Health and Culture Quarterly • ORTHOPAEDICS
DR. Maurilio BRUNO
DIRECTOR – HAND SURGERY OPERATING UNIT II
Galeazzi Orthopaedic Institute – Research Hospital (Milan)
Rheumatoid arthritis and arthrosis are not the same thing: while the first is an autoimmune pathology, the second results from progressive wear-and-tear of joint cartilage. Doctor Maurilio Bruno, director of the Hand Surgery Operating Unit II at the Galeazzi Orthopaedic Institute – Research Hospital, discussed their characteristics with us, from a diagnostic and surgical point of view.
What is the difference from a diagnostic point of view?
“There are many differences between the two pathologies, but everything starts with the diagnosis. When a patient, more predominantly female, comes to see a hand surgeon, they do mainly because they have started to notice the pain.
The areas most affected are:
• The trapezial-metacarpal joint (the “grip” between the thumb and the second finger), which starts to deform, dislocate and hurt.
• The joints before the nail (distal inter-phalangeal).
The areas least affected are:
• The joints of the central fascia of the fingers (proximal inter-phalangeal).
• The metacarpal-phalangeal joints (knuckles).”
What is the difference from a diagnostic point of view?
“Arthrosis, a joint wear-and-tear condition where progressive depletion of the cartilage leads slowly to destruction of the joint, is linked to genetic make-up, and mainly affects the trapezial-metacarpal and the distal inter-phalangeal joints. When we talk about rheumatoid arthritis, however, we refer to a chronic autoimmune pathology, where the subjects themselves wrongly create antibodies that attack the capsular ligament area, the tendons, the cartilage, and the proximal inter-phalangeal and metacarpal-phalangeal parts in particular. With arthrosis, the onset of these dysmorphisms is relatively rapid, whereas with arthritis, thanks above all to pharmacology and early diagnosis, these lesions develop very slowly. With arthrosis, once deformed, these joints stabilise. While with arthrosis the pain depends on mechanical articular changes, with arthritis it is constant, as all of the tissues are diseased (capsule, tendons, ligaments and bone).”
When is surgery used?
“Once physical methods for treating arthrosis have been exhausted (e.g. shock waves, magnetotherapy, Tecar therapy), you move on to surgical treatment. The point is that you have to deal with a bone that is sclerotic, hard, deformed but solid, dry, and healthy from a mechanical point of view, while with arthritis, once the pharmacological phase ends, it is not possible to use physical therapies, because we would be altering delicate mechanisms within the joint.
Physiotherapy, kinesiotherapy and physical exercise are not advisable here. In this case, as well, we would need to move on to surgery. With arthrosis it is possible to use arthroplasty (re-modelling of the joint), arthrodesis (bone fusion) or prostheses (albeit more rarely), but with arthritis synovectomy is predominantly used: removing the diseased synovial membrane that is adversely affecting structures within the joint. The synovium is the membrane used for the production of synovial fluid, which contains elements for the maintenance and growth of the cartilage; for this reason, it is important that it remains healthy. When it becomes diseased and produce anomalous elements that are aggressive towards joint structures, it needs to be removed. Then, if the deformities progress, there are two possibilities: repairing these joints through prostheses, or using arthrodesis. A prosthesis enables diseased bone to be replaced as much as possible, allowing for a certain amount of mobility, whereas with arthrodesis joint movement is sacrificed completely in favour of bone stabilisation. The aim of arthrosis treatment is to protect and restore all joints, including through the use of prostheses.”
Can they also affect young people?
“Rheumatoid arthritis affects more and more young people during post-adolescence period so we need to halt the progress of the illness: on one hand with the help of the rheumatologist using pharmacology, and on the other hand with the help of the surgeon, who takes care of the “mechanical” part. If synovitis is affecting a young person, it needs to be limited through synovectomy. As the age and illness advance, we need to intervene with regard to pain, limiting it and ensuring a certain amount of functionality through the implantation of prostheses and arthrodesis. Rheumatoid arthritis has a genetic component and a family history component. It is the task of the rheumatologist to assess the patient by means of haematological and rheumatological tests, for greater diagnostic sophistication. Surgeons, however, must carry out baseline tests and then send the patient to the rheumatologist for classifying an often very complex pathology, while remaining available for any surgical need.”
◗ Predominantly affects females (ratio = 3:1).
◗ Affects 1-2% of the population and the number of cases increases with age (5% women over 55 years of age are affected).
◗ Onset is mainly observed after the end of adolescence or between the fourth and fifth decade of life; a second peak is observed between 60 and 70 years of age.
◗ An early-occurring variant is infant rheumatoid arthritis.
◗ Affects around 10% of the general adult population, and 50% of people are over 60 years of age, with a slight prevalence in females.
◗ Pre-disposing risk factors are obesity, female gender, family history, joint trauma, stress and humid environments.
By: Lara Benvenuti
Translation: TDR Translation Company
Editing: Victor Cojocaru