Knee Surg, Sports Traumatol, Arthroscopy (1995) 3:111-112 [Knee Surgery [Sports Traumatology ! Arthroscopy �9 Springer-Verlag 1995

Arthroscopic synovectomy of synovial tuberculosis of the knee joint

T. Motycka, F. Landsiedl

I. Department of the Orthopaedic Hospital Speising, Speisinger Strasse 109, A-1134 Vienna, Austria

Abstract. Synovia l tuberculosis is a rare, but important differential diagnosis of synovial diseases. Three cases of arthroscopic synovec tomy of tubercular monarthri t is af- fecting the knee joint are reported. The Lysholm scoring scale modi f ied by Klein and Kloos was excel lent in two cases, but poor in one. In all three cases there was an ex- cel lent improvemen t in the range o f mot ion compared to the preoperat ive period and no deteriorat ion of the Larsen score in the fo l low-up period (25-56 months postopera- tively). Consider ing these results arthroscopic synovec- tomy can be r e c o m m e n d e d as an al ternative to the open procedure o f synovectomy.

Key words: Arthroscopy - Synovectomy - Tuberculosis - Knee

Introduction

In three out of 117 arthroscopic synovec tomies of the knee the diagnosis was synovial tuberculosis, conf i rmed histopathologically. In all three cases it was cl inical ly rather unspecific, there were no extrasceletal foci present and diagnosis was made by arthroscopic biopsy only. Al- ways a subtotal synovec tomy was per formed by the same surgeon, using four portals, a shaver, general anesthesia and tourniquet. The patients were mobi l i sed immedia te ly by continous passive motion, fo l lowed by intensive phys- iotherapy and mobi l isa t ion with two crutches with initial partial weight bearing. A tuberculostat ic therapy with a combinat ion of isoniazid, myambuto l and r i fampicin was given for a m i n i m u m of six months, cont inuously moni- tored by a pulmologis t and by laboratory tests.

Case reports

Case 1

K.B., a 37-year-old female patient of Indian origin had been living in Austria for several years. Apart from a third degree aortic insuf-

Correspondence to: Dr. T. Motycka, Lerchenfelderstrasse 16/11, A-1080 Vienna, Austria

ficiency which she has had for ten years and which is rheologically ineffective, the anamnesis detected nothing abnormal; four months preoperatively there was massive pain for the first time, as well as an effusion in the left knee. One month preoperatively there was an effusion again, temperature up to 39~ and a good response to a~gmentin. At the time of admission the hyperthermic, extremely swollen knee was fixed in a ROM of 0-20-35 with massive pres- sure pain. The laboratory tests showed an increased blood sedi- mention rate of 88/116, C-reactive protein of 48 mg and an alka- line phosphatase of 240 U/1. Preoperative X-rays showed radio- lucent areas without identifiable foci, the bone scan showed in- creased uptake in the left patella, but also in the left head of the fe- mur, the right head of the humerus, the tenth rib bilaterally, as well as the borders between the cartilage and bone of all ribs. During the operation a lot of opaque fluid evacuated, the internal struc- tures of the knee were intact except a massive synovitis. The his- tological findings showed an active chronic synovitis with tuber- culoid granulomas, in spite of an antibiotics prophylaxis, there was a renewed rise in temperature up to 40~ on the first postoperative day, on the forth day there was a moderate effusion as well as signs of swelling with no raised temperature, the ROM was at 0-0-60, ten days later it already was 0-0-100. Even though there was a clearly subjective improvement after 54 days, the knee was still moderately swollen and hyperthermic again, the ROM being re- duced to 0-5-40. After intensive physiotherapy a ROM of 0-10- 130 was reached 6 months postoperatively, but in all the examina- tions in this period, light effusion and a moderate warming was found, alkaline phosphatase ranged between 300 and 400 U/1. sed- imentation was only slightly increased at that time. At the time of follow-up examination, 25 months postoperatively, passive ROM was 0-5-130, the contours of the knee showed no pathogenic find- ings, but there was massive pain following varus stress as well as a moderate pressure pain over the medial joint space. The patient is evidently restricted in her everyday activities.

Case 2

R.S., a 43-year-old male patient, had been working sometimes in the Middle East six years ago and also remembered lung diseases in his fellow workers. For one year he presented with moderate pain in his left knee joint, in case of higher physical strain he felt diffuse pain, with swelling and recurrent effusions. Preoperatively there was a distinct effusion, ROM of 0-10-100, increased BSR (30/56) and a positive CRP, all other laboratory findings showed no pathologies. During the operation there was evidence of a mas- sive formation of synovial villi, a yellowish softened cartilage, but no other pathologies in the knee. The histological findings showed a chronic synovitis with tuberculoid granulomas without caseous degeneration. 15 days later ROM reached 0-10-95, with moderate swelling, after three months ROM was almost unrestricted at 0-0- 140, at the time of the follow-up examination, 56 months postop-

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eratively, ROM was at 0-0-155, the knee looked absolutely nor- mal, and there was an unlimited walking range with full weight bearing.

Case 3

K.K. is a Turkish girl aged 11 1/2 years. For two years she had been suffering from medially localised pain in her right knee joint, with recurrent effusions and distinct morning stiffness. Preopera- tively there was a massive limp on the right side, ROM at 0-20-90 with pain in maximum flexion, BSR was at 95/170, radiograms showed a medial narrowing of the joint space without any other pathological findings. Intraoperatively, there was no significant ef- fusion, but a massive synovitis with fibrinous clots and yellowish- tainted cartilage surfaces. The medial compartment showed the blunt remnant of the meniscal base only, which was completely overgrown by synovial tissue, as well as a second to third degree chondromalacia as graded by the Outerbridge score, particulary in the medial femoral condyle. The histological findings showed a tu- berculous synovitis with close penetration of the synovia by partly confluent epithelial cell granulomas, partly with incipient caseous degeneration. After 22 days ROM was already 0-15-100, BSR had decreased to 53/90, after 3 1/2 months it stood at merely 15/36. At the time of the follow-up, 56 months postoperatively, ROM was at 0-0-120 with no restriction in everyday activities or sports.

Discuss ion

A m o n g the synovia l d iseases tuberculosis [2, 4] is very rare, but in the last few years there has been an increas ing number o f cases again. This differential d iagnosis [11] should always be kept in mind due to the mayor therapeutic consequences .

The fo l low-up examina t ion is made on the basis of the Lysho lm-Score [9] in the modi f ica t ion o f Kle in and Kloos: in cases 2 and 3 an excel lent result was achieved with 96 and 100 points, also subject ively the patients were ful ly satisfied. In case 1, however , a bad result was achieved with 55 out of 100 poss ib le points. In this case the long last ing increase in alkal ine phosphatase and the posi t ive bone sc int igraphy point to an osseous par t ic ipa- tion. It is also the only case with more than one focus. In all cases rad io logica l examinat ions revea led no deter iora- t ion of the Larson score [8] in the fo l low-up period, in two cases the score remained in stage I, in case 2 it r emained in stage 0. The cl inical examina t ion of R O M showed an excel lent improvemen t compared to the preopera t ive pe- riod, but the case with poor results was achieved with a residual extens ion defici t of 5 ~ , and no act ive f lexion over 90 ~ was carr ied out. In the l i terature of convent ional syn- ovec tomies [1, 5, 10, 13] s ignif icant ly worse results have been repor ted in a lmost every case of osseous par t ic ipa- tion, par t iculary as far as R O M is concerned. In untreated or insuff ic ient ly treated cases there is a s ignif icant ly h igher incidence of dest ruct ion of the joints or ankylosis .

Even though no genera l conclus ions can be drawn on the basis of the small number of cases presented, the indi- v idual results still cor respond with the previous f indings for the open opera t ive procedure.

The eff ic iency o f ar throscopic synovec tomy [3, 6, 7] is nei ther documented in genera l by prospec t ive studies nor are there any compara t ive studies avai lable because of the very smal l number o f cases for this special type of dis- ease, but in the long run all previous studies show equal ly good results for convent ional and ar throscopic procedures [12]. The benefi ts of ar throscopic procedure are less trau- mat isat ion, the super ior i ty in the ear ly pos topera t ive pe- r iod and therefore a shorter hospi ta l stay.

Cons ider ing these benefi ts in a per iod of increasing ar throscopic surgery in general , the ar throscopic synovec- tomy of the tuberculous monarthr i t is can be recom- mended as an al ternat ive to the open procedure.

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