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AUTOIMMUNE DISEASE (RHEUMATOID ARTHRITIS)
Presenter Dr Laichena
Moderator Dr Kingrsquoori
Autoimmune disorders occur when the bodys immune system inappropriately attacks the bodys own health tissues and may be restricted to specific organs or involve a particular tissue ion different parts of the body
National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
Outline
Definition of autoimmune diseases
Rheumatoid arthritis
History
Pathogenesis of RA
Investigations
Diagnosis criteria
Treatment
Specific orthopaedic manifestations in RA
Common Autoimmune diseases in Orthopaedicsbull Rheumatoid arthritis
bull Seronegative spondyloarthropathies
Ankylosing spondylitis
Reiters syndrome and reactive arthritis
Psoriatic arthritis
Enteropathic arthritis
bull Juvenile idiopathic arthritis
bull Connective tissue diseases
Rheumatoid Arthritis
History
bull Arthritis and diseases of the joints have been plaguing mankind since ancient times
bull In around 1500 BC the Ebers Papyrus described a condition that is similar to rheumatoid arthritis
bull Hippocrates described arthritis in general in 400 BC
bull A B Garrod in 1858 named the disease rheumatoid arthritis replacing the old terms arthritis deformans and rheumatic gout
History of treatment of rheumatoid arthritis
bull In the olden days treatments included bloodletting and leeching
bull In the Far East developed practices of acupuncture acupressure moxibustion (use of heat) cupping were used
bull Gold bismuth arsenic and copper salts were used with varying rates of success
bull Gold however has shown success over years of use and is still a part of DMARDs
Disease Modifying Anti-rheumatic drugs (DMARDs)
bull Payne in 1895 was the first to suggest the use of quinine
bull In 1957 Baguall used chloroquine and now hydroxychloroquine is still part of the DMARDs
bull In 1940rsquos sulphasalazine was developed as an anti-inflammatory and still forms part of DMARDs
bull It was not until 1980rsquos that the role of methotrexate in rheumatoid arthritis was discovered
Anti-TNF antibodies
In 1993 Anti-TNF antibodies were shown to be effective in the treatment of patients with rheumatoid arthritis
Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
PATHOGENESIS OF RA
bull Rheumatoid arthritis is characterized by synovial inflammation and hyperplasia autoantibody production cartilage and bone destruction and systemic features including cardiovascular pulmonary psychological and skeletal disorders
bull involves a complex interplay among genotype environmental triggers and chance
The long-established association with the HLAndashDRB1 locus has been confirmed in patients who are positive for rheumatoid factor or ACPA alleles that contain a common amino acid motif (QKRAA) in the HLA-DRB1 region termed the shared epitope confer particular susceptibility
MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Smoking and other forms of bronchial stress eg exposure to silica increase the risk of rheumatoid arthritis among persons with susceptibility HLAndash DR4 alleles
bull smoking and HLA-DRB1 alleles synergistically increase onersquos risk of having ACPA
bull The formation of immune complexes during infection may trigger the induction of rheumatoid factor a high-affinity autoantibody against the Fc portion of immunoglobulin
The gastrointestinal microbiome is now recognized to influence the development of autoimmunity in articular models and specific clinical bacterial signatures that are associated with autoantibody positive rheumatoid arthritis are emerging
Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for
autoimmunity Arthritis Rheum 201062Suppl1390 abstract
Synovial Immunologic Processes and Inflammation
bull Synovitis occurs when leukocytes infiltrate the synovial compartment
bull Leukocyte accumulation primarily reflects migration rather than local proliferation
bull Cell migration is enabled by endothelial activation in synovial microvessels which increases the expression of adhesion moleculesand chemokines
Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
Accordingly neoangiogenesis which is induced by local hypoxic conditions and cytokines and insufficient lymphangiogenesis which limits cellular egress are characteristic features of early and established synovitis
These microenvironmental changes combined with profound synovial architectural reorganization and local fibroblast activation permit the buildup of synovial inflammatory tissue in rheumatoid arthritis
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Autoimmune disorders occur when the bodys immune system inappropriately attacks the bodys own health tissues and may be restricted to specific organs or involve a particular tissue ion different parts of the body
National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
Outline
Definition of autoimmune diseases
Rheumatoid arthritis
History
Pathogenesis of RA
Investigations
Diagnosis criteria
Treatment
Specific orthopaedic manifestations in RA
Common Autoimmune diseases in Orthopaedicsbull Rheumatoid arthritis
bull Seronegative spondyloarthropathies
Ankylosing spondylitis
Reiters syndrome and reactive arthritis
Psoriatic arthritis
Enteropathic arthritis
bull Juvenile idiopathic arthritis
bull Connective tissue diseases
Rheumatoid Arthritis
History
bull Arthritis and diseases of the joints have been plaguing mankind since ancient times
bull In around 1500 BC the Ebers Papyrus described a condition that is similar to rheumatoid arthritis
bull Hippocrates described arthritis in general in 400 BC
bull A B Garrod in 1858 named the disease rheumatoid arthritis replacing the old terms arthritis deformans and rheumatic gout
History of treatment of rheumatoid arthritis
bull In the olden days treatments included bloodletting and leeching
bull In the Far East developed practices of acupuncture acupressure moxibustion (use of heat) cupping were used
bull Gold bismuth arsenic and copper salts were used with varying rates of success
bull Gold however has shown success over years of use and is still a part of DMARDs
Disease Modifying Anti-rheumatic drugs (DMARDs)
bull Payne in 1895 was the first to suggest the use of quinine
bull In 1957 Baguall used chloroquine and now hydroxychloroquine is still part of the DMARDs
bull In 1940rsquos sulphasalazine was developed as an anti-inflammatory and still forms part of DMARDs
bull It was not until 1980rsquos that the role of methotrexate in rheumatoid arthritis was discovered
Anti-TNF antibodies
In 1993 Anti-TNF antibodies were shown to be effective in the treatment of patients with rheumatoid arthritis
Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
PATHOGENESIS OF RA
bull Rheumatoid arthritis is characterized by synovial inflammation and hyperplasia autoantibody production cartilage and bone destruction and systemic features including cardiovascular pulmonary psychological and skeletal disorders
bull involves a complex interplay among genotype environmental triggers and chance
The long-established association with the HLAndashDRB1 locus has been confirmed in patients who are positive for rheumatoid factor or ACPA alleles that contain a common amino acid motif (QKRAA) in the HLA-DRB1 region termed the shared epitope confer particular susceptibility
MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Smoking and other forms of bronchial stress eg exposure to silica increase the risk of rheumatoid arthritis among persons with susceptibility HLAndash DR4 alleles
bull smoking and HLA-DRB1 alleles synergistically increase onersquos risk of having ACPA
bull The formation of immune complexes during infection may trigger the induction of rheumatoid factor a high-affinity autoantibody against the Fc portion of immunoglobulin
The gastrointestinal microbiome is now recognized to influence the development of autoimmunity in articular models and specific clinical bacterial signatures that are associated with autoantibody positive rheumatoid arthritis are emerging
Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for
autoimmunity Arthritis Rheum 201062Suppl1390 abstract
Synovial Immunologic Processes and Inflammation
bull Synovitis occurs when leukocytes infiltrate the synovial compartment
bull Leukocyte accumulation primarily reflects migration rather than local proliferation
bull Cell migration is enabled by endothelial activation in synovial microvessels which increases the expression of adhesion moleculesand chemokines
Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
Accordingly neoangiogenesis which is induced by local hypoxic conditions and cytokines and insufficient lymphangiogenesis which limits cellular egress are characteristic features of early and established synovitis
These microenvironmental changes combined with profound synovial architectural reorganization and local fibroblast activation permit the buildup of synovial inflammatory tissue in rheumatoid arthritis
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Outline
Definition of autoimmune diseases
Rheumatoid arthritis
History
Pathogenesis of RA
Investigations
Diagnosis criteria
Treatment
Specific orthopaedic manifestations in RA
Common Autoimmune diseases in Orthopaedicsbull Rheumatoid arthritis
bull Seronegative spondyloarthropathies
Ankylosing spondylitis
Reiters syndrome and reactive arthritis
Psoriatic arthritis
Enteropathic arthritis
bull Juvenile idiopathic arthritis
bull Connective tissue diseases
Rheumatoid Arthritis
History
bull Arthritis and diseases of the joints have been plaguing mankind since ancient times
bull In around 1500 BC the Ebers Papyrus described a condition that is similar to rheumatoid arthritis
bull Hippocrates described arthritis in general in 400 BC
bull A B Garrod in 1858 named the disease rheumatoid arthritis replacing the old terms arthritis deformans and rheumatic gout
History of treatment of rheumatoid arthritis
bull In the olden days treatments included bloodletting and leeching
bull In the Far East developed practices of acupuncture acupressure moxibustion (use of heat) cupping were used
bull Gold bismuth arsenic and copper salts were used with varying rates of success
bull Gold however has shown success over years of use and is still a part of DMARDs
Disease Modifying Anti-rheumatic drugs (DMARDs)
bull Payne in 1895 was the first to suggest the use of quinine
bull In 1957 Baguall used chloroquine and now hydroxychloroquine is still part of the DMARDs
bull In 1940rsquos sulphasalazine was developed as an anti-inflammatory and still forms part of DMARDs
bull It was not until 1980rsquos that the role of methotrexate in rheumatoid arthritis was discovered
Anti-TNF antibodies
In 1993 Anti-TNF antibodies were shown to be effective in the treatment of patients with rheumatoid arthritis
Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
PATHOGENESIS OF RA
bull Rheumatoid arthritis is characterized by synovial inflammation and hyperplasia autoantibody production cartilage and bone destruction and systemic features including cardiovascular pulmonary psychological and skeletal disorders
bull involves a complex interplay among genotype environmental triggers and chance
The long-established association with the HLAndashDRB1 locus has been confirmed in patients who are positive for rheumatoid factor or ACPA alleles that contain a common amino acid motif (QKRAA) in the HLA-DRB1 region termed the shared epitope confer particular susceptibility
MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Smoking and other forms of bronchial stress eg exposure to silica increase the risk of rheumatoid arthritis among persons with susceptibility HLAndash DR4 alleles
bull smoking and HLA-DRB1 alleles synergistically increase onersquos risk of having ACPA
bull The formation of immune complexes during infection may trigger the induction of rheumatoid factor a high-affinity autoantibody against the Fc portion of immunoglobulin
The gastrointestinal microbiome is now recognized to influence the development of autoimmunity in articular models and specific clinical bacterial signatures that are associated with autoantibody positive rheumatoid arthritis are emerging
Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for
autoimmunity Arthritis Rheum 201062Suppl1390 abstract
Synovial Immunologic Processes and Inflammation
bull Synovitis occurs when leukocytes infiltrate the synovial compartment
bull Leukocyte accumulation primarily reflects migration rather than local proliferation
bull Cell migration is enabled by endothelial activation in synovial microvessels which increases the expression of adhesion moleculesand chemokines
Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
Accordingly neoangiogenesis which is induced by local hypoxic conditions and cytokines and insufficient lymphangiogenesis which limits cellular egress are characteristic features of early and established synovitis
These microenvironmental changes combined with profound synovial architectural reorganization and local fibroblast activation permit the buildup of synovial inflammatory tissue in rheumatoid arthritis
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Common Autoimmune diseases in Orthopaedicsbull Rheumatoid arthritis
bull Seronegative spondyloarthropathies
Ankylosing spondylitis
Reiters syndrome and reactive arthritis
Psoriatic arthritis
Enteropathic arthritis
bull Juvenile idiopathic arthritis
bull Connective tissue diseases
Rheumatoid Arthritis
History
bull Arthritis and diseases of the joints have been plaguing mankind since ancient times
bull In around 1500 BC the Ebers Papyrus described a condition that is similar to rheumatoid arthritis
bull Hippocrates described arthritis in general in 400 BC
bull A B Garrod in 1858 named the disease rheumatoid arthritis replacing the old terms arthritis deformans and rheumatic gout
History of treatment of rheumatoid arthritis
bull In the olden days treatments included bloodletting and leeching
bull In the Far East developed practices of acupuncture acupressure moxibustion (use of heat) cupping were used
bull Gold bismuth arsenic and copper salts were used with varying rates of success
bull Gold however has shown success over years of use and is still a part of DMARDs
Disease Modifying Anti-rheumatic drugs (DMARDs)
bull Payne in 1895 was the first to suggest the use of quinine
bull In 1957 Baguall used chloroquine and now hydroxychloroquine is still part of the DMARDs
bull In 1940rsquos sulphasalazine was developed as an anti-inflammatory and still forms part of DMARDs
bull It was not until 1980rsquos that the role of methotrexate in rheumatoid arthritis was discovered
Anti-TNF antibodies
In 1993 Anti-TNF antibodies were shown to be effective in the treatment of patients with rheumatoid arthritis
Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
PATHOGENESIS OF RA
bull Rheumatoid arthritis is characterized by synovial inflammation and hyperplasia autoantibody production cartilage and bone destruction and systemic features including cardiovascular pulmonary psychological and skeletal disorders
bull involves a complex interplay among genotype environmental triggers and chance
The long-established association with the HLAndashDRB1 locus has been confirmed in patients who are positive for rheumatoid factor or ACPA alleles that contain a common amino acid motif (QKRAA) in the HLA-DRB1 region termed the shared epitope confer particular susceptibility
MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Smoking and other forms of bronchial stress eg exposure to silica increase the risk of rheumatoid arthritis among persons with susceptibility HLAndash DR4 alleles
bull smoking and HLA-DRB1 alleles synergistically increase onersquos risk of having ACPA
bull The formation of immune complexes during infection may trigger the induction of rheumatoid factor a high-affinity autoantibody against the Fc portion of immunoglobulin
The gastrointestinal microbiome is now recognized to influence the development of autoimmunity in articular models and specific clinical bacterial signatures that are associated with autoantibody positive rheumatoid arthritis are emerging
Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for
autoimmunity Arthritis Rheum 201062Suppl1390 abstract
Synovial Immunologic Processes and Inflammation
bull Synovitis occurs when leukocytes infiltrate the synovial compartment
bull Leukocyte accumulation primarily reflects migration rather than local proliferation
bull Cell migration is enabled by endothelial activation in synovial microvessels which increases the expression of adhesion moleculesand chemokines
Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
Accordingly neoangiogenesis which is induced by local hypoxic conditions and cytokines and insufficient lymphangiogenesis which limits cellular egress are characteristic features of early and established synovitis
These microenvironmental changes combined with profound synovial architectural reorganization and local fibroblast activation permit the buildup of synovial inflammatory tissue in rheumatoid arthritis
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Rheumatoid Arthritis
History
bull Arthritis and diseases of the joints have been plaguing mankind since ancient times
bull In around 1500 BC the Ebers Papyrus described a condition that is similar to rheumatoid arthritis
bull Hippocrates described arthritis in general in 400 BC
bull A B Garrod in 1858 named the disease rheumatoid arthritis replacing the old terms arthritis deformans and rheumatic gout
History of treatment of rheumatoid arthritis
bull In the olden days treatments included bloodletting and leeching
bull In the Far East developed practices of acupuncture acupressure moxibustion (use of heat) cupping were used
bull Gold bismuth arsenic and copper salts were used with varying rates of success
bull Gold however has shown success over years of use and is still a part of DMARDs
Disease Modifying Anti-rheumatic drugs (DMARDs)
bull Payne in 1895 was the first to suggest the use of quinine
bull In 1957 Baguall used chloroquine and now hydroxychloroquine is still part of the DMARDs
bull In 1940rsquos sulphasalazine was developed as an anti-inflammatory and still forms part of DMARDs
bull It was not until 1980rsquos that the role of methotrexate in rheumatoid arthritis was discovered
Anti-TNF antibodies
In 1993 Anti-TNF antibodies were shown to be effective in the treatment of patients with rheumatoid arthritis
Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
PATHOGENESIS OF RA
bull Rheumatoid arthritis is characterized by synovial inflammation and hyperplasia autoantibody production cartilage and bone destruction and systemic features including cardiovascular pulmonary psychological and skeletal disorders
bull involves a complex interplay among genotype environmental triggers and chance
The long-established association with the HLAndashDRB1 locus has been confirmed in patients who are positive for rheumatoid factor or ACPA alleles that contain a common amino acid motif (QKRAA) in the HLA-DRB1 region termed the shared epitope confer particular susceptibility
MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Smoking and other forms of bronchial stress eg exposure to silica increase the risk of rheumatoid arthritis among persons with susceptibility HLAndash DR4 alleles
bull smoking and HLA-DRB1 alleles synergistically increase onersquos risk of having ACPA
bull The formation of immune complexes during infection may trigger the induction of rheumatoid factor a high-affinity autoantibody against the Fc portion of immunoglobulin
The gastrointestinal microbiome is now recognized to influence the development of autoimmunity in articular models and specific clinical bacterial signatures that are associated with autoantibody positive rheumatoid arthritis are emerging
Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for
autoimmunity Arthritis Rheum 201062Suppl1390 abstract
Synovial Immunologic Processes and Inflammation
bull Synovitis occurs when leukocytes infiltrate the synovial compartment
bull Leukocyte accumulation primarily reflects migration rather than local proliferation
bull Cell migration is enabled by endothelial activation in synovial microvessels which increases the expression of adhesion moleculesand chemokines
Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
Accordingly neoangiogenesis which is induced by local hypoxic conditions and cytokines and insufficient lymphangiogenesis which limits cellular egress are characteristic features of early and established synovitis
These microenvironmental changes combined with profound synovial architectural reorganization and local fibroblast activation permit the buildup of synovial inflammatory tissue in rheumatoid arthritis
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
History of treatment of rheumatoid arthritis
bull In the olden days treatments included bloodletting and leeching
bull In the Far East developed practices of acupuncture acupressure moxibustion (use of heat) cupping were used
bull Gold bismuth arsenic and copper salts were used with varying rates of success
bull Gold however has shown success over years of use and is still a part of DMARDs
Disease Modifying Anti-rheumatic drugs (DMARDs)
bull Payne in 1895 was the first to suggest the use of quinine
bull In 1957 Baguall used chloroquine and now hydroxychloroquine is still part of the DMARDs
bull In 1940rsquos sulphasalazine was developed as an anti-inflammatory and still forms part of DMARDs
bull It was not until 1980rsquos that the role of methotrexate in rheumatoid arthritis was discovered
Anti-TNF antibodies
In 1993 Anti-TNF antibodies were shown to be effective in the treatment of patients with rheumatoid arthritis
Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
PATHOGENESIS OF RA
bull Rheumatoid arthritis is characterized by synovial inflammation and hyperplasia autoantibody production cartilage and bone destruction and systemic features including cardiovascular pulmonary psychological and skeletal disorders
bull involves a complex interplay among genotype environmental triggers and chance
The long-established association with the HLAndashDRB1 locus has been confirmed in patients who are positive for rheumatoid factor or ACPA alleles that contain a common amino acid motif (QKRAA) in the HLA-DRB1 region termed the shared epitope confer particular susceptibility
MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Smoking and other forms of bronchial stress eg exposure to silica increase the risk of rheumatoid arthritis among persons with susceptibility HLAndash DR4 alleles
bull smoking and HLA-DRB1 alleles synergistically increase onersquos risk of having ACPA
bull The formation of immune complexes during infection may trigger the induction of rheumatoid factor a high-affinity autoantibody against the Fc portion of immunoglobulin
The gastrointestinal microbiome is now recognized to influence the development of autoimmunity in articular models and specific clinical bacterial signatures that are associated with autoantibody positive rheumatoid arthritis are emerging
Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for
autoimmunity Arthritis Rheum 201062Suppl1390 abstract
Synovial Immunologic Processes and Inflammation
bull Synovitis occurs when leukocytes infiltrate the synovial compartment
bull Leukocyte accumulation primarily reflects migration rather than local proliferation
bull Cell migration is enabled by endothelial activation in synovial microvessels which increases the expression of adhesion moleculesand chemokines
Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
Accordingly neoangiogenesis which is induced by local hypoxic conditions and cytokines and insufficient lymphangiogenesis which limits cellular egress are characteristic features of early and established synovitis
These microenvironmental changes combined with profound synovial architectural reorganization and local fibroblast activation permit the buildup of synovial inflammatory tissue in rheumatoid arthritis
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Disease Modifying Anti-rheumatic drugs (DMARDs)
bull Payne in 1895 was the first to suggest the use of quinine
bull In 1957 Baguall used chloroquine and now hydroxychloroquine is still part of the DMARDs
bull In 1940rsquos sulphasalazine was developed as an anti-inflammatory and still forms part of DMARDs
bull It was not until 1980rsquos that the role of methotrexate in rheumatoid arthritis was discovered
Anti-TNF antibodies
In 1993 Anti-TNF antibodies were shown to be effective in the treatment of patients with rheumatoid arthritis
Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
PATHOGENESIS OF RA
bull Rheumatoid arthritis is characterized by synovial inflammation and hyperplasia autoantibody production cartilage and bone destruction and systemic features including cardiovascular pulmonary psychological and skeletal disorders
bull involves a complex interplay among genotype environmental triggers and chance
The long-established association with the HLAndashDRB1 locus has been confirmed in patients who are positive for rheumatoid factor or ACPA alleles that contain a common amino acid motif (QKRAA) in the HLA-DRB1 region termed the shared epitope confer particular susceptibility
MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Smoking and other forms of bronchial stress eg exposure to silica increase the risk of rheumatoid arthritis among persons with susceptibility HLAndash DR4 alleles
bull smoking and HLA-DRB1 alleles synergistically increase onersquos risk of having ACPA
bull The formation of immune complexes during infection may trigger the induction of rheumatoid factor a high-affinity autoantibody against the Fc portion of immunoglobulin
The gastrointestinal microbiome is now recognized to influence the development of autoimmunity in articular models and specific clinical bacterial signatures that are associated with autoantibody positive rheumatoid arthritis are emerging
Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for
autoimmunity Arthritis Rheum 201062Suppl1390 abstract
Synovial Immunologic Processes and Inflammation
bull Synovitis occurs when leukocytes infiltrate the synovial compartment
bull Leukocyte accumulation primarily reflects migration rather than local proliferation
bull Cell migration is enabled by endothelial activation in synovial microvessels which increases the expression of adhesion moleculesand chemokines
Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
Accordingly neoangiogenesis which is induced by local hypoxic conditions and cytokines and insufficient lymphangiogenesis which limits cellular egress are characteristic features of early and established synovitis
These microenvironmental changes combined with profound synovial architectural reorganization and local fibroblast activation permit the buildup of synovial inflammatory tissue in rheumatoid arthritis
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Anti-TNF antibodies
In 1993 Anti-TNF antibodies were shown to be effective in the treatment of patients with rheumatoid arthritis
Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
PATHOGENESIS OF RA
bull Rheumatoid arthritis is characterized by synovial inflammation and hyperplasia autoantibody production cartilage and bone destruction and systemic features including cardiovascular pulmonary psychological and skeletal disorders
bull involves a complex interplay among genotype environmental triggers and chance
The long-established association with the HLAndashDRB1 locus has been confirmed in patients who are positive for rheumatoid factor or ACPA alleles that contain a common amino acid motif (QKRAA) in the HLA-DRB1 region termed the shared epitope confer particular susceptibility
MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Smoking and other forms of bronchial stress eg exposure to silica increase the risk of rheumatoid arthritis among persons with susceptibility HLAndash DR4 alleles
bull smoking and HLA-DRB1 alleles synergistically increase onersquos risk of having ACPA
bull The formation of immune complexes during infection may trigger the induction of rheumatoid factor a high-affinity autoantibody against the Fc portion of immunoglobulin
The gastrointestinal microbiome is now recognized to influence the development of autoimmunity in articular models and specific clinical bacterial signatures that are associated with autoantibody positive rheumatoid arthritis are emerging
Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for
autoimmunity Arthritis Rheum 201062Suppl1390 abstract
Synovial Immunologic Processes and Inflammation
bull Synovitis occurs when leukocytes infiltrate the synovial compartment
bull Leukocyte accumulation primarily reflects migration rather than local proliferation
bull Cell migration is enabled by endothelial activation in synovial microvessels which increases the expression of adhesion moleculesand chemokines
Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
Accordingly neoangiogenesis which is induced by local hypoxic conditions and cytokines and insufficient lymphangiogenesis which limits cellular egress are characteristic features of early and established synovitis
These microenvironmental changes combined with profound synovial architectural reorganization and local fibroblast activation permit the buildup of synovial inflammatory tissue in rheumatoid arthritis
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
PATHOGENESIS OF RA
bull Rheumatoid arthritis is characterized by synovial inflammation and hyperplasia autoantibody production cartilage and bone destruction and systemic features including cardiovascular pulmonary psychological and skeletal disorders
bull involves a complex interplay among genotype environmental triggers and chance
The long-established association with the HLAndashDRB1 locus has been confirmed in patients who are positive for rheumatoid factor or ACPA alleles that contain a common amino acid motif (QKRAA) in the HLA-DRB1 region termed the shared epitope confer particular susceptibility
MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Smoking and other forms of bronchial stress eg exposure to silica increase the risk of rheumatoid arthritis among persons with susceptibility HLAndash DR4 alleles
bull smoking and HLA-DRB1 alleles synergistically increase onersquos risk of having ACPA
bull The formation of immune complexes during infection may trigger the induction of rheumatoid factor a high-affinity autoantibody against the Fc portion of immunoglobulin
The gastrointestinal microbiome is now recognized to influence the development of autoimmunity in articular models and specific clinical bacterial signatures that are associated with autoantibody positive rheumatoid arthritis are emerging
Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for
autoimmunity Arthritis Rheum 201062Suppl1390 abstract
Synovial Immunologic Processes and Inflammation
bull Synovitis occurs when leukocytes infiltrate the synovial compartment
bull Leukocyte accumulation primarily reflects migration rather than local proliferation
bull Cell migration is enabled by endothelial activation in synovial microvessels which increases the expression of adhesion moleculesand chemokines
Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
Accordingly neoangiogenesis which is induced by local hypoxic conditions and cytokines and insufficient lymphangiogenesis which limits cellular egress are characteristic features of early and established synovitis
These microenvironmental changes combined with profound synovial architectural reorganization and local fibroblast activation permit the buildup of synovial inflammatory tissue in rheumatoid arthritis
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
The long-established association with the HLAndashDRB1 locus has been confirmed in patients who are positive for rheumatoid factor or ACPA alleles that contain a common amino acid motif (QKRAA) in the HLA-DRB1 region termed the shared epitope confer particular susceptibility
MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Smoking and other forms of bronchial stress eg exposure to silica increase the risk of rheumatoid arthritis among persons with susceptibility HLAndash DR4 alleles
bull smoking and HLA-DRB1 alleles synergistically increase onersquos risk of having ACPA
bull The formation of immune complexes during infection may trigger the induction of rheumatoid factor a high-affinity autoantibody against the Fc portion of immunoglobulin
The gastrointestinal microbiome is now recognized to influence the development of autoimmunity in articular models and specific clinical bacterial signatures that are associated with autoantibody positive rheumatoid arthritis are emerging
Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for
autoimmunity Arthritis Rheum 201062Suppl1390 abstract
Synovial Immunologic Processes and Inflammation
bull Synovitis occurs when leukocytes infiltrate the synovial compartment
bull Leukocyte accumulation primarily reflects migration rather than local proliferation
bull Cell migration is enabled by endothelial activation in synovial microvessels which increases the expression of adhesion moleculesand chemokines
Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
Accordingly neoangiogenesis which is induced by local hypoxic conditions and cytokines and insufficient lymphangiogenesis which limits cellular egress are characteristic features of early and established synovitis
These microenvironmental changes combined with profound synovial architectural reorganization and local fibroblast activation permit the buildup of synovial inflammatory tissue in rheumatoid arthritis
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
bull Smoking and other forms of bronchial stress eg exposure to silica increase the risk of rheumatoid arthritis among persons with susceptibility HLAndash DR4 alleles
bull smoking and HLA-DRB1 alleles synergistically increase onersquos risk of having ACPA
bull The formation of immune complexes during infection may trigger the induction of rheumatoid factor a high-affinity autoantibody against the Fc portion of immunoglobulin
The gastrointestinal microbiome is now recognized to influence the development of autoimmunity in articular models and specific clinical bacterial signatures that are associated with autoantibody positive rheumatoid arthritis are emerging
Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for
autoimmunity Arthritis Rheum 201062Suppl1390 abstract
Synovial Immunologic Processes and Inflammation
bull Synovitis occurs when leukocytes infiltrate the synovial compartment
bull Leukocyte accumulation primarily reflects migration rather than local proliferation
bull Cell migration is enabled by endothelial activation in synovial microvessels which increases the expression of adhesion moleculesand chemokines
Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
Accordingly neoangiogenesis which is induced by local hypoxic conditions and cytokines and insufficient lymphangiogenesis which limits cellular egress are characteristic features of early and established synovitis
These microenvironmental changes combined with profound synovial architectural reorganization and local fibroblast activation permit the buildup of synovial inflammatory tissue in rheumatoid arthritis
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
The gastrointestinal microbiome is now recognized to influence the development of autoimmunity in articular models and specific clinical bacterial signatures that are associated with autoantibody positive rheumatoid arthritis are emerging
Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for
autoimmunity Arthritis Rheum 201062Suppl1390 abstract
Synovial Immunologic Processes and Inflammation
bull Synovitis occurs when leukocytes infiltrate the synovial compartment
bull Leukocyte accumulation primarily reflects migration rather than local proliferation
bull Cell migration is enabled by endothelial activation in synovial microvessels which increases the expression of adhesion moleculesand chemokines
Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
Accordingly neoangiogenesis which is induced by local hypoxic conditions and cytokines and insufficient lymphangiogenesis which limits cellular egress are characteristic features of early and established synovitis
These microenvironmental changes combined with profound synovial architectural reorganization and local fibroblast activation permit the buildup of synovial inflammatory tissue in rheumatoid arthritis
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Synovial Immunologic Processes and Inflammation
bull Synovitis occurs when leukocytes infiltrate the synovial compartment
bull Leukocyte accumulation primarily reflects migration rather than local proliferation
bull Cell migration is enabled by endothelial activation in synovial microvessels which increases the expression of adhesion moleculesand chemokines
Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
Accordingly neoangiogenesis which is induced by local hypoxic conditions and cytokines and insufficient lymphangiogenesis which limits cellular egress are characteristic features of early and established synovitis
These microenvironmental changes combined with profound synovial architectural reorganization and local fibroblast activation permit the buildup of synovial inflammatory tissue in rheumatoid arthritis
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Accordingly neoangiogenesis which is induced by local hypoxic conditions and cytokines and insufficient lymphangiogenesis which limits cellular egress are characteristic features of early and established synovitis
These microenvironmental changes combined with profound synovial architectural reorganization and local fibroblast activation permit the buildup of synovial inflammatory tissue in rheumatoid arthritis
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Cartilage Damage
bull A hyperplastic synovium is the major contributor to cartilage damage
bull Loss of the normally protective effects of synovium alter the protein-binding characteristics of the cartilage surface promoting FLS adhesion and invasion
bull FLS synthesis of MMPs promotes disassembly of the type II collagen network a process that alters glycosaminoglycan content and water retention and leads directly to biomechanical dysfunction
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
bull MMP-14 appears to be the predominant MMP expressed by FLSs to degrade the collagenous cartilage matrix
bull Other matrix enzymes (eg ADAMTS 5) degrade aggrecan and thus further diminish cartilage integrity
bull Endogenous enzyme inhibitors such as TIMPs fail to reverse this destructive cascade
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
bull Chondrocytes physiologically regulate matrix formation and cleavage under the influence of synovial cytokines and reactive nitrogen intermediates cartilage is progressively deprived of chondrocytes which undergo apoptosis
bull These processes ultimately lead to the destruction of the surface cartilage and the radiographic appearance of joint-space narrowing
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Bone destruction
bull Bone Erosion Bone erosion occurs rapidly and is associated with prolonged increased inflammation
bull Synovial cytokines particularly macrophage colony-stimulating factor and receptor activator of NF-κB ligand (RANKL) promote osteoclast differentiation and invasion of the periosteal surface adjacent to articular cartilage
Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
bull TNF-α and interleukin-1 6 and potentially 17 amplify osteoclast differentiation and activation
bull Moreover clinical inhibition of TNF-α interleukin-6 and RANKL retards erosion in rheumatoid arthritis Notably blockade of RANKL acts only on bone with no effect on inflammation or cartilage degradation
bull Osteoclasts have the acidic enzymatic machinery necessary to destroy mineralized tissues including mineralized cartilage and subchondral bone destruction of these tissues leads to deep resorption pits which are filled by inflammatory tissue
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect joints from damage in rheumatoid
arthritis Arthritis Rheum 2008582936-48
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
bull Mechanical factors predispose particular sites to erosion
bull Breach of cortical bone permits synovial access to the bone marrow which causes inflammation of the bone
bull Eroded periarticular bone shows little evidence of repair in rheumatoid arthritis unlike bone in other inflammatory arthropathies
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid
arthritis J Immunol 2005175 2579-88
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Systemic long term complications in RA
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Investigations -LAB
bull Routine viral screening by serologic testing does not significantly facilitate the diagnosis of RA in patients with early RA nor is it helpful as a potential identifier of disease progression
bull Potentially useful laboratory studies in suspected RA fall into 3 categoriesmdashmarkers of inflammation hematologic parameters and immunologic parameters
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
IMAGING
bull Radiography remains the first choice for imaging in RA it is inexpensive readily available and easily reproducible and it allows easy serial comparison for assessment of disease progression
bull Magnetic resonance imaging (MRI) provides a more accurate assessment and earlier detection of lesions than radiography does
Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology
(Oxford) 2000 Jun 39 suppl 19-16
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Diagnosis- CRITERIA
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Treatment
bull DMARDS - Patients with mild disease and normal radiographic findings can begin treatment with hydroxychloroquine sulfasalazine or minocycline although methotrexate also is an option
bull Patients with more severe disease or radiographic changes should begin treatment with methotrexate
bull If symptoms are not adequately controlled leflunomide azathioprine or combination therapy (methotrexate plus one of the newer agents) may be considered
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
NSAIDSbecause they do not alter the disease course they should not be used alone Patients with rheumatoid arthritis are almost two times more likely to have serious complications from NSAID use than patients with osteoarthritis and they should be observed closely for symptoms of gastrointestinal side effects
GLUCOCOTICOIDS The American College of Rheumatology (ACR) guidelines recommend that patients being treated with glucocorticoids take 1500 mg of calcium and 400 to 800 IU of vitamin D daily
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
DURATION OF TREATMENT
bull Rheumatoid arthritis is a lifelong illness
bull Combinations of methotrexate and the new biologic agents can lead to remission in 30 to 40 percent of patients with rheumatoid arthritis but for most patients significant disease persists despite treatment
bull Complete remission rarely occurs
In clinical trials improvement has been tracked using the ACR improvement criteria most often ACR 20 ACR 50 or ACR 70
bull The numbers represent the percentage of improvement in the following criteria number of tender joints number of swollen joints global disease activity pain level physical disability score and acute phase response (as measured by CRP or ESR)
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Rheumatoid nodules
bull Seen in 20-30 of patients with RA and associated with aggressive diseasebull An extraarticular process found most commonly on extensor surfaces at
sites of frequent mechanical irritation over IP joints over olecranon and over ulnar border of the forearm
bull Rheumatoid factor is almost high in RN and when its negative the diagnosis is almost improbable
bull patients complain of pain and cosmetic concernsbull Treatment - non operative-steroid injection
operative surgical excision
Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Arthritis mutilans
bull A form of chronic rheumatoid arthritis in which osteolysisoccurs with extensive destruction of the joint cartilages and bony surfaces with pronounced deformities chiefly of the hands and feet similar changes occur in some cases of psoriatic arthritis
bull Digits develop gross instability with bone lossbull Treated with interposition bone grafting and fusion
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Ulna drift at MCP
bull Current mechanical factors that are postulated to play a role secondary to joint synovitits
i) failure of the collateral ligamentsii) intra-articular pressure changesiii) degenerative changes in the carpal and metacarpal
anatomyiv) muscle hypoxia induced changes in wrist tension v) exacerbating activities of daily living
Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Treatment of ulna drift
bull Synovectomy extensor tendon centralization and intrinsic release
Arthroplasty
bull Silicone MCP arthroplasty is most common
bull Indicated for late disease
bull Techniques -important to correct wrist deformity at same time if it is radially deviated
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Boutonneire defomity
bull Treatment of boutonniere finger is individualized and is based on the patients current level of function deformity medical status limitations of the surgeon and expectations
bull A Corticosteroid injection is useful if active PIP joint synovitis is present
bull Surgical Tenotomy of the terminal extensor tendon and reconstruction of the central slip
bull PIP arthrodesis
bull The choice of surgical treatment
is based on the flexibility of the PIP
joint and the status of the articular cartilage
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Swan neck deformity
bull The deformity is the end result of synovitis of the joints tendon sheaths and ligaments which disrupts the balance of flexion and extension forces across a joint and results in deformity weakness and loss of function
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
bull Nonsurgical treatment Extension block splinting
bull Surgical procedures that limit PIP joint hyperextension and restore DIP joint extension
DIP joint arthrodesis
tenodesis of the flexor digitorum superficialis
reconstruction of the oblique retinacular ligament
volar PIP joint dermodesis
lateral band translocation
In late-stage disease soft-tissue procedures alone may not result in lasting correction of deformity
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
WRIST ndashcaput ulna syndrome
Pathoanatomy
bull Synovitis in the DRUJ gt ECU subsheath stretching gt ECU subluxation gt supination of the carpal bones away from the head of the ulna gt volar subluxation of the carpus away from the ulna gt increased pressure over the extensor compartments gt tendon rupture
Early synovectomy of the radiocarpal and DRUJ can be done as an open procedure or when extensor tendon synovitis is absent as an arthroscopic procedure
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Treatment of manifest caput ulnae syndrome
Resection of the ulnar head together with a dorsal wrist stabilization is indicated
Less often arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated (Sauveacute-Kapandji)
When choosing the procedure the type and stage of wrist changes have to be considered
The DRUJ usually has to be treated together with the radiocarpal joint Its isolated treatment is rarely indicated
Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Radiocarpal Destruction
Synovitis and capsular distension leads to supination radial deviation and ulnar and volar translocation of the carpus on the radius this causes ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
Treatment
bull Synovectomy for early disease
bull Transfer of ECRL to ECU to diminish deforming forces (Claytons procedure)
bull Radiolunate fusion (Chamay) for intermediate disease
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
RHEUMATOID ELBOW
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
bull Synovitis- swelling and pain- may develop FFD due to holding in flexed position
bull Annular ligament may rupture- anterior displacement of radial head due to pull of biceps
bull Collateral ligaments may rupture ML instability
bull Ulna nerve neuropathy secondary to synovitis and rheumatoid nodule
bull Cartilage and bone destruction- severe cartilage damage causing instability and bony destruction
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Treatment options
bull Synovectomy +- radial head excision
bull Arthrodesis Resection arthroplasty
bull Arthroplasty= non constrained semiconstrained and constrainedIndications pain loss of motion and instability
Semiconstrained device has best results
Reliable procedure for advanced RA of elbow
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Shoulder conditions
RA is most prevalent form of inflammatory process affecting the shoulder with gt90 developing shoulder symptoms
Commonly associated with rotator cuff tears
Classic radiographic findings include
bull Central glenoid wearbull Periarticular osteopenia
bull Cysts
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
bull Nonsurgical management is the primary treatment including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability
bull Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief
bull The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Knee RA
bull Pathoanatomy as described above
bull Surgical options
bull Synovectomy of knee
bull Decreases pain and swelling but does not alter prevent radiographic progression and does not prevent the need for TKA in the future
bull Normal synovium reforms but degenerates to rheumatoid synovium over time
bull Range of motion is not improved
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
bull In advanced disease TKA has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients
bull However as rheumatoid arthritis patients carry additional potential for late complications many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients
bull Resurfacing of the patella during total knee arthroplasty
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
bull The life span of RA patients with a knee replacement is not well known however assuming that RA patients have a normal life span a TKA in this subgroup of patients on average needs to last longer and accordingly the potential risk of late complications increases
bull Many authors also expressed concern that late failure of the PCL could lead to late posterior instability
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Foot and Toe
Usually bilateral and symmetricForefoot joints are the first to be affected
bull Toe hyperextension deformityThe earliest manifestation of RA of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad painful plantar callosities and skin ulcerations over bony prominences
bull Rx Arthrodesis of the 1st MTP joint and lesser MTP joint resections
bull Talonavicular arthritisCommon to have degenerative changesTreatment - fusion
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
HIP
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
Tendon problems
bull Extensor tenosynovitis is a common presenting upper extremity problem and unless it resolves with medical management preventative tenosynovectomy is indicated to prevent tendon rupture
bull When a rupture has occurred
tendon reconstruction with either
a transfer or a graft has a reasonable
chance of restoring function as long
as the number of tendons involved is limited
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
bull Rupture of a single extensor tendon requires surgical treatment to eliminate the cause and prevent further damage as well as repairing the injured tendon
bull Extensor Tendon Rupturebull Frequency EDM gt EDC (ring) gt EDC (small) gt EPL
bull Treatment - tendon transfer interposition graft or Darrachs procedure
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
bull Mannerfelt syndrome -rupture of FPL in carpal tunnel due to scaphoid osteophytes
FDS to FPL tendon transfer
bull Vaughan-Jackson syndrome -describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
EIP to EDC transfer and distal ulna resection
Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
References
bull National institute of Arthritis and Musculoskletal and Skin diseases Autoimmune Diseases
bull Apleys System of Orthopaedics and fractures page 59 -76
bull Historical Perspective on the Etiology of Rheumatoid Arthritis Pouya Entezami BS David A Fox MD Philip J Clapham BS and Kevin C Chung MD MS
bull MacGregor AJ Snieder H Rigby AS et al Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins Arthritis Rheum 20004330-7
bull Wellcome Trust Case Control Consortium Genome-wide association study of 14000 cases of seven common diseases and 3000 shared controls Nature 2007 447661-78
bull Scher JU Ubeda C Pillinger MH et al Characteristic oral and intestinal microbiotain rheumatoid arthritis (RA) a trigger for autoimmunity Arthritis Rheum 201062Suppl1390 abstract
bull Szekanecz Z Pakozdi A Szentpetery A Besenyei T Koch AE Chemokines and angiogenesis in rheumatoid arthritis Front Biosci (Elite Ed) 2009144-51
bull Polzer K Baeten D Soleiman A et alTumour necrosis factor blockade increases lymphangiogenesis in murine and
human arthritic joints Ann Rheum Dis 2008671610-6
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
bull Visser H le Cessie S Vos K Breedveld FC Hazes JM How to diagnose rheumatoid arthritis early a prediction model for persistent (erosive) arthritis Arthritis Rheum 200246357-65
bull Schett G Teitelbaum SL Osteoclasts and arthritis J Bone Miner Res 2009241142-6bull Schett G Stach C Zwerina J Voll R Manger B How antirheumatic drugs protect
joints from damage in rheumatoid arthritis Arthritis Rheum 2008582936-48
bull Jimenez-Boj E Redlich K Turk B et al Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis J Immunol 2005175 2579-88
bull Radiographic imaging the lsquogold standardrsquo for assessment of disease progression in rheumatoid arthritis Rheumatology (Oxford) 2000 Jun 39 suppl 19-16American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines Guidelines for the management of rheumatoid arthritis 2002 update Arthritis Rheum 200246328-46
bull Rheumatoid nodules differential diagnosis and immunological findings annals of the rheumatic diseases 199352 625-626
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
bull Biomech 2015 Feb 2648(4)725-8jbiomech201412052 Epub 2015 Jan 5
Ulnar drift in rheumatoid arthritis a review of biomechanical etiology Morco S Bowden A
bull Orthopade 2004 Jun33(6)692-7 The caput-ulnae-syndrome Pathogenesis clinic and therapy Borisch N Haussmann P
bull Rheumatoid Arthritis of the Shoulder Chen Andrew L MD MS Joseph Thomas N MD Zuckerman Joseph D MD AAOS Journal of the American Academy of Orthopaedic Surgeons JanuaryFebruary 2003 - Volume 11 - Issue 1 - p 12ndash24
bull Total shoulder replacement in rheumatoid disease A 16- TO 23-YEAR FOLLOW-UP H M Betts R Abu-RajabT Nunn A J Brooksbank JBJS
bull Cemented Versus Cementless Total Hip Replacements in Patients Fifty-five Years of Age or Older with Rheumatoid Arthritis By Keijo T Mumlakelumla MD PhD Antti Eskelinen MD PhD Pekka Pulkkinen PhD Et al Amulticenter study
bull Cervical spondylosis stenosis and rheumatoid arthritis- Mathew mcdowell MD and Philip lucas MD
bull Hand Clin 1996 Aug12(3)551-9 Extensor tendon problems in rheumatoid arthritis Wilson RL DeVito MC
