Quantitative magnetic resonance imaging as marker of synovial membrane regeneration and recurrence of synovitis after arthroscopic knee joint synovectomy: a one year follow up study

OBJECTIVES: By repeated magnetic resonance imaging (MRI) to study synovial membrane regeneration and recurrence of synovitis after arthroscopic knee joint synovectomy in patients with rheumatoid arthritis (RA) and other (non-RA) causes of persistent knee joint synovitis. METHODS: Contrast enhanced MRI was performed in 15 knees (nine RA, six non-RA) before and one day, seven days, two months, and 12 months after arthroscopic synovectomy. Synovial membrane volumes, joint effusion volumes, and cartilage and bone destruction were assessed on each MRI set. Baseline microscopic and macroscopic assessments of synovitis and baseline and follow up standard clinical and biochemical examinations were available. RESULTS: Synovial membrane and joint fluid volumes were significantly reduced two and 12 months after synovectomy. However, MRI signs of recurrent synovitis were already present in most knees at two months. No significant differences between volumes in RA and non-RA knees were seen. Synovial membrane volumes at two months were significantly inversely correlated with the duration of clinical remission, for all knees considered together (Spearman's correlation r(s)=-0.67; p<0.05), for RA knees (r(s)=-0.76; p<0.05), and for non-RA knees (r(s)=-0.83; p<0.05). Baseline volumes were not significantly correlated with clinical outcome. Only three knees (all RA) showed erosive progression. The rate of erosive progression was not correlated with MRI volumes or with clinical or biochemical parameters. CONCLUSION: The synovial membrane had regenerated two months after arthroscopic knee joint synovectomy and despite significant volume reductions compared with baseline it often showed signs of recurrent synovitis. MRI seems to be valuable as a marker of inflammation, destruction and, perhaps, as a predictor of therapeutic outcome in arthritis.     

The effectiveness of radioisotope synovectomy for chronic synovitis in Turkish paediatric haemophiliacs: Ankara experience

Summary. Between January 2006 and December 2009, 37 radioisotope synovectomy (RS) in 18 severe haemophilic patients (factor 8 < 1%) have been performed at our centre. The distribution of joint injected was as follows: rhenium‐186 [Re186], 19 joints (ankles, 8 and elbows, 11) and yttrium‐90 [Y90] 18 joints (knees, 18). Their mean age was 12 years (range: 8–20 years). Mean follow‐up period after procedure was 22.6 months. We preferred to use Y90 for all large joints and Re186 for small joints. Haemophilic patients with grade‐II or III synovitis were selected for RS in our study. Radioisotope synovectomy was performed in eight ankles for seven patients, 11 elbows for seven patients and 18 knees for 13 patients. Mean bleeding counts before the procedure and after the procedure were as follows: Ankles, 3.43 vs. 0.62 (P = 0.002); elbows, 3.12 vs. 0.55 (P = 0.000); and 3.83 vs. 0.62 (P = 0.011). No major complications requiring secondary treatments were observed. In summary, an early RS is the best way to halt the evolution of chronic haemophilia synovitis to devastating haemophilic arthropathy. Radioisotope synovectomy is very effective and safe in the treatment of chronic synovitis of children with haemophilia. Our data confirm the efficacy of RS for the treatment of chronic haemophilic synovitis, which has been previously published by many authors around the world. We highly recommend this procedure for developing countries to prevent joint disabilities. For a better and a healthier generation, RS has to be introduced in all the developing countries.     

Radioactive synovectomy with Yttrium90 citrate in haemophilic synovitis: Brazilian experience

Summary. Recurrent haemarthroses leading to chronic synovitis and arthropathy remain a major cause of morbidity in patients with haemophilia. Radioactive synovectomy (RS) is considered the first choice of treatment for chronic haemophilic synovitis. The aim of this study was to evaluate the effect of RS with Yttrium⁹⁰ citrate (C‐Y⁹⁰) in the joints of patients with chronic haemophilic synovitis. From 2003 to 2007, 245 joints (118 knees, 76 elbows, 49 ankles and two shoulders) of 190 patients with haemophilia or von Willebrand disease were submitted to RS with C‐Y⁹⁰ at Hemocentro de Mato Grosso, Brazil. Forty joints had radiographic Pettersson scores above 8. There were 36 joints of 22 patients with inhibitors to factor VIII. The procedure was safe with low occurrence of adverse events. The main effect was the overall reduction in joint bleeding frequency, from 19.8 to 2.6 per year post‐RS. Similar results were obtained in cases with high radiographic scores and in inhibitor patients. Pain reduction was observed in most cases. Average range of motion was maintained or increased 1 year post‐RS in most joints. Extension was stable or increased in 88.2% of the knees and 86.5% of the elbows. Ankle plantarflexion was stable or increased in 90.9%, whereas dorsiflexion was maintained or increased in 87.9%. Worsening of the range of motion, when present, ranged from 14 to 17 degrees. We concluded that RS with C‐Y⁹⁰ represents an important resource for the treatment of chronic haemophilic synovitis, markedly reducing joint bleeding frequency and pain, irrespective of the radiographic stage and inhibitor status.     

90Yttrium‐hydroxyapatite: a new therapeutic option for radioactive synovectomy in haemophilic synovitis

Summary. Recurrent haemarthroses often lead to chronic synovitis in patients with haemophilia and von Willebrand disease. Radioactive synovectomy with yttrium‐90 (⁹⁰Y) citrate is frequently used to treat this complication, usually with good results. Since 2006, the Nuclear Energy Research Institute (IPEN, Sao Paulo, Brazil) has produced hydroxyapatite particles labelled with ⁹⁰Y for radioactive synovectomy. The aim of this study was to compare the results achieved by both forms of ⁹⁰Y in the treatment of haemophilic synovitis. We included 221 joints from 136 patients (age range: 6–20 years), treated by one of the two radiopharmaceuticals, at the Hemocenter of Mato Grosso, Brazil. The outcomes analysed were the annual frequency of haemarthrosis, articular pain and joint range of motion before and 1 year after RS. Similar results were achieved regardless of whether ⁹⁰Y hydroxyapatite or ⁹⁰Y citrate was used, and results were independent of the joint type, age, gender, radiologic stage and presence of inhibitors. ⁹⁰Y hydroxyapatite appears to be equivalent to the reference product ⁹⁰Y citrate in the treatment of chronic synovitis associated with bleeding disorders.     

Treatment for chronic synovitis of knee: arthroscopic or open synovectomy

Chronic synovitis of knee joints that cannot be treated by conservative measure effectively can be treated successfully by the operations through resecting the inflamed synovium. The operations include open synovectomy and arthroscopic synovectomy. The purpose of this study is to compare the two operations in alleviating symptoms and cosmetic effect. There were 42 patients in this study, and they suffered from chronic synovitis of knee joints, including rheumatoid arthritis and non-specific synovitis. Twenty-two knees of 22 patients underwent arthroscopic synovectomy with two to five approaches whose lengths were about 1.0?cm, and 20 knees of 20 patients underwent open synovectomy with two approaches whose lengths were more than 10.0?cm. Patients were evaluated by visual analog scale for pain at the 24th hour after operation. Patients were followed up for 16–20?months and were evaluated by the Ogilvie–Harris scoring system. This study showed that both arthroscopic synovectomy and open synovectomy successfully alleviated the symptoms and the short-term results are similar after operation. However, the scars in the patients of the former group were much shorter than the latter group. Pain intensity of patients underwent arthroscopic synovectomy was less than that of open synovectomy at the 24th hour after operation. Both operations could treat chronic synovitis successfully. However, the arthroscopic synovectomy is the preferred operation due to fast recovery, less postoperative pain, and excellent cosmetic effect.     

An evaluation of the efficacy of arthroscopic synovectomy of the knee in rheumatoid arthritis: 12-24 month results

Nine patients with rheumatoid arthritis (10 knees) with chronic knee synovitis unresponsive to medical therapy were entered into a prospective study of arthroscopic total synovectomy of the knee. Histopathological examination of the synovium revealed a proliferative synovitis in all knees. Patients were ambulatory and exhibited 90 degrees of knee flexion on the day after surgery and were discharged at 24 to 48 h postoperation. Mean joint tenderness and swelling improved from the preoperative level and was maintained for the initial 12 months of the study. Knee range of movement was improved in all patients (mean 21 degrees). Improvement of joint function in daily activities was also demonstrated, but patients with Grade IV articular cartilage damage failed to show significant improvement. Nine knees were followed for at least 24 months and 4 required repeat surgery. Arthroscopic synovectomy is comparable to synovectomy by arthrotomy in short term reduction of pain and swelling. The chief benefit of arthroscopic synovectomy is a reduction in morbidity, hospital stay and postoperative rehabilitation.     

Treatment of chronic knee synovitis with arthroscopic synovectomy: longterm results

OBJECTIVE: We examined the longterm results of arthroscopic synovectomy in chronic knee synovitis of rheumatoid arthritis (RA). METHODS: Forty-one knees of 38 patients (30 women, 8 men), mean age of 42.7 +/- 15.3 years, were evaluated clinically and radiographically at a mean 8.9 years (range 5.0-12.3) after arthroscopic synovectomy. Arthroscopic synovectomies were always performed with a shaver by the same physician after failure of at least one radioactive or chemical synovectomy. Radiographs were blindly read by 2 examiners. RESULTS: At the final evaluation, the clinical results (pain, range of motion, recurrent effusion) were good in 29 cases (70.7%) and poor in 12 cases (knee arthroplasty was required in 11 cases). Radiographs highlighted significant progression of joint damage (more than one Larsen score grade) in 16 knees (39.0%). No radiographically detectable change was observed in 12 cases (29.3%), and 11 knees (26.8%) had a change of only one Larsen score grade. There was a close correlation between the Larsen score at final examination and both Larsen score and arthroscopic score for cartilage damage at baseline. Only 4 knees (22%) with grade 0 or I on preoperative radiographs had significant progression of joint damage, compared to 12 knees (57%) with Larsen scores of 2 or 3 at baseline. CONCLUSION: These data suggest that arthroscopic synovectomy is a useful alternative treatment for chronic knee synovitis in RA after failure of radiation or chemosynovectomy, and that less severely damaged joints deteriorate less rapidly after synovectomy.     

Arthroscopic synovectomy: a prospective study

Seven patients undergoing arthroscopic synovectomy for painful knee joint synovitis with marked synovial swelling were assessed preoperatively and up to 24 months postoperatively. Six patients had rheumatoid arthritis and one psoriatic arthritis. Patients were assessed for overall disease activity and indices of synovitis and function of the knees. There was minimal or no loss of function in the operated knee at one month. Subsequent improvement was reflected in reduction of pain on walking, pain on using steps, and swelling of the knee, with improvement occurring up to 6 months and maintained at 24 months. No sustained loss of movement was observed in the operated knee and all patients had improvement in knee flexion at 24 months. Patients universally regarded the procedure as worthwhile. These results highlight the lesser morbidity of arthroscopic synovectomy compared to that known to be associated with open synovectomy. Further study is required to evaluate the longterm value of this procedure.     

Comparison of the effect of knee synovectomy in haemophilic patients with 153Sm‐ and 90Y ‐labelled hydroxyapatite 1 year after

To compare the use of 740 Mbq (20 mCi) of ¹⁵³Sm and 185 Mbq (5mCi) of ⁹⁰Y, both labelling hydroxyapatite (HA), for knee synovectomy in haemophilic patients, 1 year after the intervention. Thirty three men (36 knees) were studied, divided into two groups: 1 – treatment using 740 Mbq of ¹⁵³Sm‐HA: 20 knees of 18 patients, with mean age of 21.4 ± 13.3 years (ranging from 7 to 56 years) and mean Pettersson score of 5.3; 2 – treatment using 185 Mbq of ⁹⁰Y‐HA: 16 knees of 15 patients, with mean age of 26.3 ± 10.3 (ranging from 7 to 51 years) and mean Pettersson score of 6.3. The following criteria were adopted for the evaluation before and 1 year after synovectomy: reduction in haemarthrosis episodes and pain using a visual analogue scale, as well as improved joint mobility. The occurrence of adverse events in the treatment was also considered. The chi‐square, Wilcoxon and Mann–Whitney tests were used with P ≤ 0.05 set as significant. The occurrence of haemarthrosis declined by 65.7% with the use of ¹⁵³Sm‐HA and 82.6% for ⁹⁰Y‐HA, with no statistical difference between the groups (P = 0.632); pain reduction was 42.5% in group 1 and 30.7% in group 2, once again with no statistical difference (P = 0.637). Improvement in joint mobility was not significant for both groups. Two cases of mild reactive synovitis were observed in group 1 and one in group 2, which cleared up without medical intervention. Although the beta energy from ⁹⁰Y is the gold standard for knee synovectomy, higher activities of ¹⁵³Sm may be used in places which have only production of this material.     

Radioisotope synovectomy with rhenium186 in haemophilic synovitis for elbows, ankles and shoulders

Summary. We have performed 221 radioisotope synovectomy (RS) in more than 150 children and young adults with haemophilia, age ranging 3–30 years (mean 15) in Ege Hemophilia Center, Izmir, Turkey for last 7 years. We always preferred to use Yttrium 90 (Y⁹⁰) for knees; however, since 2005, we started using rhenium 186 (Re¹⁸⁶) for medium‐sized joints with respect to safety. In this article, we have evaluated long‐term experience ranging from 6 months to 3 years (mean 18 months) with Re¹⁸⁶ for elbows (n = 35), ankles (n = 26) and shoulders (n = 2) in total of 63 RS procedures for 49 patients. Their age range was 3–30 years and mean age was 15.5. Two mCi of Re¹⁸⁶ intra‐articularly injected for treating target joints and chronical synovitis. After RS, joint bleedings were decreased for all patients. The best results were obtained for all joints in patients with grade‐II synovitis as like earlier experience with Y⁹⁰. Excellent rates (no bleeding) were observed in grade‐II synovitis in 81% and 46% for elbows vs. 86% and 57% for ankles after 6 months and after 1 year follow‐up of patients, respectively. In grade‐III synovitis, excellent rates were 53% and 25% for elbows and 44% and 29% for ankles, respectively. In five joints for five patients, repeated injections were needed for better outcome. No adverse events such as radioisotope leakage, local inflamatory reactions or malignancy development were observed during and after RS. For medium‐sized joints, RS with Re¹⁸⁶ seems to be either effective or safe treatment method. Our results confirm those previously published by others on the value of Re¹⁸⁶ synoviorthesis in medium‐sized joints in haemophilia patients. After this experience, we changed our protocol and we use Re¹⁸⁶ for all medium‐sized joints for treating chronical synovitis.     

Long-term evaluation of radioisotope synovectomy with Yttrium 90 for chronic synovitis in Turkish haemophiliacs: Izmir experience

Since 2001 we have performed 105 radioisotope synovectomy (RS) in 65 children and young adults, age ranging from 3 to 25 years with a average of 15 years in Ege University Hospital, Izmir, Turkey. One fourth of cases were below 10 years of age. All patients had severe haemophilia A and B. Ten patients (17 joints) had high responder inhibitor. We prefer to use Yttrium 90 for all joints (5 mCi for knees; 2 mCi for others). The knees were injected in 56 cases, elbows in 24 cases, ankles in 23 cases and shoulders in two cases. Steroid injections were not preferred as the principle drug of choice. Mean follow-up period after procedure was 2 years (range: 6 months to 3.5 years). All inhibitor patients had satisfactory results. The best results were obtained in elbows than knees and ankles. Excellent rates (no bleeding) were observed in grade-II synovitis 84% for knees, 93% for elbows and 50% for ankles. Because of the excellent and good response (bleeding reduction to 75%), rates were 100% for knees and elbows and 92% for ankles. In six cases, repeated injections were given at 6-month interval and all of them had good results. The grading of synovitis seems to be an important parameter than the age of the patient. Even in patients below 10 years of age, outcomes are not satisfactory in all joints with grade-III vs. grade-II synovitis (12% vs. 73%). No serious complications were observed during and after procedure except two cases. A mild and transient inflammatory reaction was observed in the ankle. There was a minimal radioisotope leakage to superficial skin in the elbow. RS seems to be a safe and effective treatment for chronic synovitis causing recurrent joint bleedings.     

Immunohistological Indication for Arthroscopic Synovectomy in Rheumatoid Knees: Analysis of Synovial Samples Obtained by Needle Arthroscopy

To determine the histological indication for arthroscopic synovectomy in rheumatoid knees, 23 patients underwent lavage and biopsy by needle arthroscopy. Eighty-one patients were treated with arthroscopic knee synovectomy after needle arthroscopy, and 51 of these patients underwent only arthroscopic synovectomy. Thirty patients who showed no improvement following arthroscopic synovectomy underwent open surgical synovectomy. Intra-articular lavage of knee joints by needle arthroscopy did not result in any clinical improvements. In the patients who underwent only arthroscopic synovectomy, two groups (only macrophages, no macrophages or B cells) showed clinical improvement (symptoms of the knee, ESR, RF). Patients in whom open surgical synovectomy was performed because of the failure of arthroscopic synovectomy showed clinical improvement. However, there was a significant loss of movement in the knee joint and more severe radiological deterioration in patients who underwent open surgical synovectomy than in those who underwent only arthroscopic synovectomy. Arthroscopic synovectomy should be used for rheumatoid patients with synovial tissue containing only macrophages or none of these two cells. Received: 26 February 2001 / Accepted: 13 July 2001     

Treatment of refractory chronic Lyme arthritis with arthroscopic synovectomy

Of 20 patients who underwent arthroscopic synovectomy for refractory chronic Lyme arthritis of the knee, 16 (80%) had resolution of joint inflammation during the first month after surgery or soon thereafter, and they have remained well during the 3-8-year followup period. Three of these 16 patients who were more disabled preoperatively, still had mild functional limitation at long-term followup. The remaining 4 patients (20%) had persistent or recurrent synovitis. We conclude that arthroscopic synovectomy is effective in treating chronic Lyme arthritis in patients in whom the disease does not respond to antibiotic therapy.     

Arthroscopic evaluation of the synovial lining before and after open synovectomy of the knee joint in patients with chronic inflammatory joint diseases

Twenty-eight patients with chronic inflammatory joint diseases had arthroscopy immediately before synovectomy of the knee joint and 6 and 12 months postoperatively. In patients with moderate and/or severe synovitis of the knee joint all of the synovial membrane is involved in the disease process. Resynovitis (synovitis of the regenerated synovial membrane after synovectomy), however, is patchy and if biopsy should be indicated, arthroscopic guidance is advocated. Following synovectomy there is a recurrence of mild synovitis of varying degree in some cases with an increase in resynovitis between 6 and 12 months. The level of synovitis at 12 months was, however, markedly less than at synovectomy (p less than 0.01). Similar development was found both in histopathology and immunohistopathology after synovectomy. Arthroscopic examination of the synovial membrane in chronic inflammatory disease of the knee joints gives valuable information of the severity and the longitudinal changes of synovitis. A simple method of scoring is described and is imperative when comparing patients or groups of patients and when doing longitudinal arthroscopic studies. The method was used both at arthroscopy and at subsequent synovectomy giving a highly significant correlation (p less than 0.001).     

Radiation synovectomy with <Superscript>90</Superscript>Y colloid in the therapy of recurrent knee joint effusions in patients with inflammatory joint diseases

The aim of this study was to assess the effectiveness of radiation synovectomy (RSV) in the treatment of recurrent joint effusions, using ⁹⁰Y in patients with chosen inflammatory joint diseases. The group of treated patients consisted of 30 people. Qualification for the treatment was based on clinical assessment, three-phase bone scintigraphy (BS3) and biochemical analysis. Intra-articular injection of ⁹⁰Y was performed. Biochemical analysis was repeated after 48 h, 4 and 24 weeks, whereas BS3 was repeated after 24 weeks. Changes in the second phase of BS3 were assessed visually, using a four-degree scale and in the third phase, semiquantitatively with J/B ratio. The changes in the blood pool phase before RSV were 3.4 ± 0.6 and after the therapy 2.00 ± 0.8 (P < 0.001). The J/B ratio was: before RSV 2.58 ± 08; after treatment 2.09 ± 0.9 (P < 0.05). RSV is an effective method to treat recurrent effusions in patients with RA and SPA.     

Radioactive synoviorthesis for the treatment of haemophilic synovitis

Summary.  Radioactive synoviorthesis, with ⁹⁰Y (knees) and ¹⁸⁶Rh (elbows and ankles) is a highly effective procedure that decreases both the frequency and the severity of recurrent intra-articular bleeds related to joint synovitis. The procedure should be performed as soon as possible to minimize the degree of articular cartilage damage, which based on many studies is irreversible. It can also be used in patients with inhibitors. On average, radioactive synoviorthesis has a 75–80% satisfactory outcome in the long-term. From the clinical standpoint, such efficacy can be measured by the decrease in the number of haemarthroses, with complete cessation for several years in some cases. One should bear in mind that in 20–25% of cases, radioactive synoviorthesis fails to control haemarthroses. In such cases, it can be repeated. Personal experience and the general recommendation among orthopaedic surgeons and haematologists is that when three early consecutive radioactive synoviortheses (repeated every three months) fail to halt synovitis, a surgical synovectomy (open or by arthroscopy) should be immediately considered.     

Arthroscopic synovectomy in haemophilia: indications, technique and results

Summary.  Recurrent spontaneous haemarthrosis are commonly seen in patients affected by haemophilia. The knee and the elbow are most commonly affected and both are amenable to arthroscopic treatment. Arthroscopic synovectomy is indicated after failure of appropriate medical management with recurrent bleeding. Many patients also demonstrate motion loss and functional deterioration. The benefits of arthroscopic synovectomy include the ability to perform adequate synovial debridement, but also concomitant lysis of adhesion and capsular release to regain range of motion. Results of arthroscopic synovectomy demonstrate a significant decrease in episodes of haemarthrosis, and significant improvement in pain, range of motion and function. The primary predictor of outcome is degree of pre-existing degenerative changes within the joint. In more severe cases, the results of arthroscopic synovectomy are unpredictable and serious consideration should be given to primary arthroplasty.     

Long‐term evaluation of chromosomal breakages after radioisotope synovectomy for treatment of target joints in patients with haemophilia

Summary. Radioisotope synovectomy (RS) is defined as the intra‐articular injection of radioisotopic agents with the aim of fibrosis on hypertrophic synovium in the target joint. The aim of this study was to investigate genotoxic effects on lymphocytes and malign transformation induced by Yttrium⁹⁰ (Y⁹⁰) and Rhenium¹⁸⁶ (Re¹⁸⁶) in children with haemophilia undergone RS. Forty haemophilia patients were enrolled. The mean age was 16.4 ± 6.2 years (range: 8–40). Y⁹⁰ was used for knees, Re¹⁸⁶ was used for other joints. For safety, cytogenetic analysis was performed to determine potential chromosomal changes after RS procedure at three different time points as prior to procedure, 3rd day and 90th day. For the stimulation of chromosomal breakages, diepoxybutane was used (DEB test). Chromosomal breakages (CBs) were found in 23 patients (67.6%) prior to RS. We have found CBs additionally in nine of 11 patients who had no CBs prior to RS after 3 days of radioisotope exposure. At that time, the patients who had CBs were 29 (85.2%). At day 90, only 21 patients revealed (61.7%) CBs. The mean frequency of CBs slightly but not significantly increased in the 3rd day. However, there was a significant decreasing trend between 3rd and 90th days. Radioisotope synovectomy with Y⁹⁰ and Re¹⁸⁶ does not seem to induce the genotoxic effects significantly on peripheral blood lymphocytes. However, CBs even after one year in the re‐evaluation of four patients, significant decrease in the number of CBs between the 3rd and 90th days and de novo CBs after exposure may be accepted as warning signals for young population. It should also be pointed out that families and patients be informed properly related with historical and potential dangers of radioisotopic agents.     

Treatment of chronic knee synovitis with arthroscopic synovectomy after failure of intraarticular injection of radionuclide

Although satisfactory results have been obtained with conventional synovectomy of the knee, there are frequent complications, and a long period of rehabilitation is necessary after this surgery. We performed arthroscopic synovectomy of the knees of 30 patients (33 knees), 22 of whom had rheumatoid arthritis. These patients underwent the procedure after failure to respond to an intraarticular injection of either osmic acid or yttrium 90. The operated knee was moved 3-5 hours after the arthroscopy, and the patients walked the next day. No rehabilitation was needed. The followup period ranged from 6 months to 36 months, with an average of 17.7 months. Except for 1 patient with severe arthritis, all patients experienced improvement. Results were rated as "good" or "very good" in 27 knees. Six months after synovectomy, the patients were asked to rate their improvement; the mean +/- SEM degree of improvement was 79.1 +/- 22.9%. All patients had significant improvement in the range of motion of the knee. One patient required manipulation of the knee (while under anesthesia) soon after the arthroscopy. There were no other complications. There was no detectable radiographic evidence of disease progression in 24 patients who were seen 1 year after the procedure or in 9 patients who were seen 2 years after the arthroscopy. Thus, arthroscopic synovectomy appears to be an effective and simple treatment for chronic knee synovitis, and has a low morbidity rate.     

ARTHROSCOPIC SYNOVECTOMY IN RHEUMATOID AND PSORIATIC KNEE JOINT SYNOVITIS: LONG-TERM OUTCOME

A long-term prospective study was performed to evaluate thesafety and long-term outcome of surgical arthroscopy (AS) forpersistent rheumatoid (RA) and psoriatic (PsA) knee joint synovitis(KJS). Local signs of joint inflammation (tenderness, swelling,‘ballottement’) and range of motion (ROM) were scoredand the sum, taken as a global outcome measure, was recordedin 17 RA and 18 PsA knees, both before and at follow-up periodsof 2, 6, 12, 24 and 36 months after surgical AS (knee jointsynovectomy; meniscal curettage, cartilage shaving or chondrectomy,according to the degree of cartilage damage). A survival analysis(Kaplan-Meier) of the long-term outcome of surgical AS treatmentand of the predictive value of clinical parameters of knee jointinvolvement was also performed. No intra- or post-operativemorbidity, pain worsening or loss of joint motion was observedand all patients were discharged within 48 h. Comparison ofthe parameters of knee joint evaluation showed a significantreduction of the signs of joint inflammation and a significantincrease in the ROM in all follow-up periods. At 36 months,the survival curves showed a 61.2% cumulative probability ofclinical remission and 72.8% of definite improvement. No significantdifferences in the prognostic importance of RA, compared toPsA diagnosis, were observed, although higher percentages ofPsA compared to RA knees (86.3% and 45.7%, respectively) reachedthe end point of clinical remission at 36 months. KJS duration,radiographic severity and cartilage damage were not predictorsof poor long-term outcome of AS synovectomy. Surgical AS treatmentfor PsA knees with more advanced cartilage damage gave a betterlong-term outcome. A total of 50.7% of operated knees reachedthe end point of a KJS relapse at 36 months, the majority (82%)within the initial 18 months of follow-up. Our study indicatesthat AS synovectomy is a safe procedure requiring short hospitalizationwhich, in combination with second-line medical treatment, canreduce local inflammation in RA and PsA KJS, and preserve kneejoint ROM for up to 3 yr. KEY WORDS: Arthroscopic synovectomy, Knee joint synovitis, Rheumatoid arthritis, Psoriatic arthritis, Long-term follow-up