Rheumatoid Arthritis

First and foremost, please be aware that I, myself, am a Consultant Orthopaedic Surgeon (Knee Specialist) and not a Rheumatologist. Even though patients with Rheumatoid Arthritis do often end up needing orthopaedic surgery, Rheumatoid Arthritis is more of a ‘medical’ condition – and the experts on this are definitely the Rheumatologists. So, just be aware that this info covers just the very basics, from a knee surgeon’s perspective …

Rheumatoid is just one of a number of different conditions that can cause inflammation in joints – an ‘inflammatory arthropathy’. Rheumatoid is an autoimmune condition where the body’s immune system reacts in a confused way, causing inflammation in what should otherwise be normal tissue. When Rheumatoid affects joints, it causes inflammation of the lining of the joint (the synovial membrane), which is called ‘synovitis’.

Rheumatoid arthritis can affect multiple joints, but it particularly seems to affect the knees, the fingers and the wrists. It can sometimes affect just one joint in isolation, but quite often it affects multiple joints – often symmetrically (i.e. the same on the left as the right). The inflammation in the joint causes pain, heat, swelling and stiffness. The stiffness is often particularly bad first thing in the morning.

With time, the inflammation in the joint tends to cause gradual damage to the articular cartilage – this increases the rate of wear and tear in the joint, which can eventually lead to arthritis (a severely painful joint where the cartilage has worn away and there is exposed bare bone rubbing on bare bone).

Investigation

Investigation of suspected Rheumatoid Arthritis includes the following:-

  • X-rays
  • Blood tests
  • Sometimes, synovial biopsy from knee arthroscopy

The blood tests that are important for Rheumatoid are the Inflammatory Markers (the ESR and the CRP) – although these are fairly non-specific as they can be raised with any kind of inflammation (anywhere in the body) or with any kind of infection. Other blood tests include a test for ‘The Rheumatoid Factor’ and for auto-antibodies. I won’t profess to really understand these tests fully … because it seems that apparently you can have +ve Rheumatoid Arthritis, even if the Rheumatoid Factor comes back –ve … and also a +ve Rheumatoid Factor apparently doesn’t actually mean that you’ve definitely got Rheumatoid Arthritis! The same apparently applies to the various auto-antibody tests! (So, why do we even test for them?!?!)

Treatment

The mainstay of treatment for Rheumatoid Arthritis is the use of anti-inflammatories. These range in strength from just basic simply over-the-counter anti-inflammatories to super-strong anti-inflammatories such as Steroids or a drug called Methotrexate. Newer, stronger, more focused drugs are coming out all the time, such as anti-TNF drugs. However, this all falls under the remit of the Rheumatologists, and anyone with Rheumatoid Arthritis really should be under the care of a specialist Consultant Rheumatologist.

Surgery

Surgery can eventually be indicated if joint become badly affected.

For knees with early Rheumatoid, knee arthroscopy with a washout and synovectomy (removal of the inflamed synovial tissue) can help greatly (although it does not cure the underlying disease).

For badly damaged joints, knee replacement surgery might end up being required. Even though the risk of complications from knee replacement surgery is slightly higher for Rheumatoid patients than for the ‘average’ patient, knee replacement surgery in Rheumatoid patients tends to give excellent results.