RHEUMATOUD ARTHRITIS PRESENTATION_111926.pptx

1. RHEUMATOID ARTHRITIS
DR BIPUL BORTHAKUR
PROFFESOR AND HEAD
DEPARTMENT OF ORTHOPAEDICS ASSAM
MEDICAL COLLEGE
DIBRUGARH , ASSAM

2. INTRODUCTION
 Rheumatoid arthrits is an autoimmune
inflammatory disease but mainly involves synovial
joints
 Peak age of onset 40-60 years
 Females are more affected (3:1)
 Rheumatoid arthritis is most common cause of
inflammatory arthritis
 Distinctive features includes peripheral small joints
involvement ,symmetrical and morning stiffness

3. RISK FACTORS
 Familial and genetic risk factors –HLA DRB1 Alleles
 Demographic risk factors and lifestyle factors –
smoking
 Chronic inflammatory mucosal conditions and
infections
 Occupational exposures and inhalants-
silica,asbestos textile dust

4. PATHOPHYSIOLOGY

5. PANNUS
 Thick swollen synovial membrane with granulation tissue
made up of fibroblasts ,myofibroblasts and inflammatory cells,
 Immune system is responsible for pannus formation.
 Pannus damages
Cartilage
Erode bone
Surrounding sof tissues

6. CLINICAL FEATURES
 MC Inflammatory polyarthritis.
 Appendicular dominant
 Mostly involve small joints of the hands.
 Axial involvement is rare
 Symptoms >6 weeks duration
 Inflammatory synovitis
Palpable synovial swelling
 Symmetrical and polyarticular (>3 joints)
Typically involves wrists, MCP, and PIP joints
Typically spares :DIPs of the fingers and IPs of the
toes

7. CLINICAL FEATURES
 Subcutaneous or periosteal nodules at pressure
points.
 Ulnar deviation,
 Swan-neck
 Boutonniere deformities are common.

8. HAND DEFORMITIES
 FINGER DEFORMITIES

9. BOUTONNIERE DEFORMITY
Central slip distruption
Volar migration of lateral bands
Results in flexion at PIP& hyextension at PIP

10. SWANN NECK DEFORMITY
• Lateral band injury
• Results in DIP flexion and PIP Hyperextension
• Also seen in volar plate laxities and ehler danlos
syndrome

11. ULNAR DRIFT
 MCP Joint synovitis results loosening of the joint
weakness capsule and ligaments around the joint
results extensor tendon shifting to the web spaces

12. GAMEKEEPER THUMB ARTHRITIS MUTILANS
 Synovitic destruction of ulnar
collateral ligament of thumb
results in ligament laxity
 Shortening of fingers due to
destruction phalanges
 Excessive skin folds resembles
opera glass appearence

13. WRIST DEFORMITY
RA in wrist mainly affects
 Ulnar styloid
 Ulnar head
 Mid portion of scaphoid
synovitis of DRUJ causes stretching of ulnar carpal ligament complex
results in ulna subluxuates dorsally results in dorsal prominence of ulna.
 DRUJ Instability demonstrated by piano key sign.
 Z Deformity ( radial deviation of metacarpal and ulnar deviation of
phalanx)

14. TENOSYNOVITIS
EXTENSOR FLEXOR
 Can be 1st
presenting symptom of
RA.
 Painless soft tissue mass over dorum
of wrist.
 May be associated with DRUJ Injury.
 Rupture of extensor tendon results in
VAUGHAN JACKSON
SYNDROME
 Rare
 Painful soft tissue mass over
volar surface of wrist and
restrict flexion
 Rupture of FPL tendon resuts
in MANNERFELT NORMAN
SYNDROME

15. FOOT
 Earliest change seen in 4th
and 5th
metatarsal
phalangeal joints.
 The initial symptoms could be swelling and stiffness
including ankle joint.
 LANOIS DEFORMITY- Dorsal subluxuation of
metatarsal phalangeal joints with fibular deviation.
 Flattening and collapse of arch of foot are the
common deformities

16. ELBOW
 Effusion
 Ulnar neuropathy
 Subcutaneous nodules

17. EXTRA ARTICULAR MENIFESTATIONS

18. DIGNOSIS
1. LABORATORY:
HB – Normocytic normochromic anemia due to anemia of
chronic disease. Degree of anemia directly proportionate to
activity of the disease.
CRP increased
ESR increased
Platelet- Thrombocytosis
2. SEROLOGY:
RHEUMATOID FACTOR:
 Antibodies that recognize Fc portion of IgG
 Can be IgM,IgG,IgA.
 Clinical practice, IgM RF is usually measured

19. ANTI CCP
 Antibodies to cyclic citulinated peptide have a sensitivity of 78% and
specificity of 96% for RA.
 40 % seronegative RA are Anti CCP positive.
 Level of CCP is directly correlated with the development of erosions
 Negative
 Low-moderate (35-200)
 High CCP (>200)
 Useful in monitoring prognosis of the disease

20. IMAGING
 X RAY
 EARLY STAGE(SYNOVITIS):
 Soft tissue swelling, periarticular
osteopenia
 LATER STAGE(DESTRUCTIVE):
 Juxta- erosions, narrowing of joint space
 ADVANCE STAGE(DEFORMITY):
 Articular destruction and joint deformity

22. MRI
1. JOINT EFFUSION
2. MARROW EDEMA
3. SYNOVIAL INFLAMMATION

23. USG
• Joint space widening
• Fluid collection
• Synovial hypertrophy
• Cartilage defects
• Bone erosions
• Tendon sheath widening and tears

24. 2010ACR/EULAR CRITERIA

25. MANAGEMENT
 There is no cure for rheumatoid arthritis
 Aim to delay progression of the disease, alleviate
symptoms, reduce functional limitation
 Supportive and palliative

26. DRUGS
1. NSAIDs
 Ibuprofen, indomethacin, COX-2 inhibitors like
calecoxib and valdecoxib (reduce inflammation and
relieves pain)
2. Analgesics
 Morphine and acetaminophen (reduce pain)
3. Glucocorticoids or prednisolone
 Prescribed in a small dose to slow joint damage caused by
inflammation

27. DRUGS
4. DMARDS :
 Methotrexate, Hydroxychloroquine, azathioprine,
sulfasalazine
 New: Leflunomide, Etanercept
5. Biologic Response Modifiers
 Abatacept,Etanercept, Infliximab, Adalimumab, Anakinra,
Rituximab

29. METHOTREXATE
• 1ST
line of choice in RA
• MOST POTENT
• Adenosine efflux mechanism
• DOSE:10-25 mg/week
• Side effects:
 diarrhea, stomatitis
 hepatotoxic
 bone marrow suppression
 ILD
• Follow up: Baseline CBC,LFT every 3 month
• C/I in pregnancy

30. LEFLUNOMIDE
• Secreted in bile
• Loading dose 100mg/day for 3-5 days then
Maintenance dose 20 mg/day
• Severe hepatotoxicity.should not be considered with
methotrexate.
• Contraindicated in pregnancy and breast feeding.

31. SULFASALAZINE
• Safe in pregnancy
• 500 mg -2 gm/day oral
• Sulfa group of drugs causes granulocytopenia
and reduced sperm count
• C/I in G6PD deficiency anemia

32. HYDROXYCHLOROQUINE
• 1st
choice of drug in pregnancy
• Least effective among all 4 drugs,preferred in mild
cases
• 200-400 mg/day
• Side effects:
 bulls maculopathy
 phototoxicity
 torsades de pointes
• Follow up: fundoscopy annually and ECG

33. BIOLOGICS
 These are monoclonal antibodies derived from
live cell cultures
 They act on specific pathogic processes ,effect
faster disease control,are effective even when
DMARDs fail, and prevent or radiological
worsening of joints.
 Side effects:
 High cost
 Parentral admissions
 Risk of infections
 Unknown long term adverse effects

34. MECHANISM OF ACTION
TNF-α BLOCKERS:
•Infliximab
•Certolizumab
•Adalimumab
•Golimumab
•Etanarcept
IL-1 BLOCKERS:
Anakinra
3. IL-6 BLOCKERS:
Sarilumab
Tocilizumab
4. T Cell MODULATOR:
Abatacept
Anti CD20:
Rituximab

35. IMMUNOLOGICS
• TOFACITINIB - blocks JAK 1/3
• BARICITINIB – blocks JAK 1/2
• Tofacitinib was approved by the FDA in June 2012 at
a dose of up to 5 mg administered twice daily for the
treatment of moderate-to-severe RA with an
inadequate response to methotrexate

36. TREATMENT PROTOCOL

37. NON PHARMACOLOGICAL
 REST
 EXERCISE
 DIET/ WEIGHT CONTROL
 PHYSICAL THERAPY
 OCCUPATIONAL THERAPY
 USE OF ASSISTIVE DEVICE
 SURGICAL METHODS

38. SURGERY
 SYNOVECTOMY—Done if synovitis doesn’t respond
to medical treatment
 Common surgeries performed in cases of RA are---
 Decompression of entrapped nerves
 Reconstructive procedures including
arthroplasty
 Corrective arthrotomies of the metatarsals
 Arthrodesis,particularly of ankle joint

39. THANK YOU