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Rheumatoid Arthritis

Rheumatoid Arthritis. Corolinda S. Helu, DPM Surgical Resident New York Community Hospital. Overview. Epidemiology History Physical Examination Laboratory Tests Radiographical signs Pharmological Treatment Surgical Treatment of Foot Hoffman-Clayton Case. What is Rheumatoid Arthritis?.

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Rheumatoid Arthritis

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  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 > 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 > 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. Laboratory Tests • Initial work-up • CBC, Metabolic panel, Urinalysis, Sed rate • Rheumatoid factor, Anti-nuclear antibody • Chem: nl, slight decr albumin, incr total protein • Hema:hemocrit- ACD, wbc- mildly up, platelet- rare thrombocytosis

  15. 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

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

  17. 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

  18. Accurate & early= early referral Early referral = early tx Early tx = improved outcomes Most rapid deterioration of jt func 2 yrs after diag NSAIDS Cortisone Best anti-inflam Worst SE DMARDS Gold Methotrexate Leflunomide (Arava) Optimal RA Tx?

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

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

  21. Surgical Treatment? • Goal: Relieve pain • Consider: • Medical condition • Age • Activity level • Condition of Bone & ST

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

  23. Tx for dislocation of lesser MPJ • C: Clayton • D: Modified Clayton

  24. Incisional Approaches • A: Transverse Plantar • B:Elliptic Plantar • C/D: Transverse dorsal • E: 3 Dorsal Longitudinal • F: 5 Dorsal Longitudinal

  25. 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

  26. Case presentation • Labs:CBC w/diff, Chem Panel X, Urinalysis, CXR, EKG, PT/PTT • Xrays:severe 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

  27. 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, antimalarials…which 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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