05/02/2023 Dr. Prakhar Chhawchharia 1

ROLE OF ARTHROSCOPIC SYNOVECTOMY OF KNEE JOINT IN PATIENTS WITH

RHEUMATOID ARTHRITIS

-BYDr. Prakhar Chhawchharia

Orthopaedic surgeonFellowship in Arthroscopy

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INTRODUCTION

• INFLAMMATORY SYNOVITIS

• MONOARTICULAR OR POLYARTICULAR

• KNEE SYNOVIUM COMMONLY INVOLVED

• FEMALES :MALE RATIO 3:1

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CLINICAL FEATURES OF KNEE JOINT SYNOVITIS

• PAIN• SWELLING DUE TO EFFUSION• WARMTH• DECREASED ROM DUE TO PAIN, EFFUSION• STIFFNESS

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CLINICAL EXAMINATION

• SWELLING• ERYTHEMA• WARMTH • PATELLA BALLOTING• PATELLA TAP• TENDERNESS OVER SOFT TISSUE

STRUCTURES• ROM- ACTIVE & PASSIVE• VARUS/VALGUS STRESS TEST

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PATHOPHYSIOLOGY

• IMMUNE MEDIATED INFLAMMATORY DISEASEANTIGEN BINDS

WITH MHC

C28 MOLECULE ACTIVATES

T -CELL

PROLIFERATE AND SECRETE IL-2, IFN,TNF,IL-4

B CELLS GET ACTIVATED

SECRETE CYTOKINES, BECOME ANTIGEN

PRESENTING CELL TO T LYMPHOCYTES

PLASMA CELLS

RELEASE RF, anti-CCP,ACPA

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PATHOPHYSIOLOGY OF SYNOVIUM

• INTIMAL LAYER(1-3 CELLS THICK) HYPERTROPHIED-FILLED WITH FIBROBLASTS AND MACROPHAGES

• SUBINTIMAL LAYER- (VASCULAR LAYER) HEAVILY INFILTERATED WITH T & B CELLS, MACROPHAGES, OSTEOCLASTS, ANGIOGENESIS

• THIS IS CALLED PANNUS-HYPERTROPHIED SYNOVIUM

• PANNUS INVADES AND ERODES THE CONTIGOUS CARTILAGE AND BONE

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INVESTIGATIONS/DIAGNOSIS

• HAEMATOLOGY- RA FACTOR, anti-CCP, ANCP, ESR, C-RP

• RADIOLOGY- XRAY, MRI• BIOCHEMISTRY- SYNOVIAL FLUID ANALYSIS• HISTOPATHOLOGY- SYNOVIAL TISSUE BIOPSY

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TREATMENT

• MEDICAL LINE OF MANAGEMENT• NSAID’S• DMARD’S

CONVENTIONAL BIOLOGICS

METHOTREXATE ETARNECEPT

LEFLUNOMIDE INFLIXIMAB

SULFASALAZINE ADALIMUNAB

HYDROXYCHLOROQUINE ABATACEPT

AZATHIOPRINE RITUXIMAB

CYCLOSPORIN ANAKINRA

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TREATMENT• SURGICAL- ARTHROSCOPIC SYNOVECTOMY,

TOTAL KNEE REPLACEMENT• INDICATIONS OF ARTHROSCOPIC SYNOVECTOMY1. ACUTE INFLAMMATION2. CHRONIC INFLAMMATION NOT RESPONDING TO

DMARD’S3. EARLY STAGE OF DISEASE4. NO ADVANCED BONY CHANGES5. TO DELAY TKR IN YOUNG OR WITH OTHER CO-

MORBITIES

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ATHROSCOPIC SYNOVECTOMY• ADVANTAGES1. SIGNIFICANT IMPROVEMENT IN PAIN SCORES2. COMPLETE REMISSION OF DISEASE IN A JOINT3. CAN BE MANAGED WITH SINGLE DMARD4. MORE ACCURATE DIAGNOSIS VIA SYNOVIAL

BIOPSY AND SYNOVIAL FLUID ANALYSIS5. NEAR COMPLETE REMOVAL OF SYNOVIUM

UNDER VISUALISATION6. DIMUNITION OF JOINT STIFFNESS POST SURGERY7. SHORT HOSPITAL STAY

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ARHTROSCOPIC SYNOVECTOMY-MATERIALS AND METHOD

1. STANDARD 5MM SCOPE2. 5.5 MM RESECTOR/SHAVER3. PUNCH BIOPSY FORCEPS4. BITE FORCEPS5. GRASPER

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ARHTROSCOPIC SYNOVECTOMY-MATERIALS AND METHOD

• PORTALS

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ARHTROSCOPIC SYNOVECTOMY-MATERIALS AND METHOD

• SEQUENCE OF PERFORMING A TOTAL SYNOVECTOMY1. INTERCONDYLAR NOTCH,2. POSTEROLATERAL COMPARTMENT, 3. POSTEROMEDIAL COMPARTMENT, 4. MEDIAL COMPARTMENT,5. LATERAL COMPARTMENT, 6. SUPRAPATELLAR COMPARTMENT, 7. RETROPATELLAR COMPARTMENT.8. UNDERSURFACE OF EACH MENISCUS IS CAREFULLY EXAMINED9. ANY POPLITEAL CYST, FOREIGN BODY & PLICA REMOVED10. AFTER RELEASING THE TOURNIQUET, BLEEDERS ARE

CAUTERIZED BY RF ABLATION PROBE,DRAIN KEPT AND COMPRESSION BANDAGE GIVEN

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ATHROSCOPIC SYNOVECTOMY-POST OPERATIVE CARE

• DRAIN REMOVAL AT 24 HRS• STATIC QUADRICEPS AND PASSIVE ROM

STARTED IN IMMEDIATE POST OP PERIOD• PHYSIOTHERAPY REHAB PROTOCOL FOR

QUADRICEPS AND HAMSTRING STRENGTHENING

• ACTIVE ROM EXERCISES• MODALITIES TO DECREASE PAIN, SWELING,

STIFFNESS IN POST OP PERIOD

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