RHEUMATOID

ARTHRITIS

Dr Dhananjaya Sabat MS DNB MNAMS

Assistant Professor Orthopedics
Maulana Azad Medical College, New
Delhi
 Rheumatoid arthritis (RA) is an
autoimmune disease that results in a
chronic, systemic inflammatory
disorder that may affect many
tissues and organs, but principally
attacks synovial joints.
Affects 1-3% of adult population
F>M: 3 to 1
Peak age of onset -35 and 45
 Diagnostic criteria
ACR criteria (1987); 4 of the following
Morning stiffness > 1hr around joints > 6weeks
Arthritis (pain + effusion) > 3 joints of the 7 joint
groups (PIP, MCP, wrist, elbow, knee, ankle, MTP)
> 6weeks
Arthritis of hand joints; PIP, MCP, wrist > 6 weeks
Symmetric arthritis at least 1 area > 6 weeks
Rheumatoid nodule
+ve Rheumatoid factor
Positive radiological changes (symmetric joint
destruction, erosions, periarticular osteopenia)
 2010 ACR-EULAR classification criteria for rheumatoid arthritis

Target population Patients who have at least 1 joint with definite clinical synovitis (swelling) with the synovitis not
better explained by another disease
Classification criteria for RA (score-based algorithm: add score of categories A - D;
a score of 6/10 is needed for classification of a patient as having definite RA).
The metacarpophalangeal joints, proximal interphalangeal joints, the interphalangeal joint of the thumb, second
through fifth metatarsophalangeal joint and wrist as small joints, and shoulders, elbows, hip joints, knees, and
ankles as large joints
A. Joint involvement
1 large joint 0
2-10 large joints 1
1-3 small joints (with or without involvement of large joints) 2
4-10 small joints (with or without involvement of large joints) 3
>10 joints (at least 1 small joint) 5
B. Serology (at least 1 test result is needed for classification)
Negative RF and negative ACPA 0
Low-positive RF or low-positive ACPA 2
High-positive RF or high-positive ACPA 3
C. Acute-phase reactants (at least 1 test result is needed for classification)
Normal CRP and normal ESR 0
Abnormal CRP or abnormal ESR 1
D. Duration of symptoms
<6 weeks 0
6 weeks 1
 PATHOLOGY
Combination of genetic and environmental factors
An important early event may result from the interaction
of antigen presenting macrophages with T cells
(helper/inducer)
HLA- DR4 is associated
It is defined as an antibody against the Fc portion of IgG
Although clinical laboratories measure IgM rheumatoid
factor, other classes of RF have been described
Generally believed that complexes of IgG rheumatoid
factor with IgG can deposit in blood vessels and lead to
vasculitis
Cellular inflammation:
Inflammation in the joint cavity can be intense
Monocyte is most responsible for mediating
tissue destruction; neutrophils also invade
Leading to degradation of articular cartilage,
menisci, and ligaments without restriction

Inciting causes:
Hepatitis B vaccine: rare
potential association between RA and two
herpesvirus infections: Epstein-Barr virus (EBV)
and Human Herpes Virus 6 (HHV-6)
Synovitis:
Normally delicate synovial membrane becomes
infiltrated with macrophages, lymphocytes, plasma
cells, and granulocytes
Synovitis in RA invades cartilage, ligaments, and
subchondral bone

Rheumatoid nodule:
Central fibrinoid necrosis surrounded by palisades of
histiocytes
Seen in 30% cases
Stages:
Proliferative: Swelling, pain with motion, limited
movement, nerve compression
Destructive: Synovial erosion causes irreversible
changes (tendon rupture, capsular weakness and
disruption, bone erosion, joint subluxation and
deformity)
Reparative: Fibrosis replaces inflammation
(adhesions, ankylosis, fixed deformity)
 PRESENTATION
Monocyclic (10%) One attack
Polycyclic (45%) Variable duration,
severity and intervals
Progressive (45%) Unremitting
 CLINICAL MANIFESTATIONS
Symmetrical polyarthralgia, morning stiffness, and fatigue are common

Morning stiffness results from increases in extracellular fluid in & around

joint

Later on, there may be limitation of motion due to pain or joint destruction

Predilection for wrists and hands; MP joints, PIP joints, and wrists are first to
become symptomatic

Ulnar deviation, and swan-neck or boutonniere deformities are common

EXTRA ARTICULAR MANIFESTATIONS:
Patients with extraarticular manifestations have
High-titer RF
More severe disability
Increased mortality rate

Heart- pericarditis, cardiomyopathy, and valvular

incompetence, interstitial fibrosis
Lungs: Rheumatoid lung (Honeycombed appearance
on CXR due to multiple nodules), Caplan
syndrome (associated with pneumoconiosis),
Idiopathic pulmonary fibrosis
Eyes- scleritis (most common ocular complication of
RA), scleromalacia perforans)
 Nervous system- mononeuritis multiplex,
compression syndromes such as median neuropathy
Kidneys- amyloid deposition
Hematopoietic system- Felty's syndrome (anemia,
splenomegaly, and leukopenia)
Vasculitis: usually is a non necrotising arteritis of the
small terminal arterials, Skin lesions, leg ulcers,
necrotizing arteritis of the viscera, digital
infarctions, and fever
Sjogren's syndrome: occurs in 15%; RA +
keratoconjunctivitis sicca, xerostomia
 Cervical Spine in RA
Cervical spine involvement is common in RA
(upto 90%), more common with long standing
disease and multiple joint involvement
Most common presentations:
Atlantoaxial subluxation: most common
and may occur in upto 40%
Atlantoaxial impaction / Basilar
invagination
Lower cervical spine: Joints of Lushka & facet
joints are affected, subluxation may occur at
multiple levels; more common in males, with
steroid use, sero-+ RA, with RA nodules, &
severe RA

Presentation: neck pain, neurologic

involvement, myelopathy, radiculopathy

Investigation: Cross table lateral X-ray, MRI

Treatment: Indications for Surgery

1. Space available for the cord: spinal

cord compression with < 14 mm of room
either at upper or lower cervical spine or
with basilar invagination

2. Atlas Dens Interval (ADI): Instability is

present when 3.5 mm ADI difference on
flex/ext views, 7 mm difference may imply
disruption of the alar ligaments; difference
of > 9 mm is assoc with increase in
neurologic injury & will usually require
posterior fusion and wiring.

3. Myelopathy: neurologic impairment

and/or instability are indications for
treatment;

Surgical Options: posterior or anterior

cervical fusion.
 RHEUMATOID HAND & WRIST
1. Palmar subluxation & Radial deviation of wrist
Ulnar carpal complex (UCC) is commonly first leading to rupture of
the triangular fibrocartilaginous complex (TFCC) distally -> DRUJ d/l
causing prominent ulnar head caput ulnar syndrome-> rupture
of EDC 4 and 5.
Radioscaphocapitate (RSC) or sling ligament is second; joined by
incompetence of the radioscapholunate (RSL) causing rotatory
subluxation of the scaphoid / loss of radial carpal height; joined by
radiolunatriquetral (RLT) and wrist subluxes into anterior position.
Dorsal radiocarpal(DRC) ligament fails causing ulnar translocation of
carpus
Triquetrohamitatocapitate (THC) can deteriorate causing volar
intercalated segment instability (VISI)
Mid-carpal joint is relatively spared usually
2. Extensor Tendon Rupture
EPL Rupture common, t/t: EIP transfer
Vaughn Jackson syndrome: Ulnar side of wrist is most
common site of extensor tendon ruptures (EDC to 4th &
5th digits) due to the attrition over the damaged ulnar
head
EDQ rupture (with intact little EDC) is diagnosed with the
Texas long horn sign, in which the index and little
finger are extended while the ring and little fingers are
flexed; this requires intact extensor indicis and EDQ
tendons.
3. Flexor Tendon Rupture FPL>FDP little> index>FDS
ring>middle; two usual causes: attrition or direct
4. Ulnar translocation of carpus
5. Ulnar drift of the fingers- with radial deviation of wrist,
cause Z deformity
6. Palmar subluxation of MCP
7.Swan neck deformity of
fingers: Hyperextension of PIP
joints with flexion of DIP joint
8. Boutonniere deformity of
fingers: Hyperextension of DIP
& MCP joints with flexion of PIP
joints
9. Lateral dislocation of any of
the IP joints
10. MP subluxation & dislocation
11. Intrinsic contracture (as
determined by Bunnel Test)
Elbow:
Synovitis
Posterior subluxation of elbow
Compression neuropathy ulnar & PIN
Hip:
Protrusio acetabuli: often progressive Flexion
deformity
 Rheumatoid Foot
Initially, RA involves the forefoot, then the
midtarsal joints, and finally the hindfoot; forefoot is
involved twice as often as the hindfoot
Rheumatoid forefoot
- Hyperpronation of rheumatoid foot
- Metatarsalgia
- Claw toes
Midfoot:
- Talonavicular arthritis
- Midfoot hyperpronation
Hind foot: calcaneovalgus
 LAB TEST
Rheumatoid Factor: Rose Waller test, present in most RA
patients (80 % of affected pts); associated w/ increased morbidity.
5% normal pts also +ve.
False +ve in- SLE, sarcoidosis, TB, syphilis, chronic liver disease
Anti CCP antibody (anti-cyclic citrullinated peptide antibodies): more
specific ( 95%) than RA factor.
Synovial Fluid Analysis: joint fluid in RA is sterile & has
pleocytosis (usually PMN), incr protein, & decreased viscosity &
decreased complement
ESR: active RA elevated; good indicator of response to medical
therapy and the activity of the disease
C Reactive Protein
Normocytic normochromic anaemia
 X-ray
Early changes are limited to the
soft tissues w/ fusiform swelling and
joint effusion
Juxta-articular osteoporosis
Cartilage destruction produces
narrowing of the joint
Erosion of bone occurs
characteristically in the
metaphyseal region underlying
collateral ligament attachments
Mal-alignment, displacement, and
ankylosis of the joint mark end-
stage
 Differential diagnoses

Crystal induced arthritis (gout, and pseudogout)

Osteoarthritis
Systemic lupus erythematosus (SLE)
One of the several types of psoriatic arthritis resembles RA
Lyme disease
Reactive arthritis (previously Reiter's disease)
Ankylosing spondylitis
Hepatitis C
Sarcoidosis
Amyloidosis,
Whipple's disease
Hemochromatosis
Acute rheumatic fever
Gonococcal arthritis
 TREATMENT
Medical Management:
1. NSAIDS
2. Oral Corticosteroids- used to alleviate intractable joint
inflammation or vasculitis
3. DMARDS
Methotrexate: anti folate, hepatic and pulmonary
toxicity; first choice DMARD
Antimalarials: stabilize lysosomal membranes and
inhibit IL1, hydroxychloroquine sulfate, major side
effect is macular degeneration
Sulfasalazine (anti folate activity)
Gold: gold salts (inhibit monocyte function), side
effects- thrombocytopenia, neutropenia, or proteinuria
D-Penicillamine (modulate lymphocyte function)
4. Anti-cytokine agents
Etanercept - TNF type II receptor fused to IgG1
Infliximab- chimeric mouse/human monoclonal
antibody to TNF
Adalimumab- human antibody to TNF
5. Immunosuppressive agents
Azathioprine
Cyclophosphamide
Cyclosporin A
Leflunomide: inhibit dihydroorotate dehydrogenase,
an essential enzyme in the pyrimidine biosynthetic
pathway. Its predominant action is to inhibit the
proliferation of T lymphocytes.
Physical Therapy
Surgical treatment
Synovectomy
Arthroplasty- hip, knee, shoulder,
elbow, wrist, MCP
Arthrodesis- wrist, PIP, MCP
Tendon transfer & reconstuctve
surgery of hand
JUVENILE RHEUMATOID ARTHRITIS

ACR dignostic criteria

Age < 16
Arthritis of 1 or more joints
Symptoms of at least 6 weeks
An onset type after 6 months of
observation pauciarticular,
polyarticular or sysytemic
Exclusion of other forms of arthritis
Types:
Pauciarticular less than 5 joints
involved; with ANA + iridocyclitis or
HLA B 27 + spondylitis
Polyarticular 5 or more joints
affected; RA factor + or -
Systemic (Stills disease)
< 20% have progressive destructive
disease; mostly systemic
Pauciarticular:
A. With ANA + iridocyclitis
F>M
Onset age < 5yr
Fewer joint involved
30-35% have chronic iridocyclitis; complications- posterior
synechia, band shaped keratopathy, cataract, glaucoma,
blindness
B. With HLA B 27 + spondylitis
M>F
Onset age- >8 years
Arthritis involve lower limbs
Radiographic sacroiliitis
Iridocyclitis, reiters seen
Polyarticular:
A. Rh factor -ve
F>>M
Symmetrical polyarthritis of small joints of hand, feet, elbow,
ankle, knee
Low grade extraarticular manifestation
Inv of temporomandibular joint & cervical spine common
10-15% develop severe destructive arthritis
B. Rh factor +ve
F>M
Onset: late in childhood
Childhood equivalent of adult RA
Symmetric small joint arthritis with rheumatoid nodules,
Feltys synd, fibrosing pneumonitis
>50% develop destructive arthritis
Systemic (Stills disease)
M>=F
Intermittent quotidian fever (>1030 F) with chill
& evanescent rash
During fever- myalgia, arthralgia, transient
arthritis, pleuritis, pericarditis, adenitis,
abdominal pain
Hepatosplenomegaly
Multiple symmetric joint involvement
Recur in > 50% cases
No iridocyclitis
Inv: leucocytosis, anaemia
Complications:
Flexion deformity at hip, knee, elbow
Triple deformity in knee (Flexion,
external rotation, posterior subluxation;
also seen in TB, Polio)
Growth defects- short stature, tortional
deformity in limbs, leg length discripancy
TREATMENT

Salicylates- promptly relieve symp.

Aspirin 100 mg/kg in 5 devided doses
Steroids in severe systemic disease
& iridocyclitis
Deformity correction, physiotherapy
Synovectomy