Rheumatoid arthritis is a chronic systemic autoimmune autoimmune disease characterized by synovitis of the joints. The persistent and recurrent attacks of synovitis can lead to destruction of cartilage and bone in the joints, joint dysfunction, and even disability. The disease is also known as rheumatoid disease because the vasculitis lesions involve various organs throughout the body.
What is rheumatoid arthritis?
Rheumatoid arthritis is a relatively common disease in China, and most patients are young adults. It is a systemic chronic disease with mainly joint lesions. It starts with synovial lesions, then spreads to connective tissues such as tendons and ligaments, and finally destroys joint cartilage and bone tissue, resulting in joint ankylosis.
The etiology of rheumatoid is not fully understood and is thought to be related to infection and systemic immunity. Some scholars believe that the occurrence of the disease may also be related to endocrine imbalance.
The onset of rheumatoid disease is insidious and often involves general malaise, loss of appetite, weight loss, sweating and joint pain, etc. Most of the symptoms are symmetric polyarthritis, most often affecting the small joints of the limbs, especially the metacarpophalangeal and proximal interphalangeal joints of the hands. The joints of the fingers become stiff in the morning and cannot be clenched into a fist, and then invade the large joints upwards.
In the early stage, the joints start to have pain and stiffness, and gradually develop swelling, fluid accumulation and local temperature increase, with obvious local pressure pain and muscle spasm, and gradually muscle atrophy and muscle contracture occur. In the late stage, due to the loss of articular cartilage destruction, ligament and tendon relaxation, and muscle force imbalance, various deformities of the joints may occur, the most common being subluxation of the metacarpophalangeal joint and ulnar deviation of the fingers, and finally, joint ankylosis.
Rheumatoid arthritis is characterized by spontaneous remission and recurrence, and joint symptoms can last for months to decades, and most patients will lose some joint function to varying degrees.
Extra-articular manifestations of rheumatoid arthritis often include subcutaneous nodules, rash, heart disease, and eye disease, but are less common.
Laboratory tests often show elevated white blood cells, secondary anemia, increased sedimentation, and a positive rheumatoid factor test.
X-ray examination of the whole body bones have varying degrees of osteoporosis and atrophy.
In rheumatoid arthritis, the synovium is inflammatory. This inflammation causes thickening of the synovium due to the release of chemical factors, which can damage the joint bone and cartilage. Inflammation of the synovium can cause pain and swelling
What is the diagnosis of rheumatoid arthritis?
The diagnosis is usually not difficult in typical cases, but in the early stages, especially when monoarthritis is present and radiographic changes are not yet obvious, follow-up is required to confirm the diagnosis. Internationally, the American College of Rheumatology’s 1985 diagnostic criteria were revised in 1987 to remove damaging tests and the less specific joint pain and tenderness, and to be more stringent about morning stiffness and joint swelling. However, rheumatoid arthritis in China is less severe than in Western countries, and the first and second criteria are not always met by our patients, so we can be flexible.
1, morning stiffness for at least 1 hour (≥ 6 weeks).
2, swelling of 3 or more joints (≥ 6 weeks).
3, Swelling of the wrist, metacarpophalangeal joint or proximal interphalangeal joint (≥6 weeks).
4.Symmetrical arthrogryposis (≥6 weeks).
5.Subcutaneous nodules.
6.Hand X-ray changes.
7, Positive rheumatoid factor (titer > 1:32).
Diagnosis of rheumatoid arthritis requires 4 or more criteria.
What is the treatment of rheumatoid arthritis?
There is no specific treatment for rheumatoid arthritis, but the treatment of inflammation and sequelae is still in place.
①Control the inflammation of joints and other tissues and relieve the symptoms;
②Maintain joint function and prevent deformity;
(iii) repair damaged joints to reduce pain and restore function.
(a) General therapy: those with fever, joint swelling and pain, and systemic symptoms should rest in bed until the symptoms basically disappear. After two weeks of improvement, activities should be gradually increased to avoid prolonged bed rest leading to joint disuse and even promoting joint ankylosis. Adequate protein and various vitamins should be included in the diet, and small blood transfusions can be given to those with significant anemia. If there are chronic lesions such as tonsillitis, they should be removed as soon as the patient’s health condition allows.
(B) drug therapy: such as non-steroidal anti-inflammatory drugs, gold preparations, penicillamine, chloroquine, levamisole, immunosuppressants, azathioprine, aminopterin, adrenocorticotropic hormones, other treatments such as thymidine, plasma removal therapy, etc. are yet to be explored. Chinese herbal medicine is mainly based on tonifying the kidney and Gu Ben, which can significantly improve the physical condition of patients, enhance the immune function and relieve the symptoms of joint swelling and pain, with better near and long-term effects. It can be combined with the use of Lei Gong Tang, Kunming Shan Hai Tang and other Chinese patent medicines that have definite effect on rheumatoid arthritis.
(C) physical therapy: The purpose of heat therapy to increase local blood circulation, muscle relaxation, to achieve anti-inflammatory, swelling and analgesic effects, while using exercise to maintain and enhance joint function. Physiotherapy methods are the following: hot water bags, hot baths, wax baths, infrared light, etc.. Physical therapy is followed by massage to improve local circulation and relax muscle spasm. The purpose of exercise is to preserve the function of joint movement and to strengthen the strength and endurance of muscles. In the acute stage, after the symptoms have subsided, as long as the patient can tolerate it, he/she should make active or passive joint exercise activities regularly at an early stage.
(iv) Surgical treatment: In the past, it was thought that surgery was only applicable to advanced deformity cases. At present, early synovectomy can be tried for those who have only 1 or 2 joints that are heavily damaged and ineffective by salicylates. In the later stage, the lesion is stationary, and osteotomy is feasible to correct the deformity of the joint.
What is the prognosis of rheumatoid arthritis?
Generally speaking, early treatment of rheumatoid arthritis will result in a better recovery. If only a few joints are involved and the systemic symptoms are mild, or if the joints involved are not symmetrically distributed, the disease is often short-lived and about 10% to 20% of patients become disabled due to untimely treatment. The disease does not directly cause death, but severe advanced cases can die from secondary infection.
The course of the disease is short in those with an acute onset, and an attack can be asymptomatic for months or years, and then recurring for some time after resting. In patients with insidious attacks, the course of the disease is slow and progressive, and can last for several years, with alternating remissions and relapses being characteristic. About 10% to 20% of patients have complete remission after each attack. With each episode the diseased joint becomes more rigid and inflexible, eventually leaving the joint fixed in an abnormal position. According to foreign statistics, complete loss of labor within a few years of the onset of the disease is found in about 10% of patients.
Some of the manifestations of the disease associated with poor prognosis are.
(i) typical lesions (symmetric polyarthritis with subcutaneous nodules and high titers of rheumatoid factor);
(ii) Those whose disease has been active for more than one year;
③People under 30 years of age with onset of disease;
(iv) Those with extra-articular rheumatoid lesions.
What is the surgical treatment for rheumatoid arthritis in the middle and late stages?
Rheumatoid arthritis patients have low resistance and are prone to postoperative infection. Therefore, it is best to use sensitive antibiotics right before surgery. What’s more, it is important to check for potential foci of infection before surgery. The artificial joint is a foreign body to the body, not a living tissue, and has no ability to resist bacterial infection. Once the artificial joint is contaminated with bacteria, it will grow more and more, causing redness, swelling, pain, and even complete failure of the artificial joint and life-threatening conditions. Antibiotics are also routinely administered for a period of time after surgery.
About 90 percent of patients with rheumatoid arthritis who are ready for surgical treatment have received hormone therapy after the onset of the disease, and many of them get worse immediately after they stop using hormones. Therefore, in patients who have been on hormones for a long time, hormone supplementation must still be administered during surgery. Patients who have been off hormones for more than 2 years are not given any special preparation, as are those who have not been on hormones. For patients who have been off hormones for more than 1 year but less than 2 years, supplemental hormone therapy is basically required, but the amount of hormone therapy is reduced as appropriate and the duration of therapy is shortened, often stopping on the second postoperative day.
Surgical treatments for rheumatoid arthritis in the middle and late stages include orthopedic surgery, joint fusion and artificial joint replacement. According to Wang, orthopedic surgery is mostly used for patients with deformed joints or those who are too young to have joint replacement. Most deformities of the hand can be corrected by orthopedic surgery, such as gooseneck-like deformity can be corrected by intrinsic muscle release. Mild buttonhole deformities can be treated with extensor tendonotomy, and moderate ones can be corrected with surgery to balance the tendons, while severe ones can only be treated with proximal interphalangeal joint fixation.
Rheumatoid foot diseases that require surgery are: bunion, claw toe, painful callus, hammertoe deformity, corns, etc. Proximal tibial osteotomy or distal femoral osteotomy is feasible for internal and external knee deformity. Joint fusion, also known as joint fixation, is now less common than in the past for fixation of large joints of the limb, mainly due to the success of artificial total joint replacements, especially of the hip and knee. Ankle fixation is more commonly performed than other large joint fixations because of its satisfactory outcome.
Small joints of the fingers and toes are also often treated with fixation. Currently, artificial joint replacement surgery is mostly used for patients with intermediate to advanced, dysfunctional joints. Artificial hip and knee joints are more mature and have better results, and are widely used.
In juvenile rheumatoid arthritis patients, if the epiphysis is immature, it is better to wait until the epiphysis is closed and the bone becomes thicker. If soft tissue release, osteotomy, synovectomy can solve the problem, artificial joint replacement should not be used as much as possible.
Artificial joints can be divided into two categories: domestic and imported. The price of domestic artificial joints is about 10,000 yuan, and the price of imported products is about 20,000 to 30,000 yuan.