[Gigantic prepatellar "tumor" in rheumatoid arthritis-a case report]. / Gigantischer präpatellarer "Tumor" bei rheumatoider Arthritis ­ ein Case Report.

In soft tissue tumors of the extremities it is of utmost importance to differentiate between benign and malignant entities. The majority of the swellings vary from benign tissue changes through soft tissue sarcomas up to pseudotumors. Because of the low incidence of malignancy and the predominantly benign alterations together with a high heterogeneity, there is a need for a reproducible diagnostic and therapeutic concept for the treatment of all tumors of the extremities. This article reports the case of a 59-year-old patient with longstanding rheumatoid arthritis who presented to the orthopedic rheumatologic consultation with a massive swelling directly ventral to the knee joint. At that point the tumor had already grown very slowly for 5 years. The staged diagnostic process (patient history, clinical, laboratory tests, sonographic examinations, X­ray, MRI with contrast medium) revealed no trace of malignancy whatsoever. The treatment then consisted of the complete surgical excision in accordance with the recommendations for tumor surgery. Histopathological findings confirmed the diagnosis of a massive prepatellar bursitis. Initially, the extreme and solid prepatellar swelling was suspected of being malignant; however, this could already be broadly excluded preoperatively. This article presents the rationale and the orthopedic rheumatologic approach for addressing unclear space-occupying lesions of the musculoskeletal system in patients with rheumatism. In the inflammatory systemic disease in the differential diagnosis periarticular swellings can ultimately also have benign causes, such as an organized bursitis.

[Perioperative management in the treatment of trauma for rheumatics under immunosuppression]. / Perioperatives Management bei der Traumaversorgung von "Rheumatikern" unter Immunsuppression.

With an almost 3.5% manifestation rate in Germany, rheumatoid arthritis is a relatively frequent disease. Due to the involvement of diverse locations on the skeleton and often multiple comorbidities, treatment of these patients in cases of acute trauma potentially represents a substantial risk. The anti-inflammatory drug treatment harbors dangers, such as delayed wound healing and infections in the perioperative management of these patients. In an emergency a modification of the basic anti-inflammatory medication is hardly possible, so that the postoperative phase after trauma surgery is of special importance. If necessary, orthopedic or internist rheumatologists should be consulted for additional support. Absolute and urgent surgical interventions do not constitute a contraindication with respect to the antirheumatic medication but should be considered in the assessment of the perioperative risk profile. A close cooperation with anesthesia, the meticulous control of intraoperative positioning and postoperative management are of particular importance.

[Surgery for inflammatory rheumatic joint destruction]. / Operative Verfahren bei entzündlich-rheumatologischen Systemerkrankungen.

Orthopaedic and traumatologic involvement in patients with rheumatic diseases require extensive knowledge of these immunologically impairing illnesses. This concerns both the handling of medication and conservative treatment. The destructive processes of the joints and the spine follow established pathways. Various operating procedures are helpful depending on the stage of articular destruction. The special features of the entire perioperative management of affected persons has to be observed. Soft tissue surgical interventions are followed by arthrodesis or arthroplasty in later courses of destruction. In Germany, the orthopaedic rheumatologist specializes in the conservative and surgical treatment of inflammatory systemic diseases. Audited centres for operative interventions of the German Society for Orthopaedic Rheumatology (DGORh) seem to be the best fit for this purpose.

[Physical therapy options in rheumatic diseases: what is evidence-based?] / Physikalische Therapieoptionen bei rheumatologischen Erkrankungen: Was gibt es an Evidenz?

Rheumatic diseases usually progress towards morphological and functional deficits and thus cause impairment of physical health and function. Based on this fact, physiotherapeutic options are elementary and indispensable. This article focuses on the significance and importance of physiotherapy in inflammatory and degenerative rheumatic diseases. Furthermore, an overview is presented on the consequences of rheumatic diseases, the reality of supply of physiotherapy, the principles and therapeutic options, and the evidence.

[Acute pain therapy in orthopedics/trauma surgery]. / Akutschmerztherapie in Orthopädie/Unfallchirurgie.

The management of acute pain is of utmost importance in the treatment regimen of orthopedic and trauma patients. Pain perception is different for each patient and has to be individually addressed. Especially in a postoperative setting often with a very dynamic course of pain, it is optimal that the pain management is adapted to the individual course of pain. In this situation it makes sense to apply patient-controlled systems. By combining different analgesic substance classes and non-pharmaceutical therapy in the sense of a multimodal concept, the mechanisms of action complement each other and side effects can be reduced. Patient satisfaction is higher when they are actively involved in the (medicinal) pain therapy and in the decision making. This is particularly important for patient-controlled analgesia (PCA). In addition to invasive catheter administration procedures, there are also modern approaches for oral individual self-administered opioid treatment.

Visfatin alters the cytokine and matrix-degrading enzyme profile during osteogenic and adipogenic MSC differentiation.

OBJECTIVES: Age-related bone loss is associated with bone marrow adiposity. Adipokines (e.g., visfatin, resistin, leptin) are adipocyte-derived factors with immunomodulatory properties and might influence differentiation of bone marrow-derived mesenchymal stem cells (MSC) in osteoarthritis (OA) and osteoporosis (OP). Thus, the presence of adipokines and MMPs in bone marrow and their effects on MSC differentiation were analyzed. METHODS: MSC and ribonucleic acid (RNA) were isolated from femoral heads after hip replacement surgery of OA or osteoporotic femoral neck fracture (FF) patients. Bone structural parameters were evaluated by microcomputed tomography (µCT). MSC were differentiated towards adipocytes or osteoblasts with/without adipokines. Gene expression (adipokines, bone marker genes, MMPs, TIMPs) and cytokine production was evaluated by realtime-polymerase chain reaction (realtime-PCR) and enzyme-linked immunosorbent assay (ELISA). Matrix mineralization was quantified using Alizarin red S staining. RESULTS: µCT showed an osteoporotic phenotype of FF compared to OA bone (reduced trabecular thickness and increased ratio of bone surface vs volume of solid bone). Visfatin and leptin were increased in FF vs OA. Visfatin induced the secretion of IL-6, IL-8, and MCP-1 during osteogenic and adipogenic differentiation. In contrast to resistin and leptin, visfatin increased MMP2 and MMP13 during adipogenesis. In osteogenically differentiated cells, MMPs and TIMPs were reduced by visfatin. Visfatin significantly increased matrix mineralization during osteogenesis, whereas collagen type I expression was reduced. CONCLUSION: Visfatin-mediated increase of matrix mineralization and reduced collagen type I expression could contribute to bone fragility. Visfatin is involved in impaired bone remodeling at the adipose tissue/bone interface through induction of proinflammatory factors and dysregulated MMP/TIMP balance during MSC differentiation.

[Tendinopathy in rheumatic diseases]. / Tendinopathien bei rheumatischen Erkrankungen.

Involvement of tendons and tendon sheaths is frequently found in the most common inflammatory systemic diseases, rheumatoid arthritis and spondyloarthritis. In rheumatoid arthritis tendon manifestations occur as tenosynovitis, with swelling and pain of the tendons mainly on the hands and feet. In spondyloarthritis the involvement of tendons presents as enthesitis with pain and swelling directly at the attachment points of tendons to the bony structures and more commonly in the lower extremities. Pathological alterations of tendons can be normally visualized by sonography and only sometimes with magnetic resonance imaging (MRI) or scintigraphy. Furthermore, it is important for diagnostics and effective therapy to detect all joints involved by means of clinical, sonographic and radiological examination as well as laboratory parameters of inflammation, antibody serology (e.g. anti-CCP antibodies) and HLA-B27. The histopathological alterations of tendinopathy in rheumatic diseases differ from degenerative/posttraumatic tendinopathy in their expression of the changes; however, a clear differentiation of the different rheumatic inflammatory systemic diseases is histopathologically not possible. Therapeutically, systemic medication is the most important part of treatment in rheumatic diseases. Local therapeutic measures can be employed in the treatment of tenosynovitis and enthesitis. In the case of failure or lack of efficacy of the medication and conservative therapy, tenosynovectomy is performed for persistent tenosynovitis and reconstructive surgical procedures are necessary for tendon ruptures.

[Treat-to-target (T2T) recommendation for patients with spondyloarthritis - translation into German]. / "Treat-to-target (T2T)" Empfehlungen für die Behandlung von Patienten mit Spondyloarthritis ­ Übersetzung ins Deutsche.

The management of patients with spondyloarthritis (SpA) has experienced a paradigm shift in recent years. This is true for the treatment of axial as well as peripheral manifestations. International treat to target (T2T) recommendations for SpA based on the T2T strategy have now also been published, which contain 5 higher level principles (A-E) in addition to the 15 recommendations. In order to make the recommendations known and to promote national distribution, German experts have now issued a translation of the T2T recommendations for SpA into German.

[Approach to joint effusion]. / Vorgehen bei Gelenkerguss.

The fundamental components of the differential diagnostics of joint effusions are the patient history and clinical examination. In the case of unclear findings, arthrosonography can provide information for the distinction between intra-articular and extra-articular pathologies. In atraumatic joint effusions inflammatory parameters in blood are determined in order to differentiate between systemic inflammatory and local inflammatory joint effusions. In the case of normal values further diagnostics are carried out using imaging. With elevated inflammatory parameters the main differential diagnoses are gouty arthritis, autoimmune joint processes and septic arthritis. When in doubt, a joint aspiration and synovial fluid analysis should be performed to rule out septic arthritis or if necessary confirmation of gouty arthritis.

[Standards of care for people with rheumatoid arthritis in Europe : Translation and comments of the eumusc.net recommendations supported by EULAR performed by a national task force of the professional organisations DGRh and VRA supported by "Deutsche Rheumaliga"]. / Europäische Versorgungsstandards für Menschen mit rheumatoider Arthritis : Übersetzung und Kommentierung der von der EULAR unterstützten Vorschläge des eumusc.net durch eine Task Force von DGRh und VRA mit Unterstützung der Deutschen Rheuma-Liga.

In a joint initiative by the boards of the German Society for Rheumatology (DGRh) and the Association of Rheumatology Clinics (VRA) the European "standards of care" for rheumatoid arthritis, recently suggested by the European Musculoskeletal Conditions Surveillance and Information Network (eumusc.net) and supported by the European League Against Rheumatism (EULAR), were translated and annotated. The recommendations include aspects of the management of the disease, actual medical care, and access to information - this includes all types of support people with RA need, and, last but not least communication of the necessary knowledge. Furthermore, health care structures such as the availability of medical staff with relevant expertise are also important.

[Juvenile rheumatoid diseases: Endoprosthetic care of destroyed hip joints]. / Juvenile rheumatische Erkrankungen: Endoprothetische Versorgung zerstörter Hüftgelenke.

BACKGROUND: Patients with juvenile idiopathic arthritis (JIA) often suffer from involvement of the hip joints, with joint destruction and related functional limitations, making hip replacement necessary. OBJECTIVES: To discover what special features are to be expected in patients with JIA and hip arthroplasty and what impact they have on surgical indication, choice of implant, and technique. METHODS: Selective literature review and evaluation of our patient population. RESULTS: Compared with osteoarthritis patients, JIA patients are on average much younger at the time of hip replacement. Owing to the onset of the disease in childhood or adolescence and the frequent glucocorticoid therapy, growth disorders or abnormal anatomical findings are common in these patients. Bone density is often reduced at an early age. The perioperative management of medication has to be planned. Special implants for patients with rheumatic diseases do not exist, but the above peculiarities of this group of patients should be considered for surgical procedure and choice of implant and material. Overall, the results of hip arthroplasty in juvenile rheumatic diseases, in terms of pain relief and functional improvement, are good. The limited life of the arthroplasty is problematic. CONCLUSIONS: By relieving pain, improvement of the range of motion and activity level very high patient satisfaction is usually achieved by hip arthroplasty in JIA patients. In the case of involvement of the contralateral hip or the ipsilateral knee joint it may be useful to perform a simultaneous, single-stage joint replacement of both joints.

[Endoprosthetic replacement of the elbow joint in rheumatoid arthritis : Video article]. / Endoprothetischer Ersatz des Ellenbogengelenks bei rheumatoider Arthritis : Videobeitrag.

Endoprosthetic replacement of the elbow joint is comparatively rare with less than 100 cases per year in Germany. Patients with forms of rheumatism constitute the major proportion and they also show the significantly best results. The indications are assessed in a stage-adapted manner and depend mostly on the stability and the grade of bony destruction. An acceptable function of this joint, which transmits high strength but is not load bearing, is the main target. The accompanying video demonstrates the implantation of a total elbow endoprosthesis.

[Role of orthopedic rheumatologist in the therapy of rheumatic diseases with biologics]. / Rolle des Orthopäden bei der Therapie rheumatischer Erkrankungen mit Biologika.

The international strategies in the treatment of rheumatic diseases have changed dramatically in the last 10 years. In addition to the prescription of a basic medication as soon as possible, biologics are increasingly being used for drug treatment of rheumatic diseases in Germany. The domains of orthopedic surgeons and orthopedic rheumatologists are still the extended conservative and surgical treatment of inflammatory systemic diseases, which continue to play an important role despite the improved drug therapy options. Orthopedic surgeons should principally be familiar with the use of antirheumatic drugs, especially with respect to the perioperative management. However, there is also a role for the orthopedic surgeon in the early detection of inflammatory systemic diseases and in cooperation with rheumatologists in the medicinal treatment of selected diseases. Because patients with initial stages of joint pain, e.g. from rheumatoid arthritis (RA), spondyloarthritis (SpA) or psoriatic arthropathy often present first to an orthopedic surgeon, recognition of the early stages by the primary treating physician, including the necessary rapid induction of drug therapy is especially important. In addition there is a shortage of internist rheumatologists in Germany so that selective referral and close cooperation between the two physicians become of great importance.

[Sport and rheumatoid arthritis]. / Sport und rheumatoide Arthritis.

BACKGROUND: Sport is becoming increasingly more important in our society. Due to the changing age spectrum with a greater number of elderly and substantially more active people, an increasing number of people with underlying orthopedic diseases are becoming interested in participating in sport. MATERIAL AND METHODS: This article deals with the possibilities and effects of sporting activities for people with rheumatoid arthritis within the framework of a conservative therapy. A literature search was carried out using medical search engines, in particular PubMed, and also via the recommendations of specialist societies and patient help groups. RESULTS: The quality of life of patients with rheumatoid arthritis consists of physical, mental and social components. Sport as a means of rehabilitation influences all of these components. Sport should be comprehended as a form of therapy and be adapted to the needs of the individual patient. The willingness to actively participate in sport should always be highly rated and encouraged. Sport is therefore an important pillar of therapy in a conservative total concept. The main aspects of sport therapeutic activities are functional, pedagogical and experience-oriented aspects. The clinical symptoms, extent of damage and physical impairment must, however, be evaluated and taken into consideration for the therapeutic concept. CONCLUSION: The amount of data on the complex topic of sport and rheumatoid arthritis is low and is mainly dealt with as retrospective reviews. A prospective randomized study basis is lacking. The aim must therefore be to confirm the currently available recommendations for various types of sport in controlled studies.

[Recommendations of the German Society for Rheumatology on the perioperative approach under therapy with DMARDs and biologicals in inflammatory rheumatic diseases]. / Empfehlungen der Deutschen Gesellschaft für Rheumatologie zur perioperativen Vorgehensweise unter Therapie mit DMARD und Biologicals bei entzündlich-rheumatischen Erkrankungen.

BACKGROUND: The perioperative administration of antirheumatic medication can lead to an increased risk of infection and to a malfunction in wound healing up to a manifest infection; however, the termination of antirheumatic therapy can result in a flare up of the disease. Both situations can endanger the success of the operation, particularly in arthroplasty. METHOD: The recommendations have been developed and approved by the Pharmacotherapy Commission of the German Society for Rheumatology following a systematic literature search (as of 30 April 2013) and a consensus process. RESULTS: As very little data with sufficiently high evidence are available, the present recommendations should be considered as having an advisory quality and an individual risk assessment should always be carried out. Classical disease-modifying antirheumatic drugs (DMARD), such as methotrexate can be continued in normal cases but whether this is also true for leflunomide is still undecided. For biologicals a break of two half-life periods before the operation is recommended. The therapy can be continued after wound healing has been completed and when there are no signs of infection.