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

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Introduction

 Chronic inflammatory disease. 

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

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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

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Clinical Features

 Chronic, Symmetrical, small joint

polyarthritis. H/O Morningstiffness. Joint deformity. Subcutaneousnodule. Systemic symptoms.

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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}

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Investigation

Blood tests Normocytic normochromic anemia. Rasied ESR.

Serological test Rheumatoid factor. Anti CCP. Synovial fluid Analysis Raised WBC. Mucin test. Low sugar.

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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.

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Investigation

Radiological Juxta articular osteoporosis. Joint destruction. Deformity.

Ankylosis. CT Scan MRI

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Differential Diagnosis OfPolyarthritis

SLE. Psoriatic arthropathy.

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

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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.

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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.

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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.

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Role of Corticosteroids

.Indications

During acute & severe flare.

Prominent extra-articular features. Bridge therapy. Rheumatoid vasculitis. In elderly. Failure of DMARDs.

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Drug Treatment

NO DRUG HAS GREATERTOXICITY THAN RHEMATOIDARTHRITIS ITSELF 

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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.

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Surgery

.Articular disease

Synovectomy. Arthroplasty. Arthrodesis,

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Surgery

.Extra - Articular disease

Release of nerve entrapment.

Release of contractures. Correction of deformities. Tendon repair.

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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.

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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

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Ankle Joint

Synovectomy Arthrodesis Arthroplasty

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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.

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Major Joints

Arthrodesis

 Rarely indicated.

 For severe U/Ljoint involvement inyoung individual.

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Total Condylar

Major Joints

TKR

Cemented THR

Arthroplasty

 Surgical treatment ofchoiceTSR

Semiconstrained

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