Ebook Hospital for special surgery manual of rheumatology and outpatient orthopedic disorders - Diagnosis and therapy (5th edition): Part 1

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HOSPITAL FOR SPECIAL SURGERY MANUAL OF
RHEUMATOLOGY AND OUTPATIENT ORTHOPEDIC
DISORDERS: DIAGNOSIS AND THERAPY
Fifth Edition


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HOSPITAL FOR SPECIAL SURGERY MANUAL OF
RHEUMATOLOGY AND OUTPATIENT ORTHOPEDIC
DISORDERS: DIAGNOSIS AND THERAPY
Fifth Edition
Editors

Associate Editor

Stephen A. Paget,

M.D.

Joseph P. Routh Professor of Medicine
Weill Medical College of Cornell University
Physician-in-Chief
Division of Rheumatology
Hospital for Special Surgery-New York
Presbyterian Hospital

New York, New York

Allan Gibofsky,

M.D., J.D.

Professor of Medicine and Public Health
Weill Medical College of Cornell University
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
Professor of Law
Fordham University
New York, New York

John F. Beary III,

M.D.

Clinical Professor of Medicine
University of Cincinnati
Attending Physician
Division of Rheumatology & Immunology
Veterans Administration Medical Center
Cincinnati, Ohio

Thomas P. Sculco,

Doruk Erkan,

M.D.

Assistant Professor of Medicine
Weill Medical College of Cornell University
Associate Physician-Scientist
Barbara Volcker Center for Women
and Rheumatic Disease
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

International Editors

Josef S. Smolen,

M.D.

Professor of Medicine
Chairman, Department of Rheumatology
Medical University of Vienna
Chairman, 2nd Department of Medicine
Rheumatic Disease Center, Lainz Hospital
Vienna, Austria

Stefano Bombardieri,

M.D.

Professor of Rheumatology

Chief, Rheumatic Diseases Unit
University of Pisa
Pisa, Italy

M.D.

Professor of Orthopedic Surgery
Weill Medical College of Cornell University
Surgeon-in-Chief
Department of Orthopedics
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Coordinator

Cookie Reyes
Clinical and Research Administrator
Hospital for Special Surgery
New York, New York


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Acquisitions Editor: Sonya Seigafuse
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Fifth Edition
© 2006 by Lippincott Williams & Wilkins
© 2000 by Lippincott Williams & Wilkins
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All rights reserved. This book is protected by copyright. No part of this book may be reproduced in
any form or by any means, including photocopying, or utilizing by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews.
Printed in the United States
Library of Congress Cataloging-in-Publication Data
Hospital for Special Surgery manual of rheumatology and outpatient orthopedic disorders :
diagnosis and therapy / editors, Stephen A. Paget ... [et al.] ; associate editor, Doruk Erkan ;
coordinator, Cookie Reyes ; forewords, Sir Ravinder Maini, Charles L. Christian. — 5th ed.
p. ; cm. — (Spiral manual series)
Rev. ed. of: Manual of rheumatology and outpatient orthopedic disorders. 4th ed. c2000.
Includes bibliographical references and index.
ISBN 0-7817-6300-2
1. Rheumatology—Handbooks, manuals, etc. 2. Orthopedics—Handbooks, manuals, etc.
I. Paget, Stephen A. II. Hospital for Special Surgery. III. Manual of rheumatology and
outpatient orthopedic disorders. IV. Title: Manual of rheumatology and outpatient orthopedic
disorders. V. Series: Spiral manual.
[DNLM: 1. Rheumatic Diseases—diagnosis—Handbooks. 2. Ambulatory Care—Handbooks.
3. Bone Diseases—Handbooks. 4. Rheumatic Diseases—therapy—Handbooks. WE 39 H828
2006]
RC927.M346 2006
616.7'23—dc22
2005020653

Care has been taken to confirm the accuracy of the information presented and to describe generally
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expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the
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dosage set forth in this text are in accordance with current recommendations and practice at the time of
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insert for each drug for any change in indications and dosage and for added warnings and precautions.
This is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of health care
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With love, we dedicate this book to our families:
Sandra Paget, Daniel, Matthew, and Lauren
Karen Gibofsky, Lewis, Esther, and Laura
Bianca Beary, John Daniel, Vanessa, Webster, and Nina
Cynthia Sculco, Peter, and Sarah Jane
And to L. Robert Vermes, Jr.

“He who saves a single life saves the world entire.”
-Talmud
And to our colleague and friend
Mary (Peggy) K. Crow, M.D.
Professor of Medicine
Weill Medical College of Cornell University
Attending Physician, Hospital for Special Surgery
President of the American College of Rheumatology 2005–2006


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CONTENTS

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Forewords . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xv

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Contributing Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix

I: MUSCULOSKELETAL DATABASE
1

Musculoskeletal History and Physical Examination . . . . . . . . . . . . . . . . .
Stephen A. Paget, Charles N. Cornell, and John F. Beary, III

1

2

Thinking Like a Rheumatologist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Arthur M. F. Yee

3

Immunology for the Primary Care Physician . . . . . . . . . . . . . . . . . . . . . . . 14
Mary K. Crow

4

Rheumatologic Laboratory Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Dalit Ashany, Anne R. Bass, and Keith B. Elkon

5

Immunogenetic Aspects of Rheumatic Diseases . . . . . . . . . . . . . . . . . . . 27
Allan Gibofsky

6

Bone, Connective Tissue, Joint and Vascular Biology,
And Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Linda A. Russell and Edward F. DiCarlo

7

Diagnostic Imaging Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Robert Schneider and Helene Pavlov

8

Arthrocentesis, Intra-articular Injection, and Synovial
Fluid Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Jessica R. Berman, Theodore R. Fields, and Richard Stern

9

Measuring Clinical Outcomes in Rheumatic Disease . . . . . . . . . . . . . . . . 55
Melanie J. Harrison and Lisa A. Mandl

10

Ethical and Legal Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
C. Ronald MacKenzie and Allan Gibofsky

11

Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Laura Robbins and John P. Allegrante

12

Psychosocial Aspects of the Rheumatic Diseases . . . . . . . . . . . . . . . . . . 70
Sharon Danoff-Burg and Tracey A. Revenson

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viii

Contents

II: THE STAT RHEUMATOLOGY AND ORTHOPEDIC
CONSULTATION: YOUR GUIDE TO ACUTE CARE
13

Acute Management of Musculoskeletal
And Autoimmune Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Arthur M. F. Yee and Edward Su

III: CLINICAL PRESENTATIONS
14

Monarthritis/Polyarthritis: Differential Diagnosis . . . . . . . . . . . . . . . . . . .
Stephen Ray Mitchell and John F. Beary, III

97

15

Muscle Pain and Weakness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Lawrence J. Kagen

16

Rash and Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Henry Lee, Rachelle Scott, and Animesh A. Sinha

17

Raynaud’s Phenomenon
Kyriakos A. Kirou

18

Autoimmune and Inflammatory Ophthalmic Diseases . . . . . . . . . . . . . . 130
Sergio Schwartzman, C. Michael Samson, and Scott S. Weissman

19

Neck Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
James C. Farmer, David A. Bomback, and Thomas P. Sculco

20

Low Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
H. Hallett Whitman, III, Daniel J. Clauw, and John F. Beary, III

21

Shoulder Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Andrew D. Pearle and Russell F. Warren

22

Elbow Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Robert N. Hotchkiss

23

Hip Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Thomas P. Sculco and Paul Lombardi

24

Knee Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Norman A. Johanson and Paul Pellicci

25

Ankle and Foot Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
David S. Levine

26

Sports Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Riley J. Williams and Thomas L. Wickiewicz

27

The Female Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Lisa R. Callahan, Jo A. Hannafin, and Monique Sheridan

28

Bursitis and Tendinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Paul Pellicci and Richard R. McCormack

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122


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Contents

ix

IV: DIAGNOSIS AND THERAPY
A. CONNECTIVE TISSUE DISORDERS
29

Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Ioannis Tassiulas and Stephen A. Paget

30

Systemic Lupus Erythematosus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Jane E. Salmon and Robert P. Kimberly

31

Antiphospholipid Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Doruk Erkan and Lisa R. Sammaritano

32

Dermatomyositis, Polymyositis, and Inclusion
Body Myositis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Petros Efthimiou and Lawrence J. Kagen

33

Sjögren’s Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Stuart S. Kassan

34

Systemic Sclerosis and Related Syndromes . . . . . . . . . . . . . . . . . . . . . . 259
Robert F. Spiera

35

Polymyalgia Rheumatica and Giant Cell Arteritis . . . . . . . . . . . . . . . . . . 268
Richard Stern

36

Childhood Rheumatic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Thomas J. A. Lehman

37

The Vasculitides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
Yusuf Yazici and Michael D. Lockshin

38

Pregnancy and Connective Tissue Disorders . . . . . . . . . . . . . . . . . . . . . 297
Doruk Erkan and Lisa R. Sammaritano

B. SPONDYLOARTHROPATHIES
39

Ankylosing Spondylitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Eric S. Schned

40

Arthritis Associated with Ulcerative Colitis
And Crohn’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Kyriakos A. Kirou and Allan Gibofsky

41

Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
Petros Efthimiou and Joseph A. Markenson

42

Reactive Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
Robert D. Inman

C. CRYSTAL ARTHROPATHIES
43

Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Theodore R. Fields

328

44

Pseudogout (Calcium Pyrophosphate Dihydrate
Crystal Arthropathy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
Theodore R. Fields


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Contents

D. INFECTIOUS DISEASES INVOLVING
THE MUSCULOSKELETAL SYSTEM
45

Human Immunodeficiency Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
Edward Parrish

46

Infectious Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
Barry D. Brause and Juliet Aizer

47

Lyme Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Anne R. Bass and Steven K. Magid

48

Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Juliet Aizer and Barry D. Brause

49

Rheumatic Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Allan Gibofsky and John B. Zabriskie

50

Whipple’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Stephen A. Paget and Kristina Belostocki

E. OSTEOARTHRITIS, METABOLIC BONE
AND ENDOCRINE DISORDERS
51

Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
John F. Beary, III and Michael E. Luggen

52

Osteonecrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393

John H. Healey and Andrea Piccioli

53

Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Alexander Krawiecki, Joseph M. Lane, and Joseph L. Barker

54

Paget’s Disease of Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402
John H. Healey and Andrea Piccioli

55

Endocrine Arthropathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
Michael D. Lockshin

F. OTHER RHEUMATIC DISEASES
56

Fibromyalgia and Chronic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409
Daniel J. Clauw and John F. Beary, III

57

Paraneoplastic Musculoskeletal Syndromes
And Hypertrophic Osteoarthropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
Alan T. Kaell

58

Miscellaneous Diseases with Rheumatic Manifestations . . . . . . . . . . . . 427
Diana A. Yens, Chiara Baldini, and Stefano Bombardieri


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Contents

xi

V: ORTHOPEDIC SURGERY AND REHABILITATION:
PRINCIPLES AND PRACTICE
59

Prosthetic Joint Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443
Mark Figgie and Harry E. Figgie, III

60

Perioperative Care of the Patient with Rheumatic Disease . . . . . . . . . . 447
C. Ronald MacKenzie and Nigel Sharrock

61

Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
Sandy B. Ganz and Louis L. Harris

62

Occupational Therapy: Therapist’s Management
Of Rheumatologic Disorders of the Hand . . . . . . . . . . . . . . . . . . . . . . . . 482
Aviva Wolff

VI: COMPLEMENTARY AND ALTERNATIVE MEDICINE

489

Gina Kearney and C. Ronald MacKenzie

VII: FORMULARY

497

Arthur M. F. Yee and Jane E. Salmon

VIII: APPENDICES
A

American College of Rheumatology Criteria for Diagnosis
And Classification of Rheumatic Diseases . . . . . . . . . . . . . . . . . . . . . . . . 557
Allan Gibofsky

B

Neurologic Dermatomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562
Allan Gibofsky

C

Functional Outcome Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
Lisa A. Mandl and Melanie J. Harrison

D

Myositis Functional Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569
Sandy B. Ganz and Louis L. Harris

E

Normal Laboratory Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 570
Allan Gibofsky and Stephen A. Paget

F

Basic Rheumatology Library and Information Web Sites . . . . . . . . . . . . 572
Theodore R. Fields
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575


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ACKNOWLEDGMENTS

W

e gratefully acknowledge our many friends, colleagues, and alumni of the Hospital for Special Surgery who have made helpful suggestions and contributions to this volume

over the past quarter-century. We also gratefully appreciate the excellent assistance of
JoAnn Vega in the preparation of this volume.

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FOREWORDS

T

he composition and authorship of the Manual of Rheumatology and Outpatient
Orthopedic Disorders continues to reflect the fact that rheumatology and orthopedic surgery have a seamless interface in pursuit of education and patient care goals relative to
musculoskeletal disease. The inter-relationship of these two disciplines is a special and
unique feature of the Hospital for Special Surgery, where many of the authors have trained
or practiced.
The primary goal of this manual has been to serve the needs of students and physiciansin-training. Yet professionals of all ages (perhaps especially senior colleagues) find it useful
for reviewing miscellaneous things not successfully committed to memory. These include:
American College of Rheumatology Criteria for Diagnosis and Classification of Rheumatic
Disease, neurologic dermatomes, molecular targets of autoantibodies, normal laboratory
values, details in the formulary, etc. Between the fourth and fifth editions, there has been an
explosion of the rheumatologic formulary; new anti-inflammatory drugs and biologic disease modifying antirheumatic drugs, some based on new insights relative to the pathogenesis of rheumatoid arthritis.
Over the span of our five editions, several new chapters have been added, reflecting
our knowledge of recent advances: antiphospholipid syndrome, pregnancy, and connective
tissue diseases, rheumatic associations with HIV infection, diagnostic imaging, patient education, perioperative management, ethical and legal considerations, measuring functional
status, thinking like a rheumatologist, acute management of musculoskeletal and autoimmune disorders, and so on. In this edition, as in all previous ones, the emphasis remains the

discussion of practical aspects of management of musculoskeletal disorders.
Charles L. Christian, M.D.
Physician-in-Chief Emeritus
Hospital for Special Surgery
New York, New York

T

his remarkable manual celebrates the publication of its fifth edition this year. Innovations in diagnosis, therapeutics, and management strategies that have emerged in the
5 years since the last edition make this update timely. The succinct, authoritative, and didactic style of presenting the rationale and practical information in this publication will
doubtless continue to assist and guide physicians in their clinical practice.
The scope of the book is comprehensive, covering the full spectrum of therapy and
practice of rheumatology. The broad church of the specialty covered extends to regional
pain syndromes, fibromyalgia, diseases of bone, sports injuries, and the principles and
practice of surgery and rehabilitation. New chapters in the general sections cover not only
immunology, genomics, and proteomics but also ethical and legal issues and psychological
aspects of rheumatic disease.
Making knowledge-based therapeutic interventions that maximize benefit and minimize risk has increasingly become part of rheumatological practice since publication of the
last edition. The widespread use of anti-tumor necrosis factor (TNF) biologics added to
methotrexate therapy has profoundly altered the health outcomes for patients with moderate-to-severe rheumatoid arthritis whose disease is not controlled by more effective regimens employing standard drugs as monotherapy or in combination. The recent emphasis

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Forewords

on suppression of disease with judicious use of the available therapeutic armamentarium
has permitted control of signs, symptoms, and joint damage in most patients. Not only has
this permitted the maintenance of a good quality of life, but epidemiologic data also
demonstrate that it has reduced cardiovascular complications and prolonged the life expectancy of these patients.
The use of currently available biologics, and those in the development phase, has been
shown to be effective not only in rheumatoid arthritis but also in other inflammatory arthritides. The repertoire of targeted drugs that is now being developed shows promising results
for systemic rheumatic disease and will enlarge the pharmacopoeia. However, these advances
come at a price of unwanted side effects, such as increasing infection rates, in some patients.
As another example, the widespread use of cyclo-oxygenase-2 (COX-2) inhibitors that control pain with an improved gastric tolerance profile has apparently led to an increase in cardiovascular occlusive events. This has sparked a debate on the safety and indications of all
nonsteroidal anti-inflammatory drugs. The widespread public dissemination of this information has alarmed and confused patients at a time when the potential for the good of patients,
resulting from technical and scientific developments, has never been greater.
The rheumatological practice landscape has changed and will continue to change with
the advent of targeted biologic and chemical drugs and improvement in laboratory and imaging technologies. Managing this change will require a sharper focus and skill base in
rheumatological practice. The responsibility and role of thought leaders and educationalists in this process has therefore become increasingly important. It is worth recalling that
the origins of research with Coley’s toxin that led to the discovery of TNF almost a century
later originated at the Hospital for Special Surgery. The cooperation between surgeons and
physicians and their allied health associates remains a hallmark of this institution in their
quest for a better future for the health of patients. The editors and authors of this book,
coming from this center of excellence in research and practice, have much to offer in this regard to the community of rheumatological practitioners worldwide. Their book deserves a
place on the desk of trainees and established practitioners.
Professor Sir Ravinder Maini, B.A., M.B., BChir, Hon DSc, FRCP FRCP(E) FMed Sci
Emeritus Professor of Rheumatology
The Kennedy Institute of Rheumatology Division
Imperial College
London, W6 8RF
United Kingdom


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PREFACE

I

n the 5 years since the last edition of Manual of Rheumatology and Outpatient Orthopedic Disorders: Diagnosis and Therapy, the clinical and investigative tectonic plates of
rheumatology have shifted in a profound manner, all for the good of our patients. Through a
combination of explosions in our knowledge about the basic mechanisms of disease, advances in our appreciation of the clinical “personalities” of autoimmune and musculoskeletal
disorders, and the rapidity with which basic scientific wisdom is catapulted into therapeutic
advances at the bedside, our patients are living longer and better lives. Nowhere is this sea
change better seen than in the development of worldwide use of biologic drugs such as tumor
necrosis factor (TNF)-␣ blockers. The three commercially available anti-TNF drugs have significantly and safely improved the lives of hundreds of thousands of patients with rheumatoid
arthritis (RA), psoriatic arthritis, spondyloarthropathies, inflammatory bowel disease, and
other systemic inflammatory disorders. Despite these advances, we are still treating the
pathogenesis of diseases (such as RA) and not their etiology; although we can now block a
centrally important proinflammatory cytokine, we are still unable to identify and destroy the
etiologic agents that initiate the process of RA. However, just as systemic diseases such as
rheumatic fever, polio, syphilis, and tuberculosis fell to the development of antibiotics in the
last century, similar paradigm shifts will likely occur in the field of rheumatology.
We have moved from a “wait and see” attitude with regard to so many disorders to a
“get tough and take no prisoners” approach, stimulated by the fact that illnesses such as RA,
if not countered early and aggressively, are intrinsically joint damaging, life shortening, and
work limiting. Rheumatologists have adopted the therapeutic approaches employed by our
colleagues in the field of endocrinology and oncology. We now employ induction and maintenance treatment regimens in many diseases in order to optimally balance disease control with
drug-related side effects, and we do so to achieve a “no evidence of disease” (NED) status. Just
as endocrinologists aim for “tight control” of diabetes by decreasing glycosylated hemoglobin
levels so as to avoid the development of neuropathy, nephropathy, and retinopathy, rheumatologists also “aim” at decreasing signs and symptoms of RA inflammation using sensitive and
responsive clinical research tools such as the Health Assessment Questionnaire and the Disease
Activity Score. Given the amazing effectiveness of anti-TNF medications, we have even resurrected the term disease remission and aim for it day by day in our care of our patients.
We have learned a great deal about both the diseases we treat and the medications we
use to treat them. The former is possible through data obtained from randomized, controlled trials; observational studies; and use of and advances in clinical epidemiology and

health services research. The latter has arisen from drug trials, postmarketing surveillance,
and robust registries. In view of our newfound ability to really make a difference in the lives
of our patients, early arthritis centers have risen, first in Europe and more recently in the
United States, in an attempt to treat RA and other inflammatory disorders as close to their
onset as possible. Studies have recently shown that with self-limited, 1-year courses of antiTNF drugs, sustained remissions can be achieved.
Systemic inflammatory disorders such as RA and systemic lupus erythematosus (SLE)
not only affect joints and kidneys, respectively, but are also associated with significant collateral damage in the form of premature atherosclerosis and osteoporosis. Life span is
shortened in RA by approximately 10 years primarily due to ischemic heart disease. Therefore, treatment of these disorders demands a global approach, one that focuses not only on
the characteristic disease manifestations themselves but also on those tissues affected by the
“spill over” effect of systemic inflammation. We now treat RA and SLE like we would treat
diabetes, with low-dose aspirin, aggressive lipid lowering, and smoking avoidance.

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Preface

We have changed the look of our Manual to make it more user-friendly, added new
chapters in order to keep the manual up-to-date in this rapidly changing field, and always
kept in mind the need to deliver information in its most edible and rapidly digested form.
We have carefully integrated the new science into each line of the Manual in an attempt to
easily bring our increasing knowledge of the basic science to your patient. It is only with
early disease recognition and the institution of the proper therapeutic approach that we can
prolong our patient’s lives and keep our patients diseasefree and damagefree, functional,
and productive.
Stephen A. Paget, M.D.

Allan Gibofsky, M.D., J.D.
John F. Beary, III, M.D.
Thomas P. Sculco, M.D.


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CONTRIBUTING AUTHORS

Juliet Aizer, M.D., M.P.H.
Rheumatology Fellow
Weill Medical College of Cornell University
Hospital for Special Surgery
New York, New York
John P. Allegrante, Ph.D.
Professor of Health Education
Department of Health and Behavior
Studies, Teachers College
Department of Sociomedical Sciences,
Mailman School of Public Health
Columbia University
Senior Scientist
Hospital for Special Surgery
New York, New York

John F. Beary, III, M.D.
Clinical Professor of Medicine
University of Cincinnati
Attending Physician
Division of Rheumatology and

Immunology
Veterans Administration Medical Center
Cincinnati, Ohio
Kristina Belostocki, M.D.
Assistant Professor of Medicine
Weill Medical College of Cornell University
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Dalit Ashany, M.D.
Assistant Professor of Medicine
Weill Medical College of Cornell University
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Jessica R. Berman, M.D.
Assistant Professor of Medicine
Weill Medical College of Cornell University
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Joseph L. Barker, M.D.
Orthopedic Resident
Weill Medical College of Cornell University

Hospital for Special Surgery
New York, New York

David A. Bomback, M.D.
Orthopedic Surgeon
Connecticut Neck and Back Specialists
Danbury, Connecticut

Chiara Baldini, M.D.
Rheumatology Fellow
Department of Internal Medicine
University of Pisa
Pisa, Italy

Stefano Bombardieri, M.D.
Professor of Rheumatology
Chief, Rheumatic Diseases Unit
University of Pisa
Pisa, Italy

Anne R. Bass, M.D.
Assistant Professor of Clinical Medicine
Weill Medical College of Cornell University
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Barry D. Brause, M.D.
Professor of Clinical Medicine

Weill Medical College of Cornell University
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

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Contributing Authors

Lisa R. Callahan, M.D.
Assistant Professor of Clinical Medicine
Weill Medical College of Cornell University
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Keith B. Elkon, M.D.
Professor and Division Head
Division of Rheumatology
University of Washington
Seattle, Washington

Daniel J. Clauw, M.D.

Professor of Medicine and Chief
Division of Rheumatology
Department of Medicine
Assistant Dean of Clinical and Transitional
Research
University of Michigan Medical School
Ann Arbor, Michigan

Doruk Erkan, M.D.
Assistant Professor of Medicine
Weill Medical College of Cornell University
Associate Physician-Scientist
Barbara Volcker Center for Women
and Rheumatic Disease
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Charles N. Cornell, M.D.
Professor of Orthopedic Surgery
Weill Medical College of Cornell University
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

James C. Farmer, M.D.
Assistant Professor of Orthopedic Surgery
Weill Medical College of Cornell University

Assistant Attending Physician
Hospital for Special Surgery
New York, New York

Mary K. Crow, M.D.
Professor of Medicine
Weill Medical College of Cornell University
Director, Autoimmunity and Inflammation
Program
Senior Scientist
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Theodore R. Fields, M.D.
Associate Professor of Clinical Medicine
Weill Medical College of Cornell University
Director, Rheumatology Faculty
Practice Plan
Associate Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Sharon Danoff-Burg, Ph.D.
Associate Professor
Department of Psychology
State University of New York at Albany
Albany, New York

Harry E. Figgie, III, M.D.
Deceased

Edward F. DiCarlo, M.D.
Associate Professor of Clinical Pathology
Weill Medical College of Cornell University
Chief Surgical Pathologist
Director, Histology Laboratory
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Petros Efthimiou, M.D.
Assistant Professor of Medicine
University of Medicine and Dentistry of
New Jersey
Attending Physician
The University Hospital
Newark, New Jersey

Mark Figgie, M.D.
Associate Professor of Orthopedic Surgery
Weill Medical College of Cornell University
Chief, Surgical Arthritis Service
Associate Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Sandy B. Ganz, P.T., D.Sc., G.C.S.
Faculty, Division of Geriatrics and
Gerontology

Weill Medical College of Cornell University
Director of Rehabilitation
Amsterdam Nursing Home
Associate in Research
Hospital for Special Surgery
New York, New York


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Contributing Authors

Allan Gibofsky, M.D., J.D.
Professor of Medicine and Public Health
Weill Medical College of Cornell University
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
Professor of Law
Fordham University
New York, New York
Jo A. Hannafin, M.D., Ph.D.
Assistant Professor of Orthopedic Surgery
Weill Medical College of Cornell University
Director, Orthopedic Research
Director, Women’s Sports Medicine Center
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Louis L. Harris, M.D.
Senior Administrator and Director
Network Development and Planning
Burke Rehabilitation Hospital
White Plains, New York
Melanie J. Harrison, M.D., M.S.
Assistant Research Professor of Medicine
and Public Health
Weill Medical College of Cornell University
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
John H. Healey, M.D.
Professor of Orthopedic Surgery
Weill Medical College of Cornell University
Chief, Orthopedic Service
Memorial Sloan-Kettering Cancer Center
New York, New York

xxi

Norman A. Johanson, M.D.
Professor and Chairman of Orthopedic
Surgery
Drexel University College of Medicine
Hahnemann University Hospital
Philadelphia, Pennsylvania
Alan T. Kaell, M.D.
Professor of Clinical Medicine

State University of New York at
Stony Brook
Stony Brook, New York
Chief, Division of Rheumatology
St. Charles Health System
Port Jefferson, New York
Lawrence J. Kagen, M.D.
Professor of Medicine
Weill Medical College of Cornell University
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Stuart S. Kassan, M.D.
Clinical Professor of Medicine
University of Colorado Health Sciences
Center
Colorado Arthritis Associates
Denver, Colorado
Gina Kearney, M.S.N., R.N., C.S.,
A.H.N.-B.C.
Holistic Nurse Practitioner
Integrative Care Center
Hospital for Special Surgery
New York, New York

Robert N. Hotchkiss, M.D.
Associate Professor of Orthopedic Surgery
Weill Medical College of Cornell University
Director of Clinical Research

Attending Physician
Hospital for Special Surgery
New York, New York

Robert P. Kimberly, M.D.
Howard L. Holley Professor
of Medicine
University of Alabama at Birmingham
Director, University of Alabama Arthritis
and Musculoskeletal Center
Division of Clinical Immunology
and Rheumatology
University Hospital
Birmingham, Alabama

Robert D. Inman, M.D.
Professor of Medicine and Immunology
University of Toronto
Director, Arthritis Center of Excellence
Division of Rheumatology
Toronto Western Hospital
Ontario, Canada

Kyriakos A. Kirou, M.D.
Assistant Professor of Medicine
Weill Medical College of Cornell University
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

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Contributing Authors

Alexander Krawiecki, M.D.
Hospital for Special Surgery
New York, New York
Joseph M. Lane, M.D.
Professor of Orthopedic Surgery
Weill Medical College of Cornell University
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Henry Lee, M.D.
Dermatology Resident
Weill Medical College of Cornell University
New York Presbyterian Hospital
New York, New York
Thomas J. A. Lehman, M.D.
Professor of Clinical Pediatrics
Weill Medical College of Cornell University
Chief, Division of Pediatric Rheumatology
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

David S. Levine, M.D.
Assistant Professor of Orthopedic Surgery
Weill Medical College of Cornell University
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Michael D. Lockshin, M.D.
Professor of Medicine and Obstetrics
Weill Medical College of Cornell University
Director, Barbara Volcker Center
for Women and Rheumatic Disease
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

C. Ronald MacKenzie, M.D.
Associate Professor of Clinical Medicine
Weill Medical College of Cornell University
Associate Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Steven K. Magid, M.D.
Associate Professor of Clinical Medicine
Weill Medical College of Cornell University
Associate Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital

New York, New York
Lisa A. Mandl, M.D., M.P.H.
Assistant Professor of Medicine
Weill Medical College of Cornell University
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Joseph A. Markenson, M.D.
Professor of Medicine
Weill Medical College of Cornell University
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Richard R. McCormack, M.D.
Orthopedic Surgeon Emeritus
Hospital for Special Surgery
Weill Medical College of Cornell University
New York, New York
Stephen Ray Mitchell, M.D.
Director, Residency Program, Department
of Medicine
Georgetown University
Washington, District of Columbia

Paul Lombardi, M.D.
Senior Clinical Associate in Orthopedic
Surgery
Weill Medical College of Cornell University

Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Stephen A. Paget, M.D.
Joseph P. Routh Professor of Medicine
Weill Medical College of Cornell University
Physician-in-Chief, Division of
Rheumatology
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Michael E. Luggen, M.D.
Professor of Clinical Medicine
University of Cincinnati Medical Center
Rheumatology Consultants
Department of Internal Medicine
University Hospital
Cincinnati, Ohio

Edward Parrish, M.D.
Associate Professor of Medicine
Weill Medical College of Cornell University
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

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Contributing Authors

xxiii

Helene Pavlov, M.D.
Professor of Radiology
Weill Medical College of Cornell University
Chief, Department of Radiology and
Imaging
Hospital for Special Surgery
New York, New York

Lisa R. Sammaritano, M.D.
Associate Professor of Medicine
Weill Medical College of Cornell University
Associate Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Andrew D. Pearle, M.D.
Instructor in Orthopedic Surgery
Weill Medical College of Cornell University
Assistant Attending Orthopedic Surgeon
Hospital for Special Surgery
New York, New York

C. Michael Samson, M.D.

Co-Director, Uveitis Service
New York Eye and Ear Infirmary
New York, New York

Paul Pellicci, M.D.
Professor of Orthopedic Surgery
Weill Medical College of Cornell University
Chief, Hip Service
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Andrea Piccioli, M.D.
Orthopedic Surgeon
Centro Traumatologico e Ortopedico
Rome, Italy
Tracey A. Revenson, Ph.D.
Professor of Psychology
The Graduate Center of the City
University of New York
New York, New York
Laura Robbins, D.S.W.
Associate Professor
Graduate School of Medical Sciences
Clinical Epidemiology and Health Sciences
Research
Weill Medical College at Cornell University
Vice President, Education and Academic
Affairs
Associate Scientist

Hospital for Special Surgery
New York, New York
Linda A. Russell, M.D.
Assistant Professor of Medicine
Weill Medical College of Cornell University
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Jane E. Salmon, M.D.
Professor of Medicine
Weill Medical College of Cornell University
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Eric S. Schned, M.D.
Medical Director
Park Nicollete Clinic
Minneapolis, Minnesota
Robert Schneider, M.D.
Associate Professor of Radiology
Weill Medical College of Cornell University
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Sergio Schwartzman, M.D.
Associate Professor of Medicine

Weill Medical College of Cornell University
Associate Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Rachelle Scott, M.D.
Associate Professor of Clinical
Dermatology
Weill Medical College of Cornell University
Assistant Attending Physician
New York Presbyterian Hospital
New York, New York
Thomas P. Sculco, M.D.
Professor of Orthopedic Surgery
Weill Medical College of Cornell University
Surgeon-in-Chief, Chairman
Department of Orthopedics
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Nigel Sharrock, M.B., Ch.B.
Clinical Professor of Anesthesiology
Weill Medical College of Cornell University
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York


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xxiv

Contributing Authors

Monique Sheridan
Research Coordinator
Women’s Sports Medicine Center
Hospital for Special Surgery
New York, New York
Animesh A. Sinha, M.D., Ph.D.
Assistant Professor of Dermatology
Weill Medical College of Cornell University
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Robert F. Spiera, M.D.
Associate Professor of Medicine
Weill Medical College of Cornell University
Director, Vasculitis and Scleroderma
Programs
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Richard Stern, M.D.
Clinical Associate Professor
Weill Medical College of Cornell University
Attending Physician

Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Edward Su, M.D.
Clinical Instructor of Orthopedic Surgery
Weill Medical College of Cornell University
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Ioannis Tassiulas, M.D.
Assistant Professor of Medicine
Weill Medical College of Cornell University
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Russell F. Warren, M.D.
Professor of Orthopedic Surgery
Weill Medical College of Cornell University
Surgeon-in-Chief Emeritus
Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York

Scott S. Weissman, M.D.
Adjunct Clinical Scientist
Columbia University College of Physicians
and Surgeons

Attending Physician
Manhattan Eye, Ear, and Throat
Hospital
Attending Physician and Director
Uveitis Service, New York Eye and Ear
Infirmary
New York, New York
H. Hallett Whitman, III, M.D.
Assistant Professor of Clinical Medicine
Clinical and Research Associate
Cardiovascular Hypertension Center
Weill Medical College of Cornell University
Chief of Rheumatology
Summit Medical Group
Summit, New Jersey
Physician to the Outpatient Department
Hospital for Special Surgery
New York, New York
Thomas L. Wickiewicz, M.D.
Associate Professor of Orthopedic Surgery
Weill Medical College of Cornell University
Chief, Sports Medicine and
Shoulder Service
Associate Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Riley J. Williams, M.D.
Associate Professor of Orthopedic Surgery
Weill Medical College of Cornell University

Sports Medicine and Shoulder Service
Associate Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Aviva Wolff, O.T.R., C.H.T.
Senior Hand Specialist
Department of Rehabilitation
Hospital for Special Surgery
New York, New York
Yusuf Yazici, M.D.
Assistant Professor of Clinical Medicine
New York University
Attending Rheumatologist
Hospital for Joint Diseases
New York, New York


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Contributing Authors

Arthur M. F. Yee, M.D., Ph.D.
Assistant Professor of Medicine
Weill Medical College of Cornell University
Assistant Attending Physician
Hospital for Special Surgery-New York
Presbyterian Hospital
New York, New York
Diana A. Yens, M.D.

Assistant Professor of Clinical Medicine
Weill Medical College of Cornell University
Assistant Attending Physician
Hospital for Special Surgery
New York, New York

xxv

John B. Zabriskie, M.D.
Associate Professor Emeritus
Clinical Microbiology and Immunology
Rockefeller University
Senior Physician
Rockefeller University Hospital
New York, New York