Inflammation & Infection In Bones & Joint

Dr. Ashok Jaisingani

Rheumatoid Arthritis The commonest type of inflammatory arthritis is rheumatoid

arthritis affects approx. 3% of women & 1% men. The disease appear to arise from cell-mediated (T-cell)

autoimmune response, but there may be underlying infectious etiology.

After triggering of T-cell response there release of cytokines,Interleukin – I & 6 (IL-I & IL-6) Tumor Necrosis Factor (TNF)

The disease mostly affect small joints of hands & feet, however any joint of body or soft tissue can be involved.

A layer of inflammatory tissues called ‘panus’ spread over the joint surface erode subchondrial bone, denuding articular cartilage.

Rheumatoid Factor (RF) is +ve in 80% of cases

Extra-articular Manifestation Extra-articular manifestation of rheumatoid

arthritis include:Skin – Subcutaneous Nodules Eyes – Scleritis, iritis Lungs – Interstitial lung disease, pleural

effusion. Heart – Myocarditis Kidneys – Nephritis Amyloid – Lungs, kidney, heart & bowl Compression & vascular neuritis.

Clinical FeaturesMostly the disease onset insidiously, with joint

stiffness & polyarthritis, some time disease may onset acutely in about 30% of the pts & may present with malaise & low grade fever.

Hands & feet are commonly affected in early stage of the disease.

On examination there may be effusion & synovitis of affected joints, which may cause SwellingWarmth Erythema Stiffness of affected joints with pain on movement.

Characteristic pattern Of Disease There may be deformity seen in hand & wrist Inflammation of tendon (Tenosynovitis), commonly

affect flexor & extensor muscles of hand & wrist. Rupture of extensor tendon, most commonly of little

finger. ESR & CRP are usually elevated Radial deviation of wrist Ulner deviation of metacarpophalangeal joints Z – deformity of thumb Boutonniere deformity of thumb Swan neck deformity Carpel tunnel syndrome

Rheumatology Criteria For Diagnosis Of RA

This involve pt having four of seven criteria 1- Morning stiffness lasting atleast 1 – hour 2- Active arthritis of three or more joints 3- Active arthritis of atleast one hand joint (wrist,

MCPJ, PIPJ) 4- Symmetrical arthritis 5- Subcutaneous rheumatoid nodules on extensor

surface, juxta -articular or bony prominences 6- Rheumatoid factor positive 7- Radiographic changes of particular erosion, or

osteopenia in affected joints not osteoarthritis.

Treatment Long standing, stable, mild cases of rheumatoid arthritis can be

treated with analgesic and NSAIDs. The disease – modifying anti-rheumatic drugs (DMARDs) can be

useful in preventing long term recruitment of autoimmune cascade. DMARDs are following

1- Methotrexate 2- Gold 3- Sulphasalazine/ Salazopyrine4- Lefunomide 5- Penicillamine 6- Ciclosporine

The most recent development of anti – TNF drugs such as “Etanercept & Infliximab” may revolutionize treatment

Corticosteroid therapy continue to be useful systemically & locally and by injection into joints or around tendon.

Surgery For Rheumatoid Arthritis Splints can be useful to reduce the pain & improve function

(unstable wrist, swan neck deformity) Orthotics are useful for the foot & ankle joints Arthodesis (fusion) for cervical spine, finger (PIPJ), wrist,

ankle & hind foot. Joint replacement for major joints including hip, knee, elbow

& shoulder joints. There are few sites where excision arthoplasty is used such

as distil ulna & radial head. Tenosynovectomy for inflamed tendon sheath in case of

resistant to medical treatment to prevent tendon rupture.In case of resistant to anti-inflammatory treatment perform

synovectomy