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Rheumatoid Arthritis M06.9 714.0

 

synonyms: RA

Rheumatoid Arthritis ICD-10

Rheumatoid Arthritis ICD-9

  • 714.0 (rheumatoid arthritis)

Rheumatoid Arthritis Etiology / Epidemiology / Natural History

  • Rheumatoid pannus = inflammed synovial tissue which leads to erosion of articular cartilage, and characteristic periarticular erosions.
  • TNF-alpha and interleukin-1B are the major inflammatory cytokines involved in RA. Others=interleukin-2, inferferon gamma,

Rheumatoid Arthritis Anatomy

  • Classically involves: wrists, MCP PIP joints in the hand and MTP joints in the foot.

Rheumatoid Arthritis Clinical Evaluation

  • Symmetric, erosive and deforming.
  • Early morning stiffness, joint swelling.

Rheumatoid Arthritis Xray / Diagnositc Tests

  • Xrays demonstrate:
    1-symmetric joint space narrowing
    2-periarticular osteopenia
    3-erosive changes.
  • Lateral flexion/extention C-spine xrays are indicated for any RA patient who is undergoing general anesthesia to evaluated for C1-2 instability. Posterior atlanto-dens interval >14mm is predictive of neurologic progression and pt should be considered for fusion (Boden SD, JBJS 1993;75:1282).
  • Anticyclic citrullinated antibody: most specific lab finding; present in 2/3 of RA pts.
  • Rheumatoid factor: immunoglobulin M antibody against immunoglobulin G. Present in 90% of patients.
  • Nonspecific labs: elevated ESR, elevated CRP, decreased Hgb, elevated platelets.

Rheumatoid Arthritis Classification / Treatment

  • Diagnosed by symmetric inflammatory polyarthritis affecting small joints of hands, feet and wrists persitting >6months with characteristic lab findings.
  • Generally referred to Rheumatologist for disease modifying treatment. Infliximab (targets TNF), etanerceopt(targets TNF), adalimumab(targets TNF), anakinfa(targets IL-1), abatacept, rituximab, corticosteriods, doxycyline, methotrexate, hydroxycloroquine, sulfasalazine leflunomide. (Korpela M, Arthritis Rheum 2004;50:2072). Medications have many sometime severe adverse effects.
  • Surgical considerations: 2-4x increased infection risk, RA medications may increase infection risk, delay wound healing; stopping RA meds before surgery remains controversial.

Rheumatoid Arthritis Associated Injuries / Differential Diagnosis

Rheumatoid Arthritis Complications

  • Adverse medication reactions: TB reactivation, pneumoxystis carinii, candidiasis, histoplasmosis, listeriosis, nocardiosis, aspergillosis, cytomegalovirus, cryptococcosis, coccidioidmyocosis, demyelinating disease, infusion/injection reactions, malignancy, CHF

Rheumatoid Arthritis Follow-up Care

  • Generally refer to rheumatology for medical management.

Rheumatoid Arthritis Review References

  • Abdo RV, Iorio LJ. Rheumatoid arthritis of the foot and ankle. J Am Acad Orthop Surg. 1994 Nov;2(6):326-332. 
  • Jaakkola JI, Mann RA. A review of rheumatoid arthritis affecting the foot and ankle. Foot Ankle Int. 2004 Dec;25(12):866-74.
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