arthroscopic synovectomy in hemophilic arthropathy of the knee

Scand J Haematol - Suppl40, Vol33, 1984,263-270

Arthroscopic Synovectomy in Hemophilic Arthropathy of the Knee

J. D. WIEDEL

Department of Orthopedics University of Colorado, School of Medicine, Denver, Colorado

Five patients with chronic hemophilic arthropathy of the knee underwent arthroscopic synovectomies between June of 1980 and June of 1981. Four of the five patients have had no spontaneous bleeds and have had no recurrence of synovial hypertrophy. Two of these patients did have a trauma-induced bleed. One patient, who did not have a posteromedial synovectomy, had a persistent posteromedial synovial hypertrophy which was the site of recurrent bleeds, requiring a repeat synovectomy. All patients obtained their preoperative range-of-motion, and only two patients required manipulation. No complications occurred as a result of these arthroscopic synovectomies. From this preliminary report, arthroscopic synovectomy in the hemophilic knee proved to be a safe and effective procedure.

Key words: Arthroscopy, Hemarthrosis, Joint motion, Recurrent bleeds Synovectomy, Synovial hypertrophy

Correspondence to: Jerome D. Wiedel, M.D., Associate Professor, 4200 East Ninth Avenue, Denver, Colorado 80262, USA

Synovectomy for chronic hemophilic synovitis is performed for the main pur- pose of stopping recurrent hemarthroses. The indications being those of frequent recurrent bleeds and synovial hypertrophy, which persist in spite of adequate factor replacement therapy.

Traditionally, synovectomy of the knee is performed through medial and lateral parapatellar arthrotomy incisions. However, without posteromedial and posterolateral arthrotomies, only a limit- ed (subtotal) synovectomy is accomplished. Such an extensive surgical approach causes considerable postoperative pain and significantly interferes with the patient’s attempt at regaining muscle control and performing range-of-motion exercises. This, no doubt, contributes to the loss of motion frequently observed

after synovectomy. Although Storti and co-workers (1969) reported improved joint mobility in all their patients following knee synovectomy, other authors report a loss of motion in many patients (Arnold & Hilgartner 1977, Clark 1978, McCollough et a1 1979, Pietrogrande et a1 1972, Greer 1980). Even Storti & Ascari (1975) in a later publication, reported that knee mobility remained unchanged in 33 percent of his patients and even worsened in 12 percent. Other complications reported have been wound heal- ing problems, infection, and fractures as- sociated with manipulation (Clark 1978).

These difficulties encountered following open synovectomy led to the consi- deration of alternatives. Because of the known low morbidity following arthroscopic surgery, manifested mainly in the

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minimal pain and early return of knee motion, synovectomy by arthroscopic means was attempted in the hopes of significantly reducing these recognized complications.

This paper reports on five patients with hemophilia who have had arthroscopic synovectomies performed on the knee between June of 1980 and June of 1981.

Four patients had classic hemophilia (F VIII deficiency) and one had F IX deficiency. The patients with F VIII deficiency all had less than 1 percent levels and the patient with F IX deficiency had a level of 1 percent.

The stage of knee joint involvement was classified radiographically as Stage 2 in one patient, Stage 3 in two patients, and Stage 4 in two patients.

All patients had symptoms of frequent hemarthrosis with persistent knee joint swelling. In addition, the patients with Stage 4 disease had symptoms of pain with activity.

Examination of the knees demon- strated marked synovial hypertrophy and effusion in the patients with Stage 2 and 3 disease (Figure 1) while the two patients with Stage 4 disease showed a moderate synovial hypertrophy plus crepitance with joint motion.

The range-of-motion was reduced slightly, particularly in flexion, in Stage 3 and Stage 4 (Table 1).

TABLE 1 .

Pat. Age Factor Joint Range of Motion Deficiency Stage Extension Flexion

1 , 13 VIII &l%) I1 O0 150'

3. 1 5 VlII (<l%) 111 Oo 125' 4. 18 VIII (<l%) IV 5' 115'

2 . 13 VIII (51%) 111 oo 125O

5 . 36 IX ( 1%) IV 5 0 l l o o

Figure 1 . Marked synovial hypertrophy and effusion of left knee in a 13-year-old male with Stage 2 hemophilic arthropathy.

All of the patients had a preoperative evaluation in the comprehensive hemophilia clinic, at which time a factor level and an inhibitor study was performed. The presence of an inhibitor was considered a contraindication to surgery.

Throughout hospitalization, the hema- tology and orthopaedic services jointly cared for the patients. One hour before surgery the patient received the appro- priate factor replacement in the amount to produce a 100 percent plasma factor level. This was repeated in 12 hours. The dose was then reduced to half and repeated every 12 hours for approximately 7-10 days, and then the frequency was decreased to a daily dose. The length of time that a scheduled dose of factor replacement was given depended upon the individual case, with special considera- tion given to the intensity of the physical therapy and the status of the knee. Every other day, factor replacement was given for 2-3 weeks if physical therapy was prolonged. Usually, by 3-4 weeks, fac-

ARTHROSCOPIC SYNOVECTOMY 265

tor replacement was given only on a need basis.

The surgical procedure required a standard arthroscopic surgery setup. A tourniquet was used but generally not inflated until after the diagnostic examination was completed.

To assure adequate distention of the joint and good fluid flow, two 3-liter bags of sterile saline, located at least one meter above the level of the knee, were attached to a large inflow cannula at least 4 mm in diameter via Y-tubing (TUR tubing).

For viewing, a 30 degree and 70 degree arthroscope with a video system was used. It was necessary to use a high intensity light source when using the video to assure good visualization.

Examination of the joint was accomplished through an inferolateral portal, using a 30 degree arthroscope. Once this was accomplished, the tourniquet was inflated and the synovectomy begun, using motorized instruments. Four anterior in- sertion sites were routinely used: the standard inferomedial and inferolateral sites plus medial and lateral suprapatellar sites. Three of these sites were used si- multaneously: one for the inflow cannula, one for the arthroscope, and one for the shaver.

In addition to these four anterior portals, a posteromedial approach was used to remove synovium from the posteromedial compartment. Either two portals were used, one for the arthroscope and the other for the shaver, or if the 70 degree arthroscope could be inserted through the intercondylar notch to observe the posterior compartments, then a single posterior portal was used for inser- tion of the synovial resector. Occasional-

ly, a posterolateral portal was used if satisfactory removal of synovium was not accomplished through the anterior inferolateral portal.

Various types of cartilage and meniscal shavers were used to most effectively remove synovium. Shavers with the larg- est windows and variable speed control, including the 5.5 mm synovial resector, performed best on large surfaces, whereas, smaller meniscal cutters worked better in small spaces like the notch and posterior compartments and along bony margins, such as erosions, osteophytes, and adjacent to the articular surfaces.

The synovium most accessible was removed first. This was usually the suprapatellar pouch and the medial and lateral recesses. Synovectomy in the posterior compartments was performed next. A problem of bleeding was frequently encountered after removal of synovium from the fat pad area, making visualization more difficult when attempting synovectomy in the posterior compartments. Therefore, complete excision of the synovium from the infrapatellar fat pad and anterior intercondylar notch area was generally performed last.

The procedure requires meticulous technique, patience, and time. Initially, between 2 and 3 hours were required to accomplish these synovectomies. If the tourniquet was deflated before comple- tion, which was done any time the procedure extended past 90 minutes, the joint was easily cleared once the tourniquet was reinflated and continuous irri- gation reestablished. A decrease in the total operating time was possible once larger and more aggressive synovial re- sectors became available.

Once the procedure was completed,

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two one-eighth inch drainage tubes were inserted through the inferior medial and lateral portals by means of a sharp trocar, then passed superiorly into the suprapatellar pouch and out through the skin and attached to a suction system.

The incisions were closed with either subcuticular absorbable suture or a steri- strip tape. A sterile dressing was then ap- plied, followed by a long leg compression dressing with medial and lateral plaster splints holding the knee in extension.

Postoperatively, within the first 24 hours, the patient started physical therapy, consisting of isometrics and leg lifts. Range-of-motion exercises began when the compression dressing was removed, which was 48-72 hours postoperatively and 24 hours after removal of the drains. The drains were removed in 24-48 hours, depending upon the amount of drainage, but never left in place more than 48 hours. Whirlpool baths were in- stituted to assist in range-of-motion exercises after 72 hours or when all incisions were dry.

RESULTS

The hospitalization time averaged 17 days, ranging from 5-30 days.

Two of the five patients required manipulation; one, with Stage 3 , at 14 days, and the other, with Stage 4, at 27 days. Manipulation was considered if the patient was not showing a progressive in- crease in range-of-motion and had not passed 60 to 70 degrees by 14 days.

All patients in followup regained com- pletely their preoperative range-of-motion.

Figure 2. Same patient as Figure 1 , 24 months post arthroscopic synovectomy, demonstrating absence of synovial hypertrophy and effusion.

All five patients have had a decrease in swelling without evidence of synovial hypertrophy (Figure 2). An effusion per- sists in the two patients with Stage 3 disease.

No spontaneous bleeds or recurrent bleeds have been noted in four patients; however, two patients have reported trauma induced hemarthroses.

One of the patients with a persistent effusion did not have a posteromedial compartment synovectomy because of a mechanical breakdown with the shaver. Postoperatively, palpable synovial thickening persisted in the posteromedial compartment. This patient had documented recurrent bleeds, which he was able to identify quite clearly as beginning in the posteromedial compartment. Because of the continued recurrent bleeds, averaging one per week, a second arthroscopic procedure was performed 10 months after the initial procedure. During the second procedure, the remaining posteromedial synovium was removed.

ARTHROSCOPIC SYNOVECTOMY 26 7

Figure 3. Histologic section of synovial lining from site of previous synovectomy, demonstrating scattered single synovial cells overlying loose connective tissue.

Figure

268 WIEDEL

This second procedure also allowed me to directly observe the synovial lining from the previous synovectomy. There was not evidence of hypertrophic pig- mented synovial tissue. The lining of the joint appeared white and glistening; however, there were numerous large vessels appearing on the surface. In some areas there were noted small hemorrhages from these vessels.

A biopsy was taken of the surface membrane in the suprapatellar pouch where the previous synovectomy had been accomplished.

A thin synovial layer with underlaying loose connective tissue appeared in most places (Figure 3). Scattered throughout the biopsy area were very small areas of synovial proliferation but no villous formation (Figure 4).

Presently, this patient is not reporting any recurrent bleeding into this joint.

Other than this problem, no complications occurred as a result of the arthroscopic synovectomies.

DISCUSSIONS

The main objectives of synovectomy for chronic hemophilic arthropathy are to stop recurrent hemarthroses and, hope- fully, prevent further destruction of articular cartilage. To accomplish this, synovectomy should be done before advanced joint changes have occurred.

Most authors agree that the results are better when the synovectomy is performed early, before radiographic evidence of cartilage involvement (Arnold & Hilgartner 1977, Dyszy-Laube et a1 1974, Pietrogrande et a1 1972, Post & Telfer 1978). These results are based upon the number of postoperative bleeds and joint

mobility. The followup of our patients is still

too short to determine if synovectomy will, indeed, prevent further cartilage destruction.

Although radiographic changes have traditionally been used to stage the disease process, actual articular cartilage involvement is impossible to determine unless directly observed. In fact, in this group of patients, joints which are classified radiographically as Stage 2 and 3 had more advanced articular cartilage changes when directly observed than what the classification indicates.

In this series of patients, one had Stage 2 and two had Stage 3 involvement of their knees. Stage 3 is usually considered the latest stage at which arthropathy is still reversible with treatment. Two patients had Stage 4 involvement of the knee. Both of these patients complained of discomfort with activity, probably related to the advanced nature of their disease process and secondary degenerative arthritic condition. In addition, these patients had documented recurrent bleeds with palpable synovial thickening. Both patients felt the recurrent bleeds inter- fered enough with their activity that they were willing to undergo synovectomy, knowing the risks of possible loss of joint mobility.

These two patients were also highly motivated individuals, which aided in making the decision to perform the synovectomy. This aspect of the patient’s pscyhological makeup is an extremely important preoperative evaluation. With- out a doubt, the best results are seen in patients who are cooperative, motivated, and who are tolerant to pain.

Lower morbidity with the arthroscopic

ARTHROSCOPIC SYNOVECTOMY 269

method also influenced my decision to attempt synovectomy in joints with Stage 4 involvement. From the results, to date, it appears that the arthroscopic method may, indeed, have less morbidity in these patients.

The average hospitalization of 17 days is a significant decrease, compared to reported open synovectomies. This com- pares to an average of 30 days hospitalization for the open synovectomies performed at our institution.

The return to full preoperative range- of-motion is also an improvement over the frequently reported loss of motion. These patients who had the arthroscopic synovectomies were able to initiate straight leg lifts and perform isometric quadriceps exercises in the first 24 hours. Range-of-motion exercises, beginning as early as 72 hours, were also more effectively performed than what I have observed with the conventional open synovectomies. The fact that only two of the five patients required manipulation would also indicate a relatively easier postoperative course. Of these two patients requiring manipulation, one had Stage 3 and one had Stage 4 involvement.

No recurrent bleeds reported by four of the five patients would suggest that this procedure was successful in ade- quately removing the synovium and ac- complishing the main objective of synovectomy. The decrease in swelling and the absence of detectable synovial hypertrophy in followup would also indicate that the technique has been successful in removing the synovium.

The one patient with continued posteromedial synovial hypertrophy with recurrent bleeds occurring at the site re- sulted because of a failure to remove the

posteromedial compartment synovium. This, as mentioned previously, was due to a mechanical breakdown of the shaver. I elected not to complete the synovectomy by an arthrotomy but, rather, wait and observe, hoping that the remaining synovium would not cause problems. Be- cause of the continued recurrent bleeds, averaging one per week, a second arthroscopic procedure was performed 10 months after the initial procedure. This provided the opportunity to observe the previously operated sites. The absence of synovial hypertrophy throughout the area where synovectomy was performed further demonstrates the effectiveness of arthroscopic synovectomy. The presence of increased number and size of synovial blood vessels observed may be the result of the recurrent hemarthroses occurring from remaining posteromedial synovium, or it may represent the beginning of early recurrent hemarthrosis, which will lead to chronic synovial hypertrophy.

The other patient who had a persistent effusion but no recurrence of bleeds slipped on some ice eight months postop, sustaining a severe twisting injury to the operated knee, resulting in a severe hemarthrosis. He recovered from this injury within three weeks. Although he continues to have a persistent effusion, he does not report any recurrent hemorrhages in this knee.

A second patient reported an acute bleed secondary to twisting his knee while bowling. He, too, has a mild persistent effusion but no recurrent bleeding.

This report, with a relatively short followup period, must be considered preliminary and demands continued observa- tion. The results, to date, however, are encouraging. Whether or not the con-

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tinued absence of recurrent bleeds and no recurrence of synovial hypertrophy will compare with those of the reported open synovectomies remains to be seen.

REFERENCES

Arnold W & Hilgartner M (1977) Hemophilic arthropathy: Current concepts of pathogenesis and management. J B o n e Joint Surg 59A, 287- 305.

Clark M (1978) Knee synovectomy in hemophilia. Orthopedics 1, 285-290.

Dyszy-Laube B, Kaminski W, Gizycka I, Kaminska D, Sekowska-Zmuda J & Ludert, E (1 974) Synovec- tomy in the treatment of hemophilic arthropathy. J P e d i a t S u r g 9 , 123-125.

Greer R, I11 (1980) Operative Management of hemophilic arthropathy - An overview. Orthopedics 3, 135- 138.

McCollough N, 111, Enis J , Lovitt J , Chun-Yet Lian E Niemann K & Loughlin E, Jr (1979) Synovectomy or total replacement of the knee in hemophilia. J Bone Jo in t Surg 61A, 69-75.

Pietrogrande V, Dioguardi N & Mannucci P (1972) Short-term evaluation of synovectomy in haerno- philia.BritMed J 2 , 378-381.

Post M & Telfer M (1975) Surgery in hemophilic patients. J B o n e Jo in t Surg S I A , 1136-1145.

Storti E & Ascari E (1975) Surgical and chemical synovectomy. Ann N Y Acad Sci 240, 316-327.

Storti E, Traldi A, Tosatti E & Davoli P (1969) Syno- vectomy - A new approach t o haemophilic arthropathy. Acta Haemat 41, 193-205.

arthroscopic synovectomy in hemophilic arthropathy of the knee

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