1. RHEUMATOID ARTHRITIS
Dr Dhananjaya Sabat MS DNB MNAMS
Assistant Professor Orthopedics
Maulana Azad Medical College, New Delhi

2. • Rheumatoid arthritis (RA) is an autoimmune
disease that results in a chronic, systemic
inflammatory disorder that may affect many
tissues and organs, but principally attacks
synovial joints.
• Affects 1-3% of adult population
• F>M: 3 to 1
• Peak age of onset -35 and 45

3. Diagnostic criteria
• ACR criteria (1987); 4 of the following
– Morning stiffness > 1hr around joints > 6weeks
– Arthritis (pain + effusion) > 3 joints of the 7 joint
groups (PIP, MCP, wrist, elbow, knee, ankle, MTP) >
6weeks
– Arthritis of hand joints; PIP, MCP, wrist > 6 weeks
– Symmetric arthritis – at least 1 area > 6 weeks
– Rheumatoid nodule
– +ve Rheumatoid factor
– Positive radiological changes (symmetric joint
destruction, erosions, periarticular osteopenia)

4. 2010 ACR-EULAR classification criteria
for rheumatoid arthritis
Target population Patients who have at least 1 joint with definite clinical synovitis (swelling) with the
synovitis not better explained by another disease
Classification criteria for RA (score-based algorithm: add score of categories A - D;
a score of ≥6/10 is needed for classification of a patient as having definite RA).
The metacarpophalangeal joints, proximal interphalangeal joints, the interphalangeal joint of the thumb,
second through fifth metatarsophalangeal joint and wrist as small joints, and shoulders, elbows, hip
joints, knees, and ankles as large joints
A. Joint involvement
1 large joint 0
2-10 large joints 1
1-3 small joints (with or without involvement of large joints) 2
4-10 small joints (with or without involvement of large joints) 3
>10 joints (at least 1 small joint) 5
B. Serology (at least 1 test result is needed for classification)
Negative RF and negative ACPA 0
Low-positive RF or low-positive ACPA 2
High-positive RF or high-positive ACPA 3
C. Acute-phase reactants (at least 1 test result is needed for classification)
Normal CRP and normal ESR 0
Abnormal CRP or abnormal ESR 1
D. Duration of symptoms
<6 weeks 0
≥6 weeks 1

5. PATHOLOGY
• Combination of genetic and environmental factors
• An important early event may result from the interaction of
antigen presenting macrophages with T cells
(helper/inducer)
• HLA- DR4 is associated
• It is defined as an antibody against the Fc portion of IgG
• Although clinical laboratories measure IgM rheumatoid
factor, other classes of RF have been described
• Generally believed that complexes of IgG rheumatoid factor
with IgG can deposit in blood vessels and lead to vasculitis

6. Cellular inflammation:
• Inflammation in the joint cavity can be intense
• Monocyte is most responsible for mediating tissue
destruction; neutrophils also invade
• Leading to degradation of articular cartilage,
menisci, and ligaments without restriction
Inciting causes:
• Hepatitis B vaccine: rare
• potential association between RA and two
herpesvirus infections: Epstein-Barr virus (EBV) and
Human Herpes Virus 6 (HHV-6)

7. Synovitis:
• Normally delicate synovial membrane becomes
infiltrated with macrophages, lymphocytes, plasma cells,
and granulocytes
• Synovitis in RA invades cartilage, ligaments, and
subchondral bone
Rheumatoid nodule:
• Central fibrinoid necrosis surrounded by palisades of
histiocytes
• Seen in 30% cases

8. Stages:
• Proliferative: Swelling, pain with motion, limited
movement, nerve compression
• Destructive: Synovial erosion causes irreversible changes
(tendon rupture, capsular weakness and disruption, bone
erosion, joint subluxation and deformity)
• Reparative: Fibrosis replaces inflammation (adhesions,
ankylosis, fixed deformity)

9. PRESENTATION
• Monocyclic (10%) – One attack
• Polycyclic (45%) – Variable duration, severity
and intervals
• Progressive (45%) – Unremitting

10. CLINICAL MANIFESTATIONS
• Symmetrical polyarthralgia, morning stiffness, and fatigue are common
• Morning stiffness results from increases in extracellular fluid in & around
joint
• Later on, there may be limitation of motion due to pain or joint
destruction
• Predilection for wrists and hands; MP joints, PIP joints, and wrists are first
to become symptomatic
• Ulnar deviation, and swan-neck or boutonniere deformities are common

11. EXTRA ARTICULAR MANIFESTATIONS:
Patients with extraarticular manifestations have –
• High-titer RF
• More severe disability
• Increased mortality rate
• Heart- pericarditis, cardiomyopathy, and valvular
incompetence, interstitial fibrosis
• Lungs: Rheumatoid lung (Honeycombed appearance on
CXR due to multiple nodules), Caplan syndrome
(associated with pneumoconiosis), Idiopathic
pulmonary fibrosis
• Eyes- scleritis (most common ocular complication of
RA), scleromalacia perforans)

12. • Nervous system- mononeuritis multiplex, compression
syndromes such as median neuropathy
• Kidneys- amyloid deposition
• Hematopoietic system- Felty's syndrome (anemia,
splenomegaly, and leukopenia)
• Vasculitis: usually is a non necrotising arteritis of the
small terminal arterials, Skin lesions, leg ulcers,
necrotizing arteritis of the viscera, digital infarctions,
and fever
• Sjogren's syndrome: occurs in 15%; RA +
keratoconjunctivitis sicca, xerostomia

13. Cervical Spine in RA
• Cervical spine involvement is common in RA
(upto 90%), more common with long standing
disease and multiple joint involvement
Most common presentations:
• Atlantoaxial subluxation: most common and
may occur in upto 40%
• Atlantoaxial impaction / Basilar invagination
• Lower cervical spine: Joints of Lushka & facet
joints are affected, subluxation may occur at
multiple levels; more common in males, with
steroid use, sero-+ RA, with RA nodules, &
severe RA
• Presentation: neck pain, neurologic involvement,
myelopathy, radiculopathy
• Investigation: Cross table lateral X-ray, MRI

14. Treatment: Indications for Surgery
• 1. Space available for the cord: spinal cord
compression with < 14 mm of room either
at upper or lower cervical spine or with
basilar invagination
• 2. Atlas Dens Interval (ADI): Instability is
present when 3.5 mm ADI difference on
flex/ext views, 7 mm difference may imply
disruption of the alar ligaments; difference
of > 9 mm is assoc with increase in
neurologic injury & will usually require
posterior fusion and wiring.
• 3. Myelopathy: neurologic impairment
and/or instability are indications for
treatment;
• Surgical Options: posterior or anterior
cervical fusion.

15. RHEUMATOID HAND & WRIST
1. Palmar subluxation & Radial deviation of wrist
• Ulnar carpal complex (UCC) is commonly first leading to rupture of the
triangular fibrocartilaginous complex (TFCC) distally -> DRUJ d/l causing
prominent ulnar head “caput ulnar syndrome”-> rupture of EDC 4 and 5.
• Radioscaphocapitate (RSC) or sling ligament is second; joined by
incompetence of the radioscapholunate (RSL) causing rotatory subluxation
of the scaphoid / loss of radial carpal height; joined by radiolunatriquetral
(RLT) and wrist subluxes into anterior position.
• Dorsal radiocarpal(DRC) ligament fails causing ulnar translocation of carpus
• Triquetrohamitatocapitate (THC) can deteriorate causing volar intercalated
segment instability (VISI)
• Mid-carpal joint is relatively spared usually

16. 2. Extensor Tendon Rupture
• EPL Rupture common, t/t: EIP transfer
• Vaughn Jackson syndrome: Ulnar side of wrist is most
common site of extensor tendon ruptures (EDC to 4th & 5th
digits) due to the attrition over the damaged ulnar head
• EDQ rupture (with intact little EDC) is diagnosed with the
Texas long horn sign, in which the index and little finger are
extended while the ring and little fingers are flexed; this
requires intact extensor indicis and EDQ tendons.
3. Flexor Tendon Rupture FPL>FDP little> index>FDS
ring>middle; two usual causes: attrition or direct
4. Ulnar translocation of carpus
5. Ulnar drift of the fingers- with radial deviation of wrist, cause
Z deformity
6. Palmar subluxation of MCP

17. 7.Swan neck deformity of fingers:
Hyperextension of PIP joints
with flexion of DIP joint
8. Boutonniere deformity of
fingers: Hyperextension of DIP
& MCP joints with flexion of PIP
joints
9. Lateral dislocation of any of the
IP joints
10. MP subluxation & dislocation
11. Intrinsic contracture (as
determined by Bunnel Test)

18. Elbow:
• Synovitis
• Posterior subluxation of elbow
• Compression neuropathy – ulnar & PIN
Hip:
• Protrusio acetabuli: often progressive Flexion deformity

19. Rheumatoid Foot
• Initially, RA involves the forefoot, then the midtarsal
joints, and finally the hindfoot; forefoot is involved
twice as often as the hindfoot
Rheumatoid forefoot
• - Hyperpronation of rheumatoid foot
• - Metatarsalgia
• - Claw toes
Midfoot:
• - Talonavicular arthritis
• - Midfoot hyperpronation
• Hind foot: calcaneovalgus

20. LAB TEST
• Rheumatoid Factor: Rose Waller test, present in most RA
patients (80 % of affected pts); associated w/ increased morbidity.
5% normal pts also +ve.
False +ve in- SLE, sarcoidosis, TB, syphilis, chronic liver disease
• Anti CCP antibody (anti-cyclic citrullinated peptide antibodies): more
specific ( 95%) than RA factor.
• Synovial Fluid Analysis: joint fluid in RA is sterile & has
pleocytosis (usually PMN), incr protein, & decreased viscosity &
decreased complement
• ESR: active RA – elevated; good indicator of response to medical
therapy and the activity of the disease
• C Reactive Protein
• Normocytic normochromic anaemia

21. X-ray
• Early changes are limited to the soft
tissues w/ fusiform swelling and joint
effusion
• Juxta-articular osteoporosis
• Cartilage destruction produces
narrowing of the joint
• Erosion of bone occurs
characteristically in the metaphyseal
region underlying collateral ligament
attachments
• Mal-alignment, displacement, and
ankylosis of the joint mark end-stage

22. Differential diagnoses
• Crystal induced arthritis (gout, and pseudogout)
• Osteoarthritis
• Systemic lupus erythematosus (SLE)
• One of the several types of psoriatic arthritis resembles RA
• Lyme disease
• Reactive arthritis (previously Reiter's disease)
• Ankylosing spondylitis
• Hepatitis C
• Sarcoidosis
• Amyloidosis,
• Whipple's disease
• Hemochromatosis
• Acute rheumatic fever
• Gonococcal arthritis

23. TREATMENT
Medical Management:
1. NSAIDS
2. Oral Corticosteroids- used to alleviate intractable joint
inflammation or vasculitis
3. DMARDS
• Methotrexate: anti folate, hepatic and pulmonary toxicity;
first choice DMARD
• Antimalarials: stabilize lysosomal membranes and inhibit
IL1, hydroxychloroquine sulfate, major side effect is
macular degeneration
• Sulfasalazine (anti folate activity)
• Gold: gold salts (inhibit monocyte function), side effects-
thrombocytopenia, neutropenia, or proteinuria
• D-Penicillamine (modulate lymphocyte function)

24. 4. Anti-cytokine agents
• Etanercept - TNF type II receptor fused to IgG1
• Infliximab- chimeric mouse/human monoclonal
antibody to TNF
• Adalimumab- human antibody to TNF
• 5. Immunosuppressive agents
• Azathioprine
• Cyclophosphamide
• Cyclosporin A
• Leflunomide: inhibit dihydroorotate dehydrogenase, an
essential enzyme in the pyrimidine biosynthetic
pathway. Its predominant action is to inhibit the
proliferation of T lymphocytes.

25. Physical Therapy
Surgical treatment
• Synovectomy
• Arthroplasty- hip, knee, shoulder, elbow, wrist,
MCP
• Arthrodesis- wrist, PIP, MCP
• Tendon transfer & reconstuctve surgery of
hand

26. JUVENILE RHEUMATOID ARTHRITIS
ACR dignostic criteria
• Age < 16
• Arthritis of 1 or more joints
• Symptoms of at least 6 weeks
• An onset type after 6 months of observation –
pauciarticular, polyarticular or sysytemic
• Exclusion of other forms of arthritis

27. Types:
• Pauciarticular – less than 5 joints involved;
with ANA + iridocyclitis or HLA B 27 +
spondylitis
• Polyarticular –5 or more joints affected; RA
factor + or -
• Systemic (Still’s disease)
• < 20% have progressive destructive disease;
mostly systemic

28. Pauciarticular:
A. With ANA + iridocyclitis
• F>M
• Onset age < 5yr
• Fewer joint involved
• 30-35% have chronic iridocyclitis; complications- posterior synechia,
band shaped keratopathy, cataract, glaucoma, blindness
B. With HLA B 27 + spondylitis
• M>F
• Onset age- >8 years
• Arthritis involve lower limbs
• Radiographic sacroiliitis
• Iridocyclitis, reiter’s seen

29. Polyarticular:
A. Rh factor -ve
• F>>M
• Symmetrical polyarthritis of small joints of hand, feet, elbow, ankle,
knee
• Low grade extraarticular manifestation
• Inv of temporomandibular joint & cervical spine common
• 10-15% develop severe destructive arthritis
B. Rh factor +ve
• F>M
• Onset: late in childhood
• Childhood equivalent of adult RA
• Symmetric small joint arthritis with rheumatoid nodules, Felty’s
synd, fibrosing pneumonitis
• >50% develop destructive arthritis

30. Systemic (Still’s disease)
• M>=F
• Intermittent quotidian fever (>1030 F) with chill &
evanescent rash
• During fever- myalgia, arthralgia, transient arthritis,
pleuritis, pericarditis, adenitis, abdominal pain
• Hepatosplenomegaly
• Multiple symmetric joint involvement
• Recur in > 50% cases
• No iridocyclitis
• Inv: leucocytosis, anaemia

31. Complications:
• Flexion deformity at hip, knee, elbow
• Triple deformity in knee (Flexion, external
rotation, posterior subluxation; also seen in
TB, Polio)
• Growth defects- short stature, tortional
deformity in limbs, leg length discripancy

32. TREATMENT
• Salicylates- promptly relieve symp. Aspirin 100
mg/kg in 5 devided doses
• Steroids in severe systemic disease &
iridocyclitis
• Deformity correction, physiotherapy
• Synovectomy