Rheumatoid arthritis and osteoarthritis

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1. RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS GUIDED BY-DR. USHA JAIPAL PRESENTED BY-DR. SONAL SARAN

2. RHEUMATOID ARTHRITIS Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease predominantly affecting diarthrodial joints and frequently a variety of other organs. Peak incidence is between 4 th and 6 th decade. Females are two to three times more affected than males. Genetic and autoimmune factors are mainly responsible for the initiation of disease process.

3. PATHOGENESIS The pathologic hallmark of RA is synovial membrane proliferation and outgrowth associated with erosion of articular cartilage and subchondral bone. There is role of both cellular and humoral immune mechanism in the onset of inflammation.

4. C/F Small joints of Hand-Pain/Stiffness > 1HR. The pattern of joint involvement is typically polyarticular and symmetrical and involves- proximal interphalangeal (PIP) metacarpophalangeal (MCP) wrist, elbow, shoulder, knee, ankle,MTP joints and cervical spine . The distal interphalangeal (DIP) joints of the fingers are usually spared .

5. C/F FEVER/MALAISE/HEADACHE JOINT SWELLING/TENDERNESS. With persistent inflammation, a variety of characteristic joint changes develop like- Z-deformity Swan neck deformity Boutonniere deformity.

6. DIAGNOSTIC INVESTIGATION CLINICAL. MRI IOC for early detection of disease ULTRASOUND X-RAYS. CT SCAN. SYNOVIAL FLUID ASPIRATION ANEMIA,RAISED ESR… SEROLOGICAL TESTS.

7. DIAGNOSIS Guidelines for classification a. Four of seven criteria are required to classify a patient as having rheumatoid arthritis (RA). b. Patients with two or more clinical diagnoses are not excluded.

8. DIAGNOSIS Criteria a. Morning stiffness : Stiffness in and around the joints lasting 1 h before maximal improvement. b. Arthritis of three or more joint areas : The 14 possible joint areas involved are right or left proximal interphalangeal , metacarpophalangeal , wrist, elbow, knee, ankle, and metatarsophalangeal joints.

9. DIAGNOSIS c. Arthritis of hand joints : Arthritis of wrist, metacarpophalangeal joint, or proximal interphalangeal joint. d. Symmetric arthritis : Simultaneous involvement of the same joint areas on both sides of the body. e. Rheumatoid nodules : Subcutaneous nodules over bony prominences, extensor surfaces, or juxtaarticular regions observed by a physician.

10. DIAGNOSIS f. Serum rheumatoid factor : Demonstration of abnormal amounts of serum rheumatoid factor. g. Radiographic changes : Typical changes of RA on posteroanterior hand and wrist radiographs that must include erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints.

11. Flow chart shows approach to radiographic evaluation of arthritis.

12.    RA of the metatarsophalangeal joints . left foot shows concentric joint space narrowing and subcortical cysts in all of the metatarsophalangeal joints. Erosions are seen in the second and fourth metatarsophalangeal joints, which are deformed to some extent

13.   Advanced RA. Radiograph of the hand shows severe destruction and mutilation of the radiocarpal , intercarpal , carpometacarpal , and metacarpophalangeal joints. . Intercarpal ankylosis is noted. There is also subluxation and deviation of the fourth and fifth fingers.

14. Radiograph of the right hand shows cysts along the radial aspect of the head of the second metacarpal (*).

15.  Advanced RA. Radiograph shows mutilation and deformity of the left elbow.

16. Posteroanterior wrist radiographs show discontinuity of bone cortex representing erosion (arrow) with development of osteopenia .

17.   RA of the wrist. Radiograph shows a ballooned ulnar styloid process. There are small cysts (*) in the styloid process and scaphoid bone. The radiocarpal joint space is narrowed.

18.   Longstanding arthritis of the shoulder joint. Radiograph of the left shoulder shows a deep erosion (*) at a typical site.

19.   Narrowing of joint spaces in long-standing RA. Radiograph (detail view) shows narrowing of the joint spaces of the second and fourth metacarpophalangeal joints (*). The concentricity of the narrowing is a hallmark of arthritis, whereas joint space narrowing due to degenerative changes is eccentric.

20.  CT image shows shallow erosions with sclerotic and well-demarcated margins at the second and fifth metacarpophalangeal joints (arrowheads).

21.   Bone erosion in a patient with RA. Longitudinal high-resolution sonogram shows an irregular erosion of the metacarpophalangeal joint (arrowheads).

22.    Synovitis of the metacarpophalangeal joint. Longitudinal high-resolution (10.5-MHz) sonogram shows thickened synovial tissue (arrows).

23.   RA of the atlantodental joint. Axial contrast-enhanced fat-saturated spin-echo T1-weighted MR image shows hypervascular pannus (*) around the dens axis.

24.   Axial spin-echo T1-weighted MR image of the left wrist shows extensive synovitis of the ulnar aspect (*) and erosions and deformity of the ulnar styloid process (arrowhead).

25.  Axial contrast-enhanced fat-saturated T1-weighted MR image of the wrist shows multiple intrasynovial rice bodies (arrows).

26.   Long-standing mutilating RA. Coronal spin-echo T1-weighted MR image of the left hand shows severe destructive changes in the carpus and radiocarpal joint. The carpometacarpal joints are less severely affected. Active arthritis of the third metacarpophalangeal joint is associated with reactive edema of the bone marrow (*).

27. Figure 17.  RA of the wrist. Axial contrast-enhanced fat-saturated T1-weighted MR image shows a carpal cyst (arrow) that communicates with the inflamed synovium via a small extension (arrowhead). This cyst is a typical “ subcortical erosion.”

28.   Incidentally discovered bone cyst in a middle-aged patient with RA. Coronal spin-echo T2-weighted MR image of the hand shows a hyperintense cyst with a sclerotic rim (arrow).

29.   Acute painful arthritis of the third metacarpophalangeal joint. The enhancement of the bone marrow (*) is indicative of inflammatory involvement or a reactive response.

30.   Small joint effusion in a 20-year-old woman in whom RA was later diagnosed.

31.  Acute tendovaginitis of the flexor of the middle finger in a young man with a diagnosis of RA. Axial contrast-enhanced fat-saturated T1-weighted MR image shows fluid (*) surrounded by enhancing synovium (arrowheads).

32.   Long-standing RA in a 52-year-old woman. . Coronal contrast-enhanced fat-saturated T1-weighted MR image shows synovitis of the second and third metacarpophalangeal joints. A subcortical cyst (arrowhead) is seen near the bare area. This type of lesion is called a pre-erosion or subcortical erosion by some authors owing to the high likelihood that it will progress to a clear erosion.

33. Figure 4.  RA in a 75-year-old woman. . Coronal contrast-enhanced fat-saturated T1-weighted MR image shows hyperenhancement of small joints in the hand (arrows), a finding that reflects hyperemic synovial tissue. Erosions (arrowheads) and thickened, intensely enhancing synovium are seen at the fifth metacarpophalangeal joint.

34. OSTEOARTHRITIS Most common type of arthritis. Leading cause of disability in elderly. Much more common in women than men. Definition: OA is joint failure,a disease in which all parts of joint have undergone pathologic change.initial step in the onset of disease is failure of joint protective mechanism. Joint vulnerability and joint loading are the two major factors in development of disease.

35. Primary osteoarthritis   is mostly related to aging. With aging, the water content of the cartilage increases, and the protein makeup of cartilage degenerates . Secondary osteoarthritis  is caused by another disease or condition. Conditions that can lead to secondary osteoarthritis include obesity, repeated trauma or surgery to the joint structures, abnormal joints at birth (congenital abnormalities), gout, diabetes, and other hormone disorders .

36. RISK FACTORS Increasing age. Female gender. Obesity Injurious physical activity. Bridging muscle weakness. Malalignment . Proprioceptive deficiancies ( eg.charcot arthropathy ). Genetic susceptibility.(hand and hip OA.)

37. JOINTS AFFECTED IN OA Hip Knee DIP( haberden’s node) and PIP( bouchard’s node). First carpometacarpal joint Cervical vertebrae First metatarsophalangeal joint. Lower lumber vertebrae. Involvement is asymmetric unlike RA.

38. PATHOLOGICAL HALLMARKS Cartilage is the primary target tissue for OA. There is nonuniform loss of the cartilage. Evidense of new bone formation is presence of osteophytes . There is as assymetric and nonuniform involvement of the joints. Capsule may become edematous and fibrotic. Joint space narrowing is present as seen in all types of arthritis.

39. Symptoms Pain o     Joints may ache, or the pain may feel burning or sharp. For some people, it may get better after a while. o     Pain while sleeping or constant pain may be a sign that arthritis is getting worse.  Stiffness o    When you have arthritis, getting up in the morning can be hard. o    Joints may feel stiff and creaky for a short time, until get moving. o    May also get stiff from sitting.  The muscles around the joint may get weaker o    This happens a lot with arthritis in the knee. Cracking and creaking o    Joints may make crunching, creaking sounds. Limited range-of-motion

40. Investigations X-RAY-although used for evaluating OA ,are insensitive for identifying early disease process. They correlate poorly with patients symptom. Synovial fluid analysis-WBC’s count more than 1000/ microlitre indicate inflammatory arthritis and less likely OA. ULTRASOUND. MRI. CT-scan. BONE SCAN.

41. Weight Bearing Technique o    Films obtained during weightbearing or varus and valgus stress are necessary in early stages of osteoarthritis of the knee joint. o    Ideally, the weightbearing radiographs should be obtained with a patient standing only on the involved leg in 15 to 20 degrees of knee flexion. o    With the knee in extension, early joint space loss may not be seen . o    The weightbearing technique also allows more accurate delineation of subluxation , varus or valgus angulation , and lateral instability

42. Osteoarthritis. Osteoarthritis. Posteroanterior radiograph shows interphalangeal joint space narrowing, subchondral sclerosis, and osteophyte formation (arrows).

43. CT-SCAN OF HIP JOINT SHOWING CHANGES OF OSTEOARTHRITIS.

44. CT-SCAN OF ELBOW JOINT SHOWING CHANGES OF OSTEOARTHRITIS.

45. CT-SCAN OF HAND SHOWING OSTEOPHYTE IN THE HEAD OF 4 TH METACARPAL.

46. o     The MRI is most useful for patients with very early osteoarthritis of the knee. o   For people who have knee pain without injury and who have not responded to cortisone shots or anti-inflammatory medicines, the MRI can detect meniscus cartilage  degeneration that cannot be seen on x-ray. MRI

47. Figure:  T1-weighted coronal MRI of the knee shows typical findings of osteoarthritis, including narrowing and subchondral changes at the medial femorotibial compartment and osteophyte formation.

48. An MRI shows a knee with chronic effusion, joint space narrowing due to loss of femoral and tibial articular cartilage (white arrow), and a torn meniscus (black arrow). 

49. Figure 2 MRI image of the knee joint in osteoarthritis demonstrating synovitis and subchondral bone abnormalities.

50. A rapid MRI examination for osteoarthritis (OA) include: T2 mapping to estimate the amount of cartilage collagen, and sodium imaging to estimate cartilage glycosaminoglycan content, an important component of connective tissue. These physiologic measurements should be more sensitive to early changes of OA than structural information alone.

51.  US-guided steroid injections in hip OA is an efficacious and safe therapeutic approach to achieve pain control and reduction of synovial hypertrophy avoiding the use of X-ray-guided procedure.

52. Radionuclide Bone Scans o    Radionuclide Bone Scans are very sensitive in detecting reactive bone edema associated with osteoarthritis. o    Bone scans can also image the entire skeleton in one examination and thus can provide the clinician with helpful information in patients with multiple sites of arthritic involvement .

53. Therapeutic ultrasound for osteoarthritis of the knee or hip - Therapeutic ultrasound may be beneficial for people with osteoarthritis of the knee. -Therapeutic ultrasound may improve your physical function but this finding could be the result of chance. -Therapeutic ultrasound does not have any side effects.   Therapeutic ultrasound means using sound waves to try and relieve pain or disability. This therapy is under investigation.

54. DIFFERENCE B/W RA AND OA RHEUMATOID A. Inflammatory. Symmetric involvement of small joints first. Polyarticular . Other visceral organs also affected. Erosion of adjuscent bony surface. Morning stiffnes >1hr. OSTEOARTHRITIS Degenerative. Asymmetric involvement of large joint first. Generally monoarticular . Not affected. Sclerosis of adjuscent bony surface with osteophyte formation. Morning stiffnes <1hr.

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