Rheumatoid arthritis (RA) is a systemic autoimmune disease of unknown cause characterized by an inflammatory synovitis that is destructive to articular cartilage.
The incidence of Rheumatoid arthritis increases with advancing age, with peak onset during the fourth and fifth decades. The female-to-male ratio is 2.5:1. Female hormones appear to influence the development of Rheumatoid arthritis RA because there is a decreased incidence with the use of oral contraceptives, an increased risk in nulliparous women, remission of symptoms during pregnancy, and increased onset of the disease around the time of menopause. Arthralgia is a term used for pain in a joint, without any associated signs of inflammation.
CLASSIFICATION OF ARTHRITIS
(i) monoarthritis and (ii) polyarthritis
⇛Types of arthritis
Monoarthritis →Pyogenic arthritis →Tubercular arthritis→Haemophilic arthritis →Secondary osteoarthritis →Gout – sometimes
Polyarthritis →Rheumatoid arthritis→Rheumatic fever→Juvenile chronic Polyarthritis→Primary osteoarthritis →Seronegative spondarthritis .Read more Click on Topic➨
Aetiology: The exact aetiology is not known Following factors have been thought to play a role in causation of the disease:
American Rheumatism Association 1987 Revised Criteria for the Diagnosis of Rheumatoid Arthritis
Morning stiffness of at least 1 hour* Arthritis in at least three joint areas† with swelling or fluid* Arthritis of hand joints (at least one wrist, MCP, or PIP joint swollen)* Symmetric joint swelling and involvement* Subcutaneous nodules Radiographic changes typical of rheumatoid arthritis Positive rheumatoid factor *Specified criteria that must be present for at least 6 weeks. † Right or left proximal interphalangeal (PIP), metacarpophalangeal (MCP), wrist, elbow, knee, ankle, and metatarsophalangeal (MTP) joints.❋Swelling of three or more specified joint❋ Rheumatoid factor positive X-ray changes – erosion or unequivocal periarticular osteopenia If four or more of these are present, it is rheumatoid arthritis
⏩ A genetic predisposition is strongly suspected because of certain histocompatibility markers associated with it (HLA-drw4/HLA-DR1).Agents such as mycoplasma, clostridium and some viruses (EB virus) have been implicated in its aetiology.It is now believed that rheumatoid arthritis results from exposure of a genetically predisposed individual to some infectious agent. This leads to autoimmunity and formation of immune complexes with IgM antibodies in the serum.
These immune complexes are deposited in the synovial membrane and initiate a self perpetuating chronic granulomatous inflammation of the synovial membrane.
Rheumatoid arthritis Pathology: Initially the synovium becomes oedematous, filled with fibrin exudates and cellular infiltrates.→synovial fluid ↑→Inflammation persists→ synovium gets hypertrophied → surrounds the periphery of the articular cartilage to form a pannus. → articular cartilage loses its smooth shiny appearance.→pannus extends over the cartilage→ periphery and burrows into the subchondral bone
With further progress of the disease ➨ the cartilage becomes worn off ➨ the bone surfaces become raw ↓
The joints gets distorted, at first because of severe muscle spasm associated with pain, however later due to fibrosis of the capsule and other soft tissue structures.
→→ Pathology Read more Click on link➨➪➪➪➪ Pathology of Rheumatoid arthritis
Stages of rheumatoid arthritis: rheumatoid arthritis can be divided into three stages:
1. Potentially reversible soft tissue proliferation:
↠limited to the synovium ↠synovial hypertrophy and effusion↠Non destructive changes can be seen on X-rays.
2. Controllable but irreversible soft tissue destruction and early cartilage erosions:
↠X-rays shows joint space reduction ↠outline of the articular surface is maintained
3. Irreversible soft tissue and bony changes:
↠pannus ultimately destroys the articular cartilage erodes the subchondral bone.↠The joint becomes ankylosed usually in a deformed position (fibrous ankylosis). ↠It may be subluxated or dislocated
Associated changes: In rheumatoid arthritis some cases evidence of diffuse vasculitis. The most serious lesions occur in the arterial tree, which may be mild non-necrotising arteritis, or severe and fulminant arteritis akin to polyarteritis nodosa. The latter is fatal.
Clinical features: age of 20 to 50 years it occurs . The female-to-male ratio is 2.5:1
a) An acute. symmetrical polyarthritis: stiffness and pain in multiple joints , Morning stiffness of at least 1 hour, mark the beginning of the disease and articular inflammation
The joints affected most commonly are the metacarpo-phalangeal joints particularly that of the index finger Other joints forte commonly are as given in
common -MP Joints of hand -PIP of finger -Wrists,knee,elbow,ankle
Less common -Hip Joint -Temporo-mandibular joint
Uncommon -Atlanto-axial joint -Facet joint of cervical spine
b) Others: onset may be with fever especially in children. Sometimes, visceral manifestations of the disease such as pneumonitis, rheumatoid nodules etc. may antedate the joint complaints
On examination, one finds swollen boggy joints as a result of intra-articular effusion, synovial hypertrophy and oedema of the periarticular structures. The joints may be deformed Joints of the hand show typical deformities. There may be severe muscle spasm. Range of motion of the joints may be limited. In later stages, the joints may be subluxated or dislocated. There may be fever, rash and signs suggestive of systemic vasculitis. The rash in rheumatoid arthritis is typically non pruritic and maculo-papular on the face, trunk and extremities.
Extra-articular manifestations of rheumatoid arthritis: Although, rheumatoid arthritis is primarily a chronic polyarthritis, extra-articular manifestations are very common, and sometimes gover the prognosis of a case.
Extra-articular manifestations of Rheumatoid arthritis
Vasculitis • Digital arteritis • Raynaud’s phenomenon • Fever, skin lesions, chronic leg ulcers • Peripheral neuritis (mononeuritis multiplex) • Necrotising arteritis involving coronary mesenteric or renal vessels
Rheumatoid • Commonest site – olecranon nodules
• Other sites – dorsal surface of forearm, tendon achilles
Serositis • Lung and pleura – pleurisy, parenchymatous nodules, Caplan’s syndrome Honeycomb lung • Heart – cardiomyopathy, pericarditis • Eye-iridocyclitis • Nervous system – peripheral neuritis, carpal tunnel syndrome
Others • Anaemia Felty’s syndrome • Sjogren’s syndrome • Amyloidosis
Investigations: Following investigations are useful:1) Radiological examination:X-rays of the affected joints and X-rays of both hands ➨Reduced joint space
➨Erosion of articular margins
➨ Subchondral cysts➨Juxta-articular rarefaction
➨ Soft tissue shadow at the level of the joint because of joint effusion or synovial hypertrophy ➨Deformities of the hand and fingers2) Blood• LATEX FIXATION TEST• ROSE-WAALER TEST• Synovial fluid examination• Synovial biopsy
Read more Click on link➨Investigations➽DIFFERENTIAL DIAGNOSIS
Rheumatoid arthritis must be differentiated from the following diseases:a) Systemic lupus erythematosus (SLE)b)Osteoarthritisc) Psoriatic arthropathyRead more Click on link➨DIFFERENTIAL DIAGNOSIS
TREATMENT Principles of treatment
Aims of RHEUMATOID ARTHRITIS treatment are—-a) Induction of remission and its maintenance ⬇ activity is brought under control by drugs.
b) Preservation of joint functions and prevention of deformities during the activity of the disease and thereafter, by physiotherapy and splinting
c) Repair Damage joint which already exists, if it will relieve pain or facilitate functions. It sometimes requires surgical intervention eg, synovectomy.
Medical treatment of RHEUMATOID ARTHRITIS : anti-rheumatic drugs.
These consist of:
(i) non-steroidal anti-inflammatory drugs (NSAIDs):(ii) disease modifying anti-rheumatic drugs (DMARDs)
(iii) steroids. For details please refer to a Medicine textbook.
Orthopaedic treatment in rheumatoid arthritis: aims at prevention of deformity,
preservation of joint functions and rehabilitation.
It falls essentially into non-operative and operative methods of treatment,
NON-OPERATIVE METHODS: These consist of the following:
• Physiotherapy.➧➧ This consists of:
(i)During the acute phase splintage of the joints in proper position
(ii) heat therapy – hot water fomentation and wax bath for symptomatic relief
(iii) joint mobilisation exercises to maintain joint functions
iv) muscle building exercises to gain strength.
➤Occupational therapy: Role of occupational therapy is to help the patient cope with his occupational requirements in the most comfortable way, by modifying them.
➤Rehabilitation: Role of rehabilitation is to improve the functions of the patient with the help of devices like braces, walking aids etc.
OPERATIVE METHODS: Surgical treatment of rheumatoid arthritis can be divided into:(i) preventive surgery
(ii) palliative surgery
(iii) reconstructive surgery
(iv) salvage surgery.
➤ Preventive surgery: This is done to prevent damage to the joint and nearby tendons by the inflamed, hypertrophied synovium. It include of synovectomy of the MP and wrist, knee joints
➤Palliative surgery: This is done in situations where general condition of the patient does not permit corrective surgery, but some relief can be provided by limited surgical procedures such as bone block operation, tendon lengthening etc.
➤Reconstructive surgery: This has revolutionised the rehabilitation of patients with deformed and painful joints. It includes tendon transfers, interposition arthroplasties and total joint replacement. With improvement in surgical techniques and better design of artificial joints, it is now possible to replace practically any joint of the body. The joints where total replacement is most popular are the hip, knee and metacarpophalangeal joint.
Plan of treatment: Management depends upon the stage of the disease, as discussed below:
1. Potentially reversible soft tissue proliferation, where drug therapy constitutes the mainstay of treatment
2. Controllable but irreversible soft tissue destruction and early cartilage erosion, where combination of drug therapy and orthopaedic treatment is required.
3. Later and Advance stage of joint destruction with dislocation or subluxation, where primarily surgical treatment is necessary. Drugs alone are of no use at this stage.
Plan of treatment in these three stages is as given
Staged therapy in rheumatoid arthritis
Stages Medical Surgical Physiotherapy
Stage 1 DMARDS Synovectomy Joint mobilisation NSAID.”
Stage II ⤏ NSAIDs ⤏ Soft tissue repair ⤏ Splints DMARDS Arthroplasty
Stage II NSAIDS Arthroplasty ⤏ Splints and walking aids (jointreplacement) Arthrodesis
Prognosis: Following factors decide the outcome of a patient diagnosed to have rheumatoid arthritis
➼Natural history of the disease➼Sex and age at onset➼ Type of onset➼Anaemia➼ ESR and C-reactive protein➼ Rheumatoid factor➼Radiological erosions➼Histopathological changes
Read more Click on link➨Prognosis