Rheumatoid arthritis Flashcards
epidemiology
prevalence RA: 0,5-1%
two-egg sibling: 5%
one-egg sibling: 15-20%
compromised class II HLA molecule - human leukocyte antibody especially HLA-DR 4 develop more RA than normal population
developement is a summation of genetic dispostion, risks and triggers
risks:
- fammilary disorder - strong for ACPA positive patients
- obesity
- age (40-60)
- females
- smokers
- coffeine
most common: antigens from an infection (bacteria and virus) intiate the disease
articular manifestiations
- morning stiffness
- symmetrical polyarthritis (PIP and MCP)
- also wrist, shoulder, hip, knee
- hand and wrist > 90%
- at the beginning without radiographs changing - morning stiffness and swelling
extra articular manifestions
- skin nodulars (especially RF positive - extensor surface of hand and food)
- heart
pericarditis, conduction disorders
- lung
nonspecific interstitial pneumonia (NSIP)
usual interstitial pneumonia (UIP)
cryptogenic organising pneumonia
follicular bronchiolitis
- eyes
- haematologic effects
anemia, thrombocytosis, elevated CRP and ESR
- blood vessels
small and medium vessels, rheumatoid vasculitis
- felty syndrome
splenomegalie, leukopenie, absolute granulocytopenie - seropositive RA
- chauffard syndrome
great lymphomes
EULAR classification
EULAR - European alliance of associations for rheumatology classification
A - joint involvement
1 large joint - 0
2-10 large joints 1
1-3 small joints 2
4-10 small joints 3
>10 joints 5
B- Serology
neg RF and neg ACPA 0
low pos RF and low pos ACPA 2
high pos RF and high pos ACPA 3
C - acute phase reactants (erythrocytes sedimentation rate)
no CRP and no ESR 0
high CRP and high ESR 1
D - duration of disease
< 6 weeks 0
> 6 weeks 1
more than 6 points is a manifested RA
laboratory
- RF and ACPA typical
- ANA maybe
- anemia
- thrombocytosis
- elevated ESR and CRP
pathophysiology with ACPA pos. or ACPA neg.
management
medicals
- step corticosteoids + conventional synthetic disease modyfiying antirheumatic drugs (csDMARD)
- MTX first step for active RA
- Hydroxychloroquine (HCQ - low disease activity - absence of poor prognosis)
- TNF inhibitors (csDMARD with negative response)
histology
3 zones
a - central: necrotic area, composed of fibrin
b - surrounding: histocytes and fibroblasts (palisades with radiating columns)
c - outer layer: chronic inflammatory infiltration
rheumatoid vasculitis:
extra-articular manifestation involves small and medium sized vessels (positive ANA are common)
x-rays
periarticular osteopenia:
- marginal erosions
- subchondral cyst formation (maybe large cysts)
- juxta-articular osteopenia
- subluxation
- dislocation
- deviation
- ankylosis
- DRUJ are involved in 30% in early stage RA and 75% in late stage RA
- look at the age: maybe juvenile idiopathic arthritis
- Geode cysts: subchondral cysts maybe open the joint (not typical in RA: DD calciumpyrophosphate dihydrate disease (CPPD), avascular necrosis)
x-ray changes in time:
- waist of the scaphoid - very early
- ulnar styloid - early
- DRUJ - early
- radiocarpal
- midcarpal (palmar than dorsal)
- radial angulation (carpal ulnar shift - radioscaphocapitate and radio lunate ligament damage)
- MCP
- Thumb
common:
radiocarpal > midcarpal
palmar > dorsal
RSL-Fusion common possible
instable DRUJ - ulnar dorsal luxation
diagnostic criteria
- morning stiffness - 1 hour
- soft tissue swelling - 3 or more joints
- soft tissue swelling - symmetric
- soft tissue swelling hand - MCP, PIP, wrist joint
- subcutaneous nodules - rheumatoid nodules
- seropositive - RF positive
- typical radiographics findings - periarticular erosions
4 of 7 must present to the diagnosis for a RA
DMARD
disease modyfying antirheumatic drugs
conventional:
MTX, Azathioprine, Leflunomide, Plaquenil, Sulfasalazide, Gold
biologic:
TNF-alpha (Enbrel, Remicade, Lumira)
IL-1-inhibitors
monoclonal antibodies
perioperative management:
Corticosteroids: continue
MTX: continue
conventionals DMARD - normally continue
biologic DMARD - hold for 2-4 weeks before and after surgery
soft tissue manifestion
CTS:
rice bodies through chronic tenosynovitis - not minimal
total synovektomie (DD: mycobacteria infections)
caused by microinfarcts in the synovial - rice bodies are fibrin blocks with palisate surrounding histiocytes
trigger finger:
normally the A1-pulley - tenosynovitis!!!
other impressions of infectious tissues
rheumatic nodules in pulleys
if possible no operation (release of the pulley leads to increase of ulnar deviation with a little bow stringing)
extensor ruptures - common!!!
MCP-movement:
phalanx dislocation (tightness with the intrinsic mechanism)
extensor tendon rupture (bony disorder dorsal at the wrist and DRUJ)
sagittal band rupture with tendon luxation
PIN palsy at the elbow through periarticular rheumatoid infections
tendon transfer:
always FDS over RADIAL site (ulnar deviation of the rheumatoid hand)
FCU and FCR not long enough
surgery treatment
fusion and arthroplasty lead to pain relief
more complications with arthroplasty especially with wrist athroplasty
normally:
- wrist fusion
- MCP arthroplasty - silicone
- PIP fusion
- DIP (rare) fusion
DRUJ:
- Darrach-OP: long ulnar with dorsal luxation - leads to tendon ruptur on the dorsum of the hand
- osteotomy proximal to the simoid notch and remove the ulnar head
- maybe fixation with a tendon slip from the ECU through the ulna stump
- stump instability is common with radial-ulnar-impingement
- no support of the carpus of the ulnar side
- ggf. sauve-kapandji op with ulnar support
- ulnar prothesis not for RA, instable DRUJ
surgery treatment II
hand involvement
- 70% hand involvement in the first 2y, 90 in 10y
- DIP joint is normally spared
typical:
- periarticular erosions and osteopenia
- joint space narrowing
- blood:
- ACPA pos., ESR elvated, CRP elevated, positive RF (IgM targets FC portion of normal IgG - elevated in 75-80% of RA patients)
- joint fluid: complement decreased, RF elevates
surgery treatment III
PIP-joint:
collateral ligament involvement - synovitis and disruption of extensor mechanism
boutonniere deformity:
central slip and triangular ligament is involved - lateral band subluxation to volar - boutonniere
swan neck:
volar plate and palmar plate failure - central slip overwhelms palmar failure - swan neck deformity
early repair of boutonniere:
only repair, when passive motion is complete and no arthritis changes in the joint
if not: fusion or arthroplasty (silicone is better than pyrocarbon prosthesis - only 11-13% revisons, good pain relief, minimal improvement in motion)
reasons of ulnar deviation of the fingers
- joint synovitis - radial band and volar plate strechting
- ulnar intrinsics contracts
- lax collateral ligaments also allow ulnar drift
- wrist radial deviation worsens vectors
- flexor tendon eventually drift ulnary
