Rheumatoid Arthritis
Corolinda S. Helu, DPM
Surgical Resident
New York Community Hospital
Overview
Epidemiology
 History
 Physical Examination
 Laboratory Tests
 Radiographical signs
 Pharmological Treatment
 Surgical Treatment of Foot
 Hoffman-Clayton Case

What is Rheumatoid Arthritis?
Autoimmmune dz
 1-2% prevalence
 3rd to 6th decade of life
 Women > Men
 1st degree relative double the risk
 What causes rheumatoid arthritis?

The Synovium in RA
Normal Synovium
Rheumatoid Synovium
Milestones in RA
First documented in 1800s
 Sir Alred Garrod in 1856
 Rheumatoid factor 1940
 Cortisone tx 1949
 Gold tx 1960s
 Methotrexate 1972
 Genetic Association 1976
 Anti-cytokine therapy 1997

RA in European Art
Dutch Priest 1631
Renoit in 1911
Wheelchair bound w/
classic RA in his hands
Pierre August Renoir 1876
Renoit in 1911
History
Insidious onset
 Slow development of sign & symptoms
 Stiffness
 Polyarticular
 Most common: PIP & MCP of hands
 Morning stiffness > 1hr
 Fatigue, malaise, depression

Physical Examination

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Symmetric joint
swelling
Fusiform swelling
PIP
Pain on passive
motion
Physical Examination



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Tenosynovitis &
synovitis
Synovial cysts
Displaced/
ruptured tendons
Bony erosions
***Hallmark***
Physical Examination


Ulnar deviation
Swan Neck
– Hyperexten PIPJ
– Flex DIPJ

Boutiniere
– Flex PIPJ
– Ext DIPJ
Laboratory Tests

Initial work-up
– CBC, Metabolic panel, Urinalysis, Sed rate
– Rheumatoid factor, Anti-nuclear antibody
Chem: nl, slight decr albumin, incr total
protein
 Hema:hemocrit- ACD, wbc- mildly up,
platelet- rare thrombocytosis

Laboratory Tests
ESR: elevated
 Serology: Rf Fc of IgG

– (+) not pathognomonic for RA
– Hi :erosive jt dz, aggressive
– (-) milder dz course
– Detectable in non RA pts w/ prolonged
infection
Radiology

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Symmetrical
Early: no sig changes
Late:
– Juxta-articular osteoporosis w/
decr bone density
– Uniform jt narrowing
– Marginal erosions
Radiology
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Marginal cortical erosions
Juxtaarticular osteoporosis of
lesser mets
Severe HAV
Subluxation/dislocation lesser
MPJ
Jt space narrowing
Well marginated spur
– Also Reiters, acromegaly, dish

Ill-defined ersosion of
posteroanterior aspect of
calcaneus
– Resiters, PA, AS,
hyperparathyroidism
Optimal RA Tx?


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Accurate & early= early
referral
Early referral = early tx
Early tx = improved
outcomes
Most rapid
deterioration of jt func 2
yrs after diag


NSAIDS
Cortisone
– Best anti-inflam
– Worst SE

DMARDS
– Gold
– Methotrexate
– Leflunomide (Arava)
Newer Therapies

Antiproliferative
agents

Anti-TNF therapies

Anti-IL-1 agents

Combination
– Leflunomide (Arava)
– Methotrexate
– Etanercept (Enbrel)
– Infliximab
(Remicade)
– IL-1ra (Kineret)
What is “Quality of Life”?

Ability to
– Work
– Be a parent
– Socialize with others
– Exercise and be mobile
Surgical Treatment?
Goal: Relieve pain
 Consider:

– Medical condition
– Age
– Activity level
– Condition of Bone & ST
Tx for dislocation of lesser MPJ
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A: Hoffman
B: Mod Hoffman w/ 1st MPJ arthrodesis
C: Fowler
Tx for dislocation of lesser MPJ
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C: Clayton
D: Modified Clayton
Incisional Approaches
•A: Transverse Plantar
•B:Elliptic Plantar
•C/D: Transverse dorsal
•E: 3 Dorsal Longitudinal
•F: 5 Dorsal Longitudinal
Case presentation


64 yo female w/ RA X 15 years c/o forefoot pain and metatarsalgia which
limit ambulation. Pt requires weekly forefoot padding just proximal to lesion
in addition to in depth shoe with plastazote to relieve pain. Pt uses walker to
ambulate. Pt desires sx to decrease pain and increase ambulation.
PMH:
– Illnesses HTN, osteoporosis, arthritis
– Meds: Fosoamax, ASA, Atenolol
– Allergies: PCN, betadine

PE:
– Musc: B/L HAV, contracted digits 2-5 b/l, IPK L 2/4, R 2,3,4, anterior
displacement and atrophy of fat pad, pes plano valgus
– Vasc: 2/4 DP/PT B/L, arterial doppler biphasic wave form, L PT w/ stenosis
– Derm: Interdigital maceration 1-4 b/l
– Neuro: wnl
– Gait Analysis; Shuffling gait w/ use of walker
Case presentation
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Labs:CBC w/diff, Chem Panel X, Urinalysis,
CXR, EKG, PT/PTT
Xrays:severe HAV, osteopenia, jt narrowing,
subluxation/dislocation
A/P: RA Stage IV
Sx: Modified Hoffman-Clayton w/ plantar
elliptical transverse incision b/l
Intra-op: plantarflexed met heads, soft bones,
good blood supply
Board Review Questions

Perioperative Management of RA pt w/ 7.5 mg prednisone for
past year?
–
–
–
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–
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100 mg IV hydrocortisone preop
100 mg IV hydrocortison post-op
S/P 1 D: 50 mg q 8h po
S/P 2 D: 25 mg q 8 h po
S/P 3 D: 25 mg q 12 h po
S/P 4 D: return to orginal steroid regimen
Management of pain w/ different drug classes for combination
therapy, penicillamines, gold salts, corticosteroids,
antimalarials…which drug is not specific for RA?
– Corticosteroids, although most pts will respond, does not alter
progression of dz. Others will produce gradual suppression of dz
process