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Bone mineral content (BMC) of the distal forearm was measured by single photon absorptiometry in 142 patients with rheumatoid arthritis (RA) of whom 27/54 men and 44/88 women received low-dose steroid therapy (less than 10 mg/day). To study the effect of steroid therapy a case-control analysis was undertaken in patients matched for age, sex and disease duration. Steroid therapy was associated with a reduced BMC in men (1.16 +/- 0.29 versus 1.32 +/- 0.23; P less than 0.05) and post-menopausal (0.76 +/- 0.24 versus 0.91 +/- 0.25; P less than 0.02) but not pre-menopausal women (1.1 +/- 0.28 versus 1.1 +/- 0.17). Symptomatic fractures were more common in steroid-treated patients than in those who had not received steroids (10/71 versus 2/71; P less than 0.05). Serum osteocalcin, an index of bone formation, was measured in 106 cases. It tended to be higher in patients with RA than in controls but the values observed in steroid and non-steroid RA groups did not differ significantly. We conclude that low-dose steroid therapy is associated with increased bone loss and numbers of fractures in patients with RA but this does not appear to be the result of a simple defect in bone formation.

Inflammation plays a variable part in the pathogenesis of several spinal disorders. Ankylosing spondylitis is a chronic inflammatory arthropathy of the spine and rheumatoid arthritis, whilst affecting predominantly limb joints, also affects the cervical spine in a significant proportion of people. Inflammation is also involved in disorders such as disc herniation and sciatica, which have previously been thought of as being primarily mechanical or degenerative. Anti-inflammatory agents which have been shown to be effective elsewhere in the body are discussed in this review as possible therapeutic agents in the spine. As the inflammatory cascade and immunopathology of these conditions continue to be elucidated, it has become apparent that individual molecules may be potential targets for inactivation or down-regulation. Candidates include pro-inflammatory cytokines, such as TNF-alpha, cytokines, e.g. IL-1 and IL-15, or enzymes enhancing the inflammation pathway such as the cyclooxygenases. Hence treatments based on inactivation of these molecules by various mechanisms, including antibodies, receptor antagonists, enzyme inhibitors or gene therapy, are being introduced. However, the mode of action of a particular molecule can be complex and sometimes apparently contradictory. For example, TNF-alpha is known to play an important role in promoting inflammation by upregulating expression of cell adhesion molecules on endothelial cells and stimulating the production of reactive oxygen intermediates, nitric oxide and prostaglandins. However, it can also have an immunosuppressive and anti-inflammatory role after prolonged release. Therefore, although inhibitors of many of these molecules are now in clinical application and trials (many with promising results in rheumatoid arthritis), it is important to remain vigilant and monitor long-term outcomes particularly when these treatments are used in clinical syndromes with relatively poorly defined immunopathology such as spinal disorders.

Imaging in rheumatology was in the past largely confined to radiographs of the hands and sacroiliac joints (SIJs) helping to establish the diagnosis and then monitoring disease progression. Radiographs are not very sensitive for early inflammation in inflammatory rheumatic disorders and the demand on imaging services was therefore limited. However, over the last 10–15 years new drugs and new technologies have brought new challenges and opportunities to rheumatology and radiology as specialties. New drug treatments allow more effective treatment, preventing many complications. Early diagnosis and disease monitoring has become the challenge for the rheumatologist and radiologist alike. The best possible patient outcome is only achieved if the two specialties understand each other’s viewpoint. This article reviews the role of imaging—in particular radiography, magnet resonance imaging, computer tomography, ultrasound and nuclear medicine—for the diagnosis and monitoring of rheumatological disorders, concentrating on rheumatoid arthritis, inflammatory spondylarthropathies and gout.Teaching Points• New drugs for the treatment of inflammatory disorders has led to greatly improved outcomes.• Imaging often allows for earlier diagnosis of inflammatory disorders.• Early diagnosis and treatment can often prevent the development of crippling disease manifestations.• Tailored imaging examinations are best achieved by consultation of rheumatologist and radiologist.

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Orthopaedic surgery plays a major part in the management of patients with rheumatoid arthritis and is likely to do so for the foreseeable future. This book has four respected authors: three of them orthopaedic surgeons and the fourth a rheumatologist. Chapters are devoted to the general principles of synovectomy, osteotomy, arthroplasty, and arthrodesis, and then individual chapters describe the use of these procedures for specific joints including the spine. This does tend to lead to some repetition which extends to duplication of a figure illustrating the optimal placing of a bedside locker after different approaches to hip arthroplasty, but in general this is not excessive. There are also chapters on selection of patients and procedures, perioperative care, including splinting, aetiology and pathology of rheumatoid arthritis, and medical management. A useful final chapter on 'the rheumatoid in society' includes discussion of aids and appliances, joint protection, work, recreation, and sexual aspects. There is implicit recognition throughout that successful results depend upon close liaison between orthopaedic surgeon, rheumatologist, and paramedics. As one would expect from this publisher the quality of radiographs and illustrations is high. This is not a manual of operative technique, but it provides an overview of the procedures available and the advantages and problems associated with each. The style is didactic and opinions are expressed freely, but the text is fairly sparingly referenced. This makes for provocative reading and there are probably few who will not find some areas of disagreement. However, this book clearly reflects a wealth of hard won experience and sound judgment on the treatment of this disease and it forces one to re-evaluate one's own opinions and practice.I feel that this book should be read by all orthopaedic surgeons and rheumatologists, both established and in training. The price will probably discourage individual purchase to some extent, but it should certainly be available in every hospital library.

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