Arthroscopic synovectomy of the knee joint: Indication, technique, and follow-up results
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Arthroscopy: The Journal of Arthroscopic and Related Surgery 4(2):63-71 Published by Raven Press, Ltd. 1988 Arthroscopy Association of North America
Arthroscopic Synovectomy Indication, Technique, and
of the Knee Joint: Follow-up Results
Wilhelm Klein, M.D. and Kai-Uwe Jensen, M.D.
Summary: Between 1981 and 1986, at the Orthopaedic Clinic of the University of DUsseldorf, arthroscopic synovectomy of the knee was performed on 59 joints in 56 patients. The follow-up examination covered 45 knee joints in 43 patients (18 female and 27 male patients). The follow-up results, taken at an average of 2.7 years after the arthroscopic synovectomy, have up to now been good and equal to those achieved using the conventional technique. In this experience, arthroscopic synovectomy is a surgical procedure that places less strain on the patient in the early postoperative healing period. An arthrotomy was no Longer required in the hypertrophic synovial diseases treated during this time. Fibroarthrosis, not uncommon after conventional arthrotomy, did not occur. Only a few stab incisions were necessary to reach all--in particular the posterior--knee-joint cavities. Postoperative pain was markedly reduced from a preoperative level of 16.6 points (47%) (35 maximum points possible, or 100%) to a level of 29.5 points (84%) at follow-up. Patients who experienced an open synovectomy previously in the other knee now favor the arthroscopic procedure. The majority of the patients had a range of motion between 0 and 120 degrees within the first 2 weeks after surgery. Swelling disappeared from a preoperative score of 2.9 points (19%) (15 maximal points possible, or 100%) to 12.2 points (81%). Subjectively, 78% of the patients were satisfied with the result of arthroscopic synovectomy, 7% considered the procedure a partial success, and 15% were dissatisfied. Key Words: Arthroscopic synovectomy-- Knee Joint--Indication--Technique--Follow-up results.
Editor's comments: This is one of the largest series of arthroscopic synovectomy of the knee yet re- ported. With experience and new instrumentation, it has become possible to do a complete synovee- tomy in most cases in a relatively short period of time. The authors' cases averaged slightly less than 1 h. As always, we should keep in mind that the ability to perform an operation is not an indica- tion for doing it, and in this series, about half the cases were rheumatoid arthritis. The jury is still out on whether any form of synovectomy has a benefi-
From the Department of Orthopaedic Surgery, University of Dfisseldorf, Diisseldorf, ER.G.
Address correspondence and reprint requests to Prof. Dr. Wilhelm Klein, Department of Orthopaedic Surgery, An St. Swidbert 17, 4000 Diisseldorf 31, ER.G.
cial and lasting effect on rheumatoid arthritis. The authors of this article should do longer term follow- up studies on the rheumatoid arthritis cases and, if possible, perform second-look arthroscopies.
S y n o v e c t o m y of the knee jo in t p rev ious ly in- volved, in general, a r th ro tomy with a major medial Payr incision or two parapate t lar incisions. In order to reach the poster ior knee joint cavities, it was fre- quently necessary to make a fur ther incision in the popl i t ea l reg ion or in the p o s t e r o m e d i a l c o r n e r (1-3) . This caused the patient considerable pos top- e ra t ive pa in and a r e l a t ive ly long pe r i od o f re- covery, often linked with muscular a t rophy and re- stricted range of motion. F rom a cosmet ic point o f view, major incisions presented a problem. Intraar-
64 W. K L E I N A N D K.-U. J E N S E N
ticular fibroarthrosis was one of the complications that resulted from the arthrotomy. The subsequent development of cicatricial contractions disrupted the biomechanics of the knee joint, especially in the sensitive patella (4). Other, not infrequent, compli- cations resulting from such a long skin incision were perception disorders caused by a lesion of the cutaneous branch of the saphenous nerve and damage to the proprioceptive receptors (5). The previous method of removing synovial membrane by conducting conventional arthrotomy meant too much surgery for the knee joint, especially in the case of localized forms of synovial disorders. For many patients, in particular those suffering from rheumatoid arthritis, the right moment for an oper- ation was missed and the synovectomy performed as a so-called late synovectomy (6).
Arthroscopic synovectomies without arthrotomy offer a solution to this problem. In contrast to the conventional method, it is today possible to per- form total arthroscopic synovectomy of all joint cavities (7-9). Improvements in motorized instru- ments with respect to their rotational speed, diam- eter, and shaving blade point have made total syno- vectomy of all joint sections possible while still protecting the cartilage surface and ligaments (10). Our own histological studies have shown that in this way all layers of the synovial membrane can be removed (Fig. 1) (6,11).
Arthroscopic synovectomies are today still rela-
tively unknown. The first published reports about technical implementation of the motorized removal of synovial membrane without arthrotomy began in 1984 (7,9,10,12,13). Reports on follow-up examina- tions after arthroscopic synovectomy are, as far as we are aware, even rarer in the pertinent literature (14). It was for this reason that we decided to report on our experience with arthroscopic synovectomies with respect to indication, technique, and the initial follow-up results attained after -2 .7 years.
In our experience, arthroscopic synovectomy can be best applied in all hypertrophic synovial dis- orders that partially or totally tampon the joint space. Such hypertrophic forms of synovitis in- clude aggressive rheumatoid arthritis, generalized or localized pigmented villonodular synovitis, and metaplastic disorders like chondromatosis, specific and nonspecific bacterial synovitis, and secondary arthrosynovitis (Figs. 2-4) (13,15,16). Basically, ar- throscopic synovectomy was indicated when con- servative treatment was unsuccessful and damage to the articular cartilage was expected. In the case of rheumatoid arthritis, patients were treated con- servatively for half a year before arthroscopic syn- ovectomy was performed. We believed that in case of nonhypertrophic aggressive rheumatoid arthritis, arthroscopic synovectomy was technically not practicable, because the flat growing synovium was
FIG. 1. Arthroscopic photograph taken immediately after endo- scopic shaving of the synovial membrane: view of subsynovial fibrotic joint capsule.
FIG. 2. Arthroscopic view of hypertrophic synovial villi in rheumatoid arthritis, in the medial compartment of the knee.
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A R T H R O S C O P I C S Y N O V E C T O M Y O F T H E K N E E 65
firmly attached to the fibrous joint capsule and could not be completely eliminated by arthroscopic synovial resectors. Therefore, these cases should be saved for open synovectomy.
We performed our arthroscopic synovectomies under tourniquet control in a bloodless field and general or peridural anaesthesia. A leg holder was used in all cases. The cover used was a waterproof disposable limb sheet.
A 4-mm 30 Storz arthroscope was inserted antero- laterally into the suprapatellar pouch while the knee joint was being stretched. The joint was then filled with Ringer solution under hydrostatic pres- sure from two 5-L plastic bags suspended 1.5 m above the operating table. The inflow came through a 5-ram thick Dyonics cannula via a suprapatellar medial porta into the joint. The operating instru- ments were inserted anteromedially into the joint. While constant irrigation was maintained by control of the inflow and outflow, the joints were either partially or totally synovectomized. An average of 25-30-L irrigation solution was required for each knee joint. For the operation, only motor-driven in- struments were used. In most cases we used the motor-driven Dyonics synovial resector (Figs. 5 and 6). The Aesculap motorized device developed
FIG. 4. Grapelike loose bodies in synovial chondromatosis, in the suprapatellar pouch of the knee.
by us, which has various window openings de- signed especially for arthroscopic synovectomies, was used from 1985 onwards. Without exception, the operations were conducted by the same oper- ating team, so that we can speak of a standard pro- cedure as far as the operating technique is con- cerned.
Overall, we distinguished between six sections, which, as a rule, can be reached from six ap-
tqG. 3. Generalized pigmented villonodular synovitis causing an impingement syndrome, in the medial compartment of the knee. FIG. 5. Arthroscopic aspect of motorized synovectomy Dyonics Resector Type 1.
Arthroscopy, Vol. 4, No. 2, 1988
66 W. KLEIN AND K.-U. JENSEN
FIG. 6. Rosenberg "full radius blade synovial resector" during arthroscopic synovectomy in a patient with rheumatoid arthritis of the knee.
proaches. In 21% of the cases, it was necessary to synovectomize all sections, and in the remaining cases, five or fewer sections needed to be synovec- tomized. This was because synovitis was not equally pronounced in all s6ctions.
In 62% of the cases, the number of surgical ap- p roaches was res t r ic ted to the s tandard ap- proaches: an anterolaterally inserted endoscope, a suprapatellar medial inflow, and anteromedially in- serted operating instruments. Depending on the need and accessibility of the joint lumen, the line of sight of the arthroscope could be varied medially and laterally by replugging or changing to the mo- torized device. For this purpose, so-called switch sticks were used to make it easier to place the guide cannula. To ensure thorough synovectomy of the upper recess, the suction device was inserted in the original inflow portal and the inflow became antero- medial. By way of the modified semicentral access of the endoscope, it was possible in 90% of the cases to obtain a good view for assessment of the posteromedial and lateral sections through the in- tercondylar notch past the cruciate ligaments of the knee. If proliferative synovitis was established in the posterior sections, posteromedial and postero- lateral accesses were made in addition to the stan- dard approaches for the purpose of eliminating dis- eased synovial tissue in the posterior recess.
In 20% of the cases, posteromedial access was
indicated in addition to the usual standard access. In 2% of the cases, additional posterolateral access proved necessary. Additional posteromedial and posterolateral approaches were necessary for 4% of the knee joints. Because of excessive synovitis, su- prapatellar medial and lateral approaches proved necessary in 9% of the cases (Fig. 7). The number of accesses required usually depended on the ex- tent to which the synovial disorder had spread, the elasticity of the articular capsule, and obstacles in the joint, such as broad plicae or cicatricial threads, or on the alar folds of the knee joint stretched like canvas, thereby causing problems when the endo- scope was moved from the medial to the lateral section. As a rule, the semicentral access was suffi- cient in the virtually stretched knee to enable inser- tion of the endoscope cannulas with a blunt man- drin through the fossa into the posterior recess. However, this was not possible if the intercondylar fossa was contracted by osteophytes or a synovial tamponade blocked the fossa. For this reason, it proved impossible in 10% of the cases to view the posterior sections. Upon conclusion of the syno- vectomy, the joint then received a Redon drainage and a sterile compression bandage was applied. The stab incisions were left open.
Postoperative treatment All joints received a drainage for 48 h. A com-
pressive dressing was applied in the operating room. The knee joints were immobilized for 1 day. The second postoperative day, a constant passive motion machine allowing motion between 0 and 60 degrees was applied. Patients were kept n o n - weight-bearing for 4 weeks, after which the entire synovium was resected. An isometric exercise pro- gram was started the first postoperative day.
The average period of hospitalization was 13 days, the prolonged time being due to our inexperi- ence with the new technique and the healing pro- cess of the affected knee joint. Today, the hospital- ization time has been reduced to 3-5 days.
MATERIALS AND METHODS
Between 1980 and 1986 at the Orthopaedic Clinic of the University of Dasseldorf, we performed ar- throscopic synovectomy of the knee in 59 joints of 56 patients. We were able to conduct a follow-up examination of 43 patients, two of whom had un- dergone surgery of both knee joints. There were 18 female and 27 male patients. Degenerative arthritis
Arthroscopy, Vol. 4, No. 2, 1988
ARTHROSCOPIC SYNOVECTOMY OF THE KNEE 67
FIG. 7. Percentage of standard portals to the knee for arthro- scopic synovectomy.
L o t e r o l S u p r o p o t e l l e r 9 ~
P o s t e r o l o t e r o l 2 % ( 4 ~ )
A n t e r o l a t e r a ! ( 6 2 %
( L S ) M e d l a l S u p r e p o t e l l e r 6 2 %
- - P o s t e r o m e d l o l ( P M ) 2 0 % ( 4 % )
A n t e r o m e d l o l ( A M ) 6 2 %
( was not included in this study. The follow-up exam- ination was conducted in our out-patient depart- ment, and the patients were at the same time asked to fill out a questionnaire based on the Lysholm point system (17) that we modified for specific questions on arthritis.
Twenty-five men and 18 women underwent this follow-up examination. The average age at the time of operation was 34 years, the oldest patient being 71 and the youngest 8 years old. The follow-up ex- amination period lasted, on average, 2.7 years, the longest being 5.5 years and the shortest 8 weeks. In addition to the synovectomy, we performed partial meniscectomy in 11% of the cases and cartilage shaving in 16%. The average length of the operation was 55 min.
Of the 45 operated knee joints, 25 were in pa- tients with rheumatoid arthritis (Fig. 2). Four pa- tients suffered from pigmented villonodular syno- vitis (Fig. 3). In two cases, synovitis was attribut- able to a synovia l metaplas ia in the form of chondromatosis (Fig. 4). Four patients suffered from chronic hypertrophic synovitis in conjunction with hemophilic arthropathy, which caused re- peated hemorrhaging into the knee joint. One case involved arthritis of the knee joint accompanied by ankylosing spondylitis. In five patients, chronic nonspecific synovitis had developed. Also included in the study were four patients who had developed so-called "foreign body synovitis" following im-
plantation of the Dacron cruciate ligament pros- thesis (Table 1). This "Abrasion synovit is" was caused by omitted not...