Page 99 - ASOP ROT Study Guide

4. RHEUMATOID ARTHRITIS

4 . 1 Cause

Rheumatoid arthritis is a disorder of many systems of the body and its cause is unknown. It has some clear
links with abnormalities of the immune system and there is growing evidence that there may be a genetic
abnormality which causes an abnormal reaction to certain types of bacteria. It seems that persons of a certain
genetic make up do not react in a normal way to particular bacteria and the result is a disease process which
we call rheumatoid arthritis.

4 . 2 Clinical Picture

The most obvious symptoms are severe pain, swelling and deformity of the joints. The principal joints affected
are the small joints of the hands and feet - only in a minority are the larger joints affected. The small joints are
affected symmetrically (both hands or both feet) but there is no pattern in the larger joints. There is no
known reason for this.

The disease may strike at any age and again, for no obvious reason, women are more frequently affected than
men. The patients first notice stiffness, worse in the mornings and improving through the day, in contrast to
osteoarthritis, where stiffness tends to be worse after activity.

4 . 3 The Role of Surgery

The role of the surgeon is to ensure that the patient is as comfortable as possible whilst retaining as much
function as possible. Rheumatoid arthritis is a disease to be tackled by a medical team which includes a
rheumatologist (a clinician who specializes in joint diseases) who will be responsible for prescribing drugs.

4 . 3 .1 Soft tissue surgery

The disease may result in damage to tendon sheaths and the tendons themselves. Damage may be limited
by removing diseased synovial tissue by removing the synoviurn (synovial membrane) using a procedure called
synovectomy. This is a good operation at the wrist for clearing up damage around extensor tendons.
Sometimes tendons about the wrist actually rupture and some sort of repair is needed.

4 . 3 . 2 Joint surgery

In early disease it is sometimes possible to reduce pain and stiffness by synovectomy. This is of value in the
younger patient who retains movement, but who has pain. It is useful at the elbow and wrist where it may be
combined with a limited excision of the joint - excision arthroplasty. This relieves pain but because some of
the joint has been removed there can never be a full return of function.

Most of the surgeon's role is salvage. The goals are pain relief and return of function, just as in osteoarthritis.
The surgeon must be sure that the control of the rheumatoid process by drugs is adequate otherwise doctor
and patient may be disappointed. The surgeon should also be sure that it is function he or she is aiming to
improve and not deformity. This is particularly true in the hands where even very distorted hands may have
excellent function.

5. AVASCULAR NECROSIS

5 . 1 Cause

Bone tissue death through loss of blood supply can occur in certain circumstances throughout the body. In
some cases the cause is clearly traceable to an episode of trauma occurring in an area where the blood
supply is particularly vulnerable. Quite often avascular necrosis occurs spontaneously, or for no
apparent reason.