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Orthopedic Surgery Disease:Rheumatoid Arthritis

Generalized disease caused by runaway immune system.

Human body, by nature, has an immune system, which identify first as foreign objects which are not a part of the body tissue then attack and push out microbe like bacteria or virus, or foreign objects come into the body. This immune system takes an important role in spending the healthy life. This system may not only to protect own body from unseen foreign enemy, microbe, if it functions normally, but also to inhibit cancer cell developed from own tissue. This system undertakes an important roll for leading a healthy life.

However, this immune system may cause abnormalities with some reason. In case immune system is weakened, body becomes weak for bacteria or virus infection so that symptoms may occur even with attenuated microbe, with which healthy person may not onset any diseases. On the other hand, there is a case where immune system overreacts. In this case, own body tissue is recognized as “outer enemy”, then attacked/rejected by immune system resulted the inflammation. This kind disease is called as autoimmune disease. Autoimmune disease can be divided into two groups. The one is the case where runaway immune system occur only at specific part of the body. Typical are hepatitis and kidney inflammation. The other is a case where runaway immune system occur at entire body, having inflammation at several part of the body. This is called as collagenosis.

Rheumatoid arthritis is one of the typical diseases so called collagenosis. The battle history between rheumatoid arthritis and human is old enough. In ante-Christ, it is considered that the cause of the disease is bad liquid flows inside the body, so that it is said that the ancient Greek word [Rhyeuma (stream)] is the origin of disease name. As the matter of fact, analysis for the cause of disease has advanced in modern age, but history shows many people suffered for long time hence there are still many people are being suffered with the disease.

The cause may be the excess secretion of cytokine.

Of course, “bad liquid flows” concept had already been denied completely. As for rheumatoid arthritis, it is known that inflammation occurs at immune cell in the tissue called synovial membrane covering the inside of the joint so that the destruction of joint bone or cartilage (tissue functions as cushion on the surface of bone) advances gradually.

Furthermore, in the most recent research tells that material called cytokine greatly affect to this inflammation. This cytokine is a protein secreted out from immune cell, and it works to reject foreign objects to protect human body health. But when it over-secretes, it is considered that over-secretion may develop a serious inflammation hence connecting to the symptom of rheumatoid arthritis patients’ pain on the joint or swelling.

Peak age of onset is the 40 to 60 middle-age period and women takes the majority in patients’ proportion. But there is a case where disease is onset in much younger age or in much older age so that it can be said that any matured people has a risk for the development of this disease.

Need to watch out in case of feeling stiffness in the morning.

American College of Rheumatology Standard is mostly used for the diagnosis, but in case when following symptoms appeared, it may be better to have doctor’s check or inspection.

  1. Tensed feeling on wrist continues for a while in the morning. (30 minutes to over 1 hour)
  2. Several Joints become swollen. Sometimes it is accompanied with pain.
  3. Not for one side only, symptoms like above (2) appears on both side joints.

Above mentioned symptoms at the joint may appear at the inferior limb (hip joint, knee joint or ankle joint), but it is said that symptom on hand commonly appear from early stage. Among them, need to pay attention when feeling pain or swelling appeared on the joint of base of finger. Final diagnosis is conducted with the combination of blood test and image test in addition to above symptoms and physical findings.

Blood test is used to consider rheumatic factor (RF) is important. Even now there are many people consider as important when RF is positive so that peoples are worried about rheumatoid arthritis, but there is a case where rheumatoid arthritis is denied even with RF. Therefore, it should be considered together with CRP which indicates inflammation value of entire body etc. Recently, item called as anti-CCP antibody brings into action for the diagnosis of rheumatoid arthritis. However, there is a rheumatoid arthritis which is hard to diagnose only by several blood test results, so that medical specialist’s diagnosis is necessary at the end.

As to image diagnosis, result of X-ray examination is used to classify rheumatoid arthritis progress, but X-ray image changes when inflammation has progressed and destroy bone, so that it is not suitable for early stage diagnosis. In the image examination using so called as MRI (Magnetic Resonance Imaging system), it is said that it can detect the inside bone abnormality earlier than X-ray, hence, depend on the symptoms, MRI is used for image examination.

Treatment is conducted with both inflammatory suppression and modified joint improvement.

As inflammation advances, it will destroy surrounding bones or joints, then resulted in deformation occur at the bone or joint movement is getting worse (called as contracture). These may affect to daily life. They are therefore, as the treatment;

  1. To suppress the advancement of inflammation as much as possible, and
  2. To treat deformed joint resulted by advanced inflammation to be able to spend normal daily life as much as possible.

Above two methods are taken.

Persons go about daily life are increasing with the help of biological drug.

Chemotherapy is a core method for above (1) case; to suppress inflammation advancement. This method is used to observe how it works with gradually adding inflammation suppression drug in keeping eye on numeric of blood test, but nowadays, treatment method has been changed to subtraction method from addition method.; i.e., at first, administrate the inflammation suppression drug with certain amount, then later on gradually reducing drug amount or change to less effective drug.

Also, afore mentioned drug (generally called as biological drug), which suppress cytokine directly, has progressed greatly in this decade. With these drugs, patients who are able to spend normal daily life while treatment is continuing.

However, to suppress inflammation means to reduce own immune system effects. With this reason, it becomes necessary to pay attention to not only for bad effect to inward organs other than bones or joints like lung, liver or kidney but also for weakening the own immune system. Hence periodical checkup is important. Or there is a drug which is risky when drastically stop administration. It is therefore important to stop self-diagnosed medicines and to get along with these drugs consulting with medical specialist.

In case deformation is big enough, replacement with artificial joint may be considered.

Unfortunately, however, deformation of the joint is to be gradually advanced even with having adequate pharmacological therapy from early stage. And for the joint which deformation or contracture of #2 of previous section, rehabilitation treatment is sometimes not good enough for the affect so that surgical operation may become necessary.

For large joints, like Shoulder joint, cubital joint, knee joint, or Foot joint, there is a replacing method using the polyethylene and ceramic combined artificial joint. But the deformation level or frailty of bone (there is a case where bone gets stronger with pharmacological therapy) are different for each individual so that it is necessary to consult with each medical specialist about the movement restriction after the artificial joint surgery and rehabilitation period, then taking surgical operation with full understanding.

There is one more thing to pay attention at the time when receiving surgical operation. That is a risk for the infection after the surgery in case immune system becomes weakened by pharmacological therapy. Especially when infection has developed at the above mentioned artificial joint surgery, surgical operation itself most likely become difficult so that it should be known that the careful follow-up after the surgery is necessary.

Cooperation of internal medicine and orthopedic department is important from now on.

Treatment of articular rheumatism has progressed greatly with the introduction of biological products. But in the meantime, this means that the knowledge of internal medicine and technique of orthopedic surgery should be combined in high level. It may become important for the patient to select medical specialist who can take close medical cooperation.