Arthroscopic synovectomy of the knee joint in early cases of rheumatoid arthritis: follow-up results of a multicenter study

Recurrence-Free Survival after Synovectomy and Subsequent Radiosynoviorthesis in Patients with Synovitis of the Knee-A Retrospective Data Analysis

BACKGROUND

Persistent knee synovitis leads to joint discomfort, incapacitating inflammation, and functional limitations. The conventional approach has involved surgical procedures to eliminate the actively inflamed synovial membrane. This study aims to investigate the recurrence-free survival and functional outcome after synovectomy and subsequent radiosynoviorthesis (RSO) in patients with knee synovitis.

METHODS

Thirty-seven knees diagnosed with pigmented villonodular synovitis (PVNS), rheumatoid arthritis (RA), and peripheral spondyloarthritis underwent synovectomy and subsequent RSO between May 2005 and October 2016. The mean age was 34.9 ± 15.1 years, and the mean follow-up period was 84 ± 36.4 months. Clinical outcomes were assessed using the Oxford Knee Score and the presence of swelling and pain at the last follow-up. Recurrence-free survival denotes the duration from synovectomy to surgical re-synovectomy.

RESULTS

In general, twelve knees underwent re-synovectomy after a mean follow-up of 34.8 ± 24.9 months. The recurrence-free survival was 83.8% at two years, 71.3% at five years, and 61.7% at ten years. The subgroup analysis revealed recurrence-free survival at two years in 63.6% of patients with PVNS, 86.7% of those with RA, and 100% of individuals with peripheral spondyloarthritis.

CONCLUSIONS

This study demonstrates that combined therapy for synovitis is an effective approach, significantly improving clinical outcomes.

Perioperative Management of Immunosuppressive Medications in Rheumatic Disease Patients Undergoing Arthroscopy

PURPOSE OF REVIEW

This manuscript reviews relevant prior literature regarding management of immunosuppressants in patients with rheumatic diseases around the time of orthopedic surgery, highlighting important considerations specifically regarding arthroscopy.

RECENT FINDINGS

Utilization rates of arthroscopic surgery in patients with rheumatic diseases are on the rise, as immunosuppressive treatment options enable them to lead more active lives and hence experience more injuries. Physicians regularly manage patients' glucocorticoids and conventional synthetic and biologic disease modifying antirheumatic drugs around the time of orthopedic surgery, aiming to minimize infection risk while optimizing disease control. However, there is a paucity of randomized controlled trial data for orthopedic surgery-and specifically nothing in the literature pertaining to arthroscopic surgery. Recent guidelines for rheumatic disease patients undergoing elective total hip and knee arthroplasty recommend that most immunosuppressive medications should be held perioperatively, citing the high-risk profile of arthroplasty cases and arthroplasty patients. While 2017 societal guidelines for perioperative immunosuppression during arthroplasty currently serve as a guide for physicians, they may not be applicable to arthroscopy. The less aggressive arthroscopic surgeries span a broader range of patient ages and risk profiles, indications for surgery, and procedural complexity and associated risks. Given these considerations, the majority of routine arthroscopic patients may not require holding of their immunosuppressive medications in the perioperative period.

Improved quality of life and joint functions in patients with knee rheumatoid arthritis who underwent five portal arthroscopic synovectomy

Objectives

To evaluate the outcomes of patients with rheumatoid arthritis (RA) of the knee who underwent five portal arthroscopic synovectomy, with or without post-operative negative pressure drainage (NPD).

Material and Methods

A prospective clinical trial was performed. Patients with class I, II, and III RA of the knee were enrolled. They underwent five portal arthroscopic synovectomy. Post-operatively, they received either NPD (group A) or non-NPD (group B). Health assessment questionnaire (HAQ), disease activity score 28 (DAS 28), and Lysholm knee joint score were evaluated before the operations, and at six weeks, three months, and one year after the operations.

Results

A total of 36 patients were enrolled into the study, with 63.9% (23) female patients and mean age of 47.2 years old. All of the patients had clinical symptoms (joint swelling, pain, and dysfunction) for at least six months with poor responses to the traditional pharmaceutical therapy. There were 12, 16, and eight patients in class I, II, and III RA groups, respectively (six IA, six IB, eight IIA, eight IIB, four IIIA, and four IIIB). One year after the operation, patients had statistically significant improvements on HAQ, DAS 28, and Lysholm knee joint scores. More improvements were observed in patients with class I diseases. There were no statistically significant differences between group A and B.

Conclusion

Five portal arthroscopic synovectomy could increase the quality of life, decrease disease activities, and improve joint functions in patients with RA. More benefits were observed in patients with early disease developments. Patients in the NPD group did not show more improvements compared to the patients in the non-NPD group.

Comparison of arthroscopic, radioactive and combined synovectomy in the treatment of chronic non-specific knee synovitis

OBJECTIVE

To compare the outcomes of arthroscopic, radioactive and combined synovectomies in patients with chronic non-specific recurrent synovitis who did not respond to conservative therapy.

SUBJECTS AND METHODS

Twenty-nine patients enrolled between 2007 and 2011 were divided into 3 groups: group 1 was treated with arthroscopy, group 2 received a radioactive drug and group 3 received a combined (radioactive and arthroscopic) synovectomy. Treatment efficacy was evaluated by comparing pre- and post-operative Lysholm knee scores (LKS), night pain, resting pain, activity pain and effusions using visual analogue scales (VAS). Patient satisfaction was assessed using the visual analogue patient satisfaction scale (VAPSS).

RESULTS

The mean age of the study participants was 41.5 ± 5.2 years (range 14-76), and the mean follow-up period was 33.6 ± 3.2 months (range 17-78). Before treatment, the mean LKS was 41.4 ± 3.4 in group 1, 39.6 ± 3.3 in group 2 and 37.1 ± 4.6 in group 3. After treatment, the corresponding mean LKS were 77.7 ± 2.1, 81.6 ± 2.8 and 91.3 ± 2.7 in groups 1, 2 and 3, respectively; the increase was statistically significant (p < 0.05). The VAS scores before and after treatment decreased significantly (p < 0.05). The mean VAPSS score, a measure of patient satisfaction, was 5.1 ± 1.7, 5.8 ± 1.5 and 7.4 ± 1.8 in groups 1, 2 and 3, respectively, and the difference between groups 1 and 2 was not statistically significant, while that between group 3 and the other two groups was significant (p < 0.05).

CONCLUSION

This study showed that the three methods used in individuals with chronic non-specific recurrent synovitis were effective; however, arthroscopic synovectomy in combination with radioactive synovectomy was more effective than the other methods and superior in terms of patient satisfaction.

Arthroscopic synovectomy of the ankle in rheumatoid arthritis

PURPOSE

To evaluate the outcome of arthroscopic synovectomy of the ankle joint in patients with early-stage rheumatoid arthritis (RA).

METHODS

Between 2005 and 2009, 18 consecutive patients with RA involving the ankle underwent arthroscopic synovectomy. Pain was measured using a visual analog scale (VAS), and clinical outcome was determined by calculating the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score with a mean follow-up of 5 years (60 months). Assessments were performed preoperatively, at 6 and 12 months postoperatively, and then yearly thereafter. Clinical success was defined as the absence of synovitis symptoms or when patients demonstrated good or excellent outcomes (AOFAS Ankle-Hindfoot Scale score ≥80) with >50% improvement in VAS score for pain. Demographic, laboratory, and radiological variables were evaluated to determine possible factors predicting clinical outcome.

RESULTS

VAS and AOFAS scores were significantly improved at the final follow-up (60 months; P < .0001). The greatest improvements in clinical scores were observed after 12 months; thereafter, they steadily declined. Of the 18 patients examined, 14 (77.8%) were considered to have had clinical success with no reintervention. Variables predictive of clinical success were short duration of symptoms (P = .042) and minimal radiographic changes based on the Larsen grading system (P = .030).

CONCLUSIONS

Arthroscopic synovectomy is a safe and successful procedure in ankle joints affected by RA. The best clinical outcomes are achieved when the procedure is performed early in the disease course and when there is no evidence of cartilage degeneration.

LEVEL OF EVIDENCE

Level IV, prognostic case series.

Rheumatoid synovectomy: does the surgical approach matter?

BACKGROUND

Surgical synovectomy relieves pain in patients with rheumatoid arthritis (RA). The comparative effect of arthroscopic versus open synovectomy on pain reduction, recurrence of synovitis, radiographic progression, and need for subsequent total joint arthroplasty (TJA) is unclear. Whether synovectomy relieves pain in patients with advanced degenerative joint changes is also controversial.

QUESTIONS/PURPOSES

We therefore asked whether arthroscopic synovectomy resulted in equal pain relief, recurrence rates, rates of radiographic progression, likelihood of arthroplasty, and whether surgical synovectomy relieved pain and halted progression in the presence of advanced RA.

METHODS

We searched PubMed, Cochrane Database of Systematic Reviews, and BMJ Clinical Evidence. After appropriate selection criteria, 58 studies were identified, including 36 on open synovectomy and 22 on arthroscopic synovectomy, with a total of 2589 patients and a mean followup of 6.1 years. Meta-analysis was performed for knees and elbows, comparing open versus arthroscopic synovectomy. Variables included the percentage of patients with pain reduction, recurrence of synovitis, radiographic progression, and need for subsequent TJA or arthrodesis.

RESULTS

Patients undergoing arthroscopic synovectomy had similar pain reduction, but more frequent recurrences of synovitis and radiographic progression than patients with open synovectomy. Patients undergoing arthroscopic synovectomy had similar and decreased risks of subsequent elbow and knee arthroplasties, respectively. Advanced preoperative radiographic RA did not correlate with worse pain scores nor increased need for subsequent arthroplasty when compared with minimal degenerative joint changes.

CONCLUSIONS

Arthroscopic synovectomy, while providing similar pain relief, may place patients at higher risk for recurrence and radiographic progression of RA. Advanced preoperative degenerative joint disease should not be an absolute contraindication to synovectomy.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

[Large-joint synovectomy in the era of biological therapies]

Since the mid 1980s, a global decrease in surgical procedures related to rheumatoid arthritis (RA) has been documented for joint-preserving procedures such as synovectomy as well as joint replacement surgery. This reflects improvements in the early management of rheumatoid arthritis and availability of more effective medical treatment. The present review summarizes the recent literature on the frequency of orthopaedic surgery in RA patients as well as the role of synovectomy in the rheumatoid hip, knee and shoulder in times of biological RA therapy.

Surgical synovectomy decreases density of sensory nerve fibers in synovial tissue of non-inflamed controls and rheumatoid arthritis patients

Surgical synovectomy is a technique to treat synovitis and pain in patients with rheumatoid arthritis (RA) resistant to DMARDs or therapy with biologics. Indication to synovectomy is subject to tight cooperation of orthopaedic surgeons and rheumatologists. It was thought that synovectomy leads to a reduction of sensory nerve fibers, called sensory denervation. Since sensory denervation after synovectomy has never been histologically tested, we aimed to investigate sensory and sympathetic innervation in synovial tissue before and after synovectomy. Eight non-inflamed control subjects and eight patients with RA were included in this study with a two-stage synovectomy approach (interval 40–50 days). Nerve fibers and cells in synovial tissue were detected and counted using immunofluorescence. Density of sympathetic nerve fibers did not change after synovectomy, whereas density of sensory nerve fibers decreased in all control subjects and seven of eight patients with RA. In parallel, the density of synovial cells increased after synovectomy in all control subjects and six of eight RA patients, which is indicative of a wound healing response. In one female RA patient, density of sensory nerve fibers increased and a very marked rise of cellular density was observed, too. This indicates that probably not all patients profit from surgical synovectomy. The majority of patients (94%) demonstrated sensory denervation after surgical synovectomy accompanied by a wound healing cell response. This study can help to explain the positive effects of surgical synovectomy which usually leads to pain reduction and improved mobility.

Combined arthroscopic and radiation synovectomy of the knee joint in rheumatoid arthritis: 14-year follow-up

PURPOSE

To investigate the long-term outcome of combined arthroscopic and radiation synovectomy of the knee joint in early cases of rheumatoid arthritis (RA) with regard to knee function and the need for surgical re-interventions.

METHODS

Between 1993 and 1997, a consecutive series of 38 RA patients with therapy-refractory synovitis of the knee joint and only mild cartilage lesions (not exceeding Outerbridge grade II at surgery) were treated with combined arthroscopic and radiation synovectomy. Knee function was assessed preoperatively; at 6 months, 1 year, and 5 years; and finally, at a mean of 14 years with 4 different functional scores. A Kaplan-Meier survival curve was calculated with "any re-intervention" and "total knee arthroplasty" as endpoints.

RESULTS

Of 38 knees, 32 were available for the final 14-year follow-up with a total of 22 re-interventions: intra-articular steroid injection (n = 3), arthroscopic (n = 2) or radiation (n = 1) re-synovectomy, and total knee arthroplasty (n = 16). The remaining 10 patients with no re-intervention showed knee function not significantly different from the postoperative state. With any surgical re-intervention as the endpoint, the survival rate was 84% at 5 years (95% confidence interval [CI], 67.0% to 86.7%), 44% at 10 years (95% CI, 26.7% to 60.0%), and 32% at the 14-year assessment (95% CI, 16.0% to 49.3%). With total knee arthroplasty as the endpoint, the joint survival rate was 88.5% at 5 years (95% CI, 68.5% to 96.2%), 53.9% at 10 years (95% CI, 33.3% to 71.6%), and 39.6% at 14 years (95% CI, 18.9% to 48.6%).

CONCLUSIONS

Combined arthroscopic and radiation synovectomy leads to a stable improvement of knee function for a minimum of 5 years, but surgical re-interventions were frequently observed at the 14-year assessment and challenge the long-term benefit of the procedure. Patients with no interventions had a significantly shorter history of disease (7 v 11 years).

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

[Effectiveness of arthroscopic synovectomy in rheumatoid arthritis]

Arthroscopic synovectomy in rheumatoid arthritis has proven beneficial in terms of pain relief and joint function, both for upper limb joints (shoulder, elbow, wrist) and the knee. The clinical long-term improvement, such as pain reduction and improved joint mobility, seems more distinct in joints with no or mild joint destruction (early synovectomy) compared to advanced joint damage (late synovectomy). Late-stage elbow arthritis, synovitis of the metacarpophalangeal and proximal interphalangeal joints and the rheumatoid ankle can better be addressed by an open approach. Although a real joint-preserving effect has not been demonstrated, pain reduction and improvement in joint function recommend arthroscopic synovectomy as a substantial treatment option in patients with rheumatoid arthritis.

The therapeutic outcome of minimally invasive synovectomy assisted with arthroscopy in the rheumatoid knee

The purpose of the present study was to retrospectively evaluate the therapeutic outcome of minimally invasive synovectomy assisted with arthroscopy (MISAA). From 1995 to 2003, MISAA was performed on 30 knees of 18 rheumatoid arthritis patients. The mean follow-up period was 74.4 months. Radiographic assessment according to Larsen's radiological classification, the conversion ratio to total knee arthroplasty (TKA), and postoperative change of the range of flexion were evaluated retrospectively. There were 10 knees in grade I, 14 knees in grade II, and 6 knees in grade III, preoperatively. All the knees in grade I and 8 of 14 knees in grade II maintained the same grade until the latest follow-up. The other 6 knees in grade II and all the knees in grade III deteriorated to grade IV and were converted to TKA after MISAA. The mean range of flexion significantly increased postoperatively except the knees that were converted to TKA. MISAA is effective for rheumatoid knees in grade I or II, and improves range of flexion.

[Update on rheuma-orthopedics - role and therapeutic options]

Orthopaedic treatment options for rheumatological patients have been further developed over recent years. For orthopaedic treatment, a range of different interventions are offered: orthoses and special technical aids as well as injections for joints and tendons, or surgery. Surgical interventions cover joint preservation, restitution and arthrodeses. Improvements in equipment and surgical procedures also make minimally invasive interactions possible for rheumatoid diseases. Thus, postoperative morbidity has been reduced significantly. Improvement in function, reduction of pain and prevention of recurrent local inflammation are primary. Considering these aims, arthrodeses are restricted to special indications. Joint preservation and restitution are the predominant measures used. The various procedures are discussed.

Arthroscopic synovectomy of the knee joint in rheumatoid arthritis: surgical steps for complete synovectomy

For successful arthroscopic total synovectomy in rheumatoid arthritis of the knee, proper sequential steps are required. First, we resect hypertrophied synovial villi on the intercondylar notch to make a gateway for the posterior compartments. We also perform synovectomy at the posterolateral chamber because of the narrower space of the chamber than that of the posteromedial chamber and the intra-articular crowding due to swollen synovial villi with the passage of operation time. Special care should be taken not to overlook both posterior back corners and roofs, which cannot be seen through the transnotch view, even with a 70 degrees arthroscope. The posterior back corners and roofs can be visualized by using the trans-septal approach technique. In this approach, we prefer to perforate the posterior septum in the posterolateral-to-posteromedial direction to avoid damaging the neurovascular structures because the structures are located just behind and lateral to the midline septum and the posteromedial capsule bulges a bit more posteriorly than the posterolateral capsule. Attention is then directed to the medial, lateral, and suprapatellar compartments, and finally the retropatellar compartment. Our surgical steps are safe and effective for complete synovectomy of the rheumatoid arthritic knee joint and other synovial disorders.

Site-specific intraoperative efficacy of arthroscopic knee joint synovectomy in rheumatoid arthritis

PURPOSE

To assess the intraoperative reduction of inflammatory infiltrates achieved by arthroscopic knee joint synovectomy in patients with rheumatoid arthritis (RA) with special regard to the removal site, using preoperative and postoperative synovial tissue (ST) samples.

TYPE OF STUDY

A histologic and immunohistochemical study.

METHODS

Eleven patients with treatment-refractory RA knee synovitis underwent arthroscopic synovectomy. In each patient, ST specimens were obtained immediately before and after synovectomy from 9 defined sites covering the whole joint. The samples were graded using an acute synovitis score (ASS; presence of polymorphonuclear neutrophilic leukocytes [PMN] and fibrin) and a chronic synovitis score (CSS; e.g., lining cell hyperplasia, presence of diffuse and lymphoid aggregates). Immunohistologic analyses were performed using 7 monoclonal antibodies directed against PMN, macrophages, and T-cell subsets (total of 1,584 preparations). Knee function was assessed after an average follow-up of 28 months by Lysholm score (modified by Klein and Jensen), Insall functional and knee scores, and Lequesne score.

RESULTS

Arthroscopic synovectomy led to an overall significant (P between .005 and .05) reduction of the acute inflammatory infiltrates (ASS) by 82.1%, but to a significant reduction of chronic inflammatory infiltrates (CSS) by only 62.5%. Accordingly, the density of PMN was reduced by 81.8%, whereas that of macrophages and different T-cell subsets was only decreased by < or = 61.6%. With respect to the anatomic regions, a significantly (P < or = .05) less marked reduction of inflammatory infiltrates was observed in the upper lateral and central recess, at the medial and lateral capsule, as well as at the femoral insertion of the anterior cruciate ligament. All knee joint scores showed a significant (P < or = .01) improvement over preoperative values at follow-up.

CONCLUSIONS

Arthroscopic synovectomy effectively reduces acute and chronic inflammatory infiltrates in patients with RA who have refractory synovitis of the knee joint (immediately after synovectomy) and improves knee function (28-month follow-up). However, the reduction of inflammatory infiltrates appears to depend on the anatomic region of the joint.

LEVEL OF EVIDENCE

Level III.

Dose response of the AIA rabbit stifle joint to boron neutron capture synovectomy

This study assessed the treatment with boron neutron capture synovectomy of synovitis in the antigen-induced arthritis (AIA) model. A boron compound, potassium dodecahydrododeca-borate (K(2)B(12)H(12)), was injected into stifle joints of 24 AIA and 12 normal rabbits and activated by neutron bombardment of the joint to achieve doses from 800 to 81,000 RBE-cGy. Synovial ablation in the AIA joint was accomplished at doses of 6,000 to 7,000 RBE-cGy with no adverse effects to skin or extracapsular tissues.

Have the new drugs relieved the burden of the orthopedic surgeon?

Rheumatoid arthritis (RA) represents a chronic joint inflammation that leads to destructive lesions of joint cartilage and periarticular bone. Increased understanding of the molecular and cellular mechanisms of RA and recent advantages in molecular technology have resulted in new antirheumatic drugs such as tumor necrosis factor-alpha blockers, inhibitors of interleukin-1, and novel disease-modifying antirheumatic drugs such as leflunomide. This review summarizes the important effects of the novel antirheumatic drugs and their potential impact on the work of orthopedic surgeons. The ability of these agents not only to improve the clinical signs and symptoms of RA but also to prevent progressive joint damage promises support to the work of orthopedic surgeons and to the interdisciplinary treatment of RA patients. The challenge, however, will be to conduct studies that show the concrete way in which the single drugs may best relieve the burden of the orthopedic surgeon.