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RHEUMATOID ARTHRITIS

Introduction

Rheumatoid arthritis (RA) is a chronic, inflammatory condition characterized by joint swelling and tenderness and synovial joint degeneration, which leads to chronic pain, extensive joint damage and severe disability.1 RA is considered an autoimmune disease, and the development and optimal use of disease-modifying antirheumatic drugs (DMARDs) have greatly improved patient management and clinical outcomes. Moreover, early diagnosis and intervention has been shown to reduce the progression of joint damage and disability.

Pathophysiology

Pathophysiology of RA involves complex cellular and molecular interactions between the innate and adaptive immune systems, and the synovium is the primary site of the inflammatory and degenerative processes. Early changes result from non-specific inflammation. In the amplification phase, T cells and B cells are activated, which in turn, activate cytokines and proteases. In the chronic phase of RA, destruction of cartilage and bone is primarily due to interleukin 1 (IL-1), tumor necrosis factor alpha (TNF-α) and IL-6.

Incidence and Related Conditions

  • RA prevalence estimates range from 0.5–1.0% in Europe and North America; estimates are lower in Asia (0.2–0.3%).
  • There are genetic (eg, human leukocyte antigen [HLA], protein tyrosine phosphatase [PTP] N22 variant) and non-genetic risk factors (eg, female gender, tobacco, bacterial and viral infection) for RA.
  • Cardiovascular disease is the leading cause of death among patients with RA, and osteoporosis is a major comorbidity that can result from the disease as well as the use of corticosteroids.

Differential Diagnosis

  • Psoriatic arthritis
  • Viral-induced arthritis
  • Systemic lupus erythematosus
  • Mixed connective tissue disease
  • Sjögren’s syndrome
  • Spondyloarthropathy
  • Scleroderma
  • Dermatomyositis

Radiographic Findings

  • In rheumatoid arthritis, typical X-ray findings can include soft tissue swelling, joint space narrowing, periarticular osteoporosis, bone erosions and eventually joint subluxation, dislocation or even auto-arthrodesis in the wrist.
Clinical Presentation Photos and Related Diagrams
  • Classic Rheumatoid right hand with ulnar drift of fingers and subluxed MP joints (Hover over right edge to see more images)
    Classic Rheumatoid right hand with ulnar drift of fingers and subluxed MP joints (Hover over right edge to see more images)
  • Classic Rheumatoid right hand with ulnar drift of fingers, subluxed MP joints with synovitis
    Classic Rheumatoid right hand with ulnar drift of fingers, subluxed MP joints with synovitis
  • Rheumatoid hand and wrist (1) subluxed distal ulna, (2) dorsal tenosynovitis, (3) MP joint synovitis
    Rheumatoid hand and wrist (1) subluxed distal ulna, (2) dorsal tenosynovitis, (3) MP joint synovitis
  • Classic Rheumatoid right hand with destroyed right MP joints
    Classic Rheumatoid right hand with destroyed right MP joints
  • Swan neck deformity secondary to rheumatoid arthritis
    Swan neck deformity secondary to rheumatoid arthritis
  • Rheumatoid hand and wrist subluxed distal ulna and ruptured extensor tendons
    Rheumatoid hand and wrist subluxed distal ulna and ruptured extensor tendons
Basic Science Photos and Related Diagrams
  • A pyramidal approach to the treatment of RA (Ref5)
    A pyramidal approach to the treatment of RA (Ref5)
Symptoms
Pain, swelling and stiffness in multiple joints
Morning joint stiffness or stiffness after sitting.
Affected joints often symmetrical
Joints are warm and red intermittently
Complaints of fatigue, malaise, decreased appetite and weight loss
Aching pain in extremity muscles
Lumps under the skin (Rheumatoid Nodules)
Typical History
  • In most patients, the onset of joint pain and swelling is gradual. In a small percentage, there is an abrupt onset of polyarthritis; other may present with transient bouts of mono- or poly-arthritis. In early RA, the carpals, metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints of the fingers and interphalangeal (IP) joints of the thumbs are most frequently affected. Systemic symptoms include low-grade fever, malaise, fatigue, anorexia and weight loss. In chronic cases, rheumatoid nodules may develop on the elbows, Achilles tendons and fingers.
Positive Tests, Exams or Signs
Boutonniere - observation
Collateral Ligament Stability and Tenderness
Dorsal Tenosynovitis
Extensor Tendon Exam
Flexor Tendon Exam
Piano Key Test
Pinch Strength
Range of Motion: Active
Range of Motion: Passive
Thumb (Grind) Compression Test
Tinel's Sign: Median Nerve
Trigger Finger
Tuck Sign
Grip Strength
Work-up Options
Magnetic resonance imaging - MRI without contrast
Sonographic studies - Ultrasound
Electrophysiological testing - EMG/NCV
Laboratory tests - blood tests
Radiology studies - X-ray
Images (X-Ray, MRI, etc.)
  • Xray of rheumatoid hand - Noted destroyed wrist, finger MP joints and thumb CMC joint (Hover over right edge to see more images)
    Xray of rheumatoid hand - Noted destroyed wrist, finger MP joints and thumb CMC joint (Hover over right edge to see more images)
  • Xray of rheumatoid hand - Noted (1&2) Replaced index and long MP joints, (3) Destroyed but stable wrist and (4) distal ulna previously resected secondary to a damaged joint and pain with forearm rotation.
    Xray of rheumatoid hand - Noted (1&2) Replaced index and long MP joints, (3) Destroyed but stable wrist and (4) distal ulna previously resected secondary to a damaged joint and pain with forearm rotation.
Treatment Options
Conservative: 

RA can follow a moncyclic, polycyclic or progressive course in about 35%, 50% and 15% of patients, respectively. Therefore, in any given patient, it is difficult to evaluate the effect of treatment – pharmacological, physical or surgical – independent of spontaneous, disease-related changes in activity. It is important to consider a step-wise approach to the management of RA, even within the category of conservative treatment options (see Figure).

  • Classes of drugs

−  NSAIDS and cyclooxygenase-2 (COX-2) inhibitors

−  DMARDs and biologics (see Table)

−  Corticosteroids

 

Table. Disease-modifying antirheumatic drugs (DMARDs)6

Medication

Mechanism of Action

Monitoring

Side Effects

Methotrexate

Reduces adenosine

CBC, LFTs

Nausea, stomatitis, hepatotoxicity

Hydroxychloroquine

Unknown

Retina exam

Rare vision loss

Sulfasalazine

Unknown

CBC, LFTs

Nausea, diarrhea

Leflunomide

Inhibits pyrimidine synthesis

LFTs

Diarrhea, rash, hepatoxicity

Azathioprine

Inhibits purine synthesis

CBC, LFTs

Nausea, pancytopenia

Etanercept

Blocks TNF

Screen for TB

Infection

Infliximab

Blocks TNF

Screen for TB

Infection

Abatacept

Blocks TNF

Screen for TB

Infection

Anakinra

Blocks IL-1

None

Infection

Abatacept

Inhibits T-cells

None

Infection activation

Rituximab

Depletes B-cells

None

Infection, lymphocytes

CBC, complete blood count; IL-1, interleukin-1 receptor; LFT, liver function test; TB, tuberculosis; TNF, tumor necrosis factor


 

Operative: 
  • Fusion with internal fixation
  • Tenosynovectomy
  • Arthrodesis
  • Arthroplasty
  • Interposition arthroplasty
Treatment Photos and Diagrams - Open Surgery
  • Index MP joint replacement for RA. (1) Metacarpal head, (2) Silicone prosthesis, (3) Joint capsule for later repair (4) Extensor tendon (Hover over right edge to see more images)
    Index MP joint replacement for RA. (1) Metacarpal head, (2) Silicone prosthesis, (3) Joint capsule for later repair (4) Extensor tendon (Hover over right edge to see more images)
  • Index MP joint replacement for RA - Silicone prosthesis not attached to bone but flexes and pistons back and forth in bones to provide motion.
    Index MP joint replacement for RA - Silicone prosthesis not attached to bone but flexes and pistons back and forth in bones to provide motion.
  • Extensor tendon ruptures in RA; Ulna suluxates dorsally because it's arthritic rough edges wear through the DRUJ capsule and then cut the tendons.
    Extensor tendon ruptures in RA; Ulna suluxates dorsally because it's arthritic rough edges wear through the DRUJ capsule and then cut the tendons.
  • RA: (1) Retracted opened DRUJ capsule, (2) Distal with absent cartilage, (3) Hypertrophic dorsal tenosynovitis, & (4) Ruptured tendon end.
    RA: (1) Retracted opened DRUJ capsule, (2) Distal with absent cartilage, (3) Hypertrophic dorsal tenosynovitis, & (4) Ruptured tendon end.
  • RA: Repaired extensor tendons
    RA: Repaired extensor tendons
  • RA: FPL and FDP II Ruptures - Note lack of thumb and index flexion
    RA: FPL and FDP II Ruptures - Note lack of thumb and index flexion
  • RA: FPL and FDP II Ruptures: (1) Transfer FDS IV to replace FPL, (2) Median Nerve, (3&4) Ruptured flexor tendons
    RA: FPL and FDP II Ruptures: (1) Transfer FDS IV to replace FPL, (2) Median Nerve, (3&4) Ruptured flexor tendons
Complications
  • Operative: infection, neurovascular injury, pulmonary embolus, dislocation, periprostheticosteolysis, sepsis
Outcomes
  • Operative: difficult to generalize owing to heterogeneity and poor design of studies conducted to date.7,8
Key Educational Points
  • Rheumatoid factor is seen only in patients who are 8 years of age or older at presentation.
Practice and CME
References

Cited

  1. Aletaha D, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum 2010;62(9):2569-81. PMID: 20872595
  2. Dougados M, et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: results of an international, cross-sectional study (COMORA). Ann Rheum Dis 2014;73:62-8. PMID: 24095940
  3. Malahias M, et al. The future of rheumatoid arthritis and hand surgery – combining evolutionary pharmacology and surgical techniques. Open Orthop J 2012 6(Suppl 1:M11):88-94. PMID: 22423304
  4. Chung KC, Kotsis SV. Outcomes of hand surgery in patients with rheumatoid arthritis. Curr Opin Rheumatol 2010;22(3):336-41. PMID: 20061956
  5. Ferlic DC, et al. Medical considerations and management of rheumatoid arthritis. J Hand Surg Am 1983;8(5):662-6. PMID: 6415155
  6. Brasington R. TNF-α antagonists and other recombinant proteins for the treatment of rheumatoid arthritis. J Hand Surg Am 2009;34:349-50. PMID: 19135810
  7. Chung KC, et al. Patient outcomes following Swanson silastic metacarpophalangeal joint arthroplasty in the rheumatoid hand: a systematic overview. J Rheumatol 2000;27(6):1395-402. PMID: 10852260
  8. Alderman AK, et al. Effectiveness of rheumatoid hand surgery: contrasting perceptions of hand surgeons and rheumatologists. J Hand Surg Am 2003;28(1):3-11. PMID: 12563630

New Articles

  1. Lee HI, et al. Long-term results of arthroscopic wrist synovectomy in rheumatoid arthritis. J Hand Surg Am 2014;39(7):1295-300. PMID: 24861384
  2. Bidwai AS, et al. Short to medium results using the remotion total wrist replacement for rheumatoid arthritis. Hand Surg 2013;18(2):175-8. PMID: 24164120

Reviews

  1. Trieb K. Arthrodesis of the wrist in rheumatoid arthritis. World J Orthop 2014;5(4):512-5. PMID: 25232527
  2. Chim HW, et al. Update on the surgical treatment for rheumatoid arthritis of the wrist and hand. J Hand Ther 2014;27(2):134-41. PMID: 24530143

Classics

  1. Cregan JC. Indications for surgical intervention in rheumatoid arthritis of the wrist and hand.  Ann Rheum Dis 1959;18(1):29-33. PMID: 13650455
  2. Kestler OC. Histopathology of the Intrinsic Muscles of the Hand in Rheumatoid Arthritis. Ann Rheum Dis 1949;8(1):42-58. PMID: 18623795