joints (large joints not counted). 3
? >10 joints (at least one small joint) 5
SEROLOGY
? Negative RF AND negative ACPA 0
? Low positive RF OR low positive ACPA 2
? High positive RF OR high positive ACPA 3
SYMPTOM DURATION /ACUTE PHASE REACTANTS
? < weeks - 0
? > 6 weeks - 1
? Normal CRP AND normal ESR 0
? Abnormal CRP OR abnormal ESR 1
SURGERY FOR RHEUMATOID ARTHRITIS
Indicated when the disease has progressed to such a stage
? Pain is unrelieved by medication
? Mechanically unstable joint
? Arthroscopic synovectomy/ open synovectomy
? Proximal tibial osteotomy
? Arthrodesis
? Total joint arthroplasty
Goals
? Relieve pain
? Prevent destruction of cartilage or tendon
? Improve function of joints by
? Increasing or decreasing motion
a) Correcting deformity
b) Increasing stability
c) Improving effective muscle forces
Functional Impairment
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
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
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
? Refractory to pharmacological agents.
? Open synovectomy
? Arthroscopic synovectomy.
Synovial vil i with nodular lymphocytosis , marked
increase in plasma cells with synovial cell
hyperplasia and hypertrophy
Synovectomy
? Removing the superficial layers of the synovium with a shaver
? Down to a defining plane between the synovium and subsynovial
tissues.
? 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
Case 1
? 36 years old
? Seropositive Rheumatoid Arthritis
? CRP 5
? ESR 34 mm
? Unable to walk more than a dozen steps
? Severe restriction of movement
? Received DMARDS for 15 years
What is the appropriate further
Management?
a) Arthroscopic synovectomy
b) Tibio-femoral Fusion
c) Total knee replacement
d) Unicondylar knee replacement
Bl TKR
Total Knee Replacement
Complications may be more frequent in patients with rheumatoid
arthritis than in those with osteoarthrosis because of
? Poor healing of tissue
? Deep wound infections
? Severe flexion contracture
? Severe joint laxity or osteopenia
? Involvement of multiple other joints limiting
rehabilitation.
Pre op radiographs
Post Op after knee replacement
Rheumatoid Arthritis Hip
The following procedures have proved useful
? Synovectomy,
? Arthrodesis
? Total hip arthroplasty
? Resection of the femoral head and neck
SYNOVECTOMY
? Indicated early in the course of juvenile rheumatoid arthritis when
joint destruction is minimal.
? Temporary symptomatic relief and improved function can often be
achieved in careful y selected patients.
RESECTION ARTHROPLASTY
? Severe rheumatoid arthritis of long duration and contractures of
multiple joints are not candidates for hip arthroplasty.
? Rare functional class IV patients -there is no hope for rehabilitation to
an ambulatory status.
? When there is increasing pain and when deformities interfere with
perineal hygiene- Girdlestone resection or neck resection have been
useful
Case 2
? 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
Radiographs
MCQ 2
? Which of the following
radiological feature is not
present?
a) Shentons arch is broken
b) Reduced joint space
c) Protrusio acetabuli
d) Medialization of head
Cemented
THR
UPPER EXTREMITY
? Shoulder- Adduction and internal rotation deformity
? Elbow - flexion deformity of the, limitation of pronation and
supination
? Flexion deformity of the wrist
? Ulnar deviation of the hand, and flexion and ulnar deviation of the
fingers
Treating the affected part with rest usually relieves pain
Loss of function often follows.
Total shoulder Arthroplasty
Elbow
? 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
elbow
? Synovectomy (most often combined with radial head excision)
? Total elbow arthroplasty.
? Often requires a release of the collateral ligaments and complete
capsulotomy to optimize movement after surgery.
? Combined with a resection of proximal radial head to improve
pronation and supination.
Radiographic - Lateral view
TER
MC Q 1 What is the appropriate further
Management?
a) Arthroscopic synovectomy
b) Tibio-femoral Fusion
c) Total knee replacement
d) Unicondylar knee replacement
MCQ 2
? Which of the following
radiological feature is not
present?
a) Shenton's arch is broken
b) Reduced joint space
c) Protrusio acetabuli
d) Medialization of head
Conclusions
? 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
? Joint replacement ? End stage disease
Thank You
This post was last modified on 07 April 2022