[Synovectomy of the knee joint and postoperative exercise treatment in peridural anesthesia and analgesia]

The operative treatment of synovialitides of the knee-joint requires apart from an exact operative technique an effective postoperative therapy. The painless postoperative gymnastik treatment is an important factor to achieve a satisfactory result of therapy. The exercise of this "wounded articulation" by the "Frankfurter-mowing splint" needs sufficient analgesie for a long period which will be attained through our experience under continuous epidural anaesthesia and analgesia.

Comparison between arthroscopic and open synovectomy for the knee in rheumatoid arthritis

Ten surgical anterior capsulosynovectomies following Mori's four-block capsular incision technique in nine rheumatoid patients and 14 arthroscopic synovectomies utilizing a Wolf arthroscope with a large pituitary rongeur or a motorized intra-articular shaver in 11 patients were performed in our department. In three patients with bilateral involvement at nearly the same stage (III), we operated on the knees simultaneously, using open capsulosynovectomy on one side and arthroscopic synovectomy on the other side; we comparatively assessed the postoperative course, the subjective evaluation of the patients, and the follow-up results. Surgical intervention is milder in the arthroscopic operation, and postoperative knee pain during motion exercise is markedly less in the arthroscopically synovectomized knee. Although the postoperative management was more complex for open capsulosynovectomized knees, the results obtained at 1-2 months after synovectomy showed no significant difference between the two procedures.

[Value of passive postoperative mobilization treatment following knee joint synovectomy in chronic polyarthritis]

One group of 17 Knee joints was treated postoperatively with continuous passive motion, while the control group received cyclical changes of the Knee's position in flexion and extension. In the postoperative period the CPM-treated patients suffered less pain than the control group. Furthermore the patients of the CPM-group reached free extension and 90 degrees of flexion earlier than the control group. The amount of liquid in the suction drainage was higher in the CPM-group than in the control group. Based on the results of our examination continuous passive motion is considered to be a useful contribution to the postoperative treatment of synovectomy of the knee joint in rheumatoid arthritis.

Chronic arthritis of the knee in Lyme disease. Review of the literature and report of two cases treated by synovectomy

The arthritis that may be a part of Lyme disease, a spirochetal infection transmitted by ticks, has not been widely reported in the orthopaedic literature. Established chronic arthritis in patients who have Lyme disease most commonly affects the knee and may cause erosive joint disease. Antibiotics given early in the course of the disease can prevent chronic arthritis. When the arthritis is established, penicillin administered intravenously is curative in as many as 55 per cent of patients, but medical therapy alone may be insufficient to successfully treat the chronic stage of arthritis.

[The knee joint]

The knee is very important in the treatment of rheumatic diseases. Differentiating between the indications for different forms of therapy is dependent upon knowledge of the prospects for success. Synovectomy, preventive and palliative procedure, is the most important joint-saving measure, as confirmed by the long-term results presented here. Synoviorthese and arthroscopic operative procedures are alternatives and have expanded the spectrum. However, their long-term effectiveness has not yet been proved. Rheumatic, recurring synovitis has not yet been defined satisfactorily. Additional soft tissue operations should always be included in preoperative planning and determine the form of therapy. Alloarthroplasty of the knee is the foremost reconstructive measure, and excellent long-term results have already been achieved in some cases. It should be remembered, however, that modifications of individual models occasionally have a considerable influence on the results. Particularly for rheumatic knee joint deterioration, knee prosthesis models that guarantee long-term success should be given preference if the time and effort expended are justifiable. Continuous passive mobilization seems to be the most valuable postoperative measure.

[Rheumatoid hip joint and its orthopedic surgical treatment]

In the early stage of the disease, synovectomy of the hip seems to be a successful technique, but the timing of the operation is difficult because of interference with conservation treatment. Osteotomy in rheumatoid arthritis of the hip is not very successful; arthrodesis is not recommended. In the late stage of the disease the treatment of choice is joint replacement. Here osteoporosis and the protrusion of the acetabulum present more technical problems than in other hip diseases. Implants with various designs and various implantation techniques with or without bone cement are used. The use of bone grafts, especially for protrusion, represents real progress, and there is a trend toward using cementless implantation, especially for young patients. Failures are due to difficulties in morphology, but there are no more reoperations than in osteoarthritis, and mortality seems to be higher than in osteoarthritis.

[New knowledge and clinical trends in the diagnosis and therapy of inflammatory rheumatism]

Progress in the diagnosis of forms of inflammatory rheumatism represent not only a semantic problem reflected by the changes in and differentiation of rheumatological nosology. The line of demarcation between reactive forms of arthritis and chronic, destructive processes--the chronic polyarthritis (RA) model--is decisively important from a therapeutic point of view. Knowledge regarding rheumatoid joint destruction is not only the prerequisite for an understanding of radiological morphology, the loss of form and function but also forms the bridge to rheumatic orthopedics. This connection between internal rheumatology and orthopedic rheumatology--the "Rheumatism center" model--represents the recent types of progress made in the long-term treatment of chronic joint disease. Corresponding models and hypotheses are presented with regard to an effective therapy structure for rheumatic diseases.

[Rheumatoid changes in the foot]

The clinical importance, incidence and clinical appearance of foot deformities as a result of rheumatism are described. The pathomechanics of rheumatic deformities and the connection with inflammatory changes in the anterior and posterior parts of the foot are described. The possible types of conservative treatment are introduced briefly. The operative form of therapy is presented in detail and subdivided according to preventive and reconstructive measures in various parts of the foot. The peculiarities and subsequent requirements of the therapeutic procedure are addressed.

[The shoulder joint in chronic polyarthritis]

In patients with rheumatoid arthritis, shoulder problems are very common. In the present study, 96 of 105 patients, i.e., 91%, reported shoulder problems. Thirty-one percent of the patients had such severe shoulder disability that they considered it to be their main rheumatic problem. With increasing duration of the rheumatic shoulder disease, there are progressive destructive changes and a decrease in the range of motion and functional capacity even with conservative treatment, indicating that intervention with surgical procedures may be warranted. In the early effusive stages of rheumatic shoulder disease, radiological synovectomy with beta-emitting radionuclides may be indicated. In proliferative synovitis, surgical synovectomy gives good pain relief and increased shoulder mobility and function. In shoulders with more advanced painful shoulder arthropathy, shoulder replacement is gaining in popularity. However, it is mandatory that candidates must be selected very carefully for shoulder replacement and in patients with severe fibrotic capsulitis, muscular atrophy or mutilation with severe loss of bone, the results after shoulder replacement surgery are often less successful.

[Surgical therapy of chronic polyarthritis of the hand]

Surgical therapy and the common surgical procedures for the rheumatoid hand are presented: synovectomy, boutonnière deformity, swan-neck deformity, arthroplasty, and surgical therapy of the rheumatoid thumb. The indications, early and late results, and the prophylactic value of synovectomy are discussed and compared with synoviorthesis (intra-articular injection of radioisotopic beta-emitters) in early stages of synovitis. In general, radioisotope synovectomy has reduced the need for early operative synovectomy. If synoviorthesis has no significant effect or if biomechanical factors are predominant in the affected joint (tenosynovitis, massive distension of the capsule and extensor mechanism or large masses of fibrin), then operative synovectomy is indicated. Multicenter studies have confirmed that pain can be relieved and joint swelling reduced by synovectomy for over 10 years after the operation. However, no significant preventive or retarding effects could be proven with regard to the progression of deformity or further radiologic changes. The risks in tenosynovectomy are minimal and the prognosis for improved function and prevention of ruptures is excellent. Restorative procedures on tendons are discussed in conjunction with restoration of joint function. Pathogenetic mechanisms of boutonnière and swan-neck deformities and their therapeutical consequences (soft tissue procedures and arthroplasty of the respective joints) are discussed. Because of the unpredictability of joint resection arthroplasty, many attempts have been made to develop joint prostheses. Surgical experience with cemented components, constrained hinges and prostheses with a fixed axis has been disappointing and forbids their routine clinical use. The most widely used device is the silastic spacer developed by Swanson, a silicone rubber implant acting as flexible hinge to maintain the joint relationship and improve resection arthroplasty. Several authors have obtained good long-term results using the Swanson silastic prosthesis for MP and interphalangeal arthroplasty. However, the silastic spacer still leaves room for improvement, which is particularly evident in patients with constitutional or drug-induced (steroid hormones) ligamentous laxity where bone resorption can be seen due to the piston effect and abrasion of the silicone as well as to sinking and often breakage of the prosthesis. Attempts to prevent this effect are reported. To obtain good functional results with MP arthroplasty, adequate function of the interphalangeal joints and thumb is essential.(ABSTRACT TRUNCATED AT 400 WORDS)

[Elbow joint]

The elbow joint is a key joint for positioning of the hand. Four operations have to be considered for the rheumatoid elbow: removal of rheumatoid nodules and bursectomy, resection of the radial head, synovectomy, and arthroplasty. Synovectomy and arthroplasty are carefully analyzed, both from the point of view of recent international literature as well as personal experience. Synovectomy of the elbow is highly effective even when performed relatively late (stage 3 according to Larsen-Dahle-Eek) insofar as pain relief and swelling are concerned. In long-term disease, deterioration as assessed by radiology can usually not be prevented, but clinical improvement may be the reason for the relatively rare indication for arthroplasty. According to recent literature, the results of elbow arthroplasty vary greatly. Fully constrained hinges should no longer be used, and no decision has been made so far on whether semiconstrained or nonconstrained surface replacement is preferred. We use the semiconstrained GSB Mark II prosthesis, which has provided results in nearly 50 cases that rank among the best reported from the point of view of pain relief, improvement of ROM, and low complication rate. Use of our so-called transtricipital approach to the elbow has proved particularly valuable, especially with regard to lack of extension and muscle strength.

[The wrist joint]

The wrist joint is involved in a great majority of cases of rheumatoid arthritis. Tenosynovitis and synovitis can lead to severe destruction of the joint and to spontaneous ruptures of the tendons. Therefore, early tenosynovectomy and wrist-joint synovectomy are required. At the advanced stage of the disease, arthroplasty is necessary. Arthrodesis is rarely indicated in the treatment of severe wrist destruction in rheumatoid arthritis.

The scope of arthroscopy

Arthroscopic surgery is an established technique and is frequently done as an out-patient procedure. The technique requires two or three portals of entry into the joint with visual triangulation of operating instruments towards the area of pathology. Increased diagnostic accuracy, definitive endoscopic treatment, and minimal morbidity are major advances derived from arthroscopy.

[Animal experiment studies on the topic of regeneration of the synovial membrane following synovectomy of flexor tendons in the so-called no man's land]

Tenosynovectomy in patients with rheumatoid arthritis is performed most commonly in the region of the wrist and the ankle. Complications with regard to gliding ability and rupture of the flexor tendons are feared in the so-called no-man's land. The goal of this study was the morphologic examination of the regeneration of synovial membrane in flexor tendons after radical tenosynovectomy. Chronological and qualitative changes of the membrane as well as possible negative effects on the tendon such as adhesions and trophic disturbances were of interest. Synovectomies of flexor tendons were performed in 27 Albino rabbits in the region of the wrist. The synovium and the flexor tendons were histologically examined with light microscope and with scanning electron microscope at intervals between two days and 19 weeks. According to our results a new, fully functioning synovial membrane develops after four weeks. The flexor tendons show no pathologic changes and no adhesions as long as the visceral sheet around the flexor tendon remains undamaged.

[The child's foot in juvenile polyarthritis (cP)]

The foot, with particular involvement of the ankle joint and forefoot, is an early and frequent site of inflammatory changes in juvenile rheumatoid arthritis. According to the type of disease (sero+ or sero-, polyarticular or pauciarticular, HLAB-27 positive), there is a great variety of symptoms and also of prognoses. The involvement of growth cartilage is the cause of an additional deforming factor over and above the usually progressive process. Varus and cavovarus deformities with clawtoes occur most frequently. Owing to the thickness of the joint cartilage, there is mostly no severe functional deficiency; if there is it often occurs only some what late. On the other hand, extensive bony fusions belong to the characteristic picture of certain forms of juvenile rheumatoid arthritis. Since pain occurs only in the presence of severe deformities due to localized pressure, it is rather seldom that patients with juvenile rheumatoid arthritis come for surgical treatment of their feet. Therefore, it is all the more important to point out the justification of synovectomy in all of these cases, where swelling cannot be removed by conservative measures and in the presence of signs of progressive destruction. Correction of deformities can be achieved by surgery aiming at soft tissue release and osteotomy, partly avoiding arthrodesis. The latter serves to correct fixed deformities and those that disturb function at the end of the growth period.

Shoulder surgery in rheumatoid arthritis

Surgery was performed on 43 shoulders in 38 rheumatic patients with disabling pain. Fifteen of 22 synovectomized shoulders were available for examination an average of 2 years postoperatively. Twelve patients were satisfied with their operations and had painfree shoulders. Nine shoulders had almost normal mobility but four patients with an advanced shoulder arthropathy had gained little motion. Two patients with severe pain had been re-operated on with arthroplasty. In 15 patients with 18 shoulder replacements, the postoperative gain in motion was limited in all shoulders. Seven out of eleven shoulders had significant pain after hemi-arthroplasty, whereas five out of seven shoulders were painfree after total replacement. It seems that synovectomy can give results which are comparable with total arthroplasty if applied in early stages of rheumatoid disease.

Current management of rheumatoid arthritis

Although rheumatoid arthritis is usually a chronic polyarthritis, it progresses in a wide variety of ways often with organ involvement. It is characterized by periods of exacerbation and remission. Successful management, which must be tailored to individual patients' requirements, involves a multidisciplinary approach coordinated by the physician. Counselling, physiotherapy, occupational therapy, adequate drug therapy and surgery all play a part.

[Long-term results of endoprosthetic joint replacement and synovectomy]

The operations most frequently performed for chronic polyarthritis are synovectomy and artificial joint replacement. The radioisotope synovectomy has in general reduced the need for operative synovectomy. Multicenter studies of the late results of operative synovectomy (over 10 years after the operation) show a lasting improvement in pain, although radiographically the destructive changes that are seen 10 years after the operation are similar to the non-operated side. The synovectomy can therefore buy important time since re-operation, e.g. arthroplasty, is performed mainly on clinical grounds and not on the roentgenographic appearance. Operative synovectomy (Larsen 0-2) is indicated when the radioisotope synovectomy fails. It should be performed as soon as possible. Primary operative synovectomy is mainly advised when mechanical factors are predominant (tenosynovitis, large masses of fibrin in a joint etc.) and where a denervation effect is produced at the same time (e.g. in the wrist). The remainder of this report concerns the multiplicity of problems with the various wrist- and finger joint-arthroplasties. Cemented prostheses and those with a fixed axis have been shown in the world literature to have a high need for re-operation because of loosening and secondary deformities of the fingers. The silastic spacer is more adaptable but is not without problems. This is particularly seen with constitutional or cortisone-induced ligamentous laxity where bone resorption due to the piston effect and abrasion becomes evident together with sinking and often breakage of the prosthesis. The attempts made to prevent this are reported. The improvement in function from the MP-arthroplasty is very dependent upon the condition of the PIP-joints and the thumb. The significance of this with respect to the operative indication is discussed. Although the PIP-arthroplasty can initially have a good range of motion, a reduction after a number of years can be seen because of periprosthetic fibrosis. In general, when the operative indication is correctly made and with good postoperative management, arthroplasty can give good long-term results. The carpometacarpal joint of the thumb is relatively seldom involved in polyarthritis and the main indication for arthroplasty is osteoarthritis. The extent of trapezium resection and the various types of prostheses are discussed. The authors warn against treating a single joint in isolation without considering the other joints which work together with it in a functional chain.

Synovectomy of the knee in hemophilia

Synovectomy of the knee in patients with hemophilia presenting in countries with demographic characteristics that make central referral difficult is the subject of this article. Ten patients, six surgeons, and two countries contributed to this study, which demonstrated that approximately 40% of these patients had no further hemarthroses into the affected joint and the remainder had reduced frequency and severity of bleeding. Continuous passive motion has an important place in postoperative management, and manipulation with the patient under anesthesia is of doubtful value. The possible relationship between diminished range of movement and a successful outcome in terms of abolition of hemorrhage is explored. One patient underwent synovectomy of the knee without complication; the other nine suffered significant complications.

Synovial hemangioma of the knee

Synovial hemangioma is a rare, benign lesion affecting children and young adults. The lesion most commonly affects the knee joint. A recurrent history of pain and swelling is a characteristic feature. The degree of pain and tenderness can vary from mild to excruciating. Doughy consistency of the mass and quadriceps atrophy are other features. Total excision should be the object of treatment. A clinical diagnosis will be made only if the clinician is aware of the condition.