Rheumatoid arthritis Flashcards
What is rheumatoid arthritis
- Deformity of joint and periarticular tissue secondary to autoimmune disease causing synovitis.
- Charcaterized by
- pannus formation
- synovitis (hypertrophy of vili, edema of joint)
- T cell infiltration into synovium
- Cellular and humoral activity
- onset 35-65yo, F>M
- thought do be environmentla stimulus in genetically susceptible individual (having HLA-DR4 antigen + smoking/parvo/EBV,rubella viral infx)
What cytokines are active in RA and targets for DMARDs
IL-1,6, TNFalpha
What is the diagnostic criteria for RA
Score >6/10 in pt with joint synovitis and no clear other explanation
Socring based on
- Joint involvement (more pts for more/smaller jts)
- Serology (RF, ACPA)
- Acute phase reactants (ESR, CRP)
- Duration of symptoms (>6wks)
What is your management work-up for pt with RA
Hx
- symptoms progression
- joint involved, function
- previous Tx (medical, splints)
PE
- examine neck, all UE
- Joint: effusions, deformities, crepitus, stiffness, stability
- Skin: nodules
- tendon: AROM/PROM, rupture, triggering, subluxation
- Nerve: compression testing
- Cosmesis: deformity
- Objectiv etetsing: goniometer, grip and pinch strength
Investigation
- B/W: ESR/CRP, RF, ACPA
- synovial fluid: WBC 500-25 000
- Xray
What are findings on xray suggestive of RA
EARLY
- JOINT SPACE WIDENING (EFFUSION)
- osteopenia
LATE
- Joint space narrow (articular loss)
- Irregular cortical erosions (rat-bite)
- subluxation (ligamentous laxity)
How do you classify RA
- By mode of onset
- Systemic (fever, HSM, rash, no jt involved)
- Pauciarticular (usually knee)
- Polyarticular (synovitis of more than 4jts)
- By Nalebuff
- stage 1 - tenosynovitis/synovitis <6mths
- Tx: non surgical
- stage 2- tenosynovitis >6mths
- Tx: tenosynovectomy
- stage 3 - rheumatoid specific hand defority
- Tx: reconstructive sx
- stage 4- crippled hand
- Tx: salvage surgery
- stage 1 - tenosynovitis/synovitis <6mths
- By course of disease
- Remitting
- Male, acute asymmetric jt, no nodules, neg RF/ANA, no HLA marker, no bone/cartilage erosion
- Unremitting
- female >40, gradual symmetric jts, nodules, +R/ANA, + HLA, joint destruction
- Remitting
What are goals and principles of treatment for RA
GOALS
- Pain control
- Funciton improvement
- Control local disease
- Cosmesis
PRINCIPLES
- Non-operative Tx first - multidisciplinary
- Medical - DMARDs, steroid injection
- OT/PT - splints, hand therapy
- Optimize medically before surgery
- Optimize aenesthetic issues pre-op
- Operative Treatment
- Preventative (destruction/deformity
- synectomy/tenosynovectomy
- Corrective
- nerve decompression
- soft tissue recon
- tenosynovectomy
- synovectomy (preserve pulleys)
- tendon transfer
- Reconstructive/Salvage
- arthroplasty
- arthrodesis
- Preventative (destruction/deformity
- ORDER of operative treatments - Priorities -
- proximal >distal
- painful >painless
- flexor before extensor
- flexor recon before MCP arthroplasty>extensor recon
- reliable procedures - tenosynovectomy, wrist fusion, distal ulna rsx
What are perioperative considerations for RA pts
- Cervical instability (atlanto-axial subluxation)
- TMJ ankylosis
- cricoarytenoid arthristis
- Pulmonary fibrosis,s mall airway disease
- CV disease
- Steroids - wound healing, stress dosing (if >5mg/day)
- Infection & wound healing with DMARDS
What is your management of RA skin nodules
- nodulosis in areas of increased pressure (olecranon,extensors)
- negative prognostic indicator
- Tx if painful, infected, ulcarated - resection or steroid inj
What is your management of RA nerve injuries
- trasnsient paresthesia - due to vascular insufficiency, self resolving
- Polyneuritis - due to vasculitis, Tx steroids
- Compression neuropathy
- Median - CTS common. Tx synovectomy +CTR
- Ulnar - rare - due to ulnohumeral synovitis - Tx - synovectomy + cubital tunnel release
- Radial - rare - Tx - PIN decopmression
What is your management of RA EXTENSOR Tenosynovitis
TENOSYNOVITIS - EXTENSOR
- MECHANICAL OBSTRUCTION IN SHEATH =>TRIGGERING, AROM
- Tenosynovectomy at wrist if present for >6mths despite medical Tx
Extensor tenosynovectomy
- skin incision dorsal longitudinal
- watch DRSN, DSUN
- open extensor retinaculum b/w 3rd and 4th compartment in stairstep fashion w large radially- and ulnarly-based flaps
- resect all inflammed synovium, PIN at base of 4th
- if tenodn ruptured/frayed, tenodese to adjacent
- CLosure: pass radially based flap UNDer tendons and ulnarly based flap OVER tendons to improve glinding. Can capture ECU to prevent volar subluxation
- Post- op- splint in neutral, mobilize in 2days
What is your management of RA EXTENSOR Tendon rupture
- Etiology
- caput ulnae ->EDM, EDC
- synovium invasion of 4th ->EDC, EIP
- listers tubercle->EPL
- ruptures ulanr to radial
- DDX for loss of digit extension
- MCP volar dislocation - loss of passive ROM
- tendon volar subluxation - can be actively held once passively extended
- PIN compression - all extensors, tenodesis normal
TREATMENT of extensor rupture
* all graft donors include PL, strip of ECRB/L, 4th toe extensor. Graft is always option for all ruptures
Rupture EPL => transfer EIP/EPB
” EDM => Tenodese EDM/EDC4/5, transfer EIP
” EDM, EDC5 => Tenodese EDC4 to EDM/5 OR transfer EIP to EDM/5
” EDM, EDC 4/5 =>Tenodeses EDC3 to 4, transfer EIP to 5/EDM
“EDM, EDC 3/4/5 =>Tenodeses EDC2 to 3, trasnfer EIP to 4/EDM
” EDM, EDC 2/3/4/5 =>Tenodese EIP to EDC3, trasnfer FDS4 to EDC 4/EDM
‘All fingers => Trasnfer FDS3 to EIP/EDC2/3 and FDS4 to EDC4/EDM
Thumb + all fingers => FDS3 to EPL/EIP, FDS4 to EDC3/4/5
What is your management of RA FLEXOR TENOSYNOVITIS
- may present as triggering and locked in flexion or extension
- tenosynovectomy if no improvement >6mths despite optimial medical Tx
FLEXOR TENOSYNOVECTOMY @ wrist
- palmar longitudinal incision slightly more ulnar than CTR, zigzag at wrist
- perform CTR
- excise synovium and nodules on tendon until full PROM
FLEXOR TENOSYNOVECTOMY @ digits (trigger)
- Bruner incision
- synovectomy long flexor tendon +/- nodule rsx +/- repair any flexor deficit +/- excise FDS slip
- DO NOT Release A1 as may leave to MCP volar subluxation
What is your management of FLEXOR TENDON RUPTURE?
- Etiology: attrition across bony spicules, direct synovium invasion
- Occurs radial to ulnar (opposite of Extensors)
- FPL most common
- rupture 2’ osteophyte on scaphoid = Mannerfelt lesion
- Tx
- tenosynovectomy, osteophyte rsx
- interpositional graft
- IP arthrodesis
- FDS4 trasnfer w bunnell pull out
- FDP rupture
- Treatment by zone only if FUNCTIONAL loss
- Zone 2 - IP arthrodesis
- Zone 3-4 - tenodese to adj FDP
- FDS rupture
- Tx by zone onl if functional loss
- Zone 2 - 2stage recon or IP arthrodesis
- Zone 3 -4- tenodese to adj tendon
- Multiple flexors
- grafts
- trasnfers FDS to FDP
- IP arthrodesis
- split FDP to power >1 finger
What is the pathophysiology of wrist deformity in RA?
Resultant untreated RA wrist deformity is
- volar dislocation of carpus on radius
- destruction of carpal bones
- dissociation of radio-ulnar joint
Pathophysiology on radial side
- RSL and RC ligaments attenuation
- scaphoid flexion deformity
- SL dissocation
- radiocarpal collapse
Pathophysiology on ulnar side
- Ulnocarpal lig attenuation
- Radioulnar dissociation
- ECU volar displacement
NET
- carpus supination
- radial metacarpal shift
- ulnar deviation of fingers
What is the management of RA wrist defomrity
- Operative tretament only after failure of wrist stabilization, pain control, function preservation
OPTIONS
- Synovectomy
- ECRL trasner to ECU
- ECU relocation form volar to dorsal
- Wrist arthrodesis
- Partial - Radiolunate, radioscapholunate
- Total - procedure of choice
- Do darrach procedure at same time as wrist fusion
- Wrist arthroplasty
Describe the operative steps of a wrist synovectomy
- longitudinal incision
- enter b/w 3/4 compartments w rad/ulnr based flaps
- resect PIN
- distract hand to enter joint
- resect synovium, rongeur bony proimenences
- close capsule w nonabsorbing suture
Describe the operative steps of a wrist arthrodesis
- longitudinal incision
- Expose D3 MC at proximal mid MC level
- Excise ECRB off D3
- incise extenor retinaculum in 3rd compartment
- Expose dorsal radius
- excise listers tubercle if required
- enter joint through dorsal capsule
- resect synovium, articular sruface as required
- Expose capitate
- resect PIN 1-2 cm proximal to wrist jt in 4th compartment
- harvest and packed ICBG
- use limited contact DCP (3.5mm 9 hole)
- fixation at D3, capitate, dorsal radius
- close capsule, retinaculum
- Consider Darrch procedure at same time
What are your management options for RA DRUJ arthritis
- Non-operative treatment frist
- Operative options
- Darrach = distal ulnar resection
- Bower’s hemiresection interosition arthroplasty
- Sauve-Kapanji DRUJ arthrodesis
What is caput ulnae syndrome?
- Def: dorsal prominence of Ulna relative to raidus due to radioulnar dissociation (RSL/RC and ulnocarpal ligament attenuation, supination and volar displacement of carpus)
- weakness, painful/loss ROM, crepitus, extensor tendon ruptures, tenosynovitis
Describe the indications and operative steps of Darrach procedure
- Indications: elderly low demand hand with post-traumatic/OA DRUJ arthritis or RA involving DRUJ
- First line for elderly/RA
- Can be performed in RA pts at same time as wrist arthrodesis
- maintain ulnar styloid, TFCC
- Steps
- incision from ulnar styloid to 3cm proximal, volar to ECU and raise periosteal flap
- resection below ulnar styloid to sigmoid notch
- soft tissue stabilization
- splint 4wks to prevent rotation
- Complications - convergence of radius+ ulna, ulna instability
Describe the indications and operative steps of Bowers hemiresection interposition arthroplasty
- Indication: post-trauamtic/OA/RA Druj arthritis
- 2nd choice for RA (after darrach)
- STEPS
- create large ulnar based retinacular flap
- enter 5th compartment
- capsulotomy just proximal to TFCC, keeping ofveal atatchments intact, creating second ulnar based capsular flap
- shape ulnar head to size of ulnar shaft
- suture both retinacular and capsular flaps to volar DRUJ capsule to cover ulna
- Immoblization longer than darrach procedure - 3wks long arm cast, 3wks short arm, 3mths before full activity
Describe the indications and operative steps of Sauve-Kapanji Druj arthrodesis
- Indicaitions: post-trauma, OA, RA DRUJ arthritis, ulnar trasnlocatio of carpus in RA
- for high demand younger RA pts
- STEPS
- incision over 6th compartment, enter 5th compartment, retract EDM
- L shaped capsulotomy proximal to TFCC
- place 2 guide wires in ulnar head towards sigmoid notch
- denude articular surfaces of DRUJ
- insice periosteum of ulnar neck and excise 1cm of ulnar neck
- place two compression screws across DRUJ
- FCU tenodesis for stabilization if required
- closure of capsule
What is the pathophysiology and anatomic forces leading to MCP deformity in RA
Deformity of RA MCP jt
- ulnar subluxation of extensor tendon
- volar ulnar deviation of PP at MCP jt
Pathophysiology and anatomic features
- synovitis of CL, VP
- radial carpus traslocation and volar subluxation contibute to resultin fulnar drift
- pinch forces
- flexor position support ulnar palmar pull
- radial sagital band attenuation
- shape of MC head
- ulnar intrinsics pull
How do you manage RA MCP jt deformity
OPTIONS
- MCP synovectomy and tendon rebalancing
- MCP arthroplasty
MCP SYNOVECTOMY & TENDON REBALANCING
- controls local disease, indicated if synovitis only and joint surfaces intact
- dorsal longitudinal incision from PIP to MCP
- synovectomy of MCP jt
- Tendon rebalancing
- umbricate radial sagittal band
- ulnar intrinsic release
- ECD centralization with vest over pants sutures to RSband
- Or Cross intrinsic trasnfer - divide ulnar intrinsic of D2/3/4 and release ADM and trasnfer to radial D3/4/5
MCP ARTHROPLASTY
- indicated if joint destruction
- Only do MCP after wrist (proximal first!)
- Swanson silicone arthroplasty
- combined with tendon rebalancing
- release ulnar intrinsics
- umbricate RSband, centralize Extensor tendon
what is the etiology of the boutonniere deformity in RA and resulting deformity?
ETIOLOGY - always starts at PIP
- Synovitis of PIP capsule, leading to CS destruction/attenuation
- flexion of PIP, hyperextension of DIP
- volar subluxation of laterla bands
- contracture of TRL and shortened ORL
- lax flexors
How do you classify and manage boutonniere deformities in RA
Nalebuff and MIllender classification
Stage 1 => PIP full passive ROM
- Tx: splint in trough splint and AROM fo DIP
- PIP synovectomy
- if ORL tight, Fowler TT tenotomy
Stage 2 =>limited PROM, joint surface intact
- Tx: trial of splinting
- PIP synovectomy
- Central slip recon (shortening)
- Fowler TT tenotomy (release ORL tightness)
- Lateral band transfer (from conjoined T to recon CS)
Stage 3 => no passive ROM, FIXED, +jt destruction
- Tx: PIP arthrodesis (index 40, and increase by 5)
- Tx arthroplasty (2nd choice) - will need extensor/CS recon and requiring resection of CL (destab PIP)
What is the etiology of swan neck deformity in RA
ETIOLOGY:MCP SYNOVITIS
- MCP synovitis =>dorsal => attenuation of extesnor insertion on base of PP
- MCP synovitis =>volar =>laxity VP, adhesions and contracture of intrinsics
- PIP synovitis =>volar =>VP laxity, TRL attenuation, FDS rupture, dorsal translocation of conjointed latral band
- DIP synovitis =>dorsal =>TT rupture
How do you classify and mange swan neck deofmrity in RA
Nalebuff
Stage 1=> full PIP PROM
- Tx: splint PIP in FLEXION, fuse DIP in extension
- PIP ST rebalance to keep flexed (internal splint) - FDS tenodesis - one slip of FDS secured to A1/2 or through drill hole in PP. Stat AROM in DBS
Stage 2 =>limited PIP PROM, + due to intrinsic tightness (less PIP flexion with MCP hyperextension
- Tx: MCP intrinsic release, arthoplasty if required
- PIP FDS tenodesis
- DIP arthrodesis
Stage 3 => limited PIP PROM in all MCP positions
- Tx: MCP intrinsic release
- Step wise release of PIP to restore mobility - release conjoined lat bands, dorsal capsule, relase CL, lengthen CS then if needed FDS tenodesis
- DIP arhtodesis
Stage 4 => limited PROM PIP and joint destruction
- Tx: PIP arthrodesis
What are the preferred tratments for RA thumb deformities?
- CMC: trapeziectomy and teodong interposition
- MCP: arthrodesis or silicone arthroplasty
- IP: arthrodesis
How do you treat boutonniere deformity in RA thumb
- Most common defomrity
- MCP synovitis leading to EPB attenuation, MCP hyerpflexion as PL falls ulnar
- If passively correctbale, ST recon of MCP w extensor centralization
- If not, MCP arthroplasty of arthrodesis
How do you treat swan neck deformity in thumb RA
- 2nd most common deformity
- CMC issue - dorsal radial subluxation, compensatory hyperextension of MCP
- If correctable passively, CMC arthroplasy and MCP tendon centralization or arthrodesis if not correctable
At what angles are MCP arthodeses positioned for fusion and descrobe the procedure
MCP: Index 25 and increase by 5 to little finger
Thumb MCP: flex 20, pronate 20, abduct 20
Longitudinal incision along the MCP joitn, split extensors and capsule
Rongeur off articular surface and keep shape
fixate with cross kwires or plate
What is the preferred treatment option for SLE hand deformities?
- no synovitis, but periarticular disease resulting in joint laxity -ST recon not effective
- Tx:
- Wrist arthroesis + Darrach
- MCP: Swanson MCP arthroplasty
