RHEUMATOID ARTHRITIS

&
GOUT ARTHRITIS

dr Putu Feryawan Meregawa, SpOT

Orthopaedi & Traumatology Udayana University
Sanglah General Hospital, Denpasar-Bali
RHEUMATOID ARTHRITIS
What is Rheumatoid Arthritis?

the most common cause of chronic

inflammatory joint disease

Rheumatoid arthritis, which is one type of inflammatory

polyarthritis, is characterized by a variable but usually
prolonged clinical course with exacerbations and remissions
of joint pains and swelling that frequently lead to progressive
deformities and may even lead to permanent disability
(Salter, 1999)
 Introduction
Definition

• Systemic inflammatory disease of the synovium

Epidemiology

• 1-2% = most common inflammatory arthritis

• 4th-5thdecade
• Women > men

Etiology

• Genetic susceptibility = HLA-DR4

• Appearance of RF & anti-CCP
 Causes
Genetic susceptibility

An immunological reaction, possibly involving a foreign antigen,

preferentially focused on synovial tissue

an inflammatory reaction in joints and tendon sheaths

the appearance of rheumatoid factors (RF) and anti-citrullinated

antibodies (anti-CCP or ACPA) in the blood and synovium

Perpetuation of the inflammatory process

Articular cartilage destruction.

Pathology
 Pathology
• RA becomes clinically apparent, the immune pathology is
Preclinical already beginning
• Raised ESR, C-reactive protein (CRP)

• Vascular congestion
• New blood vessel formation,
• Proliferation ofsynoviocytesand infiltration of thesubsynoviallayers by polymorphs,
Synovitis lymphocytes and plasma cells
• Thickening of the capsular structures, villous formation of the synovium and a cell-
rich effusion into the joints and tendon sheaths

• Articular cartilage is eroded, partly by proteolytic enzymes, partly by vascular tissue

in the folds of the synovium, and partly due to direct invasion of the cartilage by a
Destruction pan- nus of granulation tissue creeping over the articular surface.
• swelling of the joints, tendons and bursae.
 Pathology
• The combination of articular destruction, capsular
Deformity stretching and tendon rupture leads to progressive
instability and deformity of the joints.
 Clinical Features
Insidious subacute onset over 6 weeks

Fatigue, malaise, anemia

Morningstiffnessandpolyarthritiswithswelling

Hands/wrists have early involvement: MCP and PIP

Laterdevelopcharacteristicchanges
• UlnardeviationandMCPsubluxation
• “Piano-key” ulna—hypermobile distal radioulnar joint (DRUJ)
• “Swan-neckdeformity”—PIPextended/DIPflexed
• “Boutonnière deformity”—PIP flexed/DIP extended
• “Z-linedeformity”—thumbIPextended/MPflexed

Feet affected early—30% present with foot pain

• Metatarsophalangeal(MTP)joints,clawtoes,andhalluxvalgus

Subcutaneous Rheumatoid nodule.

Clinical Features
Clinical Features

RA vs OA

Arthritis Clinical
Picture in Hand
 Systemic Manifestation
Distalsplinterhemorrhagetogangren
e

Cutaneousulcers(pyodermagangre
nosum)

Rheumatoidvascul
itis Visceralarteritis

Pericardial
Pericarditis
effusion

Pleurisym,nodules
Pulmonarydisease
,fibrosis
 Radiologic Features

Hand radiographs reveal

Radiographs show loss of
classic ulnar deviation at
joint space and bony
the metacarpophalangeal
demineralization.
joints.

Cervical spine radiographs

Magnetic resonance
may demonstrate
imaging may show
degenerative changes and
synovial hypertrophy and
vertebral body
erosions.
subluxations.
Radiologic Features
 Diagnostic Criteria
Morningstiffnesslastinglongerthan60minutes

Swelling—symmetric, both hands/feet

Nodules—20% of RA patients over life

Positivelaboratorytestresultsoftenfound:
• ESR, C-reactiveprotein (CRP)
• Rheumatoidfactor(RF) titer:
• Autoantibodies(immunoglobulin[Ig]MorIgG)toFcportionofIgG
• Positiveinabout80%
• Positiveyearsbeforesymptomsdevelop
• Anticycliccitrullinatedprotein (anti-CCP)
• Mostsensitiveandspecifictest(≈90%specific)
• Positiveyearsbeforesymptomsdevelop
• Linkedtomoreaggressivedisease
• Aspiration:
• WBCs: typically 5000 to 50,000
• OftenincreasedRF
• Decreased complement
• Radiographic findings are symmetric
• Juxta-articularerosionsandperiarticularosteopenia
Aim of Treatments
help the patient understand the nature of
the disease

to provide psychological support

alleviate pain

suppress the inflammatory reaction

maintain joint motion and prevent deformity

correct existing deformity

Salter, Textbook of
Disorder and Injuries Of
The Muskuloskeletal
improve function System

strengthen weak muscles

rehabilitate the individual patient.

Treatment

(Apley, 2017)
 Treatment - Surgical
May decrease pain and
swelling
Joint surgery =
arthrodesis, arthroplasty,
osteotomy
Does not prevent
radiographic progression
Surgical Synovectomy—less
Treatment commonly used
Does not prevent need for
arthroplasty
Total joint replacement
(not osteotomy or partial)
Does not improve ROM
GOUT ARTHRITIS
What is Gout Arthritis?
Goutis a disorder of purine metabolism characterized
by hyperuricaemia, deposition of monosodium urate
monohydrate crystals in joints and peri-articular tissues
and recurrent attacks of acute synovitis.

Late changescartilage degeneration, renal

dysfunction and urolithiasis

(Apley, 2017)
 Kuo et al, 2015 -Global epidemiology of gout:
Prevalence prevalence, incidence and risk factors
 Kuo et al, 2015 -Global epidemiology of gout:
Prevalence prevalence, incidence and risk factors
Risk Factors
Haemolytic
Older age, male Genetic enzyme
disorders,
gender defects, hyper-
myeloproliferative
parathyroidism
disorders

High consumption
Chronic
Obesity, diabetes, of red
inflammatory
hypertension meat,hyperlipidaemi
diseases
a

Long-term use of
Alcohol abuse
aspirin or diuretics
 Pathophysiology
Urate crystals are
Remains inert
deposited in minute
for months- Local trauma
clumps in connective
years
tissue

Urate deposits may build up

in joints, peri-articular
tissues, tendons and bursae Needle- like
• Common sites: 1stMTPJ, crystals
Excite an acute
Achilles tendons, olecranon dispersed into
inflammatory
bursae and the pinnae of the joint and the
ears. reaction
surrounding
• May ulcerate through the skin tissues
or destroy cartilage and peri-
articular bone
Clinical Features
Single joint is common

Often polyarticular in men with

hypertension and alcohol abuse

Painful, swollen, and

erythematous.

Chronic:

• Stiffness
• Deformity
• Tophican ulcerate through the skin
and discharge its chalky material.
Radiaographic
Examination

Periarticular erosions

The peripheral
marginthin overlying
rim of bone (cliff sign)

Chronic:
• Joint space narrowing and
2ndosteoarthritis
• Tophipunched-out ‘cysts’ or
deep erosions in the para-
articular bone ends
• Bone destruction
Pathology Examination

• Needle and rod-shaped crystals

Joint with negative birefringence
aspirationdefinitive • Joint white blood cell count
diagnostic procedure <50,000 to 60,000/μL
Hematoxylinand
eosin staining
amorphous
amorphous material
material and
andinflammatory
inflammatory cells
cells

Laboratory
 Serum uric acid level is often elevated (but
not always).
TREATMENT

Nonsteroidal anti-
inflammatory
drugs

Colchicine

Hypouricemic
therapy
• Allopurinol
• Probenecid
Differential Diagnosis

 Pseudogout  joint fluid is characterized by

positively birefringent, rhomboid-shaped
calcium pyrophosphate dihydrate crystals.
Differential Diagnosis
Cellulitis

Septic bursitis
Infection
Infected
bunion

Septic arthritis
Other DD

Reiter’s Acute pain and swelling of a

disease knee or ankle

Rheumatoid DD/ with polyarticular gout

arthritis (RA) and elbow tophi
Rehabilitation in Arthritic
 Postoperative Total Hip
Arthroplasty Rehabilitation
Programs
Postoperative Total Hip Arthroplasty
Rehabilitation Programs
Postoperative Total Hip Arthroplasty
Rehabilitation Programs
Postoperative Total Hip Arthroplasty
Rehabilitation Programs
The Arthritic Knee
Rehabiliatation
 References
 Blom, A., Warwick, D. and Whitehouse, M. (2017) Apley & Solomon’s
System of Orthopaedics and Trauma. 10th edn. New York: CRC
Press.
 Leiberman, J. R. (2014) ‘AAOS Comprehensive Orthopaedic Review’,
American Academy of Orthopaedic Surgeons. doi:
10.1016/j.ijrobp.2009.05.029.
 Maxey, L. and Magnusson, J. (2013) Rehabilitation for Postsurgical
Orthopaedic Patient. 3rd edn. Missouri: Elsevier Mosby.
 Saunders, R. J. et al. (2016) Hand and upper extremity
rehabilitation : a practical guide. 4th Ed. Missouri.
 Stephen R.Miller, M. D. and Thompson, S. R. (2016) Miller’s Review
of Orthopaedics. 7th edn. Philadelphia, USA: Elsevier.
THANK YOU