The focus of the current issue is on three different diagnostic and therapeutic issues related to joints.
The clarification of knee swelling is always an exciting diagnostic challenge in practice. Especially in rheumatology, careful anamnesis and clinical examination remain central even in today’s medicine, which is characterized by many additional examinations. They allow an initial differential diagnostic delimitation and should be the basis for a reasonable clarification. Together with a simple additional examination, the analysis of the joint punctate, a tentative diagnosis can often already be made, which makes it possible to arrive at a diagnosis quickly with a few targeted further clarifications.
Adrian Forster, MD, summarizes the current treatment strategy for rheumatoid arthritis. The realistic goal of treatment is remission of the inflammation. The prerequisite for this is the earliest possible diagnosis and the subsequent start of an effective basic therapy without delay. Drug of first choice remains methotrexate, with alternatives available in case of contraindications or intolerances. Today, combination therapies are being used more and more frequently. Steroids serve only as an initial bridging agent until the onset of action of the basic therapeutic agents. If sufficient control of the inflammatory activity is not achieved after three to six months, the therapy must be extended or changed, and in most cases the so-called biologics are then used, which intervene very specifically in the inflammatory process, but because of their costs and the increased risk of infection require a correspondingly careful indication and therapy monitoring.
The article by Luzi Dubs, MD, sheds light on a controversial topic from an orthopedic perspective: the sense or nonsense of knee arthroscopy for gonarthrosis (or degenerative meniscal lesions). From a biomechanical perspective, it is important to remember that the menisci are an integral part of the knee joint. This explains why it is well known that any meniscal (partial) resection promotes or accelerates the development of subsequent gonarthrosis, and also that the degenerative change of the knee joint always involves both the cartilage and the menisci simultaneously. Therefore, osteoarthritis and degenerative meniscal lesion (and at most also the subchondral bone) together often form the source of pain. In addition, experience has shown that with a little patience (and conservative treatment) such painful episodes or irritations often improve spontaneously after a few weeks or months. It is therefore very welcome if the orthopedic surgeon or knee surgeon is very cautious about indicating arthroscopy in an osteoarthritic knee. The article points out methodological deficiencies in the cited studies – but the question may also arise whether there are no studies that clearly show a benefit of arthroscopy (the author argues here primarily with his personal experience in the sense of “eminence-based medicine”).
We wish you a stimulating and enriching read for your everyday practice!
Andreas Krebs, MD
Andrea Stärkle-Bär, MD
HAUSARZT PRAXIS 2014; 9(4): 11
