What are the typical knee joint deformities seen in women aged 30–60 with longstanding rheumatoid arthritis and what is the first‑line management?

Knee Joint Deformities in Rheumatoid Arthritis

In longstanding rheumatoid arthritis, the knee develops flexion contracture deformity and valgus deformity as the most characteristic structural changes, and first-line management is aggressive disease-modifying antirheumatic drug (DMARD) therapy with methotrexate to prevent progression, combined with rehabilitation interventions including resistance exercise, aquatic exercise, and knee orthoses. 1, 2

Typical Knee Deformities

The knee joint is commonly damaged in polyarticular rheumatoid arthritis, with specific deformity patterns:

• Flexion contracture is the hallmark deformity, often severe enough to render patients nonambulatory in advanced disease 2, 3
• Valgus deformity frequently accompanies flexion contracture, particularly in women with longstanding disease 2
• Joint space narrowing progresses diffusely as inflammatory pannus destroys articular cartilage 4
• Marginal and central erosions develop as synovial proliferation extends across cartilage surfaces 4
• Subluxations and dislocations occur in advanced stages with ligamentous laxity 4

These deformities result from chronic synovitis causing progressive joint destruction, with the knee being one of the preferential sites after the hands, wrists, and feet 4.

First-Line Medical Management

Methotrexate is the cornerstone first-line DMARD that must be initiated promptly to prevent joint destruction and deformity progression:

• Start methotrexate 15 mg weekly, escalating to 20-25 mg weekly if inadequate response at 6-8 weeks 5
• Add short-term prednisone 10-20 mg daily for rapid symptom control while methotrexate takes effect over 6-12 weeks 5
• Target remission or low disease activity using composite measures (DAS28, SDAI, or CDAI) assessed at 3 months 1, 5
• Taper prednisone once methotrexate shows clinical effect to minimize glucocorticoid toxicity 5

The goal is complete abrogation of disease activity, as timely intervention reduces disease progression and has resulted in less need for joint reconstructive surgery than in previous decades 1.

First-Line Rehabilitation Interventions

Exercise and orthotic interventions are essential components of first-line management to maintain function and prevent disability:

Exercise Modalities (all conditionally recommended):

• Resistance exercise improves physical function and reduces pain in patients with knee involvement 1
• Aquatic exercise improves physical function with low-impact loading, particularly beneficial for patients with established deformities 1
• Aerobic exercise improves physical function, though patient preferences vary based on disease activity and joint damage 1

Orthotic Support:

• Knee bracing and orthoses are conditionally recommended for patients with knee involvement to provide stability and reduce mechanical stress 1
• These devices help accommodate deformities while maintaining ambulation 1

Comprehensive Physical Therapy:

• Conditionally recommended as part of the overall management strategy to optimize function 1
• Particularly important for patients with established flexion contractures to maintain range of motion 2

Treatment Escalation Algorithm

If disease activity remains moderate-to-high despite optimized methotrexate:

• Add sulfasalazine and hydroxychloroquine for triple-DMARD therapy, OR 5
• Add a biologic agent (TNF inhibitor, abatacept, tocilizumab, or rituximab) 5, 6
• Biological agents are used when arthritis is uncontrolled or toxic effects arise with DMARDs 6

Critical Pitfalls to Avoid

Delayed treatment initiation is the most critical error, as 80% of patients are working at 2 years but only 68% at 5 years, with work disability beginning early after disease onset 1. The window for preventing irreversible joint damage is narrow.

Underestimating disease activity in the absence of visible joint swelling is dangerous, particularly in elderly patients where elevated CRP confirms active inflammation even without obvious synovitis 5.

Inadequate disease activity monitoring leads to suboptimal outcomes—formal assessment using composite measures at 3 months is mandatory, not optional 5.

Surgical Considerations

When medical management fails to control symptoms in patients with severe joint damage:

• Total knee arthroplasty (TKA) is indicated for severe deformity with intractable pain 2, 3, 7
• TKA combined with serial casting and physical therapy can restore stable joint movement and correct deformity 2
• Long-term results are excellent, with improved function and pain reduction in the vast majority of patients 3
• Arthroscopic synovectomy is reserved for intractable synovitis with cartilage preservation 3

However, surgery should be viewed as salvage therapy—the primary goal is preventing progression to this stage through aggressive early DMARD therapy 1.