Treatment of the ankle joint in rheumatoid arthritis with surgical and radiation synovectomy

Results of surgical synovectomy and radiation synovectomy (radiosynoviorthesis) of the tibiotalar joint in rheumatoid patients are reported. The staged concept for management of the rheumatoid ankle joint is presented which is based on the radiographic appearance of disease progression. Results of 16 rheumatoid patients with disease to the ankle joint suggest that pain and walking capability is positively influenced by synovectomy and radiosynoviorthesis. Follow-up of 30 months revealed no deterioration of postoperative clinical improvement. In the absence of contraindications to radiosynoviorthesis it is suggested to combine arthroscopic synovectomy with radiosynoviorthesis for the treatment of early stages of rheumatoid disease of the ankle joint. Open synovectomy is preferred to arthroscopic synovectomy, if tenosynovectomy is simultaneously required.     

Late results of synovectomy in juvenile rheumatoid arthritis

We reviewed the records of 251 patients whose cases were diagnosed between 1958 and 1978 at the Children's Hospital Medical Center Special Treatment Center for Juvenile Arthritis. We used a computerized system that included retrieval of data on range of motion, pain, joint swelling, functional capacity, and radiographic changes at each six-month visit over the years that the patient was followed. For the patients who were operated on, the radiographic information was evaluated preoperatively and at the last radiographic follow-up (average, six years after operation). The data bank contained postoperative radiographic information for thirty-two of the joints that had been operated on. We reviewed the late results of forty-one synovectomies in thirty children. The data included range of motion, swelling, and pain before operation, at one and two years after operation, and at an average of 7.1 years of follow-up. There were few if any benefits from the operation with reference to pain or improvement of range of motion, but it did seem to provide permanent relief of the joint swelling. Furthermore, radiographic deterioration seemed to continue in the joints that had been operated on if they already had radiographic changes at the time of operation (late synovectomy). In the joints without radiographic changes at the time of operation (early synovectomy), there seemed to be a continuation of deterioration in those affected by polyarticular disease, while the changes were less pronounced in those affected by pauciarticular disease. We undertook this study with a positive attitude toward synovectomy in the treatment of juvenile rheumatoid arthritis.(ABSTRACT TRUNCATED AT 250 WORDS)     

A method of arthroscopic surgery. Clinical evaluation of synovectomy with the electric resectoscope and removal of loose bodies in the knee joint.

The structure and function of the electric resectoscope have been discussed and the application to synovectomy and removal of loose bodies in the knee joint. Our clinical results have also been reported. The advantages and problems of synovectomy and arthroscopic surgery with the electric resectoscope as used in the knee joint are discussed, especially in comparison with conventional resection of the anterior two-thirds of the synovial membrane. For intra-articular use in the knee joint the electric resectoscope used for transurethral resection in urology was modified to perform synovectomy and arthroscopic surgery. Clinical folow-up observation indicated that synovectomy performed with the electric resectoscope produced results almost comparable with those of conventional synovectomy. Arthroscopic surgery with the electric resectoscope is a new method. It is performed through a small skin incision with fewer untoward effects. The operation is relatively painless and offers more rapid recovery after surgery. A few complications were noted by this method. None were serious. There were two epsiodes of infection during the early use of this technique.     

Is synovectomy a sure treatment procedure for synovial osteochondromatosis?

In recent literature synovectomy is recommended for treating osteochondromatosis. In the case of a 25-year-old woman with an affected knee joint, who was treated with synovectomy, the authors observed recurrence 5 years later. Ten years after the operation a severe osteoarthritis had developed. Our experience suggests that this method should not be overestimated. F. Kroh came in 1932 to the same conclusion.     

Rheumatic lesions of the carpus

The wrist is frequently involved in rheumatoid arthritis. The areas where the synovial membrane is best developed are the best areas for the development of the pannus as well. Proliferation of the synovial membrane lining the joint capsules leads to loss of ligamentary support of the wrist. This is the basis for further deformation. The direction of the carpal deformation is determined by normal anatomical conditions. Destruction of the elements that are essential for the stabilization of the wrist is responsible for these deformations; these elements are described. The flexor and extensor tendons of the fingers and wrist joint are coated with synovial sheaths. These can also be infiltrated by a synovial pannus or rupture due to abrasion by osteophytes. The dislocation, elongation, or rupture of tendons also leads to deformation. In accordance with our conception of the longitudinal pillars of the carpus we classify the different possible types of rheumatic carpal deformation into three groups: deformities of the ulnar, central, and radial type. Combinations of these various types are also common in the course of the disease and lead to instability and ankylosis. Synovectomy represents the basic treatment for the rheumatic joint. It is initially performed by radiosynovectomy. If there is persistent pain and swelling, an operative synovectomy is required. The following surgical procedures are most frequently combined with synovectomy of the wrist joint: synovectomy of the extensor tendons, resection of the head of the ulna, axial realignment of the wrist joint, and reconstruction of ruptured tendons. The operative technique is described in detail. This operation is also most commonly performed in the advanced stages. This operation produces good functional results that are reliable for a prolonged period of time, so that arthrodesis or arthroplasty can be avoided. Deterioration of the radiological findings, however, is common.     

Synovectomy of the knee joint.

Patients with active rheumatoid arthritis of the knee should be considered for synovectomy to arrest the disease and to preserve joint function. Careful selection of patients on the basis of the weight bearing roentgenogram is important. Surgery should not be delayed if there is evidence of progression of the disease on serial roentgenograms, or if the original films reveal early joint disease. Preservation of the suprapatellar pouch to prevent adhesions of the quadriceps mechanism greatly improves the postoperative range of motion. Long term follow-up over 10 years has demonstrated the value of synovectomy in rheumatoid arthritis of the knee.     

关节镜下诊断与治疗滑膜软骨瘤病

目的：探讨关节滑膜软骨瘤病在关节镜下的表现、诊断要点、治疗及疗效分析。方法：本组24例,共26个关节,其中膝关节23个,肘关节2个,踝关节1个;男17例,女7例,男女比例2．4：1;年龄18－73岁,平均53岁。均行关节镜检查镜下软骨瘤取出及病变滑膜切除,并描述了该病在关节镜下的表现形式（滑膜表面型;滑膜层包裹型;关节囊纤维层包裹型;游离体型）和处理方法。结果：22例24个关节获得了平均24．5个月随访,未见复发,关节功能均好于术前,效果满意。仅有2例遗漏了2个游离体,无其它并发症。结论：关节镜下游离体摘除和滑膜切除术是治疗滑膜软骨瘤病的良好方法。     

Current role for radioisotope synovectomy

Radioisotope synovectomy has been extensively used to treat patients with chronic inflammatory joint disease but has moved to a less prominent position since the introduction of new and highly effective drugs. Remaining indications are refractory synovitis, pigmented villonodular synovitis as an adjunct to surgery, and hemophilic arthropathy. The three main radioisotopes used are yttrium-90, rhenium-186, and erbium-189. Radioisotope synovectomy should be performed only by highly experienced professionals, to minimize the risk of injection-related complications. The available safety data, in particular regarding the risk of malignancy, are reassuring. The efficacy of yttrium-90 in chronic inflammatory joint disease remains controversial.     

Synovectomy in hemophilic arthropathy. A retrospective review of 17 cases

Seventeen patients with severe hemophilic synovitis were reviewed for an average of 59.6 months after surgical synovectomy to record radiographic progression of arthropathic changes, frequency of hemarthroses, and range of motion. There were 12 knees and five elbows in the study. Most joints showed some radiographic progression of the arthropathy. In aged patients, two knees progressed to end-stage disease. The frequency of hemarthroses was greatly decreased in all joints and especially in the elbow. Range of motion was preserved for most knees but was reduced significantly for the elbow. Three of five elbows had additional procedures. This factor may be responsible, in part, for lost motion in the elbow as compared to the relatively good results in the knee having had true synovectomy. While the incidence of bleeding is significantly decreased after surgical synovectomy, it is not necessarily associated with a cessation of the progression of joint pathology. Reduced incidence of bleeds following postsurgical synovectomy may serve to delay reconstructive operations until a later period in life. Eventually, the disease proceeds to end-stage arthropathy as joint function correspondingly decreases with age. Early surgical synovectomy for intractable chronic synovitis is recommended as a useful measure in the management of hemophilic arthropathy. Patients should be treated conservatively with therapeutic doses of factor concentrate replacement for a reasonable period of time in an effort to obviate surgical treatment.     

Long-term results of synovectomy in rheumatoid patients

Seventy-eight knees in fifty-five rheumatoid patients were evaluated clinically and radiographically at an average of 14.1 years (range, ten to twenty-three years) after synovectomy. The functional result was excellent in seventeen, satisfactory in thirty-one, unsatisfactory in eighteen, and poor in twelve knees. Pain and recurrent effusions were significantly reduced after synovectomy, but the range of motion of the knee remained unchanged. Radiographs demonstrated progressive changes of degenerative joint disease but apparent arrest of inflammatory disease changes in about 67 per cent of the knees. We believe that synovectomy of the knee is a good treatment alternative for selected patients with early stage-I rheumatoid arthritis that has proved resistant to standard medical therapy.     

Excision of the distal ulna in rheumatoid arthritis

Resection of the ulna is an effective operation in the treatment of rheumatoid disorders of the distal radioulnar joint. Tenosynovectomies of the overlying extensor tendons and synovectomy of the joint are integral parts of the procedure. Following resection, the ulna usually remains in alignment with the radius, although some dorsal displacement is common. Restoring stability to the ulna as well as reconstructing a new sheath for the extensor carpi ulnaris can be accomplished in most cases by using the extensor retinaculum. In those cases where the retinaculum has been destroyed by the disease process or when the distal ulna is severely displaced, stability can be restored using the extensor carpi ulnaris for a tenodesis.     

Synovial chondromatosis in the distal interphalangeal joint

A case of synovial chondromatosis of the distal interphalangeal joint of the long finger with an 8-year follow-up is presented. The lesion recurred 4 years after simple synovectomy, requiring a second operation with arthrodesis.     

Low-dose external beam radiotherapy as a postoperative treatment for patients with diffuse pigmented villonodular synovitis of the knee

Background and purpose Pigmented villonodular synovitis (PVNS) is a rare proliferative disorder involving synovial membranes, and patients with PVNS have a variable prognosis. We retrospectively analyzed clinical outcomes after synovectomy plus low-dose external beam radiotherapy for diffuse PVNS of the knee.

Methods We reviewed the medical records of 23 patients who underwent postoperative radiotherapy between 1998 and 2007. 19 patients had primary disease and 4 had recurrent disease with an average of 2.5 prior surgeries. After synovectomy (17 arthroscopic surgeries; 6 open), all 23 patients received 4-MV or 6-MV external beam radiotherapy with a median dose of 20 (12–34) Gy in 10 fractions.

Results At a median follow-up of 9 (0.8–12) years, 4 patients had recurrent disease, with a median disease-free interval of 5 years. Of these 4 patients, 3 received salvage synovectomy and regained local control. Univariate analysis showed that age, sex, history of trauma, and total dose of radiation were not predictive of local control. 22 patients reported excellent or good joint function, and 1 who refused salvage synovectomy had poor joint function. None of the patients experienced grade 3 or higher radiation-related toxicity or radiation-induced secondary malignancies.

Interpretation Postoperative external beam radiotherapy is an effective and acceptable modality to prevent local recurrence and preserve joint function in patients with diffuse PVNS of the knee. Low-dose (20 Gy) radiotherapy appears to be as effective as moderate-dose treatment (around 35 Gy).     

Technik der Synovektomie beim infizierten Kniegelenk

In case of early diagnosis as well as correct indication and operation technique, synovectomy is an essential part in the treatment of an infected knee joint. The new formation of the synovia has been demonstrated by clinical/empirical as well as experimental studies, so that the alimentation of the cartilage can be normalized. Postoperative scarring due to adherence has to be prevented by continuous therapeutic exercises. In case of severe early infections, already existent severe cartilage lesions, and fibrous ankylosis, arthrodesis by means of external fixation is the method of choice. In these cases neither a healing of the infection nor a satisfactory function of the knee joint can be expected after the application of synovectomy.     

Long-term results following synovectomy of the knee joint in rheumatoid arthritis (author's transl)]

Late synovectomy of the knee joint in rheumatoid arthritis is considered by many authors as a positive influencing factor with regard to the local development of the disease at that particular site. Since this assumption is based on evaluation criteria which are by no means uniform, it has so far not been possible to compare the individual results achieved by different authors. For this reason, we conducted follow-up examinations of 57 knee joints in 44 patients with rheumatoid arthritis in whom the synovectomy had occurred at least five years ago, using the standardised follow-up scheme devised by Gschwent et al. Most of these cases represented a late synovectomy, as was evident from the duration of the disease and from Steinbrocker's stages. An analysis of the results showed that in our patients, pain and swelling were most impressively improved, in accordance with the reports made by other authors. Less impressive was the improvement of mobility following synovectomy. Despite increasing instability, it was usually possible to improve the ability of the patients to walk, especially in cases where this ability had been severely restricted. X-ray films showed in almost one-half of the cases that the objective finding had deteriorated, whereas in the other half of the patients the status was largely unchanged or even improved. We can sum up these results by stating that, taking into consideration the comparable results published in the literature regarding late synovectomy of the knee joint in rheumatoid arthritis, a positive influence exercised by late synovectomy on the local pathology can be assumed.     

Results of total knee arthroplasty in patients with gonarthrosis resulting from the delayed diagnosis of PVNS: a case series

Pigmented villonodular synovitis (PVNS) is a benign tumor that affects synovial lined joints, tendon sheaths and bursae. It is most commonly seen in one knee joint. The recommended treatment is total synovectomy, while radiotherapy can be used as adjuvant therapy for patients at risk for recurrence. The aim of our study was to show that the devastating effects of inactive diffuse PVNS may not be recognized for years and to evaluate the efficiency of aggressive total synovectomy on patients with PVNS during a follow-up period of 5 years. In the present study, 5 knees of four patients who had been previously followed due to gonarthrosis and diagnosed with PVNS during total knee arthroplasty (TKA) were followed and evaluated for a mean duration of 68 months. Mean age of the patients was 61.2 (52–66). All patients were women. One patient had right knee involvement, two had left knee involvement, and one had both knees involved. All patients had diffuse PVNS. Total synovectomy was performed in all patients in addition to TKA. During the follow-up, recurrence was not seen in any of the patients and prosthesis loosening was not detected. The aim of the present study was to evaluate the effectiveness of total synovectomy over the 5 years following the operation and to show that the devastating effects of inactive PVNS may sometimes be overlooked for years before being recognized during the treatment of the gonarthrosis that develops due to the disease. Although the disease is generally monoarticular, the study also presents a patient with bilateral PVNS.     

Septic arthritis of the knee. Five cases treated with synovectomy

Five cases of suppurative non-gonococcal arthritis of the knee were treated with synovectomy 1-2 weeks after the diagnoses were confirmed. Indications for operation were persistent fever and continuous effusion, in spite of adequate antibiotic treatment and serial needle aspirations. The infection subsided in all cases. At follow-up, 2 years after operation, one patient had died of other disease, and there had been no recurrences among the remaining four. One patient had disabling pain on weight-bearing and considerable restriction of knee motion with 2-3 mm radiographic narrowing of the joint space. Three knees were painless on normal motion, but in two case changes resembling osteochondritis were found radiographically.     

Synovial osteochondromatosis of the hip treated through a surgical dislocation

We report a case of osteochondromatosis in the hip joint treated through a surgical dislocation and describe the use and safety of the procedure confirmed by postoperative magnetic resonance imaging. A 44-year-old man had right hip pain with moderate limitation of the range of motion. Plain radiographs and computed tomography showed calcified loose bodies in the hip with mild joint degeneration. Magnetic resonance imaging showed remarkable expansion of the capsule containing joint fluid and loose bodies below the femoral head. Complete removal of loose bodies and synovectomy were performed through a surgical dislocation. Three months after the operation, the patient had fully recovered and returned to his job. Magnetic resonance imaging performed 5 months after surgery revealed full removal of the loose bodies and no recurrence of the disease including synovial proliferation. It also showed no evidence of avascular necrosis, meaning that the procedure had been performed safely.     

Septic arthritis of the knee: Five cases treated with synovectomy

Five cases of suppurative non-gonococcal arthritis of the knee were treated with synovectomy 1-2 weeks after the diagnoses were confirmed. Indications for operation were persistent fever and continuous effusion, in spite of adequate antibiotic treatment and serial needle aspirations.

The infection subsided in all cases. At follow-up, 2 years after operation, one patient had died of other disease, and there had been no recurrences among the remaining four. One patient had disabling pain on weight-bearing and considerable restriction of knee motion with 2-3 mm radiographic narrowing of the joint space. Three knees were painless on normal motion, but in two cases changes resembling osteochondritis were found radiographically.     

七分区法关节镜下滑膜全切术治疗类风湿性肘关节炎的中期随访结果

目的评价七分区法关节镜下滑膜全切术治疗类风湿性肘关节炎的疗效。方法 2002～2008年,行关节镜下滑膜切除肘关节清理术治疗类风湿性肘关节炎11例,共13个肘关节,4例左侧,5例右侧,2例双侧。平均病程60个月(5～120个月)。手术通过近端前内及前外入路、软点入路和后外入路,使用关节镜进行滑膜全切。在关节镜下,将肘关节分为内侧区、外侧区、桡骨头前下区、鹰嘴窝、后外区、桡骨头后下区和后内侧区,共七区,逐区切除滑膜。术前术后进行Mayo评分及HSS评分。结果随访时间12～72个月,平均34.6月。术后7个月复发1例,再次行手术治疗。其余10例12个肘关节屈肘角度由102.1°±15.9°增加至123.3°±21.4°(t=-3.275,P=0.007),伸肘角度由33.8°±21.4°改善至20.0°±17.8°(t=3.572,P=0.004)。HSS评分由48.8±18.1分改善为87.9±15.9分(t=-8.125,P=0.000)。Mayo评分由39.6±16.6分改善为92.9±13.9分(t=-9.918,P=0.000)。结论关节镜下滑膜全切术是治疗类风湿性肘关节炎的有效手段之一,多入路七分区法切除肘关节类风湿性滑膜对于提高疗效、降低复发率有一定意义,可有效缓解疼痛,增加肘关节活动度,术后Mayo评分及HSS评分均有显著提高。