Rheumatoid Arthritis

Rheumatoid Arthritis
Dr. C. C. Visser
MBChB MMed (Med Phys)
Diploma in Orthopaedic Medicine
Member of the Society of Orthopaedic Medicine, UK

Arthritis
OA
Crystal
RA
SpA
CTD
Vasculitis
Primary: DIP
PIP,hip,knee
spine, 1 MTP
Secondary:
Gout
Pseudogout
AS
Psoriatic
Enteropathic
Reactive
SLE
PSS
PM/DM
MCTD
PAN,
Wegeners
Takayasu,
GCA etc
Cartilage
Cartilage
Synovium
Soft tissue
Bone
Synovium
Joints + C-spine
>> Systemic
Synovium
Entheses
Axial + peripheral
joints>> systemic
Synovium
Systemic >>
Synovium
Synovium
Systemic >>
Synovium
XR
Synovial fluid
XR
Urate level
RF
XR
XR
HLA B27
ANF
ENA
Organ Fx tests
ANCA
Histology
Imaging

Rheumatoid arthritis
• Most common form of inflammatory
arthritis
• Affects 1 % of all populations
• Females > males 3:1

Rheumatoid Arthritis
• Wide variation in
– age at onset
– degree of joint involvement
– severity of disease
• Difficult to predict early on who will
develop more severe disease

Effects of RA
• Systemic disease but joint involvement
dominates
• RA affects morbidity and mortality
• RA reduces life expectancy
– males by 7 year
– females by 3 years

Etiology
• Immune mediated chronic inflammation
• Trigger: Environmental
Antigen
Genetic (30%)
Self Antigen
T cell activation
Chronic Inflammation
Lymphoid cells infiltrate synovium
New blood vessels form in synovium
Synovial proliferation
Joint destruction

Mechanisms of joint damage
• Synovial mass stretches joint capsule and
ligaments: joint swelling, instability &
deformity
• Cytokine and proteolytic enzyme rich synovial
fluid destroys cartilage joint space
narrowing on X-rays
• Infiltration of cartilage and later bone by
invading synovium (pannus)
marginal erosions

Onset
• 60% insidious onset of pain, stiffness,
symmetrical swelling of joints especially
small joints
• 20% acute or subacute
• 10% vague aches and pains
• 5% systemic symptoms: fatigue,
malaise, weight loss, low fever, myalgia,
morning stiffness, depression

ACR Classification Criteria
(4/7)
• EMS > 1 hour
• > 3 joint arthritis
• Symmetrical arthritis
• Wrist, MCP, PIP arthritis
• Rheumatoid nodules
• Rheumatoid factor
• X-ray changes: periarticular
osteopaenia/marginal erosions

Articular involvement

Articular involvement
Any synovial joint can be involved
Also inflammation of synovium in bursae
and tendon sheaths
Can start asymmetrically with only few
joints affected

Articular involvement
• Spreads within months to years to other
joints in symmetrical distribution
• Joint involvement reaches a plateau
after first few years
• Number of joints affected in early
disease related to severity of disease

Hand
• MCP joints
– Synovitis
– Ulnar deviation
• PIP joints
– Synovitis
– Swan neck deformity
– Boutonniere deformity
• Z-deformity of thumb
• Tendons
– Flexor tenosynovitis
– Extensor tenosynovitis
• Poor grip: power and pinch

Wrist
• Synovitis
• Piano key sign (distal radio-ulnar joint)
• Subluxation
• Radial deviation
• Ankylosis
• Carpal tunnel syndrome

Elbow
• Synovitis
• Flexion contracture
• Decreased, painful pronation and
supination
• Olecranon bursitis
• RA nodules

Shoulder
• Subacromial bursitis
• Rotator cuff tendinitis
• Glenohumeral joint arthritis
• Acromio-clavicular arthritis

Foot
•MTP
– Synovitis
– Subluxation with hammer/claw toe and
metatarsalgia
– Bunions
– Bunionettes
– Toe deviation/overriding
• Collapse of medial arch of foot

Ankle/Hindfoot
• Ankle
– Synovitis
– Retrocalcaneal bursitis
• Tenosynovitis/rupture
– Peroneal tendons
– Tibialis posterior
• Subtalar arthritis
– Reduced and painful movement
– Hindfoot valgus

Knee
• Synovitis
• Effusions
• Baker’s cyst +/- rupture
• Instability/ deformity eg valgus deformity
• Flexion contracture

Hip
• Arthritis (usually late)
– Pain especially on weight bearing
– Reduced movement
• Trochanteric bursitis

Cervical spine
• Involved in 70% patients with longstanding
RA
• Occipital pain made worse by movement
• Subluxation of C1-2 with compression of
spinal cord during neck flexion
– Significant if >10 mm instability on flexion
– Usually slowly developing myelopathy
• Subaxial subluxation

Serial cervical X-rays in a RA patient

Other joints
• TMJ: reduced mouth opening
• Sternoclavicular
• Crico-arytenoid
• Ossicles of ears

Non-articular manifestations

Non-articular manifestations
• Generalized lymphadenopathy
• Nodules
– 30% patients
– external over areas of pressure
– internally eg lung, heart, gallbladder
– central necrosis with pallisade of
fibroblasts

Non-articular manifestations
• Lungs
– Pleurisy
– Pleural effusions (NB exudate!)
– RA nodules single/multiple (Caplan
syndrome if huge nodules in coal miners)
– Lung fibrosis

Non-articular manifestations
• Heart
– pericarditis, usually asymptomatic, but can
lead to friction rubs / effusions / tamponade
– RA nodules: conduction defects

Non-articular manifestations
• Bone
– Generalized osteoporosis
•Muscle
– Muscle atrophy
– Rarely myositis

Non-articular manifestations
• Skin
– Palmar erythaema
– Digital gangrene (small arteries)
– Nail fold infarcts (small arteries)
– Skin ulcers (medium arteries)
– Purpuric papules (venules)
– Palpable purpura (leukocytoclastic
vasculitis)

Non-articular manifestations
• Eyes
– Secondary Sjögren syndrome
– Episcleritis
– Scleritis
– Scleromalacia perforans

Complications

Complications
• Infections
– More susceptible to any infection (RA,
steroids, MTX)
– ESPECIALLY susceptible to joint
infections
– Always suspect septic arthritis if sudden
increase in symptoms in one joint

Complications
• Felty syndrome
– Splenomegaly and low WBC in RA
• Neurological
– Entrapment neuropathy: CTS, ulnar nerve, tarsal
tunnel syndrome
– Mononeuritis multiplex (RA vasculitis)
– Atlanto-axial subluxation with cord compression

Complications
• Osteoporosis and fractures
–RA
– Immobility
–Steroids
• Amyloidosis
– Rare
– Longstanding disease
– Proteinuria/decreased renal function

Special investigations

Laboratory diagnosis
• Rheumatoid factor
• Raised markers of inflammation (ESR/ CRP)
• LFT abnormalities
– Raised ALP
– Raised proteins (polyclonal rise in globulins, often
also low albumin)
• FBC abnormalities:
– Anaemia of chronic disease
– Reactive thrombocytosis

Rheumatoid factor
• Antibodies against human IgG Fc
• 1-5% of normal people
• Also in chronic infections
and inflammation eg TB,
endocarditis and liver
cirrhosis

Radiological diagnosis
• Periarticular soft tissue swelling
• Periarticular osteopaenia
• Joint space narrowing
• Marginal joint erosions leading eventually to
complete joint destruction
• Subchondral cysts
• Compressive changes due to collapse of
osteoporotic subchondral bone eg protrusio
acetabuli at hip

Serial X-rays of a knee in RA

Treatment

Multidisciplinary Care
• Rheumatologist
• Orthopaedic Surgeon
• Physiotherapist
• Occupational therapist
• Orthotist
• Psychologist
• Community based support systems
– Arthritis Foundation
– Patient Partners
– Support Groups

Medical Treatment
• Greatest and irreversible joint damage
occur early in disease
•Thus: Treat early and aggressively
• No single treatment regimen
consistently halts disease progression

Medical Treatment
Symptomatic:
NSAID’s, paracetamol, opioids, low dose steroids,
atypical analgesics
Intra-articular steroids
Disease modifiers: Slow acting and side effects!
Methotrexate, Chloroquine, Sulphasalazine, D-
penicillamine, gold salts, leflunomide, high
doses steroids, immunosuppressants,
biologicals (anti TNF alpha and IL-1 agents)

Surgical Treatment
• Soft tissue:
– Carpal tunnel release
– Synovectomy
– Tendon transfers
• Joint replacement
• Arthodesis
• Excision arthroplasty eg radial head

Treatment
• Rest vs exercise
• Diet
– Avoid obesity
– “Anti-inflammatory diet”: vegetarian with
omega 3 fatty acids (fatty fish/fish oils)
– Essential fatty acids (evening primrose oil)
– Anti-oxidants?