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• Stage 1: Synovitis.
• Inflammatory cell deposition.
• Painful, swollen, tender joints.
• Stage 2: Destruction.
Chronic synovitis
• Stage 3: Deformity.
Deformity
1. Morning stiffness.
2. Arthritis of 3 or more areas.
3. Arthritis of hand joints.
4. Symmetrical Arthritis.
5. Rheumatoid Nodules.
6. Rheumatoid Factor.
7. Radiological changes.
{4 of the 7 for at least 6 weeks}
Investigation
• Blood tests
• Normocytic normochromic anemia.
• Rasied ESR.
• Serological test
• Rheumatoid factor.
• Anti CCP.
• Synovial fluid Analysis
• Raised WBC.
• Mucin test.
• Low sugar.
Rheumatoid Factor
• NOT DIAGNOSTIC
• High titers marker of poor prognosis.
• Present in 60 – 80% Pts of RA.
• Once positive no need to repeat.
• Positive RFs
–Rheumatological diseases
• RS,SS,SLE,SSc,MCTD,JCA.
–Infections
• TB,leprosy, syphilis, IE,Inf.hepatitis etc.
–Post vaccination
–Neoplasms.
–Others
• Cirrhosis,DM etc.
Investigation
• Radiological
• Juxta articular osteoporosis.
• Joint destruction.
• Deformity.
• Ankylosis.
• CT Scan
• MRI
Differential Diagnosis Of
Polyarthritis
• SLE.
• Psoriatic arthropathy.
• Ankylosing Arthropathy.
• Reiter’s disease.
• Polyarticular Gout.
• CPPD.
• Osteoarthritis.
• Sarcoidosis.
• Polymyalgia rheumatica.
Aim Of Treatment
• Drug Therapy
• First Line Drug- NSAIDs.
• Second Line Drug- DMARDs.
• Third Line Drug- Immunomodulators.
• Corticosteroids.
• Physiotherapy
• Preserve joint mobility & function.
• Splints
• Prevent & correct deformities.
• Local steroid injection
• For trigger finger and Carpal tunnel syndrome.
Role of DMARDs
Indications
• During acute & severe flare.
• Prominent extra-articular features.
• Bridge therapy.
• Rheumatoid vasculitis.
• In elderly.
• Failure of DMARDs.
Drug Treatment
• STOP:
• Salycilates – 2 Wk prior to surgery.
• NSAIDS – 5 Days prior to surgery.
• If corticosteroids taken for more than 3
Wks in previous 12months, it should be
given in pre, intra & post operative period.
Surgery
Articular disease
• Synovectomy.
• Arthroplasty.
• Arthrodesis,
Surgery
• Synovectomy
• Arthrodesis
• Arthroplasty
Major Joints
Synovectomy
• Range of motion preserved but not
increased.
• Useful in early stages of disease.
• Cartilage damage & FFD should be less.
• Minimum of 6 month of conservative
therapy being ineffective.
• In elbow radial head excision should be
combined.
• In shoulder excision of bursa should be
combined.
Major Joints
Arthrodesis
• Rarely indicated.
• For severe U/L
joint involvement in
young individual.
Major Joints Total Condylar
TKR
Cemented THR
Arthroplasty
• Surgical treatment of
choice
TSR
Semiconstrained