summary Rheumatoid Arthritis is a chronic systemic autoimmune disease caused by IgM cell-mediated immune response against soft tissues, cartilage, and bone. Patients present with insidious onset of morning joint stiffness, polyarthropathy, subcutaneous nodules, with progressive hand and wrist deformity. Diagnosis is made with a combination of physical examination, characteristic radiographs, and labs to evaluate for presence of RF and anti-CCP antibodies. Treatment is primarily medical management with NSAIDS, DMARDS, biologics, antimalarials, and steroids. Epidemiology Incidence most common form of inflammatory arthritis Demographics affects 3% of women and 1% of men Etiology Pathophysiology immunology login to view 11 more bullets pathoanatomy login to view 6 more bullets Genetics associated with specific HLA loci (HLA-DR4 & HLA DW4) ~15% rate of concordance amongst monozygotic twins Associated conditions orthopaedic manifestations login to view 1 more bullet medical conditions & comorbidities login to view 8 more bullets Presentation Symptoms insidious onset of morning stiffness and polyarthropathy usually affects hands and feet login to view 2 more bullets Physical exam subcutaneous nodules in 20% (strong association with positive serum RF) ulnar deviation with metacarpophalangeal (MCP) subluxation, swan neck deformity hallux valgus, claw toes, metatarsophlanageal (MTP) subluxation joints become affected at later stage in disease process Imaging Radiographs periarticular erosions and osteopenia protrusio acetabuli login to view 2 more bullets joint space narrowing central glenoid erosion Studies Labs anti-CCP (cyclic citrullinated peptide, most sensitive and specific test) anti-MCV (mutated citrullinated vimentin) elevated ESR elevated CRP positive RF titer (most commonly IgM) login to view 2 more bullets joint fluid testing login to view 2 more bullets Diagnostic Criteria (1987 Revised Criteria for Diagnosis of RA) Morning stiffness ≥ 1h Swelling in ≥ 3 joints Rheumatoid nodules Radiographic changes of the hand including bony erosions and decalcification Symmetric arthritis Serum rheumatoid factor Arthritis of the hand (MCP, PIP) and wrist have ≥4 of 7 criteria for a 6 week period Treatment Nonoperative pharmacologic treatment login to view 7 more bullets Operative operative treatment dictated by specific condition login to view 1 more bullet important to obtain preoperative cervical spine radiographs Pharmacologic Management of RA Low dose steroids Corticosteroids Disease modifying anti-rheumatic drugs (DMARDs) Methotrexate A folate analogue with anti-inflammatory properties linked to inhibition of neovascularization therapeutic effects increased when combined with tetracyclines due to anti-collagenase properties Leflunomide An inhibitor of pyrimidine synthesis Sulfasalazine Exact mechanism unknown, but associated with a decrease in ESR and CRP Hydroxychloroquine Blocks the activation of toll-like receptors (TLR), which decreases the activity of dendritic cells, thus mitigating the inflammatory process Others D-penicillamine Biologic Agents / TNF antagonists Etanercept (Enbrel) TNF-alpha receptor fusion protein (TNF type II receptor fused to IgG1: Fc portion) that binds to TNF-alpha Infliximab (Remicade) Human mouse chimeric anti-TNF-alpha monoclonal antibody Adalimumab (Humira) Human anti-TNF-alpha monoclonal antibody Golimumab (Simponi) Human anti-TNF-alphamonoclonal antibody Certolizumab (Cimzia) Pegylated human anti-TNF-alpha monoclonal antibody DMARDS / Biologic Agents /IL-1 antagonists Anakinra (Kineret) Recombinant IL1 receptor antagonist Rituximab (Rituxan) Monoclonal antibody to CD20 antigen (inhibits B cells) Abatacept (Orencia) Selective co-stimulation modulator that binds to CD80 and CD86 (inhibits T cells) Ustekinumab (Stelera) Monoclonal antibody targeting IL-12 and IL-23 Tocilizumab (Actemra) IL6 receptor inhibitor (2nd line treatment for poor response to TNF-antagonist therapy) Preoperative management Medication When to Stop/Restart NSAIDs Stop 5 half lives before surgery (stop ASA 7-10 days before) Steroids Dosing depends on level of potential surgical stress Methotrexate (MTX) Continue Leflunomide Continue for minor procedures. Stop 1-2 days before major procedures, restart 1-2 wks after Sulfasalazine Continue Hydroxychloroquine Continue Ustekinumab Stop 1 week prior to procedure. Restart >14 days postoperatively. TNF antagonists (etanercept, infliximab, adalimumab) Plan surgery at the end of dosing +1 week interval (~13 weeks last dose). Restart 10-14 days after. IL-1 antagonist (anakinra) Continue for minor procedures. Stop 1-2 days before for major procedures. Restart 10 days after. Rituximab Stop 7 months before major surgery. Cervical Spondylitis Cervical spondylitis includes atlantoaxial subluxation basilar invagination subaxial subluxation Finger Conditions Rheumatoid nodules epidemiology login to view 3 more bullets prognosis login to view 1 more bullet presentation login to view 1 more bullet treatment login to view 6 more bullets Arthritis Mutilans seen in patients with RA or psoriatic arthritis digits develop gross instability with bone loss (pencil in cup deformity, wind chime fingers) treated with interposition bone grafting and fusion Ulnar drift at MCP joint introduction login to view 10 more bullets presentation login to view 1 more bullet treatment login to view 23 more bullets Boutonniere deformity pathoanatomy login to view 4 more bullets treatment login to view 6 more bullets Swan neck deformity pathoanatomy login to view 4 more bullets treatment login to view 6 more bullets Thumb Conditions Nalebuff Classification of Rheumatoid Thumb Deformities Type Description Treatment Type 1 Boutonniere (most common deformity, MCP flexion and IP extension) Stage 1: Synovectomy with extensor hood reconstruction Stage 2: MCP fusion or arthroplasty Stage 3: IP and MCP fusion (if CMC is normal). IP fusion and MCP arthroplasty (if CMC is diseased) Type 2 Boutonniere with CMC subluxation (uncommon, deformity primarily at CMC) Same as Type 1 and 3 Type 3 Swan neck deformity (MCP hyperextension, IP flexion) Stage 1:splinting vs CMC arthroplasty Stage 2: MCP fusion Stage 3: MCP fusion with first web release Type 4 Gamekeeper deformity (metacarpal adduction, radial deviation of P1 with lax volar plate and UCL) Stage 1 (passively correctable): synovectomy, UCL reconstruction, and adductor fascia release Stage 2 (fixed deformity) MP arthroplasty or fusion Type 5 Swan neck with MCP disease (MCP volar plate laxity) MP stabilized in flexion by volar capsulodesis Type 6 Skeletal collapse (arthritis mutilans) (MCP volar plate laxity) Combination of arthrodesis Flexor Tendon Conditions Triggering treatment login to view 1 more bullet Mannerfelt syndrome introduction login to view 1 more bullet treatment options login to view 3 more bullets FDP rupture treatment login to view 1 more bullet FDS rupture treatment is observation Extensor Tendon Conditions Extensor Tendon Rupture epidemiology login to view 1 more bullet treatment login to view 1 more bullet Radial sagittal band failure extensor tendons migrate slip into ulnar gutter and volar to center of rotation of MCP joint physical exam login to view 2 more bullets treatment login to view 1 more bullet Vaughan-Jackson syndrome introduction login to view 1 more bullet pathoanatomy login to view 2 more bullets treatment login to view 1 more bullet Differentials for loss of digital extension PIN neuropathy extensor tendon rupture extensor tendon subluxation (torn radial sagittal band) MCP volar subluxation trigger finger Common Tendon Transfers in RA Ruptured Tendon Tendon Transfer EPL EIP to EPL EDQM leave alone EDQM and EDC5 EIP to EDC5 or EDQM to EDC piggyback transfer EDQM, EDC5, EDC4 EIP to EDQM and EDC4 side to side to EDC3 Multiple tendon rupture Use palmaris graft and FDS Wrist Conditions Caput-ulna syndrome pathoanatomy login to view 2 more bullets treatment login to view 6 more bullets Radiocarpal Destruction pathoanatomy login to view 5 more bullets treatment login to view 17 more bullets Elbow Conditions Rheumatoid elbow nonoperative login to view 1 more bullet operative login to view 28 more bullets Shoulder Conditions Introduction RA is most prevalent form of inflammatory process affecting the shoulder with >90% developing shoulder symptoms commonly associated with rotator cuff tears Evaluation classic radiographic findings include login to view 3 more bullets Hip Conditions Protrusio acetabuli Knee Conditions Operative synovectomy of knee login to view 3 more bullets total knee arthroplasty login to view 1 more bullet Foot & Toe Conditions Introduction usually bilateral and symmetric forefoot joints are the first to be affected human leukocyte antigen (HLA)-DR4 positive Toe hyperextension deformity the earliest manifestation of rheumatoid arthritis of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad, painful plantar callosities and skin ulcerations over bony prominences. treatment login to view 1 more bullet Talonavicular arthritis common to have degenerative changes treat with fusion Cervical Conditions Present in 90% of patients with RA diagnosis often missed Cervical rheumatoid spondylitis includes three main patterns of instability atlantoaxial subluxation login to view 1 more bullet basilar invagination subaxial subluxation Complications Postoperative infection history of prior surgical site infection (SSI) login to view 1 more bullet immunosuppressive therapy login to view 7 more bullets Prognosis Significant advances in pharmacologic management have led to a decrease in surgical intervention