slides of ra

1. Rheumatoid Arthritis &
Juvnile Chronic Arthritis
DR SUSHIL POKHREL
MS ORTHOPEDICS RESIDENT, TU
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2. • Term “rheumatoid arthritis" was coined by Garrod in 1859
• Rheumatoid arthritis (RA) is a chronic inflammatory disorder of
autoimmune origin that may affect many tissues and organs but
principally attacks the joints, producing a nonsuppurative proliferative
and inflammatory synovitis
• Rheumatoid arthritis (RA) is the most common cause of chronic
inflammatory joint disease
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3. Epidemology
• Prevalance ranges from 0.5 -1% world wide in adult
• Studies from Asia and Africa have low prevalence 0.2-0.4% *
• More common: female>male at ratio of 2-3:1 *
- estrogen ↑immune response by stimulating TNF-α
-peak incidence in 40’s-50’s
Harrison 20 e
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4. Etiology
• Unknown mechanism provoke immune response
• Genetic susceptibility:
RA is more common in first-degree relatives of patients(2-10 times)
Twin studies -revealed concordance rate of 30% if one is affected
HLA DR4B1- allelic variation in gene encoding MHC II - β chain
HLA DR4B1- share amino acid sequence in 70-74 position
of hypervariable region called shared epitope
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Lancet 2017 ,Pathogenetic insights RA
Porphyromonas gingivalis , Epstein-
Barr virus (EBV) Strains of streptococci
antiCCP

7. Pathology
(a) Stage 1 Pre-clinical (no c/f ,↑esr &crp RA f +/-)
(b) Stage 2 – Synovitis and joint swelling
(thickening of the capsule, effusion, painful
, swollen and tender& joint mobile)
(c) Stage 3 – Early joint destruction
with peri-articular erosions.(pannus of granulation)
(d) Stage 4 – Advanced joint destruction and deformity.
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Synovitis occur at
capsular attachment
Destruction of the
periarticular
cartilage
Rice
bodies

9. Clinical features
• Usually Insidious onset
• Presenting symptoms of RA typically result from inflammation of joints, tendons
and bursae
Early stages:-
Polysynovitis :- pain, swelling and loss of mobility of proximal fingers
joints & soft-tissue swelling
Stiffness : generalized stiffness after periods of inactivity, and
especially after rising from bed in early morning lasting > 1 hours
• Earliest involved joints are typically the small joints of hands and feet.
• Joint involvement: monoarticular, oligoarticular (≤4 joints), or polyarticular (>5
joints), usually in a symmetric distribution
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10. 10/6/2019 10*The Rheumatoid Hand Diagnostic Imaging

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12. • Large joints, including knees and shoulders, are often affected in
established disease
• Atlantoaxial involvement of the cervical spine(time with progressive
instability of C1 on C2) :cause compressive myelopathy and neurologic
dysfunction but Neurologic manifestations are rare
• Radiographic abnormalities of the temporomandibular joint occur
commonly in patients with RA
• Extra-articular manifestations may develop during clinical course of RA in
up to 40% of patients, even prior to the onset of arthritis
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13. • CONSTITUTIONAL: previous history of muscle pain, tiredness, loss of
weight & generalized lack of well-being fever, fatigue,
malaise,depression, and in the most severe cases, cachexia
• Later stages: erosions, ankylosis, luxations, and instability
• Rheumatoid deformities: combination of joint instability and tendon
rupture
• “Piano-key movement”of the ulnar styloid:- Inflammation about ulnar
styloid and tenosynovitis of the extensor carpi ulnaris may cause
subluxation of the distal ulna & protruding ulna in full pronation
• pes planovalgus (“flat feet”):-chronic inflammation of the ankle and
midtarsal regions
• Hammer toe, Bunion (hallux valgus)
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Erosive arthropathy of the wrist
stress distribution for the palmar aspect of the ( a ) healthy
model and ( b ) RA model
c. Characteristic “ Z ” deformity of hand. Ulnar translocation
and radial deviation of the wrist are commonly associated with
ulnar drift of the fingers

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Swan-neck deformity:Hyperextension of the PIP
joint with flexion of the DIP joint
Boutonnière deformity: Flexion of the PIP joint
with hyperextension of the DIP joint
Ulnar deviation: results from subluxation of the
MCP joints
Z-line deformity:subluxation of the first MCP joint
with hyperextension of the first interphalangeal
(IP) joint

16. Rheumatoid noudles :30–40% of patients
more commonly in those with the highest levels of disease activity,
RA factor positive , and radiographic evidence of joint erosions.
• Osteoporosis: Osteoporosis is more common in patients with RA than
an age- and sex-matched population,
prevalence rates of 20–30%.
Inflammatory milieu of joint spills over into the rest of body
and promotes generalized bone loss by activating osteoclasts.
Chronic use of glucocorticoids, disability-related immobility
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Harrison 20 e
Extraarticular disease :usually have
history of cigarette smoking, and
test positive for serum RF or anti-
CCP antibodies

18. Imaging
• Early stage - X-rays shows only features of synovitis: soft-tissue swelling
and periarticular osteoporosis, periarticular osteopenia ,subchondral
erosions, most frequently in wrists & hands (MCPs and PIPs) and feet
(MTPs).
• Later stages - marked by appearance of marginal bony erosions &
narrowing of articular space, especially in proximal joints of the hands and
feet
Advanced disease: articular destruction and joint deformity seen
• Flexion and extension views : cervical spine may show subluxation at the
atlantoaxial or mid-cervical levels
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periarticular osteoporosis ,
erosions
loss of joint space affecting
the carpus, the radiocarpal
joints, the thumb bases and
several metacarpophalangeal
and proximal interphalangeal
joints

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Plain cervical spine radiographs of a patient with
rheumatoid arthritis, demonstrating anterior subluxation
of the atlas (C1) on flexion, with increased distance
between the odontoid peg and anterior arch of the atlas

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Radiological
changes of hand+
monitering disese activity

23. • MRI:Presence of bone marrow edema has been recognized to be an
early sign of inflammatory joint disease and can predict the
subsequent development of erosions on plain radiographs
• Ultrasound Ultrasound with color Doppler :detect synovitis, including
increased joint vascularity indicative of inflammation
• SYNOVIAL FLUID ANALYSIS: white blood cell (WBC) counts –
generally range between 5000 and 50,000 WBC/μL
<2000 WBC/μL for a noninflammatory condition such as osteoarthritis
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24. Lab investigation
RA factor :
• Serum IgM RF has been found in 75–80% of patients with RA
• Serum RF may also be detected in 1–5% of the healthy population
Normocytic, hypochromic anaemia
Active phases : ESR and CRP concentration usually raised
Anti CCP :sensitivity of ACPA assays for RA varies from about 50 to 75 %
:specificity approaches 95%
ANA :antinuclear factors are present in 30%
Synovial biopsy: needle biopsy via: arthroscope or by open operation
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CONCLUSION :A new modified anti-CCP antibody test had a moderate sensitivity (47.1%)
but a high specificity (97.4%) in patients with RA and was found as a valuable supplement to
diagnosis of RA. Anti-CCP correlated with APF, AKA, RF, and HLA-DR4 gene complex, but
did not completely overlap with them. Anti-CCP antibody could be regarded as a new
diagnostic marker for RA.
Diagnostic value of anti-cyclic citrullinated Peptide antibody in patients with rheumatoid arthritis.
Zeng X, Ai M, Tian X, Gan X, Shi Y, Song Q, Tang F
J Rheumatol. 2003;30(7):1451.

26. Biopsy finding in RA
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Photomicrograph of synovial tissue in RA
showing prominent hyperplasia of the synovial
lining layer. The inflammatory infiltrate in the
sublining is comprised predominantly of
lymphocytes, plasma cells, and macrophages
(hematoxylin and eosin).

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Undifferentiated arthritis (UA) is a diagnosis
of exclusion made in patients with arthritis ,
which has caused at least one clinically
swollen joint in the absence of further
abnormalities sufficient to meet criteria for
a specified alternative diagnosis

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D/D OF RA

31. Principles management
• Early recognition and diagnosis & multidisciplinary approach
• Care by an expert in the treatment of rheumatic diseases, such as a
rheumatologist, orthopaedic surgeon, physiotherapist, occupational therapist,
orthotist and social worker
• Early use of disease-modifying antirheumatic drugs (DMARDs)
• Tight control, treat-to-target strategy, with goal of remission or low disease
activity
• Use of antiinflammatory agents, (NSAIDs) and glucocorticoids, only as adjuncts
to therapy
• Frequent modification of therapy with utilization of combination therapy where
appropriate & individualization of therapy in an attempt to maximize response
and minimize side effects
• GOALS :STOP SYNOVITIS, KEEP JOINT MOVING,PREVENT DEFORMITY
RECONSTRUCTION & REHABILITATION
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32. NONPHARMACOLOGIC AND PREVENTIVE
THERAPIES
• Patient education
• Psychosocial interventions
• Rest, exercise, and physical and occupational therapy
• Nutritional and dietary counseling
• Interventions to reduce risks of cardiovascular disease, including
smoking cessation and lipid control
• Screening for and treatment of osteoporosis
• Immunizations to decrease risk of infectious complications of
immunosuppressive therapies
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Simplified Disease Activity Index (SDAI)
(range 0–86.0)

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CONCLUSION:Tight control in RA resulted in significantly better clinical outcomes than usual care. It is
suggested but not proved that tight control with protocolized treatment adjustments is more beneficial than if no
such protocol is used.
Meta-analysis of tight control strategies in rheumatoid arthritis: protocolized treatment has additional value with
respect to the clinical outcome.
Schipper LG, van Hulst LT, Grol R, van Riel PL, Hulscher ME, Fransen J
Rheumatology (Oxford). 2010 Nov;49(11):2154-64. Epub 2010 Jul 29.

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EARLY RA

36. Eular guidelines
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ESTABILISHED RA

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Ann Rheum Dis. 2014 July

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45. An association between consistent DMARD use and improvement in long-term
functional outcomes in RA is supported by these data.
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46. DRUGS MOA S/E
Hydroxychloroquine
200–400 mg/d orally
interference with "antigen processing" in
macrophages and other antigen-presenting cells
headache, dizziness, ringing in your ear, nausea,
vomiting, stomach pain, loss of appetite
Methotrexate:10–25
mg/week orally or SQ
Folic acid 1 mg/d to
reduce toxicities
inhibition of interleukin-1 (IL-1) activity or other
inflammatory cytokine(IL-6,TNFα)
fever, chills, tiredness, mouth sores,
nausea, upset stomach,dizziness,
abnormal liver function test
Sulfasalazine
Initial: 500 mg orally
twice daily
Maintenance: 1000–
1500 mg twice daily
directly alter adenosine metabolism , inhibition of
synovial neovascularization
common minor gastrointestinal (GI) and central
nervous system (CNS) abnormalities, and
uncommon serious haematological and hepatic
side-effects
Infliximab,
Etanercept,
Certolizumab
TNF α INHIBITORS
Infleximab:3 mg/kg IV at weeks
0, 2, 6, then every 8 weeks. Max 10 mg/kg
infusion and injection site reactions, infections
particularly reactivation of tuberculosis,
autoantibody formation and drug induced lupus
erythematosus, liver function abnormalities
Leflunomide
10–20 mg/d
inhibit dihydroorotate dehydrogenase (DHODH) de
novo synthesis of uridine monophosphate
diarrhea,nausea,stomach pain,loss of
appetite,weight loss,headache,
Anakinra :100 mg SQ
daily
IL-1 receptor antagonist nausea, vomiting, diarrhea, stomach
pain;headache;joint pain;
Tofacitinib:5 mgorally
BID OR11 mg orally daily
jak 1& jak 3 inhibition which mediate production of
IL-2, 4, 7, 9, 15, and 21 aswell as IFN-γ and IL-6.
kin rash, shingles;increased blood pressure;
abnormal blood tests;headache10/6/2019 46

47. Surgical assessment & treatment
• In the upper limb, joints are addressed in a proximal to distal direction
• Surgery for the rheumatoid hand and wrist falls into one of six groups:
• Nerve decompression:-Carpal and cubital tunnel syndromes
• Synovectomy :prior to the development of significant destruction or
deformity
Tenosynovectomy
Tendon surgery
Arthroplasty
Arthrodesis
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48. RA IN ELDERLY :
RA presents in up to one-third of patients
after the age of 60
Older individuals may receive less
aggressive treatment due to concerns about
increased risks of drug toxicity
Decline in renal function should be
considered
Methotrexate is usually not prescribed for
patients with a serum creatinine >2 mg/dL
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49. Juvenile Chronic Arthritis
• In 1977 the European League Against Rheumatism(EULAR) proposed the term JCA
4 criteria (1) onset before age 16 years
(2) arthritis in one or more joints
(3) disease duration of at least 3 months
(4) a pattern of pauciarticular (fewer than five joints
affected), polyarticular (more than four joints affected), or
RF-negative or systemic arthritis with characteristic fever
The American College of Rheumatology: perposed term JIA -5 criteria
EULAR ( duration3 months -6weeks & exclusion of other forms of arthritis)
• The EULAR also included JRA (more than four joints affected and RF-positive status),
juvenile ankylosing spondylitis, and juvenile psoriatic arthritis in the classification
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50. Epidemology
• The prevalence of the disorder is in the range of 113 per 100,000 children
• Demographics: most age at onset is between 1 and 3 years
: girls predominate
:most often have pauciarticular disease
A second peak :approximately age 9 years
: boys = girls
Overall,JIA is twice as common in girls as in boys.
• With pauciarticular disease the ratio is 3 : 1, and with uveitis and arthritis
girls outnumber boys by 5 : 1 or 6 : 1
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51. pathogenesis
• Etiology: unknown
• Human leukocyte antigen (HLA) product, T-cell receptor, and an
antigen called trimolecular complex plays critical role
• Heredity: reported familial incidence of the disorder ranges from 23%
to 41%
• Infection: Mycoplasma fermentans, rubella virus , Bartonella henselae
Perinatal infection with influenza virus
Physical trauma and psychological trauma: flare
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52. Clinical Features
• Pauciarticular Juvenile Idiopathic Arthritis:
Fewer than five joints ,50% presentation Girls :boys by a ratio 7 : 3
Peak period of onset is between 2 and 4 years of age,usually at 4 years
In approximately 50% patients only one joint is involved
Knee is most often affected, with the ankle–subtalar and elbow joints
next in frequency
Small joints of hands and feet are usually spared
Morning stiffness is a frequent complaint
Swelling is persistent & joints are usually mildly tender and swollen
• Hip involvement is unusual and, when present, may raise other
diagnostic considerations.
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53. • Polyarticular- Juvenile Rheumatoid Arthritis:
> =Five or more joints are involved within first 6 months of illness
Two peaks :-first between 1 and 3 years
:- second between 8 and 10 years
Onset is insidious, large joints of lower extremity are often involved,
and pain and swelling are moderate.
Small joints of the hands and feet are commonly involved
Joints of the cervical spine and temporomandibular joints may involve
Joint range of motion is almost always limited
Systemic manifestations:
low-grade fever, hepatosplenomegaly, lymphadenopathy,
subclinical pleural and pericardial inflammation
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54. • Systemic JIA accounts for approximately 4–15% of JIA
defined :arthritis in 1 joint for at least 6 weeks duration
< age 16 years
with or preceded by fever of at least 2 weeks duration that is
documented to be daily (“quotidian”) for at least 3 days
accompanied by one or more of following: evanescent
erythematous rash, generalized lymphadenopathy,
hepatomegaly or splenomegaly, and serositis
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56. Laboratory Evaluation
• No single or definitive test
• Anemia, leukocytosis
• WBC counts of 30,000 to 50,000/mm3 usually with systemic disease
• Elevation of the ESR and CRP level - to the severity
• Synovial biopsies show villous hypertrophy, vascular endothelial
hyperplasia, and infiltration by lymphocytes and plasma cells.
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57. • Radiographic Evaluation:
• Ultrasonography and MRI are useful in the early stages of disease to
identify joint effusion and synovial hypertrophy
• X ray : as described in RA
• Cervical spine.:-Erosion of the odontoid in a “napkin ring” pattern
may be associated with atlantoaxial instability
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58. Management
Multidisciplinary approach from beginning & principle of treatment as
discussed
Medical & surgical
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physician global
assessment (MD global)
of 5 or 5 on a 10-point
numerical rating scale (0–
10 visual analog scale,
where 0 no disease
activity & 10 the most
severe)
active joint count (AJC; 0
joints,1–4 joints, or 4
joints)

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.
Systemic
JIA with
active
systemic
features and
varying
degrees of
synovitis.

61. Surgical management
Synovectomy-indicated when a trial of medical management
for more than 6 months (including intraarticular steroids) has failed
Development of flexion contractures of the hip
Knee results in loss of walking efficiency
Contracture release :
Release of knee flexion -hamstrings, lateral intermuscular septum ,
iliotibial band
Valgus deformity :- either epiphyseal stapling or percutaneous partial
epiphysiodesis
Total Joint Arthroplasty: hip or knee arthroplasty is indicated in
adolescent with marked functional impairment or severe disabling pain
from advanced structural hip or knee joint involvement
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62. Take home massage
• Chronic autoimmune disease with poorly understood
pathophysiology
• Synovitis with inflammatory arthritis
• Dignosed based on Eular and ACR criteria
• Early DMARD for progression of disease progression
• Mainly medical management and surgical management for deformity
correction
• DMARD :s/e and disease activity guide treatment
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63. Refrences
• 2015 American College of Rheumatology Guideline for the Treatment of
Rheumatoid Arthritis
• 2013 Update of the 2011 American College of Rheumatology
Recommendations for the Treatment of Juvenile Idiopathic Arthritis
• EULAR recommendations for the management of rheumatoid arthritis with
synthetic and biological disease-modifying antirheumatic drugs: 2013 update
• Apley and Solomon’s System of Orthopaedics and Trauma
• Harrison 20 e
• Cambell 13 e
• Robbins and cotran 9e
• Clinical Management of the Rheumatoid Hand, Wrist, and Elbow
• Nelson 20 e
• Internet
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