JOINT REPLACEMENT
Dr. Bharat Mody is a world renowned expert Joint replacement surgeon of India. He is a leading specialist in the field of knee and hip replacement surgery. He has trained in the UK for many years during which he mastered the skills of joint replacement surgery. He also obtained the degree of MCh in Orthopaedics from the UniversityofLiverpool, UK. He worked in reputed Orthopaedic hospitals in UK and USA before returning to India to start his own practice.
In 1999, he founded theCentre for Knee & Hip Surgery at Welcare Hospital. His Centre has the unique achievement of being able to attract patients from all over the world. He even has the distinction of having done bilateral knee replacement surgery on the Prime Minister of Fiji Islands, Mr SitiveniRabuka, at Welcare Hospital.
His new 110 bed Welcare Hospital in Vadodara, Gujarat, is a modern and technologically highly advanced facility with four state of the art Operation Theatres which are the best in India. For more details visit: www.welcarehospital.co.in
Dr. Mody hass developed his own technique of soft tissue balancing during knee replacement surgery, due to which most of his operated patients are able to sit cross-legged or perform namaz after surgery. He is well known for this technique in India and abroad.
Osteoarthritis (OA) is one of most common diseases
Osteoarthritis, sometimes abbreviated to “OA”, is the most common form of arthritis, a very common disease. It is a chronic, slowly progressing disease that involves the breakdown of articular cartilage, the normally smooth, slippery covering that allows the bones of your joints to slide over each other. OA may involve many or only one or a few specific joints…. a hip, knee, finger, the lower back, About 17 million people in USA and many more in India have pain due to Osteoarthritis. The incidence of the disease increases with age, and women are affected twice as frequently as men.
The cause of OA is not known but there are important contributing factors in development of OA
Aging, Trauma, Obesity, Genetics.
Although we don’t know the exact cause of OA, we have identified four important contributing factors. Age is one of these factors. The wear and tear on joints accumulated over the years is the only identifiable factor for many people.
Trauma (for injury) is another contributing factor. Overuse or occupational injuries, as well as sport injuries, are commonly associated with OA. Obesity plays a part, too, as extra weight puts added stress on weight bearing joints, like the hip and knee; but even light weight ballerinas are at greater risk of developing OA of the big toe and hip, due to great stresses put on these joints. http://welcarehospital.co.in/wp-content/uploads/2016/02/DSC_1612-min.jpg Genetic factors also play a role. A family history of OA can increase the risk of developing OA. People with poor joint alignment can develop OA as the joint cartilage wears unevenly.
OA tends to affect weight bearing, hard working joints
As you’d expect, the hardest working and weight-bearing joints are the ones usually affected by OA. These include the hips, knees, feet, spine, and hands. Except, as a result of injury or un-usual stress, ankles, wrists, and elbows are not common sites for OA, although other types of arthritis can affect these areas. People with OA in one joint often have OA in other joints. This so-called generalized arthritis is more common in women than in men and may be inherited.
With OA, articular cartilage breaks down and wears away
The rest of our discussion will focus on the knee joint, a common site of OA. The knee is a complex joint, composed of bone, cartilage, membranes, and joint fluid all working together for easy, comfortable motion. Normally, the articular cartilage covering the ends of each bone is smooth, and more slippery than ice. It allows the joint surfaces to glide easily and act as a shock absorber. The joint capsule is lined with the synovial membrane, which produces the synovial fluid that helps lubricate and cushion the joint. Muscles, ligaments, and tendons keep the joint aligned during joint movement.
In OA, the joint breaks down in stages, over a time; smooth cartilage becomes pitted and frayed. Damaged cartilage is less elastic, and more readily affected by overuse or injury. Synovial fluid may also lose its cushioning and lubricating properties. The ends of the bone can thicken and form spurs where the ligaments and synovial lining attach. Finally, bits of bone or cartilage (sometimes called ‘joint mice’) float in the joint space, causing further damage and pain.
Eventually, large areas of cartilage may wear away completely, so bones scrape over each other painfully. The joint may lose its proper alignment, and much of its function.
Common symptoms
If you have OA of the knee, you’re probably familiar with some of these symptoms. Pain, tenderness, and a grating or catching sensation in the knee are the common symptoms that cause most people to see a doctor.
If you’re under 40, you may not associate these symptoms with OA. But don’t discount the possibility, especially if you’re very involved in activities that put a lot of stress on your knees, like football, skiing, and high-impact aerobics.
Diagnosis
Diagnosis is based on a wide range of evidence.
There is no specific test for OA. Most people don’t even know they have OA of the knee until pain, stiffness, or an injury lead them to see their doctor. A complete clinical assessment will include a discussion of any family history of OA, and a physical examination to identify misalignment, deformities, mechanical problems and which joints are affected.
OA is often visible on X-ray, and that can confirm that the pain and stiffness is indeed due to OA. X-ray can be useful in uncovering subtitle joint abnormalities and other joint and bone diseases, like osteoporosis. However, X-ray may not pick up early arthritic changes, even if there are symptoms.
Finally, lab tests may be ordered to check for certain metabolic or endocrine disorders (such as hypothyroidism or diabetes).
Management
OA of the knee cannot be cured, but in most cases it can be effectively managed, resulting in less pain and stiffness, and better joint function. Physical therapy and exercise and, if appropriate, weight loss can be helpful in alleviating symptoms at any stage of OA. Assistance devices like canes, knee braces, and insoles can also help. For OA with mild pain and few or no functional problems, nonprescription pain relievers like acetaminophen may be tried. If this therapy does not suffice, a prescription strength anti-inflammatory drug, such as naproxen or cortisone injections, or stronger pain relievers, such as narcotic analgesics may be needed. Finally, a variety of surgical procedures are available for the management of severe OA.
Today, there’s a lot that one can do to help keep OA form interfering with daily life. Let’s take a closer look at each type of treatment.
Physical therapy and exercise
Controlled exercise is an important OA treatment. “Controlled” is the key word here, and that’s why seeing a physical therapist is so important. Physical therapists can determine what the most suitable conditioning exercises are for a given patient, then show the patient how to perform them correctly. Regular exercise will not only make joints feel better it can give patients a psychological boost to know that they’re making a difference through their own efforts.
Weight control
Shedding excess weight can be stressful, frustrating, and seemingly impossible for some people, but it can make a big difference in how the knees feel. Excess weight puts extra stress on already painful joints, making exercise that much more difficult. Inability to exercise due to pain can lead to depression and overeating, starting the cycle all over again. Some people with OA will be able to successfully control pain with a combination of exercise and weight loss alone.
Simple analgesics
Acetaminophen and paracetamol and other products are recognized as an effective medication for OA of the knee. It is generally well-tolerated, without the side effects of prescription arthritis drugs like naproxen and ibuprofen, which we’ll talk about shortly. Rarely, high dose of acetaminophen can cause liver damage when large amounts of alcohol are consumed. Acetaminophen is often used in combination with other medications.
Topical treatments
Topical treatments include rubs, hot and cold packs, and TENS, which uses electricity applied to the skin to stimulate nerve endings. These are valid methods that give many people significant pain relief. These can be tried either before starting medication or in addition to medication.
Hyaluronate preparations
The newest class of injected products for the pain of OA of the knee are the hyaluronate preparations that are injected directly into the knee. Hyaluronate is a natural substance that acts like an “Oil” and is believed to help cushion and lubricate joints such as the knee.
Anti-inflammatory medications (NSAIDs)
NSAIDs are very effective pain relievers. They include aspirin, ibuprofen, naproxen, and other drugs that relieve inflammation and pains. As we mentioned earlier, NSAIDs often cause stomach upset. However, for some people, long-term use of these drugs can sometimes cause more serious problems, such as stomach ulcers and kidney damage.
Corticosteriod injections
Corticosteriod, like cortisone, or prednisone, are powerful drugs that relieve pain and inflammation. Special formulations are available for injection into the knee so that they remain in the knee and maintain their effect. Pain relief from a typical corticosteriod injection lasts 4 to 6 weeks. However, frequent use of these drugs can damage joint tissues.
Narcotic pain relievers
For people with severe, unremitting pain, there are a variety of narcotic pain relievers. These drugs are effective against severe pain, but have no effects on inflammation. However, most patients and physicians will resist using narcotics for very long because of the potential side effects associated with these products, including addiction.
Surgery
To correct minor or major mechanical problems, treat advanced disease, or relieve pain / improve mobility when nonsurgical treatments are not adequate.
– Arthroscopic surgery – Osteotomy – Arthrodesis (fusion) – Total Knee Replacement (TKR)
If OA becomes impossible to live with, surgery may be the answer. There are many types of surgical procedures, from arthroscopy to total knee replacement. However, there are limits to what surgery can achieve. Strenuous exercise such as downhill skiing after total knee replacement may not be possible. Pain relief and greater freedom of motion are likely outcomes. A strict treatment and rehabilitation program after surgery is in large part dependent upon active participation by the patient. Now let’s look at the various surgical options available today.
Arthroscopic surgery
– For repair of damaged cartilage – For removal of loose bits of cartilage and bone – To drain infected or excess synovial fluid – May be performed in the office or in the hospital, depending upon nature of the surgery.
An arthroscope is a pencil-sized fibreoptic instrument attached to a small camera viewer that is used to look inside the joint. During surgery, special slim instruments are passed through the arthroscope to remove bits of bone and cartilage from the joint cavity, drain excess synovial fluid, or repair small tears in the meniscus, a pad of special rubbery cartilage in the knee. The arthroscope is inserted through a very small incision, which leaves little scarring. Arthroscopic surgery can, in many cases, be done in the office.
This surgery does not require general anaesthesia and is done under local anasthesia. It does not involve any blood loos. The patient usually walks home in two hours. This is a highly advanced form of surgery and requires a very high level of costly instrumentation systems. There are very few centres in India with a proper set-up offering this service.
Osteotomy
May be an option when OA involves a single, weight bearing compartment of the knee joint. – To correct deformities by selective trimming away of bone. – Improves joint alignment – Generally preferred for young and active patients.
Osteotomy literally means “bone cutting”. Even slight bone deformities can put pressure and strain on joints, and contribute to OA. The deformity is corrected by removing or adding triangular wedges of bone. Osteotomy can be useful in preventing the deterioration of joints with OA due to a preexisting deformity such as bowleggedness. Osteotomy is generally preferred for young, active patients.
Arthrodesis (Fusion)
Reserved for patients who cannot undergo total knee replacement. – Relieves pain – Leg is left permanently rigid – Interferes with walking, sitting, driving, and other movement
The word arthrodesis means ‘fusion of a joint’. When this surgery is performed on the knee, the thigh and shin bones are fused to become one bone. Pain is relieved, but the leg is left permanently rigid, which interferes with walking, sitting, driving, or moving in a narrow space. For these reasons, arthrodesis is used only when certain infections or ligaments loss make it unsafe to implant a prosthesis.
Total Knee replacement
A man-made prosthesis is used to replace the damaged joint when medical management is not effective.
– Relieves pain – Corrects alignment
During total knee replacement, or TKR, man-made materials are used to replace the damaged end of the knee bones. About 160,000 total knee replacements are performed each year in USA. There are many kinds of prostheses, each with subtle differences. prosthetic knees are strong and last on an average 15 to 20 years.
The word “total” gives the impression that the whole knee joint is cut out and replaced by a heavy metal model. However, this is not the case. In reality, only the roughened surface of the bones forming the knee joints is taken out as thin slices and replaced by an artificial surface. The muscles and ligaments are realigned. Once the implants are seated, the patient is able to walk well, and do a wide range of activities like cycling, swimming, dancing and playing light sports. This surgery has become popular all over the world because of its ability to give back a highly active life style to a patient handicapped by pain and deformities. There are many factors contributing to the success of this surgery starting from the surgeons detailed understanding and experience of the surgery, the quality of implants, the quality of operation theatre environment with a high level of instrumentation systems, as also post operative care in the form of focused para medical staff to care for patients after the operation.
There is no cure….. but you can live comfortably with Osteoarthritis – Physical therapy and exercise – Medical management – Surgical management The future ???
In summary, we’ve talked about OA of the knee and the various treatments available today. There’s no cure as of yet. But with careful use of these treatment option, and those that are likely to come in to use over the next few years, it is possible to live comfortably with OA.
OSTEOARTHRITIS OF HIPS
What is our Hip Joint like?
The hip is one of the body’s largest weight-bearing joints. It consists of two main parts: a ball (femoral head) at the top of your thighbone (femur) that fits into a rounded socket (acetabulum) in your pelvis. Bands of tissue called ligaments (hip capsule) connect the ball to the socket and provide stability to the joint.
The bone surfaces of the ball and socket have a smooth durable cover of articular cartilage that cushions the ends of the bones and enables them to move easily.
A thin, smooth tissue called synovial membrane covers all remaining surfaces of the hip joint. In a healthy hip, this membrane makes a small amount of fluid that lubricates and almost eliminates friction in your hip joint.
Normally, all of these parts of your hip work in harmony, allowing you to move easily and without pain.
What are the common causes of hip pain and loss of hip mobility?
The most common cause of chronic hip pain and disability is arthritis. Osteoarthritis, Rheumatoid Arthritis, and Traumatic Arthritis are the most common forms of this disease.
Arthritis or inflammation if the joint causes the surfaces to become rough, which clinically presents as impairment of daily functions including walking, climbing stairs and even arising from sitting position with or without limb length inequality.
Osteoarthritis usually occurs in people 50 years of age and older and often individuals with a family history of arthritis. In this form of the disease, the articular cartilage cushioning the bones of the hip wears away. The bones then rub against each other, causing hip pain and stiffness.
Rheumatoid arthritis is an autoimmune disease in which the synovial membrane becomes inflamed, produces too much synovial fluid, and damages the articular cartilage, leading to pain and stiffness.
Traumatic arthritis can follow a serious hip injury or fracture. A hip fracture can cause a condition known as osteonecrosis. The articular cartilage becomes damaged and, over time, causes hip pain and stiffness.
Avascular necrosis of head of femur, congenital anomalies, etc.
What is a total hip replacement?
Total hip replacement is a surgical procedure whereby the diseased cartilage and bone of the hip joint are surgically replaced with artificial materials. The metallic artificial ball and stem and plastic cup socket are referred to as prosthesis.
What are various types of hip replacements?
The various types are:
Cemented
– Both femoral and acetabular components are fixed using bone cement.
Non-cemented
– IN this variety, bone is not used to few or insert the prosthesis into the central core of femur and acetabular.
Hybrid:
In this variety, only the femoral component is fixed using bone cement.
Many thousands of hip replacements are completed without complications every year. In order to achieve the best chance of a smooth recovery you must,
- Avoid bending or twisting at the hip
- Avoid low chairs and toilet seats
- Try not to cross your legs
- Try not to lie on your sides and
- Always follow the advice of your doctor.
Is Hip Replacement Surgery beneficial for you?
You may benefit from hip replacement surgery if:
- Hip pain limits your everyday activities such as walking or bending.
- Hip pain continues while resting, either day or night.
- Stiffness in a hip limits your ability to move or lift your leg.
- You have little pain relief from anti-inflammatory drugs or glucosamine sulfate.
- You have harmful or unpleasant side effects from your hip medications.
- Our treatments such as physical therapy ot the use of a gait aid such as a cane do not relieve pain.
An Orthopedic Evaluation: A Prerequisite
The Orthopedic evaluation will typically include:
A medical history, in which your orthopedic surgeon gathers information about your general health, asks questions about the extent of your hip pain and how it affects your ability to perform everyday activities.
A physical examination to assess hip mobility, strength, and alignment.
Occasionally, blood tests or other tests such as MRI (magnetic resonance imaging) or bone scanning may be needed to determine the condition of the bone and soft tissues of your hip.
Rehabilitation after Hip Surgery
Early Hip Rehabilitation
Your recovery program usually begins the day after surgery. The rehabilitation team will work together to provide the care and encouragement needed during the first few days after surgery
The physical therapist will begin as early as 1-2 days after surgery. They will teach you some simple exercises to be done in bed that will strengthen the muscles in the hip and lower extremity. These exercises may include:
Gluteal Sets: Tighten and relax the buttock muscles.
Quadriceps Sets: Tighten and relax the thigh muscles.
Ankle Pumps: Flex and extend the ankles.
Your physical therapist will also teach you proper techniques to perform such simple tasks as:
- Moving up and down in bed.
- Going from lying to sitting.
- Going from sitting to standing.
- Going from standing to sitting.
- Going from sitting to lying.
Another important goal for early physical therapy is for you to learn to walk safely with an appropriate assistive device (usually a walker or crutches). Your surgeon will determine how much weight you can bear on your new hip, and your therapist will teach you the proper techniques for walking on level surfaces and stairs with the assistive device.
At Home
Following surgery, a physical therapist will help you with your rehabilitation protocol. In addition to the exercises done with the therapist, you should continue to work on the hip exercises in your free time. It is also important to continue to walk on a regular basis to further strengthen your hip muscles. An exercise and walking program helps to enhance your recovery from surgery and helps make activities of daily living easier to manage.
You must also remember to strictly follow the hip precautions and weight bearing instructions during the first few months following surgery. It is recommended that you not drive unless you have been approved by your doctor.
Long-term Hip Rehabilitation Goals
Once you have completed your rehabilitation program, you can expect to be able to perform most activities of daily living with little to no hip pain or assistance. Following total hip replacement, patients routinely are able to walk, dress, bathe, drive, garden, cook and return to work. Although final outcomes may vary from patient to patient, hip replacement surgery is one of the most successful procedures in modern medicine and most patients return to a full and active life.
RHEUMATOID ARTHRITIS
What is rheumatoid arthritis (RA)?
Reference: MedicineNet.com
Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. Autoimmune diseases are illnesses that occur when the body’s tissues are mistakenly attacked by their own immune system. The immune system contains a complex organization of cells and antibodies designed normally to “seek and destroy” invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues, where they can be associated with inflammation. Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease.
While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. However, rheumatoid arthritis is typically a progressive illness that has the potential to cause joint destruction and functional disability.
A joint is where two bones meet to allow movement of body parts. Arthritis means joint inflammation. The joint inflammation of rheumatoid arthritis causes swelling, pain, stiffness, and redness in the joints. The inflammation of rheumatoid disease can also occur in tissues around the joints, such as the tendons, ligaments, and muscles.
In some people with rheumatoid arthritis, chronic inflammation leads to the destruction of the cartilage, bone, and ligaments, causing deformity of the joints. Damage to the joints can occur early in the disease and be progressive. Moreover, studies have shown that the progressive damage to the joints does not necessarily correlate with the degree of pain, stiffness, or swelling present in the joints.
Rheumatoid arthritis is a common rheumatic disease, affecting approximately 1.3 million people in the United States, according to current census data. The disease is three times more common in women as in men. It afflicts people of all races equally. The disease can begin at any age, but it most often starts after 40 years of age and before 60 years of age. In some families, multiple members can be affected, suggesting a genetic basis for the disorder.
What causes rheumatoid arthritis?
The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected, none has been proven as the cause. The cause of rheumatoid arthritis is a very active area of worldwide research. It is believed that the tendency to develop rheumatoid arthritis may be genetically inherited. It is also suspected that certain infections or factors in the environment might trigger the activation of the immune system in susceptible individuals. This misdirected immune system then attacks the body’s own tissues. This leads to inflammation in the joints and sometimes in various organs of the body, such as the lungs or eyes.
Regardless of the exact trigger, the result is an immune system that is geared up to promote inflammation in the joints and occasionally other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers (cytokines, such as tumor necrosis factor/TNF, interleukin-1/IL-1, and interleukin-6/IL-6) are expressed in the inflamed areas.
Environmental factors also seem to play some role in causing rheumatoid arthritis. For example, scientists have reported that smoking tobacco increases the risk of developing rheumatoid arthritis.
What are the symptoms and signs of rheumatoid arthritis?
The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission). Remissions can occur spontaneously or with treatment and can last weeks, months, or years. During remissions, symptoms of the disease disappear, and people generally feel well. When the disease becomes active again (relapse), symptoms return. The return of disease activity and symptoms is called a flare. The course of rheumatoid arthritis varies among affected individuals, and periods of flares and remissions are typical.
When the disease is active, symptoms can include fatigue, loss of energy, lack of appetite, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. Arthritis is common during disease flares. Also during flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis).
In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected). The small joints of both the hands and wrists are often involved. Simple tasks of daily living, such as turning door knobs and opening jars, can become difficult during flares. The small joints of the feet are also commonly involved. Occasionally, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis, such as gout or joint infection. Chronic inflammation can cause damage to body tissues, including cartilage and bone. This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function. Rarely, rheumatoid arthritis can even affect the joint that is responsible for the tightening of our vocal cords to change the tone of our voice, the cricoarytenoid joint. When this joint is inflamed, it can cause; hoarsenessof the voice.
Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the body other than the joints. Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as Sjogren’s syndrome. Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing, shortness of breath, or coughing. The lung tissue itself can also become inflamed, scarred, and sometimes nodules of inflammation (rheumatoid nodules) develop within the lungs. Inflammation of the tissue (pericardium) surrounding the heart, called pericarditis, can cause a chest pain that typically changes in intensity when lying down or leaning forward. The rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells. Decreased white cells can be associated with anenlarged spleen (referred to as Felty’s syndrome) and can increase the risk of infections. Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure. Even though these nodules usually do not cause symptoms, occasionally they can become infected. Nerves can become pinched in the wrists to cause carpal tunnel syndrome. A rare, serious complication, usually with long-standing rheumatoid disease, is blood vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death (necrosis). This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.
How is rheumatoid arthritis diagnosed?
The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and the patient. The doctor reviews the history of symptoms, examines the joints for inflammation and deformity, the skin for rheumatoid nodules, and other parts of the body for inflammation. Certain blood and X-ray tests are often obtained. The diagnosis will be based on the pattern of symptoms, the distribution of the inflamed joints, and the blood and X-ray findings. Several visits may be necessary before the doctor can be certain of the diagnosis. A doctor with special training in arthritis and related diseases is called a rheumatologist.
The distribution of joint inflammation is important to the doctor in making a diagnosis. In rheumatoid arthritis, the small joints of the hands, wrists, feet, and knees are typically inflamed in a symmetrical distribution (affecting both sides of the body). When only one or two joints are inflamed, the diagnosis of rheumatoid arthritis becomes more difficult. The doctor may then perform other tests to exclude arthritis due to infection or gout. The detection of rheumatoid nodules (described above), most often around the elbows and fingers, can suggest the diagnosis.
Abnormal antibodies can be found in the blood of people with rheumatoid arthritis. An antibody called “rheumatoid factor” can be found in 80% of patients. Citrulline antibody (also referred to as anticitrulline antibody, anticyclic citrullinated peptide antibody, and anti-CCP) is present in most people with rheumatoid arthritis. It is useful in the diagnosis of rheumatoid arthritis when evaluating cases of unexplained joint inflammation. A test for citrulline antibodies is most helpful in looking for the cause of previously undiagnosed inflammatory arthritis when the traditional blood test for rheumatoid arthritis, rheumatoid factor, is not present. Citrulline antibodies have been felt to represent the earlier stages of rheumatoid arthritis in this setting. Another antibody called the “antinuclear antibody” (ANA) is also frequently found in people with rheumatoid arthritis.
A blood test called the sedimentation rate (sed rate) is a measure of how fast red blood cells fall to the bottom of a test tube. The sed rate is used as a crude measure of the inflammation of the joints. The sed rate is usually faster during disease flares and slower during remissions. Another blood test that is used to measure the degree of inflammation present in the body is the C-reactive protein. Blood testing may also reveal anemia, since anemia is common in rheumatoid arthritis, particularly because of the chronic inflammation.
The rheumatoid factor, ANA, sed rate, and C-reactive protein tests can also be abnormal in other systemic autoimmune and inflammatory conditions. Therefore, abnormalities in these blood tests alone are not sufficient for a firm diagnosis of rheumatoid arthritis.
Joint X-rays may be normal or only show swelling of soft tissues early in the disease. As the disease progresses, X-rays can show bony erosions typical of rheumatoid arthritis in the joints. Joint X-rays can also be helpful in monitoring the progression of disease and joint damage over time. Bone scanning, a radioactive procedure, can also be used to demonstrate the inflamed joints. MRI scanning can also be used to demonstrate joint damage.
The American College of Rheumatology has developed a system for classifying rheumatoid arthritis that is primarily based upon the X-ray appearance of the joints. This system helps medical professionals classify the severity of your rheumatoid arthritis.
Stage I
no damage seen on X-rays, although there may be signs of bone thinning
Stage II
on X-ray, evidence of bone thinning around a joint with or without slight bone damage
slight cartilage damage possible
joint mobility may be limited; no joint deformities observed
atrophy of adjacent muscle
abnormalities of soft tissue around joint possible
Stage III
on X-ray, evidence of cartilage and bone damage and bone thinning around the joint
joint deformity without permanent stiffening or fixation of the joint
extensive muscle atrophy
abnormalities of soft tissue around joint possible
Stage IV
on X-ray, evidence of cartilage and bone damage and osteoporosis around joint
joint deformity with permanent fixation of the joint (referred to as ankylosis)
extensive muscle atrophy
abnormalities of soft tissue around joint possible
How is rheumatoid arthritis treated?
There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Early medical intervention has been shown to be important in improving outcomes. Aggressive management can improve function, stop damage to joints as monitored on X-rays, and prevent work disability. Optimal treatment for the disease involves a combination of medications, rest, joint-strengthening exercises, joint protection, and patient (and family) education. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.
Medical Management
Two classes of medications are used in treating rheumatoid arthritis: fast-acting “first-line drugs” and slow-acting “second-line drugs” (also referred to as disease-modifying antirheumatic drugs or DMARDs).
The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation.
The slow-acting second-line drugs, such as gold, methotrexate, and hydroxychloroquine (Plaquenil), promote disease remission and prevent progressive joint destruction, but they are not anti-inflammatory agents.
The degree of destructiveness of rheumatoid arthritis varies among affected individuals. Those with uncommon, less destructive forms of the disease or disease that has quieted after years of activity (“burned out” rheumatoid arthritis) can be managed with rest and pain and anti-inflammatory medications alone. In general, however, function is improved and disability and joint destruction are minimized when the condition is treated earlier with second-line drugs (disease-modifying antirheumatic drugs), even within months of the diagnosis. Most people require more aggressive second-line drugs, such as methotrexate, in addition to anti-inflammatory agents. Sometimes these second-line drugs are used in combination. In some cases with severe joint deformity, surgery may be necessary.
Proper, regular exercise is important in maintaining joint mobility and in strengthening the muscles around the joints. Swimming is particularly helpful because it allows exercise with minimal stress on the joints. Physical and occupational therapists are trained to provide specific exercise instructions and can offer splinting supports. For example, wrist and finger splints can be helpful in reducing inflammation and maintaining joint alignment. Devices such as canes, toilet seat raisers, and jar grippers can assist in the activities of daily living. Heat and cold applications are modalities that can ease symptoms before and after exercise.
Surgical Management
Surgery is recommended to restore joint mobility or repair damaged joints
The types of joint surgery range from arthroscopy to partial and complete replacement of the joint.
Arthroscopy is a surgical technique whereby a doctor inserts a tube-like instrument into the joint to see and repair abnormal tissues. This surgery is very useful in the early stages of the disease, especially in the knee joint.
Total joint replacement is indicated in severe RA (stages III and IV) whereby a destroyed joint is replaced with artificial materials. Large joints, such as the hips or knees, are replaced with metal implants.