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3 CASE Rheumatoid Arthritis Mimicking Pigmented Villonodular SUMMER 2011 VOLUME 2 ISSUE 2 Grand Rounds from HSS MANAGEMENT OF COMPLEX CASES | RHEUMATOLOGY AUTHORS FROM THE EDITORS Susan M. Goodman, MD We are pleased to present the first issue of Grand Rounds Assistant Attending Physician from Hospital for Special Surgery that is devoted to Hospital for Special Surgery Assistant Professor of Clinical Medicine complex cases managed by our rheumatologists. HSS Weill Cornell Medical College Rheumatology fosters a collaborative approach to patient Michael D. Lockshin, MD care that is supported by the deep expertise of our faculty, Attending Physician Dr. Mary K. Crow Dr. Edward C. Jones the enthusiastic engagement of our rheumatology fellows, Hospital for Special Surgery and close interaction with orthopaedic surgeons, internal medicine specialists, expert Professor of Medicine and OB-GYN radiologists and musculoskeletal pathologists. The four cases presented demonstrate Weill Cornell Medical College the value of this multidisciplinary and interactive approach for excellent patient outcomes. Lisa R. Sammaritano, MD The first case, a woman with severe rheumatoid arthritis who underwent bilateral knee Associate Attending Physician Hospital for Special Surgery replacement (TKR), discusses some issues considered when weighing the risks and Associate Professor of Clinical Medicine benefits of simultaneous bilateral TKR in a patient with a significant rheumatologic Weill Cornell Medical College disease. The second case, a young woman with systemic lupus erythematosus who Arthur M.F. Yee, MD, PhD developed pulmonary hypertension, describes the excellent clinical outcome that Assistant Attending Physician followed aggressive medical therapy. The third case, a young woman who developed a Hospital for Special Surgery monoarticular synovitis that was initially diagnosed as pigmented villonodular synovitis, Assistant Professor of Clinical Medicine was later determined to have rheumatoid arthritis with a good response to therapy. The Weill Cornell Medical College fourth case describes an excellent clinical response to tumor necrosis factor (TNF) CO-AUTHORS inhibition in a patient with sarcoidosis and discusses the growing support in the literature Edward F. DiCarlo, MD for use of TNF antagonists in this inflammatory disease. We hope you enjoy reading Associate Attending Pathologist Hospital for Special Surgery about these complex cases, and we encourage readers to provide feedback through Associate Professor of Clinical Pathology [email protected]. Weill Cornell Medical College Mark P. Figgie, MD Chief, Surgical Arthritis Service Mary (Peggy) K. Crow, MD Edward C. Jones, MD, MA Associate Attending Orthopaedic Surgeon Physician-in-Chief, Chair, Division of Rheumatology Assistant Attending Orthopaedic Surgeon Hospital for Special Surgery Associate Professor of Orthopaedic Surgery in this issue Evelyn M. Horn, MD Attending Physician NewYork-Presbyterian Hospital Bilateral Knee Replacement in Professor of Clinical Medicine Weill Cornell Medical College Rheumatoid Arthritis 1 James M. Horowitz, MD Cardiology Fellow NewYork-Presbyterian Hospital/ Weill Cornell Medical Center Systemic Lupus Erythematosus and Kyriakos A. Kirou, MD, FACR Assistant Attending Physician Severe Pulmonary Hypertension Hospital for Special Surgery 2 Assistant Professor of Medicine Weill Cornell Medical College Alana B. Levine, MD Rheumatology Fellow Rheumatoid Arthritis Mimicking Pigmented Hospital for Special Surgery Villonodular Synovitis Linda A. Russell, MD 3 Assistant Attending Physician Hospital for Special Surgery Assistant Professor of Clinical Medicine Weill Cornell Medical College Tumor Necrosis Factor Inhibition Therapy for Sarcoidosis Weijia Yuan, MB Presenting as Transverse Myelitis and Uveitis Rheumatology Fellow 4 Hospital for Special Surgery 1 Bilateral Knee Replacement in Rheumatoid Arthritis Case presented by Susan M. Goodman, MD; Linda A. Russell, MD; and Mark P. Figgie, MD CASE CASE REPORT: A 44-year-old woman with widespread use of potent disease-modifying severe rheumatoid arthritis (RA) was referred drugs (DMARDS) RA has become less severe to HSS for bilateral knee replacement (TKA) and fewer patients are hospitalized for all causes, surgery. The patient had erosive RA which including arthroplasty (3). Patients such as had responded poorly to aggressive therapy. ours, however, with poor functional status, Her medication regimen at the time of surgery positive CCP antibody, and persistent joint consisted of golimumab and leflunomide. She had inflammation are at risk for joint destruction failed to benefit from adalimumab, etanercept, as well as other severe manifestations of RA. or methotrexate. She was wheelchair-bound due Cervical spine involvement is reported in 44 to knee pain and flexion deformities, but could percent of patients screened at the time of Figure 1: Bilateral standing views of the transfer with the aid of a walker. arthroplasty with flexion/extension neck films (4). Accelerated atherosclerotic disease may be knees demonstrate marked joint space Her exam revealed boggy synovitis of the wrists narrowing with severe diffuse periarticular subclinical, contributing to the excess mortality and metacarpophalangeal joints. She had a 30 osteoporosis and no osteophytes. in RA (6). History may be insufficient to screen degree flexion contracture of the right knee for cardiovascular disease in these debilitated and 20 degrees on the left, with further flexion patients, and imaging studies may be indicated to 110 degrees bilaterally. Bilateral effusions prior to surgery. with crepitus were noted. Foot, ankle and hip exams revealed normal motion. Bilateral knee We elected bilateral simultaneous knee radiographs revealed advanced severe diffuse replacement in this patient because of her joint destruction (Figures 1 and 2). significant flexion contractures, in spite of the increased perioperative risk of thromboembolic Preoperative evaluation included a normal stress events. Unilateral correction of a severe test and echocardiogram. Flexion extension contracture risks recurrence of the deformity views of the cervical spine were normal without and limits ambulation, compromising outcome. instability. She discontinued her golimumab Although database analysis reveals that the rate Figure 2: Lateral views of the knees one month prior to surgery and continued her of pulmonary embolus is doubled and mortality demonstrate diffuse joint space narrowing leflunomide until the day of surgery. and periarticular osteoporosis. increased in patients in whom simultaneous She underwent BTKR performed sequentially BTKR is performed compared to unilateral under epidural anesthesia combined with femoral procedures, staging the surgery during the nerve blocks. A standard peripatellar exposure same hospitalization does not improve the risk. was performed, but more extensive femoral bone Anticoagulation decreases the risk, but does not resection was required in order to correct the eliminate it (2, 5). flexion contractures. A complete synovectomy DMARDS may increase the risk of infection was performed including the posterior aspect and impair wound healing, but medication of the knee. In addition, the posterior capsule withdrawal leads to flare, compromising was released on both sides. Care was taken to rehabilitation. Although the use of anti-TNF protect the bone throughout the surgery as it agents such as golimumab have been beneficial was severely osteoporotic. Although the implants in decreasing joint damage, there is a clear were sized appropriately, there was a mismatch increase in infection which may include surgical Figure 3: Standing AP radiograph between the flexion and extension gaps so a site infection, currently under study at HSS. demonstrating normal alignment of the Zimmer constrained condylar knee replacement bilateral arthroplasties, utilizing Golimumab was held one month prior to surgery, was utilized and fixed with antibiotic impregnated constrained Zimmer components due to with the plan of restarting it once the sutures cement (Figure 3). the patient’s flexion-extension imbalance. were removed and the wound was healing well, DVT prophylaxis with warfarin and intermittent typically at two to three weeks. Small studies pneumatic compression was begun in the have reported increased perioperative infections recovery room. She was able to ambulate on post- with leflunomide, so this was also held, and op day two but developed tachycardia. A high restarted once bowel and kidney function were resolution CT scan revealed pulmonary emboli re-established. Given the prolonged half life of (Figure 4); enoxaparin was added. She was leflunomide, this prevents excess accumulation in discharged to a rehabilitation facility on post-op the event of perturbations of renal function, but day seven on coumadin. does not decrease tissue levels (7). DISCUSSION: Although RA patients undergoing The patient returned home on post-op day 19 arthroplasty should expect significant pain without knee pain, ambulating with a walker. relief from TKA, they may not achieve the same She remains on coumadin and has restarted Figure 4: A CT pulmonary angiogram functional outcome as OA patients (1). Reported her leflunomide and was instructed to resume reveals linear filling defect within the mortality is increased in RA patients in some golimumab. posterior segmental artery of the right series, as are perioperative infections, when lower lobe (arrow) and subsegmental Article and references continued on back page. artery (not shown). compared
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