Rheumatoid Arthritis

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Rheumatoid Arthritis

• Corolinda S. Helu, DPM
• Surgical Resident
• New York Community Hospital

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Overview

• Epidemiology
• History
• Physical Examination
• Laboratory Tests
• Radiographical signs
• Pharmological Treatment
• Surgical Treatment of Foot
• Hoffman-Clayton Case

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What is Rheumatoid Arthritis?

• Autoimmmune dz
• 1-2 prevalence
• 3rd to 6th decade of life
• Women gt Men
• 1st degree relative double the risk
• What causes rheumatoid arthritis?

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The Synovium in RA
Normal Synovium
Rheumatoid Synovium
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Milestones in RA

• First documented in 1800s
• Sir Alred Garrod in 1856
• Rheumatoid factor 1940
• Cortisone tx 1949
• Gold tx 1960s
• Methotrexate 1972
• Genetic Association 1976
• Anti-cytokine therapy 1997

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RA in European Art
Dutch Priest 1631
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Wheelchair bound w/ classic RA in his hands
Renoit in 1911
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Pierre August Renoir 1876
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Renoit in 1911
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History

• Insidious onset
• Slow development of sign symptoms
• Stiffness
• Polyarticular
• Most common PIP MCP of hands
• Morning stiffness gt 1hr
• Fatigue, malaise, depression

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Physical Examination

• Symmetric joint swelling
• Fusiform swelling PIP
• Pain on passive motion

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Physical Examination

• Tenosynovitis synovitis
• Synovial cysts
• Displaced/ ruptured tendons
• Bony erosions Hallmark

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Physical Examination

• Ulnar deviation
• Swan Neck
• Hyperexten PIPJ
• Flex DIPJ
• Boutiniere
• Flex PIPJ
• Ext DIPJ

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Laboratory Tests

• Initial work-up
• CBC, Metabolic panel, Urinalysis, Sed rate
• Rheumatoid factor, Anti-nuclear antibody
• Chem nl, slight decr albumin, incr total protein
• Hemahemocrit- ACD, wbc- mildly up, platelet-
  rare thrombocytosis

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Laboratory Tests

• ESR elevated
• Serology Rf Fc of IgG
• () not pathognomonic for RA
• Hi erosive jt dz, aggressive
• (-) milder dz course
• Detectable in non RA pts w/ prolonged infection

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Radiology

• Symmetrical
• Early no sig changes
• Late
• Juxta-articular osteoporosis w/ decr bone
  density
• Uniform jt narrowing
• Marginal erosions

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Radiology

• Marginal cortical erosions
• Juxtaarticular osteoporosis of lesser mets
• Severe HAV
• Subluxation/dislocation lesser MPJ
• Jt space narrowing
• Well marginated spur
• Also Reiters, acromegaly, dish
• Ill-defined ersosion of posteroanterior aspect of
  calcaneus
• Resiters, PA, AS, hyperparathyroidism

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Optimal RA Tx?

• NSAIDS
• Cortisone
• Best anti-inflam
• Worst SE
• DMARDS
• Gold
• Methotrexate
• Leflunomide (Arava)

• Accurate early early referral
• Early referral early tx
• Early tx improved outcomes
• Most rapid deterioration of jt func 2 yrs after
  diag

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Newer Therapies

• Leflunomide (Arava)
• Methotrexate
• Etanercept (Enbrel)
• Infliximab (Remicade)
• IL-1ra (Kineret)

• Antiproliferative agents
• Anti-TNF therapies
• Anti-IL-1 agents
• Combination

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What is Quality of Life?

• Ability to
• Work
• Be a parent
• Socialize with others
• Exercise and be mobile

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Surgical Treatment?

• Goal Relieve pain
• Consider
• Medical condition
• Age
• Activity level
• Condition of Bone ST

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Tx for dislocation of lesser MPJ

• A Hoffman
• B Mod Hoffman w/ 1st MPJ arthrodesis
• C Fowler

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Tx for dislocation of lesser MPJ

• C Clayton
• D Modified Clayton

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Incisional Approaches

• A Transverse Plantar
• BElliptic Plantar
• C/D Transverse dorsal
• E 3 Dorsal Longitudinal
• F 5 Dorsal Longitudinal

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Case presentation

• 64 yo female w/ RA X 15 years c/o forefoot pain
  and metatarsalgia which limit ambulation. Pt
  requires weekly forefoot padding just proximal
  to lesion in addition to in depth shoe with
  plastazote to relieve pain. Pt uses walker to
  ambulate. Pt desires sx to decrease pain and
  increase ambulation.
• PMH
• Illnesses HTN, osteoporosis, arthritis
• Meds Fosoamax, ASA, Atenolol
• Allergies PCN, betadine
• PE
• Musc B/L HAV, contracted digits 2-5 b/l, IPK L
  2/4, R 2,3,4, anterior displacement and atrophy
  of fat pad, pes plano valgus
• Vasc 2/4 DP/PT B/L, arterial doppler biphasic
  wave form, L PT w/ stenosis
• Derm Interdigital maceration 1-4 b/l
• Neuro wnl
• Gait Analysis Shuffling gait w/ use of walker

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Case presentation

• LabsCBC w/diff, Chem Panel X, Urinalysis, CXR,
  EKG, PT/PTT
• Xrayssevere HAV, osteopenia, jt narrowing,
  subluxation/dislocation
• A/P RA Stage IV
• Sx Modified Hoffman-Clayton w/ plantar
  elliptical transverse incision b/l
• Intra-op plantarflexed met heads, soft bones,
  good blood supply

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Board Review Questions

• Perioperative Management of RA pt w/ 7.5 mg
  prednisone for past year?
• 100 mg IV hydrocortisone preop
• 100 mg IV hydrocortison post-op
• S/P 1 D 50 mg q 8h po
• S/P 2 D 25 mg q 8 h po
• S/P 3 D 25 mg q 12 h po
• S/P 4 D return to orginal steroid regimen
• Management of pain w/ different drug classes for
  combination therapy, penicillamines, gold salts,
  corticosteroids, antimalarialswhich drug is not
  specific for RA?
• Corticosteroids, although most pts will respond,
  does not alter progression of dz. Others will
  produce gradual suppression of dz process