S. Anders

[Long-term results of synovectomy in the rheumatoid ankle joint].

Inflammatory rheumatic ankle joint destruction endangers the mobility of the rheumatic patient by pain and loss of function. In the presented patient population, 29 patients with a mean preoperative history of 14.3 years of rheumatoid arthritis and 7.6 years manifestation of ankle arthritis underwent open synovectomy of the ankle joint optionally combined with accompanying tenosynovectomy. Disease duration and the prevalence of radiological alterations (81% LDE 2-3) characterize the procedures as late synovectomies. The rate of 93% of additional tenosynovectomies and the prevalence of radiological alteration in the adjacent rear foot joints indicate a panarticular pathology of the rheumatic disease. A progression of the Larsen, Dale and Eek (LDE) grade was found in 62% of the ankle joints. The significant gain in the Kofoed ankle score (42.4 versus 55.9 points, p=0.042) was mainly caused by pain reduction and gain of mobility, whereas a decline of function was detected. Both genders showed comparable outcomes. The mean pain level on a visual analogue scale decreased from 7.6 to 3.3 (p<0.001) and 81.5% of the patients assessed the results of the synovectomy as good or very good.

Update Rheumaorthopädie – Aufgabe und therapeutische Optionen

ZusammenfassungDie orthopädischen Therapieoptionen zur Versorgung des Rheumatikers sind in den letzten Jahren maßgeblich fortentwickelt worden. Neben den konservativen Behandlungsmethoden der Orthopädie mit speziellen Schienen und Hilfsmitteln sowie lokalen Injektionen im Gelenk- und Sehnenbereich wird das Therapiespektrum wesentlich von den operativen Interventionsmöglichkeiten geprägt. Grundsätzlich können hierbei gelenkerhaltende, gelenkersetzende und gelenkversteifende Eingriffe unterschieden werden. Aufgrund apparativer Möglichkeiten und ausgefeilter technischer Vorgehensweisen haben sich auch bei Rheumatikern minimal-invasive Techniken zunehmend etabliert. Dadurch konnte die postoperative Morbidität deutlich reduziert werden. Zu den vorrangigen orthopädischen Therapiezielen gehören die Funktionsverbesserung und Schmerzreduktion sowie die Prävention der erneuten lokalen Entzündungssymptomatik. Unter diesen Therapiemaximen hat die Arthrodese nur noch in einzelnen Bereichen Bedeutung. Gelenkerhaltende und -ersetzende Maßnahmen stehen heute ganz im Vordergrund und werden in diesem Beitrag für den internistischen Rheumatologen dargestellt.AbstractOrthopaedic treatment options for rheumatological patients have been further developed over recent years. For orthopaedic treatment, a range of different interventions are offered: orthoses and special technical aids as well as injections for joints and tendons, or surgery. Surgical interventions cover joint preservation, restitution and arthrodeses. Improvements in equipment and surgical procedures also make minimally invasive interactions possible for rheumatoid diseases. Thus, postoperative morbidity has been reduced significantly. Improvement in function, reduction of pain and prevention of recurrent local inflammation are primary. Considering these aims, arthrodeses are restricted to special indications. Joint preservation and restitution are the predominant measures used. The various procedures are discussed.

Langfristige Ergebnisse nach Synovektomien am oberen Sprunggelenk des Rheumatikers

Inflammatory rheumatic ankle joint destruction endangers the mobility of the rheumatic patient by pain and loss of function. In the presented patient population, 29 patients with a mean preoperative history of 14.3 years of rheumatoid arthritis and 7.6 years manifestation of ankle arthritis underwent open synovectomy of the ankle joint optionally combined with accompanying tenosynovectomy. Disease duration and the prevalence of radiological alterations (81% LDE 2-3) characterize the procedures as late synovectomies. The rate of 93% of additional tenosynovectomies and the prevalence of radiological alteration in the adjacent rear foot joints indicate a panarticular pathology of the rheumatic disease. A progression of the Larsen, Dale and Eek (LDE) grade was found in 62% of the ankle joints. The significant gain in the Kofoed ankle score (42.4 versus 55.9 points, p=0.042) was mainly caused by pain reduction and gain of mobility, whereas a decline of function was detected. Both genders showed comparable outcomes. The mean pain level on a visual analogue scale decreased from 7.6 to 3.3 (p<0.001) and 81.5% of the patients assessed the results of the synovectomy as good or very good.

[Update on rheuma-orthopedics - role and therapeutic options].

ZusammenfassungDie orthopädischen Therapieoptionen zur Versorgung des Rheumatikers sind in den letzten Jahren maßgeblich fortentwickelt worden. Neben den konservativen Behandlungsmethoden der Orthopädie mit speziellen Schienen und Hilfsmitteln sowie lokalen Injektionen im Gelenk- und Sehnenbereich wird das Therapiespektrum wesentlich von den operativen Interventionsmöglichkeiten geprägt. Grundsätzlich können hierbei gelenkerhaltende, gelenkersetzende und gelenkversteifende Eingriffe unterschieden werden. Aufgrund apparativer Möglichkeiten und ausgefeilter technischer Vorgehensweisen haben sich auch bei Rheumatikern minimal-invasive Techniken zunehmend etabliert. Dadurch konnte die postoperative Morbidität deutlich reduziert werden. Zu den vorrangigen orthopädischen Therapiezielen gehören die Funktionsverbesserung und Schmerzreduktion sowie die Prävention der erneuten lokalen Entzündungssymptomatik. Unter diesen Therapiemaximen hat die Arthrodese nur noch in einzelnen Bereichen Bedeutung. Gelenkerhaltende und -ersetzende Maßnahmen stehen heute ganz im Vordergrund und werden in diesem Beitrag für den internistischen Rheumatologen dargestellt.AbstractOrthopaedic treatment options for rheumatological patients have been further developed over recent years. For orthopaedic treatment, a range of different interventions are offered: orthoses and special technical aids as well as injections for joints and tendons, or surgery. Surgical interventions cover joint preservation, restitution and arthrodeses. Improvements in equipment and surgical procedures also make minimally invasive interactions possible for rheumatoid diseases. Thus, postoperative morbidity has been reduced significantly. Improvement in function, reduction of pain and prevention of recurrent local inflammation are primary. Considering these aims, arthrodeses are restricted to special indications. Joint preservation and restitution are the predominant measures used. The various procedures are discussed.

Operative gelenkerhaltende Therapie der Gonarthrose

The guiding principle of operative joint-preserving therapy of gonarthrosis is the search for a safe, minimally invasive, efficient and ultimately reasonably priced therapeutic procedure to preserve or restore joint integrity. A comprehensive analysis and treatment of pathologies adjacent to and distant (axis deviations) from the joint are prerequisites for success of treatment. A comparison of results from the current literature with respect to the operative treatment of arthritis is limited due to the divergence of indications, terminologies used, techniques of the therapeutic procedure, inhomogeneity of patient collectives and the different follow-up and control schemes (scores). Conclusive, prospective, randomized double blind studies with large case numbers are associated with a high degree of organizational effort in planning, patient recruitment and execution and remain a rarity. Long-term prognosis depends on the stage of arthritis at the time of the arthroscopic intervention. Operative measures, such as correction osteotomy can be effective in the early stages. A short duration of symptoms, mechanical blocking and low-grade cartilage damage are factors which have a favorable prognosis. Cell-based cartilage repair techniques can reduce secondary degenerative alterations only in cases of local cartilage damage representing a prearthritic condition. Advantages of autologous chondrocyte transplantation compared to microfracturing have been found depending on the size of the defect and the follow-up time period. Furthermore, preservation and replacement of primary knee stabilizers, such as the anterior cruciate ligament and meniscus, have an important function for secondary prevention. A one-for-all therapy for joint-preserving operative treatment of gonarthrosis is lacking.

[Operative joint-preserving therapy of gonarthrosis].

The guiding principle of operative joint-preserving therapy of gonarthrosis is the search for a safe, minimally invasive, efficient and ultimately reasonably priced therapeutic procedure to preserve or restore joint integrity. A comprehensive analysis and treatment of pathologies adjacent to and distant (axis deviations) from the joint are prerequisites for success of treatment. A comparison of results from the current literature with respect to the operative treatment of arthritis is limited due to the divergence of indications, terminologies used, techniques of the therapeutic procedure, inhomogeneity of patient collectives and the different follow-up and control schemes (scores). Conclusive, prospective, randomized double blind studies with large case numbers are associated with a high degree of organizational effort in planning, patient recruitment and execution and remain a rarity. Long-term prognosis depends on the stage of arthritis at the time of the arthroscopic intervention. Operative measures, such as correction osteotomy can be effective in the early stages. A short duration of symptoms, mechanical blocking and low-grade cartilage damage are factors which have a favorable prognosis. Cell-based cartilage repair techniques can reduce secondary degenerative alterations only in cases of local cartilage damage representing a prearthritic condition. Advantages of autologous chondrocyte transplantation compared to microfracturing have been found depending on the size of the defect and the follow-up time period. Furthermore, preservation and replacement of primary knee stabilizers, such as the anterior cruciate ligament and meniscus, have an important function for secondary prevention. A one-for-all therapy for joint-preserving operative treatment of gonarthrosis is lacking.

Operative Therapie der rheumatischen Schulter

The duration and severity of rheumatic diseases of the shoulder correlate with symptom frequency, structural changes and associated functional limitations. The multifactorial character of the underlying rheumatic disease requires a multimodal therapeutic concept including interaction of surgical and non-surgical disciplines. In addition to basic systemic anti-inflammatory medication, injections targeting the synovial tissue by corticoid instillation and glenohumeral radiosynoviorthesis (with an intact rotator cuff) are further options. Operative interventions on rheumatic shoulders can be characterized as disease-modifying, protective, reconstructive or palliative, depending on the stage. Combining minimally invasive arthroscopic surgical techniques with modern basic therapy has the potential to shift the indications for operative interventions towards an earlier stage of disease without favoring or propagating structural alterations which have already occurred. In cases of severe joint destruction with loss of the rotator cuff, reverse shoulder arthroplasty can be an appropriate option.ZusammenfassungDie Erkrankungsdauer und -schwere einer rheumatischen Schultererkrankung korreliert mit Symptomhäufigkeit, strukturellen Veränderungen und assoziierten Funktionseinschränkungen Der multifaktorielle Charakter der rheumatischen Grunderkrankung erfordert auch an der Schulter ein multimodales Therapiekonzept mit Interaktion nichtoperativer und operativer Disziplinen. Neben systemisch antiinflammatorischer Basismedikation sind injektorische Maßnahmen mit direkter Wirkung an der Synovialis als Zielorgan per Kortikoidinstillation wie auch Radiosynoviothesen (glenohumeral bei intakter Rotatorenmanschette) möglich. Operative Maßnahmen können an der Schulter stadienabhängig einen krankheitsmodifizierenden, strukturerhaltenden, rekonstruktiven oder palliativen symptomreduzierenden Charakter haben. Mit minimalinvasiven, arthroskopischen Operationstechniken ist in Verbindung mit einer modernen Basistherapie eine Verschiebung von Operationsindikationen hin zu frühen Erkrankungsstadien ohne bereits eingetretene Strukturveränderungen zu favorisieren/propagieren. Bei ausgeprägten Gelenkdestruktionen mit Rotatorenmanschettenverlust kann eine inverse Schulterendoprothese eine probate Therapieoption darstellen.AbstractThe duration and severity of rheumatic diseases of the shoulder correlate with symptom frequency, structural changes and associated functional limitations. The multifactorial character of the underlying rheumatic disease requires a multimodal therapeutic concept including interaction of surgical and non-surgical disciplines. In addition to basic systemic anti-inflammatory medication, injections targeting the synovial tissue by corticoid instillation and glenohumeral radiosynoviorthesis (with an intact rotator cuff) are further options. Operative interventions on rheumatic shoulders can be characterized as disease-modifying, protective, reconstructive or palliative, depending on the stage. Combining minimally invasive arthroscopic surgical techniques with modern basic therapy has the potential to shift the indications for operative interventions towards an earlier stage of disease without favoring or propagating structural alterations which have already occurred. In cases of severe joint destruction with loss of the rotator cuff, reverse shoulder arthroplasty can be an appropriate option.

Operative Therapie der rheumatischen Schulter@@@Operative treatment of the rheumatic shoulder

The duration and severity of rheumatic diseases of the shoulder correlate with symptom frequency, structural changes and associated functional limitations. The multifactorial character of the underlying rheumatic disease requires a multimodal therapeutic concept including interaction of surgical and non-surgical disciplines. In addition to basic systemic anti-inflammatory medication, injections targeting the synovial tissue by corticoid instillation and glenohumeral radiosynoviorthesis (with an intact rotator cuff) are further options. Operative interventions on rheumatic shoulders can be characterized as disease-modifying, protective, reconstructive or palliative, depending on the stage. Combining minimally invasive arthroscopic surgical techniques with modern basic therapy has the potential to shift the indications for operative interventions towards an earlier stage of disease without favoring or propagating structural alterations which have already occurred. In cases of severe joint destruction with loss of the rotator cuff, reverse shoulder arthroplasty can be an appropriate option.ZusammenfassungDie Erkrankungsdauer und -schwere einer rheumatischen Schultererkrankung korreliert mit Symptomhäufigkeit, strukturellen Veränderungen und assoziierten Funktionseinschränkungen Der multifaktorielle Charakter der rheumatischen Grunderkrankung erfordert auch an der Schulter ein multimodales Therapiekonzept mit Interaktion nichtoperativer und operativer Disziplinen. Neben systemisch antiinflammatorischer Basismedikation sind injektorische Maßnahmen mit direkter Wirkung an der Synovialis als Zielorgan per Kortikoidinstillation wie auch Radiosynoviothesen (glenohumeral bei intakter Rotatorenmanschette) möglich. Operative Maßnahmen können an der Schulter stadienabhängig einen krankheitsmodifizierenden, strukturerhaltenden, rekonstruktiven oder palliativen symptomreduzierenden Charakter haben. Mit minimalinvasiven, arthroskopischen Operationstechniken ist in Verbindung mit einer modernen Basistherapie eine Verschiebung von Operationsindikationen hin zu frühen Erkrankungsstadien ohne bereits eingetretene Strukturveränderungen zu favorisieren/propagieren. Bei ausgeprägten Gelenkdestruktionen mit Rotatorenmanschettenverlust kann eine inverse Schulterendoprothese eine probate Therapieoption darstellen.AbstractThe duration and severity of rheumatic diseases of the shoulder correlate with symptom frequency, structural changes and associated functional limitations. The multifactorial character of the underlying rheumatic disease requires a multimodal therapeutic concept including interaction of surgical and non-surgical disciplines. In addition to basic systemic anti-inflammatory medication, injections targeting the synovial tissue by corticoid instillation and glenohumeral radiosynoviorthesis (with an intact rotator cuff) are further options. Operative interventions on rheumatic shoulders can be characterized as disease-modifying, protective, reconstructive or palliative, depending on the stage. Combining minimally invasive arthroscopic surgical techniques with modern basic therapy has the potential to shift the indications for operative interventions towards an earlier stage of disease without favoring or propagating structural alterations which have already occurred. In cases of severe joint destruction with loss of the rotator cuff, reverse shoulder arthroplasty can be an appropriate option.

Operative treatment of the rheumatic shoulder

The duration and severity of rheumatic diseases of the shoulder correlate with symptom frequency, structural changes and associated functional limitations. The multifactorial character of the underlying rheumatic disease requires a multimodal therapeutic concept including interaction of surgical and non-surgical disciplines. In addition to basic systemic anti-inflammatory medication, injections targeting the synovial tissue by corticoid instillation and glenohumeral radiosynoviorthesis (with an intact rotator cuff) are further options. Operative interventions on rheumatic shoulders can be characterized as disease-modifying, protective, reconstructive or palliative, depending on the stage. Combining minimally invasive arthroscopic surgical techniques with modern basic therapy has the potential to shift the indications for operative interventions towards an earlier stage of disease without favoring or propagating structural alterations which have already occurred. In cases of severe joint destruction with loss of the rotator cuff, reverse shoulder arthroplasty can be an appropriate option.ZusammenfassungDie Erkrankungsdauer und -schwere einer rheumatischen Schultererkrankung korreliert mit Symptomhäufigkeit, strukturellen Veränderungen und assoziierten Funktionseinschränkungen Der multifaktorielle Charakter der rheumatischen Grunderkrankung erfordert auch an der Schulter ein multimodales Therapiekonzept mit Interaktion nichtoperativer und operativer Disziplinen. Neben systemisch antiinflammatorischer Basismedikation sind injektorische Maßnahmen mit direkter Wirkung an der Synovialis als Zielorgan per Kortikoidinstillation wie auch Radiosynoviothesen (glenohumeral bei intakter Rotatorenmanschette) möglich. Operative Maßnahmen können an der Schulter stadienabhängig einen krankheitsmodifizierenden, strukturerhaltenden, rekonstruktiven oder palliativen symptomreduzierenden Charakter haben. Mit minimalinvasiven, arthroskopischen Operationstechniken ist in Verbindung mit einer modernen Basistherapie eine Verschiebung von Operationsindikationen hin zu frühen Erkrankungsstadien ohne bereits eingetretene Strukturveränderungen zu favorisieren/propagieren. Bei ausgeprägten Gelenkdestruktionen mit Rotatorenmanschettenverlust kann eine inverse Schulterendoprothese eine probate Therapieoption darstellen.AbstractThe duration and severity of rheumatic diseases of the shoulder correlate with symptom frequency, structural changes and associated functional limitations. The multifactorial character of the underlying rheumatic disease requires a multimodal therapeutic concept including interaction of surgical and non-surgical disciplines. In addition to basic systemic anti-inflammatory medication, injections targeting the synovial tissue by corticoid instillation and glenohumeral radiosynoviorthesis (with an intact rotator cuff) are further options. Operative interventions on rheumatic shoulders can be characterized as disease-modifying, protective, reconstructive or palliative, depending on the stage. Combining minimally invasive arthroscopic surgical techniques with modern basic therapy has the potential to shift the indications for operative interventions towards an earlier stage of disease without favoring or propagating structural alterations which have already occurred. In cases of severe joint destruction with loss of the rotator cuff, reverse shoulder arthroplasty can be an appropriate option.

Operative gelenkerhaltende Therapie der Gonarthrose@@@Operative joint-preserving therapy of gonarthrosis

The guiding principle of operative joint-preserving therapy of gonarthrosis is the search for a safe, minimally invasive, efficient and ultimately reasonably priced therapeutic procedure to preserve or restore joint integrity. A comprehensive analysis and treatment of pathologies adjacent to and distant (axis deviations) from the joint are prerequisites for success of treatment. A comparison of results from the current literature with respect to the operative treatment of arthritis is limited due to the divergence of indications, terminologies used, techniques of the therapeutic procedure, inhomogeneity of patient collectives and the different follow-up and control schemes (scores). Conclusive, prospective, randomized double blind studies with large case numbers are associated with a high degree of organizational effort in planning, patient recruitment and execution and remain a rarity. Long-term prognosis depends on the stage of arthritis at the time of the arthroscopic intervention. Operative measures, such as correction osteotomy can be effective in the early stages. A short duration of symptoms, mechanical blocking and low-grade cartilage damage are factors which have a favorable prognosis. Cell-based cartilage repair techniques can reduce secondary degenerative alterations only in cases of local cartilage damage representing a prearthritic condition. Advantages of autologous chondrocyte transplantation compared to microfracturing have been found depending on the size of the defect and the follow-up time period. Furthermore, preservation and replacement of primary knee stabilizers, such as the anterior cruciate ligament and meniscus, have an important function for secondary prevention. A one-for-all therapy for joint-preserving operative treatment of gonarthrosis is lacking.