7285812 rheumatoid arthritis

8/8/2019 7285812 Rheumatoid Arthritis

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RRRHEUHEUHEUMMMAAATTTOIDOIDOID A

AARRRTHTHTHRRRITISITISITIS

Dr. Ashish Gohiya

M.S.(Orth.)Assistant ProfessorGandhi Medical College, Bhopal



Introduction

Chronic inflammatory disease.

Waxing & waning course. Proliferative changes in synovialmembrane, periarticular structure,Muscles & perineural sheaths. Joint destruction. Ankylosis / Deformity.



Introduction

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Pathology

Stage 1: Synovitis. Inflammatory cell deposition. Painful, swollen, tender joints.

Stage 2: Destruction.Chronic synovitisProteolytic enzymes pannus Synovial hyperplasia Stage 3: Deformity.Articular cartilage destructiionDeformityJoint destruction Tendon Rupture Capsular stretching



Clinical Features

Chronic, Symmetrical, small joint

polyarthritis. H/O Morningstiffness. Joint deformity. Subcutaneousnodule. 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 RFsRheumatological diseases RS,SS,SLE,SSc,MCTD,JCA.Infections TB,leprosy, syphilis, IE,Inf.hepatitis etc.Post vaccinationNeoplasms.Others Cirrhosis,DM etc.



Investigation

Radiological Juxta articular osteoporosis. Joint destruction. Deformity.

Ankylosis. CT Scan MRI



Differential Diagnosis OfPolyarthritis

SLE. Psoriatic arthropathy.

Ankylosing Arthropathy. Reiters disease. Polyarticular Gout. CPPD. Osteoarthritis. Sarcoidosis. Polymyalgia rheumatica.



Aim Of Treatment

A locally malignant disorder thatmetastasizes 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 damagestarts early.

Early institution of DMARDs reduces use ofNSAIDs & their toxicity. Combination preferred due to different site ofaction &less toxicity. Short term low dose corticosteroids (bridgetherapy) 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 GREATERTOXICITY THAN RHEMATOIDARTHRITIS ITSELF



Prior to Surgery

STOP:

Salycilates 2 Wk prior to surgery. NSAIDS 5 Days prior to surgery. If corticosteroids taken for more than 3Wks in previous 12months, it should begiven 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 HandDeformities can be due to

Tightness of intrinsic muscles.- Intrinsic

plus Adherence of lateral bands in fixed dorsalposition.- 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 metatarsocuneiformjoint & naviculocuneiform joint. Hind foot Heel valgus Loss of longitudinal arch



Ankle Joint

Synovectomy Arthrodesis Arthroplasty



Major Joints

Synovectomy

Range of motion preserved but notincreased. Useful in early stages of disease. Cartilage damage & FFD should be less. Minimum of 6 month of conservativetherapy being ineffective. In elbow radial head excision should becombined. In shoulder excision of bursa should becombined.



Major Joints

Arthrodesis

Rarely indicated.

For severe U/Ljoint involvement inyoung individual.



Total Condylar

Major Joints

TKR

Cemented THR

Arthroplasty

Surgical treatment ofchoiceTSR

Semiconstrained

7285812 rheumatoid arthritis

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