Operative Differenzialtherapie des rheumatischen Handgelenks

Abstract

The wrists are affected in the long-term in 90% of people with rheumatism and are often (42%) the first manifestation of a destructive disease. The functionality of the wrist and the whole hand is of great importance because in many cases loss of function of the wrists leads to severe limitations. Local and operative treatment of the wrist in rheumatoid arthritis (RA) is one of the main duties in rheuma-orthopaedics. For operative treatment there is a finely tuned differential therapeutic spectrum available. The diagnostic indications take the local and total pattern of affection, the current systemic therapy as well as patient wishes and patient compliance into consideration. In the early stages according to LDE (Larsen, Dale, Eek), soft tissues operations such as articulo-tenosynovectomy (ATS) are most commonly carried out. In further advanced stages osseus stabilisation must often be performed. At this point a smooth transition from partial arthrodesis to complete fixation is possible. After initial euphoria, arthroplasty of the wrist is being increasingly less used for operative treatment due to the unconvincing long-term results and high complication rate. With reference to the good long-term results of all operative procedures, in particular early ATS with respect to pain, function and protection of tendons, after failure of medicinal treatment and persistence of inflammatory activity in the wrist, patients should be transferred to an experienced rheuma-orthopaedic surgeon.

Radiocarpal fusion and midcarpal resection interposition arthroplasty: long-term results in severely destroyed rheumatoid wrists

“…For the operative management of advanced rheumatoid hand destruction, total wrist arthrodesis is the most popular operation for most hand surgeons. Knowledge regarding the rheumatoid wrist, the long-term complex changes in these chronic diseases and the various therapies for these wrists is not widespread [ 1 , 10 ]. For destroyed wrists of Larsen-stage III to IV, there are some alternative options, including proximal fusion with distal resection interposition arthroplasty.…”

“…In more than 90% of patients, the wrist is affected. Any wrist involvement can lead to excessive pain, malfunction and conceivably to a progression of deformation of the fingers, which are usually already compromised in patients with rheumatoid arthritis [ 1 – 3 ]. The wrist is the key joint for an overall treatment strategy for hand and finger deformities and for loss of function [ 4 , 5 ].…”

Operative Eingriffe im Bereich der Hand und des Handgelenkes bei rheumatischen Affektionen in der Jugend

“…Auch an den Gelenken ist der wichtigste Eingriff die Synovialektomie. Durch rechtzeitige Artikulosynovialektomie können die oft verheerenden Spätfolgen vermieden werden 10 Aber auch im fortgeschrittenen Stadium der Erkrankung ist die Artikulosynovialektomie noch sinnvoll, da man dadurch oft noch eine weitere Verschlechterung des Gelenkzustandes verhindern und die Schmerzen lindern kann. Bei der Ablösung der Gelenkkapsel und der Exstirpation der proliferirernden Synovialmembran werden zwangsläufig zahlreiche zum Gelenk ziehende Nervenfasern unterbrochen.…”

“…Zur Operation der Gelenke werden eingesetzt: Synovialektomie Kapsel und Bandraffung Bandnaht Kapsel-und Bandplastik Tenodese Arthroplastik Arthrodese Auch an den Gelenken ist der wichtigste Eingriff die Synovialektomie. Durch rechtzeitige Artikulosynovialektomie können die oft verheerenden Spätfolgen vermieden werden[10]. Aber auch im fortgeschrittenen Stadium der Erkrankung ist die Artikulosynovialektomie noch sinnvoll, da man dadurch oft noch eine weitere Verschlechterung des Gelenkzustandes verhindern und die Schmerzen lindern kann.…”