Long term follow-up of arthroscopic synovectomy for chronic hemophilic synovitis

Recurrent hemarthrosis of the knee in hemophiliac patients leads to chronic synovitis, predisposing the joint to further hemarthroses and degeneration. Open synovectomy controls bleeding, however, significant loss of motion frequently results. We are reporting on seven patients who underwent arthroscopic synovectomy and had decreased bleeding episodes while maintaining range of motion. The seven patients had frequent recurrent hemarthroses despite medical management. All had had signs of degenerative arthritis preoperatively. Five of the seven had loss of motion. Length of follow-up averaged 4 years. Six of the seven had reduced bleeding episodes with an average of 0.22 hemarthroses per week. The seventh patient required significantly less Factor to control bleeding. No patient lost more than 10 degrees of motion. Three patients had increases in motion; two were unchanged. Radiographic progression of degenerative changes was noted in five patients, the other two were unchanged. We recommend early arthroscopic synovectomy in the treatment of recurrent hemarthrosis in hemophiliac patients.     

Magnetic resonance angiography in the management of recurrent hemarthrosis after total knee arthroplasty

Spontaneous hemarthrosis is an infrequent but disabling complication after total knee arthroplasty. The purpose of this case series is to demonstrate the utility of magnetic resonance angiography (MRA) in the evaluation of hemarthrosis after total knee arthroplasty. Patients presenting with hemarthrosis unexplained by trauma, anticoagulation, or a bleeding diathesis were retrospectively identified. Eighteen patients were referred for MRA to evaluate recurrent hemarthrosis after failing conservative therapy (n = 16) or synovectomy (n = 2). Despite artifact caused by the metallic components, diagnostic evaluation of regional vessels was made. In 12 of 13 cases that underwent embolization or synovectomy, a hypertrophic feeding artery (or arteries) was visualized on MRA. One case of negative MRA did not have subsequent surgery, and we are unable to comment on the rate of false-positives because all patients in this case series had evidence of bleeding. By characterizing the vascular anatomy and identifying a dominant artery (or arteries) supplying the hypervascular synovium, MRA can serve as a guide for subsequent embolization or synovectomy, as indicated.     

关节镜技术治疗血友病A膝关节滑膜炎

[目的]总结关节镜技术在血友病A膝关节滑膜炎中的应用,探讨其疗效。[方法]自2002年9月～2007年1月对25例血友病A膝关节滑膜炎患者,行关节镜下滑膜切除,围手术期内适量Ⅷ因子滴注,进行系统康复训练。采用HSS评分标准,对术前、术后结果进行综合评估。根据关节镜下软骨Outerbridge分期分组,按照Insall疗效标准,分别评估各组手术效果。[结果]23例患者得以随访,平均随访时间27个月。术前平均输血次数(23.4±4.6)次/年,术后(9.8±2.5)次/年(P<0.01)。HSS评分术前(58.6±4.7)分,术后(80.5±6.8)分(P<0.01)。OuterbridgeI期术后优良率100%(4/4),II期83.3%(10/12),Ⅳ期优良率差(0/2)。[结论]对于早中期血友病A膝关节滑膜炎,关节镜下滑膜切除是一种安全、有效的治疗方法。     

关节镜与切开手术在类风关膝关节滑膜清理术的疗效比较

目的评价关节镜与切开术对类风关滑膜清理术的疗效。方法对1993年3月至2000年3月膝关节滑膜清理术的52例患者进行随访,其中24例行切开术,28例行关节镜术。切开组21例,关节镜组27例平均随访5年。观察疼痛缓解程度、滑膜炎复发情况、影像学改变、接受关节置换或关节融合比例进行比较。结果关节镜滑膜切除与切开相比,疼痛减轻相似,但滑膜炎复发比例更高,影像学骨关节炎进展更快。患者关节镜滑膜切除与切开相比,后期膝关节置换比例降低。结论关节镜下类风关滑膜切除可缓解疼痛,但滑膜炎复发比例高,影像学进展更快,不增加需要人工关节置换的比例。     

Arthroscopic and open synovectomy of the elbow in rheumatoid arthritis

BACKGROUND: Synovectomy has been advocated for early treatment of the rheumatoid elbow. It has not been determined whether arthroscopic or open synovectomy is better and whether a preoperative arc of flexion of >90 degrees is an important prognostic factor. METHODS: Arthroscopic or open synovectomy was performed in fifty-eight elbows in fifty-three patients with rheumatoid arthritis and radiographic changes in the joint of Larsen grade 2 or less. Clinical symptoms, recurrent synovitis, postoperative complications, and radiographic changes were assessed ten to eighteen years (average, thirteen years) postoperatively. RESULTS: Eleven (48%) of twenty-three elbows in which arthroscopic synovectomy had been performed and sixteen (70%) of twenty-three elbows in which open synovectomy had been performed were mildly or not painful at the latest follow-up evaluation. However, no significant difference was detected between the overall clinical results of arthroscopic synovectomy and those of open synovectomy. In elbows with a preoperative arc of flexion of <90 degrees , the clinical results of the two procedures were comparable. In elbows with a preoperative arc of flexion of <90 degrees , arthroscopic synovectomy provided significantly (p < 0.05) better function than open surgery after mid-term follow-up, and motion and function continued to be better in those patients at the most recent follow-up evaluation. Recurrent synovitis was observed in six elbows that had arthroscopic synovectomy and in three that had open synovectomy, and the Larsen grade increased in both groups. Three elbows with a preoperative arc of flexion of <90 degrees underwent a total elbow arthroplasty to treat ankylosis after open synovectomy. Surgical complications were uncommon and not severe. CONCLUSIONS: Arthroscopic synovectomy of the elbow is a reliable procedure. One of the most favorable indications for either arthroscopic or open synovectomy is a preoperative arc of elbow flexion of >/=90 degrees in patients with early rheumatoid arthritis.     

Treatment of Recurrent Hemarthrosis Following Total Knee Arthroplasty Using Surgical Interventions

BackgroudRecurrent hemarthrosis following total knee arthroplasty (TKA) is a rare complication. Its pathophysiology and standard treatments have not yet been established. In this study, we report 7 cases of recurrent hemarthrosis after TKA in which failure of the initial conservative treatment was followed by angiographic embolization; in 1 of the 7 cases, arthroscopic electrocauterization was also performed after treatment failure with selective embolization.MethodsFrom January 2015 to May 2018, 7 patients visited our hospital due to recurrent hemarthrosis after TKA. Their medical records and serologic test results were reviewed to check for the presence of any bleeding disorder and history of anticoagulant use. Implant malalignment and instability were checked using X-ray. In all cases, the conservative treatment failed, so interventional angiography with selective embolization was performed, which was also followed by arthroscopic electrocauterization if the outcome was unsatisfactory.ResultsThe interval between TKA and the onset of hemarthrosis ranged from 3 to 76 months (average, 34.1 months). There was no coagulopathy and instability. All patients underwent conservative treatment at an interval of 4.3 months and the rate of relapse was 3.1 on average. On the interventional angiography, 6 cases showed vascular blush, and 1 case had pulsatile bleeding. The average duration for interventional angiography was 90.9 minutes. The average length of follow-up was 38.8 months. Embolization was successfully performed in 4 cases. In 2 of 3 failed cases, the symptoms improved without further treatment. In the remaining 1 failed case, the patient had a relapse of hemarthrosis, so an arthroscopic procedure was performed, which led to identification of the suspicious bleeding point by using preoperative angiographic findings. Electrocauterization was performed and active bleeding was stopped. All cases with recurrent hemarthrosis achieved improvement.ConclusionsInterventional angiography was used to aid in the diagnosis of recurrent hemarthrosis, and therapeutic selective embolization provided satisfactory clinical results. Even if selective embolization fails, interventional angiography may be helpful for further surgical procedures because it reveals vascular blush of a bleeding site. Therefore, interventional angiography and selective embolization should be considered to be a useful treatment for recurrent hemarthrosis after TKA.     

Arthroscopic synovectomy for recurrent hemarthrosis of the ankle in hemophilia

Nine patients with a history of recurrent hemarthroses of the ankle due to severe hemophilia were evaluated following arthroscopic ankle synovectomy. Follow-up averaged 33 months (range, 9 to 67 months) and included ankle range of motion, frequency of ankle hemarthroses, radiographic findings, and a functional assessment. The average age at the time of surgery was 12.3 years (range, 6.1 to 21.9 years). The average are of ankle motion was 48.4° (range, 30° to 70°) postoperatively. The functional score as modified from Mazur averaged 36.1 points (range, 17 to 68 points) preoperatively, and 77.9 points (range, 32 to 100 points) postoperatively. Radiographic evidence of ankle arthropathy remained stable for most ankles. Arthoscopic ankle synovectomy for recurrent hemarthrosis due to hemophilia is a viable alternative to open ankle synovectomy for controlling the frequency of ankle bleeds and maintaining ankle function.     

Recurrent hemarthrosis after unicompartmental knee arthroplasty

Recurrent hemarthrosis after knee arthroplasty can be disabling, requiring adequate and immediate diagnosis and treatment for recovery of symptoms and joint function. The most commonly reported cause is impingement of proliferative synovium between prosthetic components. Although various procedures for hemarthrosis have been reported after knee arthroplasty for patients who do not respond to conservative treatment, the recommended first-line therapy is open surgery or embolization. Although hyperplastic synovium was observed during the first and second arthrotomy, in our case, tissue impingement was not detected. We describe a rare case of recurrent hemarthrosis after unicompartmental knee arthroplasty (UKA) and successful treatment by open synovectomy. A 66-year-old woman presented with spontaneous osteonecrosis of the medial femoral condyle in the right leg. She underwent UKA of the right knee of the medial condyle. Eighteen months after UKA, the patient developed recurrent hemarthrosis. Open arthrotomy was performed 22 months after UKA, revealing only hematoma with no obvious hemorrhage or loosening of the prosthesis. No history of trauma or use of anticoagulant medications was present. After a symptom-free period of 8 months, another 2 episodes of hemarthrosis occurred over the course of 8 months. A second open arthrotomy was performed. Hyperplastic synovium with fibrin and hemosiderin pigmentation was observed, again without hemorrhage or loosening. There were no pathological features of pigmented villonodular synovitis. Synovectomy was performed, and no hemarthrosis has recurred for 2 years.     

Arthroscopic synovectomy for chronic hemophilic synovitis of the knee

Synovectomy for chronic hemophilic arthropathy is performed for the main purpose of stopping recurrent hemarthroses. The indications are frequent recurrent bleeds and persistent synovial hypertrophy. Five patients with chronic hemophilic arthropathy of the knee who underwent arthroscopic synovectomy between June 1980 and June 1981 represent the source for this discussion. Two of these patients subsequently developed a stress-induced joint bleed, one persisted in having an effusion but no recurrent bleeds, whereas the other patient developed recurrent bleeds and required a second synovectomy 4 years later. Another patient required a second arthroscopic procedure, with posteromedial synovial resection 10 months after the initial synovectomy not including the posteromedial compartment. He has not had a joint bleed since. The remaining two patients have had no recurrence of joint bleeding or synovial hypertrophy. All patients obtained their preoperative motion. No complications occurred as a result of these synovectomies. Subsequent synovectomies have produced one complication of a severe immediate postoperative hemarthrosis.     

Synovectomy of the knee for hemophilic arthropathy

Synovectomy of the knee for the control of recurrent hemarthrosis was performed in thirteen patients with hemophilic arthropathy. Preoperatively, all patients had experienced an average of three bleeding episodes into the affected joint per month, and had been unresponsive to at least six months of medical management. Radiographically, all knees had either Stage-II or Stage-III hemophilic arthropathy. The average age of the patients at the time of synovectomy was sixteen years and the average length of follow-up was 7.3 years (range, two to eleven years and seven months). Although the motion of the knee remained unchanged postoperatively in two patients, ten patients had an average loss of 41 degrees. One patient eventually required an arthrodesis. Radiographically, there was slight further joint deterioration after synovectomy, and no knee progressed beyond Stage-III hemophilic arthropathy. Only one patient in our series had a recurrent spontaneous hemarthrosis of the synovectomized knee, although two others had traumatic bleeding episodes. The complications included three immediate postoperative hemarthrosis requiring surgical evacuation, isoimmune hemolytic anemia in one patient, patellofemoral adhesions in two knees, and a total fibrous ankylosis that required a knee arthrodesis in one patient. It was concluded from our study that chronic recurrent hemarthrosis and the pain associated with persistent synovitis in the hemophilic knee can be effectively eliminated for as many as twelve years after open synovectomy, although usually with significant loss of motion of the knee. This procedure also appeared to slow the progression of arthropathy, and no patient had been considered for a total knee replacement at the time of writing.     

Rheumatological management of patients with hemophilia. Part 1: joint manifestations

The advent of factor VIII and IX replacement therapy has radically changed the physiognomy of hemophilia. In patients with no inhibitors, early replacement therapy shortens the immobilization and decreases the structural and functional alterations related to recurrent hemarthrosis. Routine prophylactic replacement therapy before or after the first episode of hemarthrosis is still rarely used in France. Recurrent hemarthrosis in the same joint can cause synovitis and chronic arthropathy. Injection synovectomy is now the preferred treatment, as opposed to secondary prophylactic replacement therapy and to arthroscopic or open synovectomy. The palliative treatment of chronic arthropathy is difficult and rests on analgesics and rehabilitation therapy, with orthotic devices and/or surgery where appropriate. The treatment of hemophilia is far more difficult in patients with inhibitors and, consequently, considerable hope is being placed in gene therapy, whose first results are encouraging.     

Editorial Commentary: Arthroscopic Treatment of Glenohumeral Arthritis—Avoiding Heavy Metal!

Arthroscopic treatment of glenohumeral arthritis is an important option in young or active patients in whom arthroplasty is not desired or ideal. Typically, arthroscopic management is a bridging procedure with the goals of decreasing pain, improving function, and delaying the need for shoulder arthroplasty. Many levels of treatment have been described ranging from simple to complex—from joint lavage to glenohumeral ligament release and loose body removal to comprehensive arthroscopic management, which includes glenohumeral chondroplasty, synovectomy, loose body removal, microfracture, capsular release, humeral osteoplasty, axillary nerve neurolysis, subacromial decompression, and biceps tenodesis. Patient selection and education are essential because patients with end-stage arthritis (<2 mm of joint space) and bony deformity of the glenoid or humerus have less favorable long-term survival. We prefer the comprehensive arthroscopic management approach, although more technically difficult, because it attempts to address the greatest amount of pathology. We believe this permits the maximum likelihood of sustained benefit and avoidance of “heavy metal,” with a 60% survival rate at minimum 10-year follow-up.     

Prise en charge rhumatologique de l’hémophilie (première partie : manifestations articulaires)

The advent of factor VIII and IX replacement therapy has radically changed the physiognomy of hemophilia. In patients with no inhibitors, early replacement therapy shortens the immobilization and decreases the structural and functional alterations related to recurrent hemarthrosis. Routine prophylactic replacement therapy before or after the first episode of hemarthrosis is still rarely used in France. Recurrent hemarthrosis in the same joint can cause synovitis and chronic arthropathy. Injection synovectomy is now the preferred treatment, as opposed to secondary prophylactic replacement therapy and to arthroscopic or open synovectomy. The palliative treatment of chronic arthropathy is difficult and rests on analgesics and rehabilitation therapy, with orthotic devices and/or surgery where appropriate. The treatment of hemophilia is far more difficult in patients with inhibitors and, consequently, considerable hope is being placed in gene therapy, whose first results are encouraging.     

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.     

Arthroscopic treatment of pigmented villonodular synovitis of the knee.

Pigmented villonodular synovitis (PVNS) is a rare disease, with multiple forms, anatomic sites, and treatment methods having been described. During a 10-year period, 14 patients, 7 male and 7 female, average age 35 years (range, 19 to 64 years) were treated for PVNS with arthroscopic partial or total synovectomy. Average follow-up was 42 months (range, 8 to 83 months). Twelve patients had diffuse and 2 had a localized form. Results were assessed subjectively, clinically, and radiographically, and were rated as excellent, good, fair, or poor. There were no complications and 10 patients (72%) were rated as excellent or good, 2 patients (14%) as fair, and 2 patients (14%) as poor. The recurrence rate was 14% and occurred in the group with diffuse PVNS. Radiographs did not show any bone erosion. The most widely accepted treatment for PVNS is synovectomy, and both open and arthroscopic synovectomy have been advocated as treatment. Advantages of arthroscopic treatment include accurate evaluation of the knee joint, treatment of other pathology, more rapid rehabilitation, decreased risk of joint stiffness, and less pain. In our experience, it appears that arthroscopic synovectomy is an effective method of treatment of this disorder.     

Surgical options in the treatment of arthritis of the shoulder: alternatives to prosthetic arthroplasty

Reconstructive options for glenohumeral arthritis revolve around the timing and success of hemi-joint arthroplasty and total joint arthroplasty techniques. The purpose of this article is to discuss the alternative treatment options of shoulder arthritis. Specific options include arthroscopic debridement, synovectomy, capsular release, osteotomy, resection arthroplasty, interposition arthroplasty, and arthrodesis. In the early stages of the arthritic process, arthroscopic debridement, synovectomy and capsular release, may delay the onset of more severe symptoms and degenerative changes requiring a prosthetic reconstruction. However, their role as a definitive procedure is limited. The use of resection arthroplasty and arthrodesis represent salvage procedures used when an implant has failed or become infected. However, function will be predictably diminished.     

Orthopedic management of hemophilia

Hemophilia is an X-linked inherited bleeding disorder characterized by a deficiency of clotting factor VIII or IX in the intrinsic pathway of the coagulation cascade. This disease can have a profound, debilitating effect on the musculoskeletal system through recurrent hemarthroses and intermuscular hematomas. Although medical management with replacement factor is often effective, patients with severe hemophilia may develop chronic synovitis and arthropathy best treated with more invasive means. Radioactive synovectomy performed at select hemophilia centers and arthroscopic or open synovectomy are helpful for chronic, active synovitis. Arthroplasty helps improve function and pain relief for most patients, but complication rates, particularly for infection, are higher than those for arthroplasty performed on patients without hemophilia.     

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.     

Extraarticular pigmented villonodular synovitis: a cause for failed knee arthroscopy

Arthroscopic treatment of diffuse pigmented villonodular synovitis of the knee is reported to have low recurrence rates and morbidity. The purpose of the current study was to evaluate demographic information, clinical symptoms, treatment parameters, and functional outcome in a group of 38 consecutive patients referred to the authors' hospital with persistent extraarticular diffuse pigmented villonodular synovitis of the knee after arthroscopic synovectomy. There were 23 males and 15 females with an average age of 31.7 years (range, 11-65 years) at the time of arthroscopy. All had an average of 1.7 (range, 1-5) arthroscopies. Thirty-four of 38 (89.5%) patients had some improvements of their symptoms after arthroscopic synovectomy, but all had worse symptoms and function at the latest followup of 3.63 years (range, 0.25-19.5 years). Although arthroscopic synovectomy offered some short-term relief, a critical review of prior reports and the data in the current study suggest poor outcomes in patients who have extraarticular diffuse pigmented villonodular synovitis of the knee after arthroscopic synovectomy. Magnetic resonance imaging is recommended for accurate staging of the disease and for long-term followup after arthroscopic treatment.