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Radiolunate arthrodesis (RLA) has become an established surgical technique for stabilising wrists destroyed by RA. Our modified surgical technique with special osteosynthesis material has enabled the spectrum of indications to be expanded to include stage IV a--sagittal instability.44 radiolunate arthrodeses were carried out from 10.96 to 6.98. 19 (43.2%) satisfied the criteria for correction RLA with correction of sagittal instability. All (100%) of the 19 radiolunate arthrodeses were included in a follow-up examination, and all were examined clinically and radiologically at specified intervals. The mean follow-up is 22.8 months.Correction of the lunate drift in the sagittal plane was successful. The radiolunate angle was reduced from a mean 23.7 degrees before surgery to 9.3 degrees afterwards. The lunate drift in the frontal plane, which is shown by the ulnar translation index (UTI) was corrected from an average of 0.35 before surgery to 0.30 afterwards. Restoration of the carpal height by bone grafting from a mean preoperative CHI of 0.47 to 0.50 after surgery was achieved. We discovered one failure, thus the consolidation rate dropped to 94.7%.Since the capitate is the centre of rotation and movement at the wrist, a stable central pivot is essential, and correction of sagittal instability is particularly important. This demand can also be met by our modified radiolunate arthrodesis.

Erosive-destructive changes in rheumatoid arthritis particularly in the large joints of the lower limbs often result in the patient's immobility. The aim of this retrospective study was to weigh the benefits of multiple joint replacement in rheumatoid arthritis against the specific complications.From January 1977 until 31 December 1998, 215 patients with proven rheumatoid arthritis (according to the ACR classification) received three or four endoprostheses in the lover limbs. In a retrospective study with a standard questionnaire and evaluation of the patient record, we were able to assess 201 rheumatoid patients (93.5%) who received 688 endoprostheses (93.7%), with 347 total hip prostheses (THR) and 341 total knee prostheses (TKR).There was a significant improvement of the patient's ability to walk and in 16.9% of the cases even a remobilization of the rheumatoid patients who had been unable to walk before surgery. On the other hand, there were significant complications--in the majority of the cases (appr. 60%) with total knee replacement. Together the complications per implant had an extremely high complication rate of 43.8% (n=88) per rheumatoid patient.Due to the long-term follow-up of 22 years (1977 through 1998), we were able to demonstrate that with a new implant generation and a more a careful indication this unacceptable complication rate can be reduced considerably. However, the multiple joint replacement of the lower limbs remains a difficult method with a high complication rate and should therefore only be performed at orthopedic rheumatological centers.

There is increasing evidence that T cell-independent pathways, such as the up-regulation of protooncogenes and the production of growth factors and matrix-degrading enzymes, lead to progressive destruction of affected joints. Therefore, identification of differentially regulated genes restricted to rheumatoid arthritis (RA) synovial fibroblasts is essential. A combination of RNA arbitrarily primed-polymerase chain reaction (RAP-PCR) and complementary DNA (cDNA) array with defined genes was used for a highly sensitive differential screening using small amounts of RNA.RNA was extracted from cultured synovial fibroblasts obtained from 6 patients with RA and 6 patients with osteoarthritis (OA). RAP-PCR was performed using different arbitrary primers for first- and second-strand synthesis. PCRs were hybridized to cDNA array membranes. RA samples were compared with OA samples for differentially expressed genes.In contrast to standard cDNA array, the identification of 12 differentially expressed genes in RA compared with OA (approximately 6%) was possible. Differentially expressed genes of interest were confirmed using semiquantitative RT-PCR and in situ hybridization.Numerous variants of the differential display method and continuous improvements, including RAP-PCR, have proven to be both efficient and reliable for examining differentially regulated genes. Our results show that RAP-PCR combined with cDNA arrays is a suitable method for identifying differentially expressed genes in rheumatoid synovial fibroblasts, using very small amounts of RNA.

Long-term results of unicompartmental arthroplasty (UCA) in medial osteoarthritis are analyzed and the influencing covariates were explored.261 UCA in 229 patients were evaluated mainly by use of a structured questionnaire, 98.5% of the UCA were analyzed after 10 (5-20) years.In the Knee Sec. Score, the items pain and function were improved significantly. Patients were very content with the UCA. Failures (total 30) were especially caused by destruction of the non-replaced compartment (n = 11) and loosening of the tibial component (n = 5). Survival with aseptic failures as the endpoint was 84.9% after 10 and 74.4% after 20 years. Gender, age at operation, design (St. Georg, Tönnis, Endo, Wessinghage) and height of tibial component could not be proved as determining covariates with sufficient statistical significance.Cemented unicompartmental knee arthroplasties show good long-term results in medial osteoarthritis, when the criteria for the indication are strictly respected.

Between January 1983 and December 1987, metatarsal head-resections were performed on 203 patients, comprising a total of 370 feet, using the Hueter/Mayo and Hoffmann procedure. Seventy-two patients, comprising a total of 126 feet, were available for post-operative review after an average of 11.4 years from the date of the original operations. The information obtained from standardized questionnaires was compared to the information found in each patient's file. In addition, every available pre- and post-operative x-ray taken from 1983 to 1987 was analyzed. Thus, with an average follow-up period of 5.6 years, the changes found in the pre- and post-operative x-rays from a total of 183 feet could be compared. Before the operations, nearly 100% of the examined feet suffered from painful synovial hypertrophy and erosion of the metatarsophalangeal joints with dislocation and subluxation, causing approximately 70% of all patients to have great difficulties in walking. After the operations, however, 90.2% of the patients reported that this condition had noticeably improved or had completely disappeared. In fact, 87.5% of all patients reported a lasting improvement in their ability to walk longer distances. As the main criteria in determining the success of an operation (namely, the noticeable reduction of pain and increased mobility) were achieved in 87.5% of the patients, we consider the metatarsal head-resection a reliable method of correcting forefoot deformities in rheumatoid arthritis.

Open synovectomy of the knee in early cases has become a standard procedure in rheumatoid patients. Therefore, this study was performed to evaluate long-term results of open knee synovectomy in later cases of rheumatoid arthritis. Clinical findings in 93 knees after late open synovectomy are presented. The average follow-up was 10.1 (6.4-12.7) years. The failure rate was 39.8 per cent and so in 60.2 per cent (56 knees) no further operation was necessary. In 12 of 37 cases the revision was done by resynovectomy and reconstructive surgery. Thus during the follow-up period (10.1 years) in 73.1 (n=68) per cent of knee synovectomy no knee arthroplasty was performed. Patients reported as well reduction of pain and swelling with a high grade of satisfaction. Despite these reasonable functional results, radiographic progression of disease (Larsen stage 2.2 to 3.7) is common after synovectomy. Our study shows that late open synovectomy can delay the need for definite replacement surgery in nearly three-quarters of the patients.

Reports on patients with hemiparalysis indicate the importance of the nervous system for the pathophysiology of rheumatoid arthritis (RA) or osteoarthritis (OA). Norepinephrine (NE) and opioids seem to be more antiinflammatory neurotransmitters whereas substance P is proinflammatory. The study aimed to investigate the direct noradrenergic nerve-immune cell interaction in human synovial membrane. We used a recently developed superfusion technique with electrical stimulation of synovial membrane to elicit local NE from synovial membrane slices. The readout parameter of synovial immune cells was interleukin-6 (IL-6). IL-6 was spontaneously secreted from RA and OA synovial membranes. Electrical field stimulation intensively reduced IL-6 secretion. In patients with OA or RA, this electrically induced reduction of IL-6 secretion was not significantly changed by alpha- or beta-adrenergic antagonists. The study demonstrates that local endogenous NE seem to play a minor role, which may be due to a depletion of NE or loss of noradrenergic fibers during chronic RA and OA.

Destruction of articular cartilage and bone by invading synovial fibroblasts is a typical histopathologic feature in rheumatoid arthritis (RA). However, little is known about specific up- or downregulation of genes leading to this aggressive phenotype. Thus, our aim was to identify genes, which are differentially expressed in RA synovial fibroblasts as compared to synovial fibroblasts derived from patients with osteoarthritis (OA) using RAP-PCR for differential display.After extraction of total RNA, the first step of RAP-PCR was performed using various different arbitrary 10-12-base primers for first-strand cDNA synthesis. Second-strand synthesis was achieved by cycling at low stringency conditions for 35 cycles using different arbitrary 10-base primers, followed by electrophoretic separation and sequence analysis of the amplified fingerprint products.On average, approximately 70 different RNAs were obtained per primer, of which most were expressed both by RA and OA synovial fibroblasts. Using 26 different primer combinations, in total 12 cDNAs were differentially expressed between RA and OA synovial fibroblasts. In the RA group strong amplification of distinct PCR products suitable for sequencing could be observed. Sequence analysis identified these PCR products as highly homologous to various genes involved in regulation of cell cycle and metabolism.The data indicate that RAP-PCR is a suitable method to identify differentially expressed genes in rheumatoid synovial fibroblasts potentially involved in the specific pathophysiology of RA.

Our aim was to identify specifically expressed genes using RNA arbitrarily primed (RAP)-polymerase chain reaction (PCR) for differential display in patients with rheumatoid arthritis (RA). In RA, amplification of a distinct PCR product suitable for sequencing could be observed. Sequence analysis identified the PCR product as highly homologous to a 434 base pair segment of the human centromere kinesin-like protein CENP-E. Differential expression of CENP-E was confirmed by quantitative reverse transcription PCR, immunohistochemistry and in situ hybridization. CENP-E expression was independent from prednisolone and could not be completely inhibited by serum starvation. RAP-PCR is a suitable method to identify differentially expressed genes in rheumatoid synovial fibroblasts. Also, because motifs of CENP-E show homologies to jun and fos oncogene products and are involved in virus assembly, CENP-E may be involved in the pathophysiology of RA., Introduction: Articular destruction by invading synovial fibroblasts is a typical feature in rheumatoid arthritis (RA). Recent data support the hypothesis that key players in this scenario are transformed-appearing synovial fibroblasts at the site of invasion into articular cartilage and bone. They maintain their aggressive phenotype toward cartilage, even when first cultured and thereafter coimplanted together with normal human cartilage into severe combined immunodeficient mice for an extended period of time. However, little is known about the upregulation of genes that leads to this aggressive fibroblast phenotype. To inhibit this progressive growth without interfering with pathways of physiological matrix remodelling, identification of pathways that operate specifically in RA synovial fibroblasts is required. In order to achieve this goal, identification of genes showing upregulation restricted to RA synovial fibroblasts is essential. Aims: To identify specifically expressed genes using RNA arbitrarily primed (RAP)-polymerase chain reaction (PCR) for differential display in patients with RA. Methods: RNA was extracted from cultured synovial fibroblasts from 10 patients with RA, four patients with osteoarthritis (OA), and one patient with psoriatic arthritis. RAP-PCR was performed using different arbitrary primers for first-strand and second-strand synthesis. First-strand and second-strand synthesis were performed using arbitrary primers: US6 (5' -GTGGTGACAG-3') for first strand, and Nuclear 1+ (5' -ACGAAGAAGAG-3'), OPN28 (5' -GCACCAGGGG-3'), Kinase A2+ (5' -GGTGCCTTTGG-3')and OPN24 (5' -AGGGGCACCA-3') for second-strand synthesis. PCR reactions were loaded onto 8 mol/l urea/6% polyacrylamide-sequencing gels and electrophoresed.Gel slices carrying the target fragment were then excised with a razor blade, eluated and reamplified. After verifying their correct size and purity on 4% agarose gels, the reamplified products derived from the single-strand confirmation polymorphism gel were cloned, and five clones per transcript were sequenced. Thereafter, a GenBank® analysis was performed. Quantitative reverse transcription PCR of the segments was performed using the PCR MIMIC® technique.In-situ expression of centromere kinesin-like protein-E (CENP-E) messenger (m)RNA in RA synovium was assessed using digoxigenin-labelled riboprobes, and CENP-E protein expression in fibroblasts and synovium was performed by immunogold-silver immunohistochemistry and cytochemistry. Functional analysis of CENP-E was done using different approaches (eg glucocorticoid stimulation, serum starvation and growth rate analysis of synovial fibroblasts that expressed CENP-E). Results: In RA, amplification of a distinct PCR product suitable for sequencing could be observed. The indicated complementary DNA fragment of 434 base pairs from RA mRNA corresponded to nucleotides 6615-7048 in the human centromere kinesin-like protein CENP-E mRNA (GenBank® accession No. emb/Z15005).The isolated sequence shared greater than 99% nucleic acid (P = 2.9e-169) identity with the human centromere kinesin-like protein CENP-E. Two base changes at positions 6624 (A to C) and 6739 (A to G) did not result in alteration in the amino acid sequence, and therefore 100% amino acid identity could be confirmed. The amplification of 10 clones of the cloned RAP product revealed the presence of CENP-E mRNA in every fibroblast culture examined, showing from 50% (271.000 ± 54.000 phosphor imager arbitrary units) up to fivefold (961.000 ± 145.000 phosphor imager arbitrary units) upregulation when compared with OA fibroblasts. Neither therapy with disease-modifying antirheumatic drugs such as methotrexate, gold, resochine or cyclosporine A, nor therapy with oral steroids influenced CENP-E expression in the RA fibroblasts. Of the eight RA fibroblast populations from RA patients who were receiving disease-modifying antirheumatic drugs, five showed CENP-E upregulation; and of the eight fibroblast populations from RA patients receiving steroids, four showed CENP-E upregulation. Numerous synovial cells of the patients with RA showed a positive in situ signal for the isolated CENP-E gene segment, confirming CENP-E mRNA production in rheumatoid synovium, whereas in OA synovial tissue CENP-E mRNA could not be detected. In addition, CENP-E expression was independent from medication. This was further confirmed by analysis of the effect of prednisolone on CENP-E expression, which revealed no alteration in CENP-E mRNA after exposure to different (physiological) concentrations of prednisolone. Serum starvation also could not suppress CENP-E mRNA completely. Discussion: Since its introduction in 1992, numerous variants of the differential display method and continuous improvements including RAP-PCR have proved to have both efficiency and reliability in examination of differentially regulated genes. The results of the present study reveal that RAP-PCR is a suitable method to identify differentially expressed genes in rheumatoid synovial fibroblasts. The mRNA, which has been found to be upregulated in rheumatoid synovial fibroblasts, codes for a kinesin-like motor protein named CENP-E, which was first characterized in 1991. It is a member of a family of centromere-associated proteins, of which six (CENP-A to CENP-F) are currently known. CENP-E itself is a kinetochore motor, which accumulates transiently at kinetochores in the G2 phase of the cell cycle before mitosis takes place, appears to modulate chromosome movement and spindle elongation,and is degraded at the end of mitosis. The presence or upregulation of CENP-E has never been associated with RA. The three-dimensional structure of CENP-E includes a coiled-coil domain. This has important functions and shows links to known pathways in RA pathophysiology. Coiled-coil domains can also be found in jun and fos oncogene products, which are frequently upregulated in RA synovial fibroblasts. They are also involved in DNA binding and transactivation processes resembling the situation in AP-1 (Jun/Fos)-dependent DNA-binding in rheumatoid synovium. Most interestingly, these coiled-coil motifs are crucial for the assembly of viral proteins, and the upregulation of CENP-E might reflect the influence of infectious agents in RA synovium. We also performed experiments showing that serum starvation decreased, but did not completely inhibit CENP-E mRNA expression. This shows that CENP-E is related to, but does not completely depend on proliferation of these cells. In addition, we determined the growth rate of CENP-E high and low expressors, showing that it was independent from the amount of CENP-E expression. supporting the statement that upregulation of CENP-E reflects an activated RA fibroblast phenotype. In summary, the results of the present study support the hypothesis that CENP-E, presumably independently from medication, may not only be upregulated, but may also be involved in RA pathophysiology.

A 22 year old male patient with antiphospholipid-antibody syndrome (APL) developed severe bilateral avascular necrosis of both femoral condyles. Extensive synovectomy and arthrolysis in combination with an arthroplastic remodeling of both knee joints resulted in reduction of pain and joint effusion. Therefore, synovectomy and arthroplastic remodeling might be a promising therapy to extend the period of time to prosthetic joint replacement in young patients with APL.

As a part of long-term follow up (I) of 544 cemented Müller-curved stem total hip replacements (THR), implanted 1977 to 1983, 207 THR in 163 patients with rheumatoid arthritis (RA) were evaluated 9 to 15 years (11 on an average) postoperatively. The feed back rate was 96.9% so the results are very reliable. 18 cups were loosened (13 already changed), but no stem had to be changed for aseptic loosening. 2 THR (1.0%) had to be revised because of deep infection. Survival rate of Kaplan and Meier for aseptic loosening was 94.6% after 10 years, 83.5% after 15 years. The ARO multi-center-study 1995 (II) includes 3113 THR implanted 1987 and 1988. Within a follow-up period of 7 to 9 years the over all rate of aseptic changing for cemented cups (1.4%) was significantly lower than for uncemented cups (2.9%)--in RA even 1% versus 5.7%. The corresponding rates for stems was 1.0% (cemented) versus 1.8% (uncemented). We contributed 110 THR in 94 patients with RA with feed back of 100%. Because of deep infection one THR had to be changed and two were explanted. But no change of cup or stem because of aseptic loosening was observed. Also in the literature survival rates up to 97% after 10 years or 77% after 25 years even in younger patients with RA can be stated.Cemented THR shows good long-term-results in RA which with uncemented designs have also to be proved. As a consequence of analysing the (few) failures the cemented THR of Wessinghage with optimized bone-cement-implant-compound was introduced. We demand a high feed back rate in long-term follow-ups also with respect to quality management and comparing data.

Extreme changes of the hip joint often require individual technical supplements in addition to the endoprosthesis. But the base of success are procedures using a model of prosthesis and a technique that are matured. This is available e.g. with the old M. E. Müller curved stem hip joint prosthesis. In special cases of extreme changes or damage of the proximal femur we perform in artificial joint-replacement of the hip or changing of prostheses a special kind of operative treatment. This is a combination of the Original-M. E. Müller curved stem endoprosthesis, long or short version of the femoral part, in addition fixated by bone-cement and M. E. Müller's special metal socket--primary indicated for stabilization of the acetabular roof. The indications for this method can be changes of proximal femur and hip-joint, especially dysplasias of pelvis or hip joint, extensive fractures especially in old patients, destructions in polyarthritis, dysplasia of pelvis and coxitis caused by juvenile chronic arthritis and long time therapy with corticosteroids, destructions, loosenings and fractures in changing operations of hip-endoprostheses. Until today we treated 15 different cases by this method--one case was operated 13 years ago--with good results, prooved by Merle d'Aubigné's score.

Between 1. 1. 1977 and 30. 6. 1988, 1470 total hip prostheses were implanted at the 1st Orthopedic Clinic in Bad Abbach/Regensburg. In 101 cases (82 patients, average age 54.8 years) the acetabular convexity was built up at the same time. This is considered indicated if the acetabulum is too shallow and thus provides insufficient lateral or dorsolateral countersupport. The main area of indication is dysplasia-coxarthrosis and congenital dislocation of the hip, destructive coxitis in chronic polyarthritis or juvenile chronic arthritis, and loosened prostheses. The material used for building up the convexity is a block of corticocancellous bone, which is fixed ventrolaterally to dorsolaterally to the ilium by osteosynthesis. Autologous material was used in 88 cases and homologous material in 13. Sixty-one patients with a total of 77 built-up convexities were followed up. In 92.2% a bony bridge between the corticocancellous block and the rising branch of the ilium was fund. The method described is a valuable addition to replacements in case of extreme hip joint changes and replacement operations. In the authors' opinion it has considerable advantages over supporting shells and similar materials.

Articular cartilage, obtained from the large toe during hallux valgus operations in 37 patients, was investigated for the presence of amyloid by using the Congo red staining method. Amyloid deposits were demonstrated, particularly in the superficial layer of the cartilage, in 30 cases. This amyloid did not react immunohistochemically with any of the antibodies against the known five major amyloid types (AA, A lambda, A kappa, AF, AB). From these data it is concluded that hyaline cartilage in older individuals is prone to infiltration by an amyloid of a hitherto unidentified class. From the morphological observations there seems to be no correlation between amyloid deposits and the development of osteoarthrosis.

Based on positive experiences in similar operations of the said method, we report 3 cases of periprosthetic fractures after total knee arthroplasty treated by the principle of intramedullary osteosynthesis. After preoperative X-ray-planning a shorted AO-medullar nail was positioned on the proximal site of the prostheses in combination with autogenous resp. homogeneous bone grafts located in the fracture area. In relation to other procedures the advantages of these compound osteosyntheses are undisturbed periosteal blood supply, correct alignment and consolidation of the fracture, early weight bearing and reliable cement fixation. They legitimate in our opinion the increased effort of partial revision arthroplasty.

Proliferation of pannus tissue cells has been investigated under in vitro conditions after labeling of joint tissues with 3H-thymidine. It was demonstrated that there is only a minimal proliferation of chondrocytes as well as of pannus tissue cells. Slight increased proliferation was observed in granulation tissue poor in lymphocytes and plasma cells, and perhaps in those areas of destroying pannus tissue that exhibited polymorphonuclear granulocytes (PMNs) at the pannus-cartilage junction. These results are in contrast to the idea that pannus tissue is a tumor-like lesion, for the present observations, even within the limits of autoradiographic investigations on a heterogeneous tissue, and indicate that pannus tissue has to be regarded as an inflammatory granulation tissue.

The meniscal surfaces from patients with and without inflammatory joint diseases were investigated for the presence of superficially located polymorphonuclear granulocytes (PMNs). In histochemically stained tissue sections as well as in electron microscopic investigations on previously paraffin-embedded menisci, PMNs were observed in cases with inflammatory rheumatoid joint diseases. The inflammatory cells were located in fibrin adhering to the meniscal surface and in the fibrous meniscal tissue just beneath the fibrin. From these observations it is concluded that PMNs in the inflammatory synovial fluid may gain access to the fibrous structures of the joint, thus participating in tissue destruction, as has been assumed from in vitro investigations by other authors.

The occurrence of the S-100 protein was studied in normal and pathological cartilage from patients with osteoarthrosis and rheumatoid arthritis. In normal cartilage all cells of the different zones exhibit immunoreactivity for this protein. An identical distribution is observed in cases of osteoarthrosis and rheumatoid arthritis. Cellular pannus tissue usually is devoid of the S-100 protein. However, if chondroid metaplasia occurs in this tissue the cells become positive for the S-100 protein. From these results it is concluded that a chondroid metaplasia not only leads to a matrix comparable to cartilage but also contains cells that gain further characteristics of original chondrocytes.

Elastase, an enzyme in the azurophilic granules of polymorphonuclear cells (PMN), is like other granular PMN proteases characterized by its degradative activity at physiological pH towards native macromolecules as shown in a serum free medium. Joint tissue specimen obtained during elective surgery in cases of various rheumatic conditions were examined in order to elucidate the role of this enzyme during joint cartilage destruction. An indirect immunofluorescence microscopic technique utilizing a rabbit immunoglobulin G preparation raised against purified elastase was used for this purpose. Immunoreactive elastase was seen bound to cells which were recognized as PMN by their nuclear characteristics and staining in a histochemical reaction with naphtol AS-D chloroacetate. PMN were encountered more or less often in the pannus but clearly accumulated in a significant amount at the pannus-cartilage junction in one case of rheumatic monarthritis and three out of four cases with rheumatoid arthritis. This finding shows that PMN--contrary to other descriptions--belong to the morphologic characteristics of inflammatory rheumatic conditions and directly supports the hypothesis that PMN enzymes play an active role in rheumatoid cartilage destruction.

In many cases, rheumatoid arthritis results in protrusio acetabuli. In order to effect a durably stable support over the whole extent of the acetabulum, the active stabilization of the socket base in an endoprothetic joint replacement through a corticospongy plastic is more promising than the application of passive measures. Rheumatoid arthritic persons underwent 127 hip-joint replacements as first-time surgeries. In 47 operations out of the 127, we also carried out the active stabilization of socket bases because of protrusio acetabuli. Through the implantation of corticospongy bone material into the protrusions, socket bases with enough strain capacity could be recreated. Loosenings or reprotrusions were not observed over a period of up to 5 years.

In rheumatoid arthritis (RA) joint inflammation is due to two processes: 1) the underlying inflammatory process (UIP) characterized by a lymphoplasmacellular infiltration of the synovial tissue, as well as pannus formation, and 2) the detritogenic synovitis (DS), a synovial response to articular wear products from cartilage and bone (detritus) that induces a preferentially fibrinous inflammation. In order to estimate the role of DS in the clinical presentation of such joints, 40 patients with RA undergoing knee-joint surgery on 48 occasions were evaluated for clinical parameters, radiological stage (Larsen), and histopathological characteristics of UIP and DS. The clinical parameters were comparable in knee joints with predominantly UIP or DS. However, DS was regularly seen in knees with advanced destruction according to Larsen's stages 4 to 5, while UIP occurres in joints even without radiological damage. In conclusion, it is assumed that the poor response of patients with advanced RA to so-called long-term drug therapy may be in part explained by the modifying influence of joint detritus on the underlying "rheumatoid" inflammatory process.

The synovial lining of tendons may participate early in chronic rheumatic diseases. As a result of the inflammatory activity degenerative changes of tendons may occur. Increasing damage to tendons ends in their rupture. At 775 tenosynovectomies, 395 of them in chronic rheumatic diseases, in 68 patients (78 hands) 173 ruptures of tendons (14 flexors, 159 extensors) were found. The value of early tenosynovectomy as a preventive measure is emphasized.

Inflammatory changes of the hip joint in rheumatoid arthritis often lead to secundary protrusio acetabuli. Total joint replacement may lead to problems, especially in mounting the acetabular component firmly to the pelvis. For about 7 years we have been using the so-called "active stabilisation of the acetabular floor" by implantation of autologeous bone prepared from the resected femoral neck. In changing the artificial joint homologeous bone from our bone bank was used. Up to Dec. 31, 1983 neither graft versus host reactions nor failure in healing were seen. 107 total joint replacements with bone transplantation in rheumatoid arthritis were performed. In all cases we could see optimal growing in of the transplanted bone, often confirmed by X-ray tomograms, with good support of the acetabular component. So far we have not seen any negative results. The active stabilisation of the acetabular floor seems to be a worthwhile addition to known surgical possibilities.

Rheumatic diseases such as rheumatoid arthritis, psoriatic arthropathy, and ankylosing spondylitis very often cause deformities of the hand. Especially during the early stages of these diseases, synovectomy of joints and tendons is indicated; destructive and degenerative lesions can be limited in this way. If they are already present, in most cases only reconstructive operations such as arthrodesis, resection, interposition arthroplasty, articial joint replacement, tendon transfer etc. can improve the impaired function.

Pathologic and radiologic investigations of rheumatoid arthritis are compared with regard to their development. Radiologic demonstration of several cases prior to and following synovectomy shows improvement as well as exacerbation of the disease. An increasing mineral content signifies an improvement of the bone lesion. The mineral content depends on reduction of inflammatory activity, increasing motility, and postoperative discontinuation of cortisone therapy. In some cases various lesions at the border line between bone and cartilage as blurring, notching and destructions are disappearing. Reduction of cartilage accompanied with narrowing of the joint spaces will subside postoperatively, too. We have to suppose a regeneration of cartilage under increasing physical strain by functional stimulation. Following synovectomy the structure of subcartilage spongiosa becomes more organized as a sign of regression of inflammatory activity, improved motility and load capacity. Following synovectomy, exacerbation of radiologic symptoms occur mainly in advanced stages of rheumatoid arthritis. We may often see progression of secondary osteoarthritis existing preoperatively in contrast to clinical recovery. The increasing load capacity may cause an identation of the articular surface in cases of extreme osteoporosis. This might result in a false position. These lesions might necessitate further surgical treatment as possibly total joint prosthesis. Following synovectomy in rheumatoid arthritis of the knee, dissolving radiologic symptoms in addition to improvement of the clinical picture may be observed. The poor results of synovectomy in advanced rheumatoid arthritis favours the of early synovectomy during the proliferative and destructive stage of the disease.

An uncommon case of a closed dorsal dislocation of the fourth and fifth metacarpal bases associated with a flake fracture of the hamate bone is described because of the rarity of this injury. In order to regain full function, an open reduction was necessary. Stability of the carpometacarpal joints was achieved by osteosynthesis using a Kirschner wire.

Leiomyosarcoma of the hand is a rare tumor. A case report of a leiomyosarcoma lying in the superficial tissues of the dorsal aspect of the right hand in a 64-year-old woman is given. Nine months after initial excision a local recurrence appeared and was treated by radical local excision and free skin grafting. The follow-up is now seven years. The patient is free of tumor and metastases. A review of the literature is given. The problems in therapy of leiomyosarcoma of skin and superficial tissues are discussed.

Previous reports describe the presence of immunoglobulins and complement components within rheumatoid articular cartilage, thereby suggesting an effect of immune complexes on the formation of pannus. This hypothesis is reinvestigated in this paper. As confirmed in our work, the superficial layer of rheumatoid hyaline cartilage may fulfill the immunohistological criteria for the presence of immune complexes. In osteoarthritis, however, a noninflammatory disease not mediated by immunologic mechanisms, similar results can be obtained. The presence of immune-proteins within hyaline cartilage therefore requires a cautious interpretation. Hyaline cartilage in rheumatoid arthritis is replaced by granulation tissue growing not only at its surface (pannus), but also in subchondral bone. We therefore also thoroughly investigated deep layers of hyaline cartilage in the vicinity of such subchondral tissue, but could not obtain any evidence for the presence of immune complexes therein. The growth of subchondral granulation tissue and the accumulation of PMN in the region of its junction with hyaline cartilage therefore appear to be independent of immune complexes within rheumatoid hyaline cartilage. It is suggested on the basis of these data that immune complexes possibly present in hyaline cartilage do not play an essential role in the formation of granulation tissue replacing cartilage in rheumatoid arthritis. It is, however, not entirely excluded that during advanced stages of rheumatic cartilage degradation immune complexes are formed within the matrix or carried into it from the extra-cartilaginous environment, and that they may then contribute to further cartilage destruction by enzyme release during phagocytic processes.

Rheumatoid arthritis already can lead to an extreme limited range of motion of the whole patient in an early age. A female patient of 39 years has been immobilized for a period of about 6 years. By accident she was suffering too from multiple fractures, especially of both femora and both elbow-joints. Rheumatoid arthritis and traumatic lesions lead to incommon surgical procedures. Both hip-, both elbow- and both kneejoints, regarding to the fractures, were replaced during three operation periods. Within half a year the patient was far extending independent of nursing and able to walk again.

As a general disease, psoriatic arthritis (which besides the skin and the joint can also affect internal organs) takes a special place amongst chronic polyarthritis conditions. It is characterized by combination of psoriasis with a seronegative polyarthritis affecting the spine and above all the joints in the hands and feet (frequently asymmetrically). The form and extent of the often painful joint and spinal involvement not uncommonly lead to an appreciable impairment of various functions and thus to a handicap for the patient. A series of different operations extending from synovectomy to arthrodesis and joint replacement improve the pain as well as functional restrictions. However, they also lead to new knowledge on the nature, etiology and development of this disease via photographic documentation of findings and investigation of the tissue obtained intraoperatively. In the years 1967 to 1984, 457 single operations were carried out in 80 patients with psoriatic arthritis. The results allow the conclusion that patients with psoriatic arthritis should be admitted to special hospitals for surgical treatment more frequently than was the practice up to now.

In rheumatoid arthritis, extreme damage to the wrist joint with rupture of the wrist extensor tendons can only be treated effectively by arthrodesis. The authors describe the technique of wrist fusion by an AO-plate. Twenty-two arthrodeses have been performed between July 1974 and June 1984, representing 7.4% of all surgical procedures on rheumatoid wrists (n = 294). Radial deviation and dorsiflexion of the hand must be avoided. Follow-up was possible in nine patients (eleven wrist-fusions). All these patients were satisfied with the result.

The pannus-cartilage junction was investigated in cases of rheumatoid joint destruction. By a histochemical method for demonstrating the presence of neutrophil granulocytes, it became obvious that these cells in some cases were found in high numbers in the immediate vicinity of the cartilage in the process of being destroyed. It is concluded that these blood-carried cells may also participate in cartilage destruction in acute phases of chronic rheumatoid disease.

In the past, D-penicillamine has been thought to cause wound healing disturbances due to its influence on connective tissue. A series of 217 operations in 150 patients with rheumatoid arthritis on D-penicillamine treatment were performed and compared with controls (106 operations in 86 patients with rheumatoid arthritis). It was shown that disturbances of wound healing were less in patients on D-penicillamine therapy (12.4%) than in patients who did not receive D-penicillamine (18.9%). A perioperative withdrawal of D-penicillamine therefore does not seem justified.