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Rheumatoid Arthritis

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3rd to 6th decade of life. Women Men. 1st degree ... Wheelchair bound w/ classic RA in his hands. Renoit in 1911. Pierre ... to orginal steroid ... – PowerPoint PPT presentation

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Title: Rheumatoid Arthritis


1
Rheumatoid Arthritis
  • Corolinda S. Helu, DPM
  • Surgical Resident
  • New York Community Hospital

2
Overview
  • Epidemiology
  • History
  • Physical Examination
  • Laboratory Tests
  • Radiographical signs
  • Pharmological Treatment
  • Surgical Treatment of Foot
  • Hoffman-Clayton Case

3
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?

4
The Synovium in RA
Normal Synovium
Rheumatoid Synovium
5
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

6
RA in European Art
Dutch Priest 1631
7
Wheelchair bound w/ classic RA in his hands
Renoit in 1911
8
Pierre August Renoir 1876
9
Renoit in 1911
10
History
  • Insidious onset
  • Slow development of sign symptoms
  • Stiffness
  • Polyarticular
  • Most common PIP MCP of hands
  • Morning stiffness gt 1hr
  • Fatigue, malaise, depression

11
Physical Examination
  • Symmetric joint swelling
  • Fusiform swelling PIP
  • Pain on passive motion

12
Physical Examination
  • Tenosynovitis synovitis
  • Synovial cysts
  • Displaced/ ruptured tendons
  • Bony erosions Hallmark

13
Physical Examination
  • Ulnar deviation
  • Swan Neck
  • Hyperexten PIPJ
  • Flex DIPJ
  • Boutiniere
  • Flex PIPJ
  • Ext DIPJ

14
(No Transcript)
15
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

16
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

17
Radiology
  • Symmetrical
  • Early no sig changes
  • Late
  • Juxta-articular osteoporosis w/ decr bone
    density
  • Uniform jt narrowing
  • Marginal erosions

18
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

19
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

20
Newer Therapies
  • Leflunomide (Arava)
  • Methotrexate
  • Etanercept (Enbrel)
  • Infliximab (Remicade)
  • IL-1ra (Kineret)
  • Antiproliferative agents
  • Anti-TNF therapies
  • Anti-IL-1 agents
  • Combination

21
What is Quality of Life?
  • Ability to
  • Work
  • Be a parent
  • Socialize with others
  • Exercise and be mobile

22
Surgical Treatment?
  • Goal Relieve pain
  • Consider
  • Medical condition
  • Age
  • Activity level
  • Condition of Bone ST

23
Tx for dislocation of lesser MPJ
  • A Hoffman
  • B Mod Hoffman w/ 1st MPJ arthrodesis
  • C Fowler

24
Tx for dislocation of lesser MPJ
  • C Clayton
  • D Modified Clayton

25
Incisional Approaches
  • A Transverse Plantar
  • BElliptic Plantar
  • C/D Transverse dorsal
  • E 3 Dorsal Longitudinal
  • F 5 Dorsal Longitudinal

26
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

27
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

28
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
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