Arthroscopic synovectomy for rheumatoid wrists and elbows

Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review

PURPOSE

To perform a systematic review of complications associated with elbow arthroscopy in adults and children.

METHODS

A literature search was performed in the PubMed, EMBASE, and Cochrane databases. Studies reporting complications or reoperations after elbow arthroscopy with at least 5 patients were included. Based on the Nelson classification, the severity of complications was categorized as minor or major. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized clinical trials, and nonrandomized trials were assessed using the Methodological Items for Non-randomized Studies (MINORS) tool.

RESULT

A total of 114 articles were included with 18,892 arthroscopies (16,815 patients). A low risk of bias was seen for the randomized studies and a fair quality for the nonrandomized studies. Complication rates ranged from 0% to 71% (median 3%; 95% confidence interval [CI], 2.8%-3.3%), and reoperation rates from 0% to 59% (median 2%; 95% CI, 1.8%-2.2%). A total of 906 complications were observed, with transient nerve palsies (31%) as the most frequent complication. According to Nelson classification, 735 (81%) complications were minor and 171 (19%) major. Forty-nine studies reported complications in adults and 10 studies in children, showing a complication rate ranging from 0% to 27% (median 0%; 95% CI, 0%-0.4%) and 0% to 57% (median 1%; 95% CI, 0.4%-3.5%), respectively. A total of 125 complications were observed in adults, with transient nerve palsies (23%) as the most frequent complication, and 33 in children, with loose bodies after surgery (45%) as the most frequent complication.

CONCLUSIONS

Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy. Higher complication rates are observed after more complex surgery. The incidence and type of complications can aid surgeons in patient counseling and refining surgical techniques to further reduce the complication rates.

LEVEL OF EVIDENCE

Level IV; systematic review of Level I-IV studies.

Treatment of Early Undifferentiated Chronic Monoarthritis of the Wrist by Arthroscopic Wrist Synovectomy Combined with Partial Denervation

OBJECTIVE

Undifferentiated chronic monosecarthritis (UCMA) is a group of inflammatory joint diseases that has the potential to progress to other diseases and can seriously affect patients' quality of life. There is yet no unified consensus regarding treatment of UCMA. This study aimed to investigate the efficacy of arthroscopic synovectomy combined with partial wrist denervation in treating Larsen 1-3 UCMA.

METHODS

In this case series, we reviewed 14 patients with UCMA treated by arthroscopic synovectomy combined with partial denervation from February 2017 to June 2020. The mean duration of symptoms was 17.4 months (range, 4-60 months), and the mean follow-up was 13.3 months (range, 6-23 months). The anterior and posterior interosseous nerves were severed at the distal forearm, and the radiocarpal, midcarpal, and distal radial ulnar joint synovial membranes were arthroscopically resected at the wrist. The clinical evaluation indices included the visual analogue scale score (VAS) for pain, grip strength, range of (active) motion of the wrist, total active motion, and Mayo wrist score. Larsen's scoring method was used as the imaging evaluation index.

RESULTS

At the last follow-up, significant clinical improvements were observed in the visual analogue scale (VAS) score for pain (6.0 (5.0-6.3) vs 1.0 (1.0-2.3), P = 0.001) and Mayo wrist score (42.1 ± 9.7 vs 61.8 ± 12.3, P < 0.0001). No significant changes were found in grip strength (15.9 ± 4.5 vs 16.6 ± 4.7, P = 0.230) or the flexion-extension arc (58.9 ± 39.0 vs 64.3 ± 36.5, P = 0.317), although the mean and median did show positive changes. Among the three patients who showed progress in imaging, there was no significant difference in their pain and functional scores compared to those who did not progress. One patient underwent total wrist fusion 17 months after the operation.

CONCLUSION

Arthroscopic wrist synovectomy combined with partial wrist denervation can provide sustained pain relief and functional recovery for patients with Larsen 1-3 UCMA.

Arthroscopic Synovectomy of the Wrist in Patients With Rheumatoid Arthritis: A Systematic Review of the Current Literature

BACKGROUND

Rheumatoid arthritis (RA) of the wrist can lead to loss of wrist function and progressive joint destruction if inadequately treated. Arthroscopic synovectomy of the wrist may prove a valuable treatment for local inflammation.

OBJECTIVE

The aim of this study was to perform a systematic review evaluating functional outcomes and pain following arthroscopic synovectomy of the wrist in RA patients.

METHODS

A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines. MEDLINE, EMBASE, The Cochrane Library, Web of Science, and Google Scholar were searched for studies describing pain or functional outcomes following arthroscopic synovectomy of the wrist in RA patients (CRD42021270846). Risk of bias was assessed using the Methodological Index for Non-Randomized Studies. Data collection included patient characteristics, pain scores, wrist function questionnaires, secondary surgery, and complications.

RESULTS

Six noncomparative cohort studies were included, with a total of 153 arthroscopic synovectomies. Disease duration of RA ranged from 32 to 89 months, and radiographic progression was mild to moderate. The Methodological Index for Non-Randomized Studies scores ranged from 8 to 10 out of 16. Mean follow-up ranged from 21 to 95 months. Improvements were seen in pooled mean visual analog scale pain score (from 7.7 to 2.2, p < 0.05), pooled mean Modified Mayo Wrist Score (from 43.3 to 70.4, p < 0.05), and the Disability of the Arm, Shoulder, and Hand (from 67.5 to 36.5, p < 0.05). Two complications occurred, and 5 patients required secondary surgery.

CONCLUSIONS

There is limited evidence suggesting that arthroscopic synovectomy of the wrist improves wrist function and pain in patients with RA, with few complications. In centers with arthroscopic expertise, it can be considered as a treatment option.

Pain, function, and patient satisfaction after arthroscopic treatment of elbow in a retrospective series with minimum of 5-year follow-up

BACKGROUND

The clinical indications for elbow arthroscopic procedures have expanded through last decades. The aim of the study was to assess the functional results and patient satisfaction after arthroscopic treatment of various elbow conditions after a minimum 5-year follow-up.

METHODS

We conducted a retrospective study of a consecutive patient cohort who had undergone unilateral elbow arthroscopy between 2008 and 2010. The main outcomes were Disabilities of the Arm, Shoulder and Hand (DASH) score and a specific patient-reported outcome measure questionnaire after a minimum 5-year follow-up.

RESULTS

In total, there were 93 patients in the cohort with different diagnoses. Majority of patients were suffering from elbow osteoarthrosis. After the average follow-up of 72 months (range 60-96 months), the response rate was 67%. Eighty two percent of patients were satisfied with the pain relief and locking of the elbow was relieved in 70% of patients. Elbow range of motion (ROM) improved in 80% of the 55 patients who had a limited ROM before the operation. The overall patient satisfaction after elbow arthroscopic treatment was good. There were no differences in median DASH score between patients with or without post-traumatic condition, but the median DASH score for patients who had severe (grade 3) osteoarthrosis before the operation was significantly worse. There were no major complications reported in this cohort.

CONCLUSIONS

Arthroscopic treatment of various elbow conditions was associated with good patient satisfaction and reduced symptoms without major complications. Level of Evidence: Level IV, therapeutic case series.

Arthroscopic Synovectomy of Wrist in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systemic inflammatory disorder affecting multiple joints. Wrist involvement is common. Patients with persistent symptoms despite medical management are candidates for surgery. Synovectomy can provide pain relief and functional improvement for rheumatoid wrist. Arthroscopic synovectomy is a safe and reliable method, with minimal postoperative morbidity. This article reviews the role, technique, and results of arthroscopic synovectomy in the rheumatoid wrist.

Arthroscopic synovectomy of the knee in rheumatoid arthritis defined by the 2010 ACR/EULAR criteria

BACKGROUND

The aims of this study were: (1) to evaluate the mid-term results and survivorship of arthroscopic synovectomy (AS) of the knee in rheumatoid arthritis (RA) defined with the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria; and (2) to identify prognostic factors.

METHODS

Patients matching the 2010 ACR/EULAR criteria, with symptomatic knee synovitis for at least six months, treated with arthroscopic synovectomy of the knee at a minimum of three year followup were included. Pre-operative evaluation included Larsen, HAQ, DAS28, and Laurin scores. Post-operatively, Laurin, WOMAC, and patient satisfaction scores were evaluated. Different variables were investigated to find associations with the outcomes. Kaplan-Meier survival analysis was performed.

RESULTS

Sixty-four patients met the inclusion criteria. Seven patients (9.6%) were lost to followup, leaving 57 patients (66 knees) for the present study. The average followup was 96.3months (SD 41). The pre-operative Laurin score was 3.91 points (SD 1.3) and significantly (P<0.001) improved after surgery (mean 8.2, SD 2). The post-operative average WOMAC score was 73.9 points (SD 45.9). Eighteen knees (27.3%) underwent revision procedures at an average of 48.6 months (SD 39.8). Joint degeneration (Larsen grade III) and range of movement (ROM) reduction (>10%) were identified as negative prognostic factors. Kaplan-Meier survivorship with total knee replacement as endpoint was: 78% at one year, 28% at four years, and six percent at 10 years.

CONCLUSIONS

Although AS of the knee has still a role as a salvage procedure in the treatment of RA synovitis with initial joint degeneration (less than Larsen grade III) and good ROM, high revision rates and limited survivorship are reported.

Effectiveness of arthroscopic elbow synovectomy in rheumatoid arthritis patients: Long-term follow-up of clinical and functional outcomes

OBJECTIVE

To determine the long-term clinical and functional results of arthroscopic elbow synovectomy in rheumatoid arthritis patients with refractory elbow synovitis in terms of improvement in pain, function, and active range of motion (AROM) or arc of motion.

METHOD

Fifteen rheumatoid elbows in 13 patients, not responding to DMARD therapy and with radiological changes not more than Larsen grade 3 were taken, who underwent arthroscopic elbow synovectomy. The main outcome measured in forms of Mayo Elbow Performance Scale (MEPS) score, measurement of pain using a Visual Analogue Scale (VAS), radiological angles of elbow, disease activity score (DAS-28), arc of motions (AOM) and complications, which were assessed at follow-up periods of 6 months, 24 months, and 30 months. Statistical analysis was done both qualitatively and quantitatively. Mann-Whitney U test, chi-square test, and Student t test were used as the statistical test for determining significance.

RESULTS

In the study group, the improvement was sustained and significant as compared to baseline (VAS 1.28, MEPS 81.07 and mean flexion range 85°) (p value <0.001). No significant complications were encountered postoperatively after elbow synovectomy.

CONCLUSION

The study assesses the long-term results of arthroscopic synovectomy in elbow synovitis secondary to rheumatoid arthritis with significant results favoring arthroscopic synovectomy.