Rheumatism orthopaedics is an essential part of the treatment of inflammatory rheumatic joint diseases. The rheumatic orthopaedist carries out surgical and conservative therapies in close cooperation with the internal rheumatologists. The aims are Joint preservation, functional improvement and removal of inflammatory tissue. In the case of joints that have already been destroyed, artificial replacement is sometimes the only option.
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Rheumatologic orthopedics - Further information
What is rheumatism and how is it treated in rheumatism orthopaedics?
The term rheumatism refers to various inflammatory connective tissue and joint diseases.
They are divided into:
- Rheumatoid arthritis (chronic polyarthritis)
- Spondylarthropathies (joint inflammation with frequent involvement of the spine)
- Inflammatory connective tissue diseases
- Inflammatory vascular diseases
- Metabolic disorders with inflammatory joint involvement (e.g. gout)
These are therefore clinical pictures with different symptoms and different forms of progression. Not all of them manifest themselves in the joints and lead to joint destruction.
In Germany, an estimated 2% of the adult population and 15,000 children and adolescents suffer from inflammatory rheumatic diseases @ ZayNyi /AdobeStock
Rheumatic diseases with joint involvement are treated surgically by rheumatologists.
Inflammatory changes in rheumatism(arthritis) are the most common reason for surgical treatment.
Such therapies are also useful for
- Spondylarthropathies and
- Metabolic disorders with inflammatory joint involvement
In close cooperation with the internal rheumatologist, the rheumatology orthopaedist continues the drug therapy. He initiates physiotherapeutic treatments, occupational therapy and the provision of aids.
If joint inflammation is still present after conservative therapies, surgical treatment is advisable.
Surgical measures are also advisable in the following cases:
- Risk of tendon rupture
- Risk of nerve pressure damage or
- Risk of acute instability of a joint
What does the rheumatologist do?
If joint or tendon inflammation persists despite conservative therapies, it is possible to surgically remove the inflammatory tissue.
In this case, the doctor performs a synovectomy/tenosynovectomy (removal of inflamed joint mucosa/tendon sheaths).
However, synovectomy only makes sense if the joint has not yet been significantly destroyed. X-ray classifications help to assess the degree of destruction.
Doctors therefore differentiate between joint-preserving and joint-replacing operations in rheumatoid orthopaedics:
Joint-preserving operations:
- Synovectomies: arthroscopic or open synovectomy of the joints and tendon sheaths
- Partial fusion of joints
Joint replacement operations:
- Implantation of artificial joint endoprostheses(arthroplasty)
- Replacement of a joint with the body's own material
- Stiffening of joints
Joint-preserving operations as part of rheumatoid orthopaedics
If a synovectomy is performed, there are various procedures depending on the localization:
Arthroscopic synovectomy
In joints with a large joint cavity, it is possible to remove the synovial membrane without any problems. This is often done by means of an arthroscopic synovectomy on the knee joint.
This is done through several approaches, including an additional approach to the popliteal fossa sections.
Arthroscopic synovectomy is similarly successful on the shoulder, ankle and elbow joints. Individual characteristics apply to all joints.
It is important for all joints that doctors carefully and comprehensively remove the inflamed synovial membrane.
In the shoulder joint, it is also necessary to remove the bursa under the acromion arthroscopically, as this is usually inflamed. This in turn leads to discomfort and damage to the rotator cuff (tendon cuff of the shoulder).
The most important symptom of rheumatism in the shoulder joint is pain @ Pixel-Shot /AdobeStock
Open synovectomy of the joints and tendon sheaths
In the case of smaller joints, such as the wrist, an open synovectomy is usually performed. Doctors remove the inflammatory tissue with a large tissue incision.
This offers the advantage of also being able to assess the overlying extensor tendons. The wrist can be stabilized again by reinforcing the capsule with the body's own ligaments.
If the joint between the ulna and radius close to the wrist is destroyed and the ability to rotate the forearm is functionally restricted, doctors remove the ulnar head.
By strengthening the joint capsule, pain-free forearm rotation is possible again.
Less frequently, a surgical synovectomy is performed on the finger and foot joints. Alternatively, injections of cortisone or radioactive substances (radiosynoviorthesis (RSO)) are used. The aim is to reduce inflammatory tissue in the treated joints.
If there are inflamed tendon sheaths in the hand, fingers, wrist or foot, a synovectomy is only performed openly via a longer skin incision.
Tenosynovectomy involves the following steps:
- Removal of the inflammatory tissue by suturing and reconstruction of the tendons
- Restoration of a functional gliding channel for the tendons
Doctors must also relieve the pressure on the nerves that run with the tendons and free them. This is done by performing a tenosynovectomy of the flexor tendons in the palm canal. At the same time, pressure is relieved from the median nerve in the case of carpal tunnel syndrome.
Partial fusion of joints
If the destruction of joints with the risk of increasing instability is far advanced, a synovectomy alone is no longer sufficient.
In these cases, a synovectomy in combination with a partial joint fusion can remove the inflammatory tissue. This stabilizes the joint in the long term and maintains its function.
An example of this is partial stiffening of the wrist. This often involves a fusion between the radius and the lunate bone.
However, there are also other partial stiffeners of the wrist. Other partial fusions can be performed in the tarsal joints with only minor resulting functional impairment.
Joint replacement operations as part of rheumatoid orthopaedics
Once joints have been destroyed by inflammatory rheumatic processes , the only option is joint replacement (endoprosthetics) or a stiffening operation.
Implantation of artificial joint endoprostheses
Doctors can replace joints with artificial endoprostheses. This joint replacement is known for hip and knee joints. These joints are also successful in rheumatism patients.
However, other joints such as the shoulder, elbow, finger or ankle joints are often affected in rheumatic patients.
Replacing these joints promises to reduce pain and improve function, especially in rheumatic diseases . As a result, the patient's independence is often maintained.
Artificial knee joint @ Henrie /AdobeStock
Replacing a joint with the body's own material
In the case of arthritic destruction, other joints are better replaced with the patient's own tendon and capsule tissue.
Joints such as the thumb saddle joint, the acromioclavicular joint and the metatarsophalangeal joints are better replaced by resection interposition arthroplasty (RIAP).
In RIAP, doctors remove the joint surfaces including the bone ends close to the joint. They stitch tendon and joint capsule tissue into the joint space.
This creates a scar pad that allows the joint to move without pain.
Stiffening of joints
Few joints are better suited to fusion in the event of inflammatory destruction. For example, the fusion of a destroyed, unstable wrist leads to a pain-free improvement in function.
Flexion and extension are no longer possible. However, firm grasping and holding as well as the important forearm rotation are possible again without any problems.
The metacarpophalangeal joint of the thumb, lower ankle joint and metatarsophalangeal joint of the big toe show similarly good results after fusion.
Overall therapeutic concept of rheumatoid orthopaedics
Rheumatoid orthopaedics therapy consists of an overall concept of medical, physical, physiotherapeutic and occupational therapy.
The following objectives exist after surgical therapy:
- Wound care
- Recovery of mobility
- Recovery of function
This is achieved through physical measures that help to reduce swelling and maintain the mobility of neighboring joints.
It should not be forgotten that rheumatic-inflammatory diseases are systemic clinical pictures.
In this respect, physiotherapy must focus onmaintaining the function, mobility and strength of the entire musculoskeletal system in the treatment plan.
Rheumatoid orthopaedics is therefore much more than just the surgical treatment of a joint!