Rheumatoid Arthritis

Dr. C. C. Visser
MBChB MMed (Med Phys)
Diploma in Orthopaedic Medicine
Member of the Society of Orthopaedic Medicine, UK
 Arthritis

OA Crystal RA SpA CTD Vasculitis

Primary: DIP Gout AS SLE PAN,

PIP,hip,knee Pseudogout Psoriatic PSS Wegeners
spine, 1 MTP Enteropathic PM/DM Takayasu,
Secondary: Reactive MCTD GCA etc

Cartilage Cartilage Synovium Synovium Synovium Synovium

Synovium Joints + C-spine Entheses Systemic >> Systemic >>
Soft tissue >> Systemic Axial + peripheral Synovium Synovium
Bone joints>> systemic

XR Synovial fluid RF XR ANF ANCA

XR XR HLA B27 ENA Histology
Urate level Organ Fx tests Imaging
 Rheumatoid arthritis
• Most common form of inflammatory
arthritis

• Affects 1 % of all populations

• Females > males 3:1

 Rheumatoid Arthritis
• Wide variation in
– age at onset
– degree of joint involvement
– severity of disease

• Difficult to predict early on who will

develop more severe disease
 Effects of RA
• Systemic disease but joint involvement
dominates

• RA affects morbidity and mortality

• RA reduces life expectancy

– males by 7 year
– females by 3 years
 Etiology
• Immune mediated chronic inflammation
• Trigger: Environmental Genetic (30%)
Antigen Self Antigen

T cell activation

Chronic Inflammation
Lymphoid cells infiltrate synovium
New blood vessels form in synovium
Synovial proliferation
Joint destruction
 Mechanisms of joint damage
• Synovial mass stretches joint capsule and
ligaments: joint swelling, instability &
deformity
• Cytokine and proteolytic enzyme rich synovial
fluid destroys cartilage joint space
narrowing on X-rays
• Infiltration of cartilage and later bone by
invading synovium (pannus)
marginal erosions
 Onset
• 60% insidious onset of pain, stiffness,
symmetrical swelling of joints especially
small joints
• 20% acute or subacute
• 10% vague aches and pains
• 5% systemic symptoms: fatigue,
malaise, weight loss, low fever, myalgia,
morning stiffness, depression
 ACR Classification Criteria
(4/7)
• EMS > 1 hour
• > 3 joint arthritis
• Symmetrical arthritis
• Wrist, MCP, PIP arthritis
• Rheumatoid nodules
• Rheumatoid factor
• X-ray changes: periarticular
osteopaenia/marginal erosions
Articular involvement
 Articular involvement

Any synovial joint can be involved

Also inflammation of synovium in bursae

and tendon sheaths

Can start asymmetrically with only few

joints affected
 Articular involvement
• Spreads within months to years to other
joints in symmetrical distribution

• Joint involvement reaches a plateau

after first few years

• Number of joints affected in early

disease related to severity of disease
 Hand
• MCP joints
– Synovitis
– Ulnar deviation
• PIP joints
– Synovitis
– Swan neck deformity
– Boutonniere deformity
• Z-deformity of thumb
• Tendons
– Flexor tenosynovitis
– Extensor tenosynovitis
• Poor grip: power and pinch
 Wrist
• Synovitis
• Piano key sign (distal radio-ulnar joint)
• Subluxation
• Radial deviation
• Ankylosis
• Carpal tunnel syndrome
 Elbow
• Synovitis
• Flexion contracture
• Decreased, painful pronation and
supination
• Olecranon bursitis
• RA nodules
 Shoulder
• Subacromial bursitis
• Rotator cuff tendinitis
• Glenohumeral joint arthritis
• Acromio-clavicular arthritis
 Foot

• MTP
– Synovitis
– Subluxation with hammer/claw toe and
metatarsalgia
– Bunions
– Bunionettes
– Toe deviation/overriding
• Collapse of medial arch of foot
 Ankle/Hindfoot
• Ankle
– Synovitis
– Retrocalcaneal bursitis
• Tenosynovitis/rupture
– Peroneal tendons
– Tibialis posterior
• Subtalar arthritis
– Reduced and painful movement
– Hindfoot valgus
 Knee
• Synovitis
• Effusions
• Baker’s cyst +/- rupture
• Instability/ deformity eg valgus deformity
• Flexion contracture
 Hip
• Arthritis (usually late)
– Pain especially on weight bearing
– Reduced movement
• Trochanteric bursitis
 Cervical spine
• Involved in 70% patients with longstanding
RA
• Occipital pain made worse by movement
• Subluxation of C1-2 with compression of
spinal cord during neck flexion
– Significant if >10 mm instability on flexion
– Usually slowly developing myelopathy
• Subaxial subluxation
Serial cervical X-rays in a RA patient
 Other joints
• TMJ: reduced mouth opening

• Sternoclavicular

• Crico-arytenoid

• Ossicles of ears
Non-articular manifestations
 Non-articular manifestations
• Generalized lymphadenopathy

• Nodules
– 30% patients
– external over areas of pressure
– internally eg lung, heart, gallbladder
– central necrosis with pallisade of
fibroblasts
 Non-articular manifestations
• Lungs
– Pleurisy
– Pleural effusions (NB exudate!)
– RA nodules single/multiple (Caplan
syndrome if huge nodules in coal miners)
– Lung fibrosis
 Non-articular manifestations
• Heart
– pericarditis, usually asymptomatic, but can
lead to friction rubs / effusions / tamponade
– RA nodules: conduction defects
 Non-articular manifestations
• Bone
– Generalized osteoporosis

• Muscle
– Muscle atrophy
– Rarely myositis
 Non-articular manifestations
• Skin
– Palmar erythaema
– Digital gangrene (small arteries)
– Nail fold infarcts (small arteries)
– Skin ulcers (medium arteries)
– Purpuric papules (venules)
– Palpable purpura (leukocytoclastic
vasculitis)
 Non-articular manifestations
• Eyes
– Secondary Sjögren syndrome
– Episcleritis
– Scleritis
– Scleromalacia perforans
Complications
 Complications
• Infections
– More susceptible to any infection (RA,
steroids, MTX)
– ESPECIALLY susceptible to joint
infections

– Always suspect septic arthritis if sudden

increase in symptoms in one joint
 Complications
• Felty syndrome
– Splenomegaly and low WBC in RA

• Neurological
– Entrapment neuropathy: CTS, ulnar nerve, tarsal
tunnel syndrome
– Mononeuritis multiplex (RA vasculitis)
– Atlanto-axial subluxation with cord compression
 Complications
• Osteoporosis and fractures
– RA
– Immobility
– Steroids

• Amyloidosis
– Rare
– Longstanding disease
– Proteinuria/decreased renal function
Special investigations
 Laboratory diagnosis
• Rheumatoid factor

• Raised markers of inflammation (ESR/ CRP)

• LFT abnormalities
– Raised ALP
– Raised proteins (polyclonal rise in globulins, often
also low albumin)

• FBC abnormalities:
– Anaemia of chronic disease
– Reactive thrombocytosis
 Rheumatoid factor
• Antibodies against human IgG Fc

• 1-5% of normal people

• Also in chronic infections

and inflammation eg TB,
endocarditis and liver
cirrhosis
 Radiological diagnosis
• Periarticular soft tissue swelling
• Periarticular osteopaenia
• Joint space narrowing
• Marginal joint erosions leading eventually to
complete joint destruction
• Subchondral cysts
• Compressive changes due to collapse of
osteoporotic subchondral bone eg protrusio
acetabuli at hip
Serial X-rays of a knee in RA
Treatment
 Multidisciplinary Care
• Rheumatologist
• Orthopaedic Surgeon
• Physiotherapist
• Occupational therapist
• Orthotist
• Psychologist
• Community based support systems
– Arthritis Foundation
– Patient Partners
– Support Groups
 Medical Treatment
• Greatest and irreversible joint damage
occur early in disease

• Thus: Treat early and aggressively

• No single treatment regimen

consistently halts disease progression
 Medical Treatment
Symptomatic:
NSAID’s, paracetamol, opioids, low dose steroids,
atypical analgesics

Intra-articular steroids
Disease modifiers: Slow acting and side effects!
Methotrexate, Chloroquine, Sulphasalazine, D-
penicillamine, gold salts, leflunomide, high
doses steroids, immunosuppressants,
biologicals (anti TNF alpha and IL-1 agents)
 Surgical Treatment
• Soft tissue:
– Carpal tunnel release
– Synovectomy
– Tendon transfers
• Joint replacement
• Arthodesis
• Excision arthroplasty eg radial head
 Treatment
• Rest vs exercise

• Diet
– Avoid obesity
– “Anti-inflammatory diet”: vegetarian with
omega 3 fatty acids (fatty fish/fish oils)
– Essential fatty acids (evening primrose oil)
– Anti-oxidants?