Rheumatoid Arthritis The commonest type of inflammatory arthritis is rheumatoid arthritis affects approx. 3% of women & 1% men. The disease appear to arise from cell-mediated (T-cell) autoimmune response, but there may be underlying infectious etiology. After triggering of T-cell response there release of cytokines, Interleukin – I & 6 (IL-I & IL-6) Tumor Necrosis Factor (TNF) The disease mostly affect small joints of hands & feet, however any joint of body or soft tissue can be involved. A layer of inflammatory tissues called „panus‟ spread over the joint surface erode subchondrial bone, denuding articular cartilage. Rheumatoid Factor (RF) is +ve in 80% of cases
Clinical Features Mostly the disease onset insidiously, with joint stiffness & polyarthritis, some time disease may onset acutely in about 30% of the pts & may present with malaise & low grade fever. Hands & feet are commonly affected in early stage of the disease. On examination there may be effusion & synovitis of affected joints, which may cause Swelling Warmth Erythema Stiffness of affected joints with pain on movement.
Characteristic pattern Of Disease There may be deformity seen in hand & wrist Inflammation of tendon (Tenosynovitis), commonly affect flexor & extensor muscles of hand & wrist. Rupture of extensor tendon, most commonly of little finger. ESR & CRP are usually elevated Radial deviation of wrist Ulner deviation of metacarpophalangeal joints Z – deformity of thumb Boutonniere deformity of thumb Swan neck deformity Carpel tunnel syndrome
Rheumatology Criteria For Diagnosis Of RA This involve pt having four of seven criteria 1- Morning stiffness lasting atleast 1 – hour 2- Active arthritis of three or more joints 3- Active arthritis of atleast one hand joint (wrist, MCPJ, PIPJ) 4- Symmetrical arthritis 5- Subcutaneous rheumatoid nodules on extensor surface, juxta -articular or bony prominences 6- Rheumatoid factor positive 7- Radiographic changes of particular erosion, or osteopenia in affected joints not osteoarthritis.
Treatment Long standing, stable, mild cases of rheumatoid arthritis can be treated with analgesic and NSAIDs. The disease – modifying anti-rheumatic drugs (DMARDs) can be useful in preventing long term recruitment of autoimmune cascade. DMARDs are following 1- Methotrexate 2- Gold 3- Sulphasalazine/ Salazopyrine 4- Lefunomide 5- Penicillamine 6- Ciclosporine The most recent development of anti – TNF drugs such as “Etanercept & Infliximab” may revolutionize treatment Corticosteroid therapy continue to be useful systemically & locally and by injection into joints or around tendon.
Surgery For Rheumatoid Arthritis Splints can be useful to reduce the pain & improve function (unstable wrist, swan neck deformity) Orthotics are useful for the foot & ankle joints Arthodesis (fusion) for cervical spine, finger (PIPJ), wrist, ankle & hind foot. Joint replacement for major joints including hip, knee, elbow & shoulder joints. There are few sites where excision arthoplasty is used such as distil ulna & radial head. Tenosynovectomy for inflamed tendon sheath in case of resistant to medical treatment to prevent tendon rupture. In case of resistant to anti-inflammatory treatment perform synovectomy