RHEUMATOID ARTHRITIS Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease predominantly affecting diarthrodial joints and frequently a variety of other organs. Peak incidence is between 4th and 6th decade. Females are two to three times more affected than males. Genetic and autoimmune factors are mainly responsible for the initiation of disease process.
PATHOGENESISThe pathologic hallmark of RA is synovialmembrane proliferation and outgrowthassociated with erosion of articularcartilage and subchondral bone.There is role of both cellular andhumoral immune mechanism in theonset of inflammation.
C/F Small joints of Hand-Pain/Stiffness > 1HR. The pattern of joint involvement is typically polyarticular and symmetrical and involves- proximal interphalangeal (PIP) metacarpophalangeal (MCP) wrist, elbow, shoulder, knee, ankle,MTP joints and cervical spine. The distal interphalangeal (DIP) joints of the fingers are usually spared.
C/F FEVER/MALAISE/HEADACHE JOINT SWELLING/TENDERNESS. With persistent inflammation, a variety of characteristic joint changes develop like- Z-deformity Swan neck deformity Boutonniere deformity.
DIAGNOSTIC INVESTIGATION CLINICAL. MRI IOC for early detection of disease ULTRASOUND X-RAYS. CT SCAN. SYNOVIAL FLUID ASPIRATION ANEMIA,RAISED ESR… SEROLOGICAL TESTS.
DIAGNOSIS Guidelines for classification a. Four of seven criteria are required to classify a patient as having rheumatoid arthritis (RA). b. Patients with two or more clinical diagnoses are not excluded.
DIAGNOSIS Criteria a. Morning stiffness: Stiffness in and around the joints lasting 1 h before maximal improvement. b. Arthritis of three or more joint areas: The 14 possible joint areas involved are right or left proximal interphalangeal, metacarpophalangeal, wrist, elbow, knee, ankle, and metatarsophalangeal joints.
DIAGNOSIS c. Arthritis of hand joints: Arthritis of wrist, metacarpophalangeal joint, or proximal interphalangeal joint. d. Symmetric arthritis: Simultaneous involvement of the same joint areas on both sides of the body. e. Rheumatoid nodules: Subcutaneous nodules over bony prominences, extensor surfaces, or juxtaarticular regions observed by a physician.
DIAGNOSIS f. Serum rheumatoid factor: Demonstration of abnormal amounts of serum rheumatoid factor. g. Radiographic changes: Typical changes of RA on posteroanterior hand and wrist radiographs that must include erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints.
Flow chart shows approach to radiographic evaluation of arthritis.
RA of the metatarsophalangeal joints.left foot shows concentric joint space narrowing and subcortical cysts in all of themetatarsophalangeal joints. Erosions are seen in the second and fourthmetatarsophalangeal joints, which are deformed to some extent
Advanced RA. Radiograph of the hand shows severe destruction and mutilation of the radiocarpal, intercarpal, carpometacarpal, and metacarpophalangeal joints.. Intercarpal ankylosis is noted. There is also subluxation and deviation of thefourth and fifth fingers.
Radiograph of the right hand shows cysts along the radial aspect of the head of the second metacarpal (*).
Advanced RA. Radiograph shows mutilation and deformity of the left elbow.
Posteroanterior wrist radiographs show discontinuity of bone cortex representing erosion (arrow) with development of osteopenia.
RA of the wrist. Radiograph shows a ballooned ulnar styloid process. There are small cysts(*) in the styloid process and scaphoid bone. The radiocarpal joint space isnarrowed.
Longstanding arthritis of the shoulder joint.Radiograph of the left shoulder shows a deep erosion (*) at a typical site.
Narrowing of joint spaces in long-standing RA. Radiograph (detail view) shows narrowing of the joint spaces of the second and fourth metacarpophalangeal joints (*). The concentricity of the narrowing is a hallmark of arthritis, whereas joint space narrowing due to degenerative changes is eccentric.
CT image shows shallow erosions with sclerotic and well-demarcated margins at the second and fifth metacarpophalangeal joints (arrowheads).
Bone erosion in a patient with RA. Longitudinal high-resolution sonogram shows an irregular erosion of the metacarpophalangeal joint (arrowheads).
Synovitis of the metacarpophalangeal joint. Longitudinal high-resolution (10.5-MHz) sonogram shows thickenedsynovial tissue (arrows).
RA of the atlantodental joint.Axial contrast-enhanced fat-saturated spin-echo T1-weighted MRimage shows hypervascular pannus (*) around the dens axis.
Axial spin-echo T1-weighted MR image of the left wrist shows extensive synovitis of the ulnar aspect (*) and erosions and deformity of the ulnar styloid process (arrowhead).
Axial contrast-enhanced fat-saturated T1-weighted MR image of the wrist shows multiple intrasynovial rice bodies (arrows).
Long-standing mutilating RA. Coronal spin-echo T1-weighted MR image of the left hand shows severe destructive changes in the carpus and radiocarpal joint.The carpometacarpal joints are less severely affected. Active arthritis of thethird metacarpophalangeal joint is associated with reactive edema of the bonemarrow (*).
Figure 17. RA of the wrist.Axial contrast-enhanced fat-saturated T1-weighted MR image shows a carpal cyst(arrow) that communicates with the inflamed synovium via a small extension(arrowhead). This cyst is a typical “subcortical erosion.”
Incidentally discovered bone cyst in a middle-aged patient with RA. Coronal spin-echo T2- weighted MR image of the hand shows a hyperintense cyst with a sclerotic rim (arrow).
Acute painful arthritis of the third metacarpophalangeal joint.The enhancement of the bone marrow (*) is indicative of inflammatory involvementor a reactive response.
Small joint effusion in a 20-year-old woman in whom RA was later diagnosed.
Acute tendovaginitis of the flexor of the middle finger in a young man with a diagnosis of RA.Axial contrast-enhanced fat-saturated T1-weighted MR image shows fluid (*) surrounded by enhancing synovium (arrowheads).
Long-standing RA in a 52-year-old woman.. Coronal contrast-enhanced fat-saturated T1-weighted MR image shows synovitis of thesecond and third metacarpophalangeal joints. A subcortical cyst (arrowhead) is seennear the bare area. This type of lesion is called a pre-erosion or subcortical erosion bysome authors owing to the high likelihood that it will progress to a clear erosion.
Figure 4. RA in a 75-year-old woman.. Coronal contrast-enhanced fat-saturated T1-weighted MR image shows hyperenhancement of small joints in the hand (arrows), a finding that reflects hyperemic synovial tissue. Erosions (arrowheads) and thickened, intensely enhancing synovium are seen at the fifth metacarpophalangeal joint.
OSTEOARTHRITIS Most common type of arthritis. Leading cause of disability in elderly. Much more common in women than men. Definition: OA is joint failure,a disease in which all parts of joint have undergone pathologic change.initial step in the onset of disease is failure of joint protective mechanism. Joint vulnerability and joint loading are the two major factors in development of disease.
Primary osteoarthritis is mostly related to aging. With aging, thewater content of the cartilage increases, and the protein makeup ofcartilage degenerates.Secondary osteoarthritis is caused by another disease orcondition. Conditions that can lead to secondary osteoarthritisinclude obesity, repeated trauma or surgery to the joint structures,abnormal joints at birth (congenital abnormalities), gout, diabetes,and other hormone disorders.
JOINTS AFFECTED IN OA Hip Knee DIP(haberden’s node) and PIP(bouchard’s node). First carpometacarpal joint Cervical vertebrae First metatarsophalangeal joint. Lower lumber vertebrae. Involvement is asymmetric unlike RA.
PATHOLOGICAL HALLMARKS Cartilage is the primary target tissue for OA. There is nonuniform loss of the cartilage. Evidense of new bone formation is presence of osteophytes. There is as assymetric and nonuniform involvement of the joints. Capsule may become edematous and fibrotic. Joint space narrowing is present as seen in all types of arthritis.
Symptoms Paino Joints may ache, or the pain may feel burning or sharp. For some people, it may getbetter after a while.o Pain while sleeping or constant pain may be a sign that arthritis is getting worse. Stiffnesso When you have arthritis, getting up in the morning can be hard.o Joints may feel stiff and creaky for a short time, until get moving.o May also get stiff from sitting. The muscles around the joint may get weakero This happens a lot with arthritis in the knee. Cracking and creakingo Joints may make crunching, creaking sounds. Limited range-of-motion
Investigations X-RAY-although used for evaluating OA ,are insensitive for identifying early disease process. They correlate poorly with patients symptom. Synovial fluid analysis-WBC’s count more than 1000/microlitre indicate inflammatory arthritis and less likely OA. ULTRASOUND. MRI. CT-scan. BONE SCAN.
Weight Bearing Techniqueo Films obtained during weightbearing or varus and valgus stressare necessary in early stages of osteoarthritis of the knee joint.o Ideally, the weightbearing radiographs should be obtained witha patient standing only on the involved leg in 15 to 20 degrees ofknee flexion.o With the knee in extension, early joint space loss may not beseen .o The weightbearing technique also allows more accuratedelineation of subluxation, varus or valgus angulation, and lateralinstability
CT-SCAN OF HIP JOINT SHOWING CHANGES OF OSTEOARTHRITIS.
CT-SCAN OF ELBOW JOINT SHOWING CHANGES OFOSTEOARTHRITIS.
CT-SCAN OF HAND SHOWING OSTEOPHYTE IN THE HEAD OF 4TH METACARPAL.
MRIo The MRI is most useful for patients withvery early osteoarthritis of the knee.o For people who have knee pain withoutinjury and who have not responded tocortisone shots or anti-inflammatorymedicines, the MRI can detect meniscuscartilage degeneration that cannot be seenon x-ray.
Figure: T1-weighted coronal MRI of the knee shows typical findings ofosteoarthritis, including narrowing and subchondral changes at the medialfemorotibial compartment and osteophyte formation.
An MRI shows a knee with chronic effusion, joint spacenarrowing due to loss of femoral and tibial articular cartilage(white arrow), and a torn meniscus (black arrow).
Figure 2 MRI image of the knee joint inosteoarthritis demonstrating synovitis andsubchondral bone abnormalities.
A rapid MRI examination forosteoarthritis (OA) include:A) T2 mapping to estimate the amount of cartilage collagen, andB) sodium imaging to estimate cartilage glycosaminoglycan content, an important component of connective tissue. These physiologic measurements should be more sensitive to early changes of OA than structural information alone.
US-guided steroid injections in hip OA is an efficacious and safe therapeuticapproach to achieve pain control and reduction of synovial hypertrophyavoiding the use of X-ray-guided procedure.
Radionuclide Bone Scanso Radionuclide Bone Scans are very sensitive indetecting reactive bone edema associated withosteoarthritis.o Bone scans can also image the entire skeleton inone examination and thus can provide the clinicianwith helpful information in patients with multiple sitesof arthritic involvement.
Therapeutic ultrasound for osteoarthritis of the knee or hip-Therapeutic ultrasound may be beneficial for people withosteoarthritis of the knee.-Therapeutic ultrasound may improve your physical function butthis finding could be the result of chance.-Therapeutic ultrasound does not have any side effects.Therapeutic ultrasound means using sound waves to try and relievepain or disability.This therapy is under investigation.
DIFFERENCE B/W RA AND OA RHEUMATOID A. OSTEOARTHRITIS Inflammatory. Degenerative. Symmetric involvement of Asymmetric involvement small joints first. of large joint first. Polyarticular. Generally monoarticular. Other visceral organs also Not affected. affected. Erosion of adjuscent bony Sclerosis of adjuscent bony surface. surface with osteophyte formation. Morning stiffnes>1hr. Morning stiffnes<1hr.