Rheumatoid Arthritis

    Author: Dr Stelios Hadjichristofi

15/11/16 Rheumatoid Arthritis

Rheumatoid Arthritis

 Rheumatoid arthritis is the most common type of inflammatory arthritis. It most frequently affects the shoulder in patients with serious systemic disease and multiple joint involvement 9. Shoulder disease is frequently bilateral and is ultimately present in more than 90% of patients with rheumatoid arthritis 10. Onset is insidious and, in keeping with the nature of the disease, episodic, with acute exacerbations interspersed with quiescent periods. Initial involvement consists of synovitis of the glenohumeral joint, acromioclavicular joint, and/or subacromial bursa. In later stages, degenerative arthropathy of the glenohumeral and acromioclavicular joints occurs, with degeneration and thinning of the rotator cuff. Complete cuff tears have been reported in approximately 25% of patients 9,10. Clinically, approximately one third to one half of patients with glenohumeral disease have symptomatic acromioclavicular arthritis, but up to 85% have radiographic changes in this joint 10,11. Disease in the acromioclavicular and glenohumeral joints may follow independent courses in both timing and severity 12.
 Clinical symptoms consist of intense pain during periods of synovitic exacerbations and loss of motion that gradually worsens as the disease becomes more chronic. Morning pain and stiffness advance to pain on motion and finally pain at rest as joint destruction progresses. On examination, motion is decreased and a small effusion may be present. The synovium is thick and spongy to palpation. With acromioclavicular involvement, there is nearly always direct tenderness to palpation. Early in the disease, the glenohumeral joint is tender to palpation during an acute episode, but tenderness is uncommon in the more chronic stages. Decreased, painful motion with crepitus becomes the predominant finding in advanced glenohumeral disease 9.
 Laboratory analysis of synovial fluid demonstrates a class II inflammatory fluid. Approximately 80% of patients with rheumatoid arthritis have positive serum rheumatoid factor 13. Radiographic changes about the shoulder begin with osteopenia on both sides of the joint, followed by the appearance of marginal erosions and narrowing of the joint space. Proximal migration or anterior subluxation of the humeral head may be seen early in the course of the disease 9. In advanced disease, there may be large erosions of the humeral head and the anterior and posterior glenoid 9,12. Radiographs of the acromioclavicular joint show bony erosions with tapering and osteolysis of the distal clavicle (Fig. 55-1).
 Shoulder disease in the rheumatoid patient is frequently neglected. Therefore, recognition of shoulder involvement is an early important step in treatment. In addition to medical management of the systemic disease, judicious use of corticosteroid injections is helpful, and a program to maintain functional range of motion should be instituted early in the disease course. Manipulation under anesthesia is never indicated in the rheumatoid population because of the potential damage to osteopenic bone structures 9.
 Although there are few reports in the literature detailing the benefits of synovectomy for the shoulder 14,15, those for selected other joints are well known 16. Arthroscopically performed synovectomy of the knee is as efficacious as the open procedure and has much less associated morbidity. Arthroscopic synovectomy of the affected glenohumeral joint should produce similar results. Access to the acromioclavicular joint and subacromial bursa may also be readily gained arthroscopically, with bursectomy, subacromial decompression, or distal clavicle resection performed as indicated. Outcome is best early in the disease course, before extensive destruction has occurred 14,17. In patients with advanced disease, glenohumeral arthroplasty has been shown to give predictably good relief of pain, with a less predictable gain in range of motion.

Throughout the years, indications and contraindications for synovectomy have evolved. Our most common current indication is rheumatoid arthritis resistant to 6 to 12 months of medical management. Other diagnostic indications include pigmented villonodular synovitis (PVNS), synovial chondromatosis, benign tumors, and chronic infectious arthritis, such as tuberculosis, Lyme disease, or coccidioidomycosis.
 Indications for arthroscopic synovectomy in rheumatoid arthritis patients consist of persistent effusion with proliferative synovitis, stage 0 or I radiographic evaluation (no joint space narrowing), and no response to medical management for a period of at least 6 months. Ideally, synovectomy should be performed when the disease is limited to the synovium before joint surface destruction occurs. A sensitive method of assessing the amount of articular cartilage damage is the 45° PA flexion weightbearing radiograph 19 (Fig. 30-2). By obtaining this view, we have found it unnecessary to obtain MRI for accurate staging of the synovial disease process.
 Although rheumatoid arthritis is the most common disease for which synovectomy is used (Fig. 30-3), multiple other synovial conditions are effectively treated with this procedure. Synovial chondromatosis is a less common condition in which cartilaginous loose bodies are produced by the synovium. Milgram reported good results in 30 cases of synovial chondromatosis treated by open synovectomy and recommended this as a treatment of choice, especially in phases I and II 20. More recently, Ogilvie-Harris and Saleh 16 showed that patients treated by loose body removal and arthroscopic synovectomy had significantly lower recurrence rates than patients who had loose body removal alone. Pigmented villonodular synovitis is an idiopathic proliferation of synovium producing hypertrophic, hemosiderin-stained villi (Fig. 30-4). It may occur as a discrete nodule of tissue or in a diffuse distribution throughout the joint. Byers et al. 21 reviewed their treatment of pigmented villonodular synovitis and concluded that the nodular form of pigmented villonodular synovitis of the knee responded well to excision. Diffuse lesions, however, did not respond to extensive open anterior synovectomy. Forty-six percent of these recurred after surgery, which was attributed to the difficulty in performing a complete excision of the synovium. To the extent that arthroscopic synovectomy achieves nearly total excision of diseased synovium in the diffuse type pigmented villonodular synovitis, longer remissions and higher remission rates exceeding 90% are obtainable.
 As a rule, secondary synovial hypertrophy resulting from compartmentally advanced chondrosis is not a recognized indication for extensive synovectomy (Fig. 30-5A). However, localized excision of chronically hypertrophied and inflamed synovium is recommended and may reduce intraarticular concentrations of interleukin 1 (IL-1). Crystalline synovitis, such as gout and pseudogout (with monosodium urate and calcium pyrophosphate crystals, respectively), may be improved symptomatically with thorough arthroscopic lavage supplemented by judicious synovectomy 22 (Fig. 30-5B), although its primary treatment remains medical not surgical.
 Arthroscopic synovectomy, therefore, appears to be applicable to several primary synovial diseases of the knee. It can be anticipated that the results obtained from the arthroscopic synovectomy would be superior to those achieved with an open procedure. However, the specific indications for the technique cannot be entirely defined as we await the results of prospective studies relating to each of the synovial disorders.



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