Synovectomy in Rheumatoid Arthritis: A General Review and an Eight-Year Follow-up of Synovectomy in 50 Rheumatoid Knee Joints

Ian F. Goldie

A T THE BEGINNING of this century, the care of the rheumatoid patient was the concern of the orthopedist. With time, however, as the natural

development of rheumatoid arthritis gave it recognition as a general disease

involving the whole connective-tissue system, internists more and more took

over and orthopedic surgeons tended to neglect what had once been one of their

main interests. The past decade has witnessed a growing awareness on the part

of orthopedic surgeons of the challenge that the treatment of rheumatoid

arthritis evokes. Rheumatoid arthritis, a term introduced by the Englishman Garrod in the

mid 18OOs, describes a chronic inflammatory condition not limited to the joint system but involving all mesenchymal tissues. The term mesenchymatosis has

been a working concept in some research centers.22S85*86,‘53 During recent years it has become more practical from the clinical aspect to use the term rheumatoid disease, thus indicating the general involvement of articular structures, peri-

articular and paraarticular tissues, tendons, tendon sheaths, muscles, fasciae, and subcutaneous fat. The rheumatoid cripple, whose fate is a slow destruction of his locomotor system, has once again assumed an important place in ortho-

pedic practice. There is a challenge to intervene at the earliest possible oppor- tunity to stop or slow down the processes that create deformities and impair function. The crucial problem is when and where to intervene. Ideally, surgical

procedures should be carried out before deformities have appeared, thus avoid- ing cumbersome skeletal interventions. This calls for an active and energetic

approach in the early stages of the disease when the soft-tissue involvement is predominant and before cartilage and bone structures have become destroyed. Evidence is accumulating28~50~60~99*‘49~‘53 that the removal of inflamed soft tissues

has a protective effect on the articular structures. The synovial tissue, which is the innermost layer of the joint capsule, readily

becomes a target organ for the initiating agent in rheumatoid disease, and the

inflammatory response calls for active therapeutic measures of which synovec- tomy has proved to be one of the most advantageous.28*‘49 Synovectomy can be

a successful procedure if it is performed at the right time, on the right patient, and for the right indications, 5o but before a nonprejudiced evaluation of the use of synovectomy in rheumatoid disease can be carried out, the following ques- tions should be considered and answered:

From the Department of Orthopedic Surgery II. University of Giiteborg. Gateborg, Sweden.

Ian F. Goldie, M.D.: Associate Professor, Department of Orthopedic Surgery II, University of

Giiteborg. Gijteborg. Sweden.

This article is dedicated to the Danish orthopedic surgeon Knud Jansen on the occasion of hi.<

60th birthday, September 26, 1973.

ZI 1974 bv Grune & Stratton, fnc.

Seminars in Arthritis and Rheumofism, Vol. 3, No. 3 (Spring), 1974 219

220 IAN F. GOLDIE

1. Why should synovectomies be performed? 2. What is the biologic rationale behind synovectomy?

3. When in the course of the disease is the time of choice for synovectomy? 4. What method-chemical or surgical-is preferable? 5. What are the long-term results?

6. What are the indications and contraindications? An attempt will be made in the course of this presentation to answer the above questions.

SYNOVECTOMY-SOME HISTORICAL ASPECTS

The reason for synovectomy in earlier days was arthritis, the origin of which

could be tuberculous, septic, chronic degenerative, or rheumatoid. With time, the procedure became more limited to rheumatoid cases only, as results in other

conditions were unsatisfactory. Recently the pendulum has swung back to the attitude of earlier times, and in Japan, especially, synovectomy has become a routine procedure for articular ailments of various kinds.82,“8

The first known synovectomies in the knee for rheumatoid arthritis were per- formed in 1887 by Schiiller,‘39 who described four cases in which complete synovectomy had been carried out. His conclusion was that hypertrophic syno- vitis was better treated surgically than by a conventional conservative regime. Volkmann’57 removed synovial tissue from a tuberculous knee joint in 1877 and

is claimed to be the first ever to have performed this procedure. In 1889 W. MtiIler”9 of Giittingen did a synovectomy in a rheumatoid knee and in 1894

reported the clinical result and pathomorphologic observations. Chronic arthri- tis following penetrating wounds in two knees was the reason for synovectomy

as reported by Albertin’ in 1896. The surgical removal of synovium as described by these authors was not as

complete as what is meant by synovectomy in modern times. It was Mignon”’ who in a report to a meeting of the Surgical Society of Paris in 1900 intro- duced the operation as it is performed today. He described a patient with chronic arthritis following trauma being operated on in the right knee through two longitudinal incisions with excision of the superior pouch and all accessible

synovium. The postoperative course was complicated by exostotic bone forma-

tion on the lateral femoral condyle, thus necessitating a second operation; 6 mo after the first operation the patient could walk without discomfort and flex his knee to 70 degrees, but he had quadriceps atrophy with 2 cm less in the circumference of the right thigh.

Goldthwait,59 Tuby,“’ and Murphy ‘I7 limited their synovectomies to excision of synovial fringes that were believed to exert a mechanical impairment on the joint function. It was not until Swett’48 in 1923 and in the following years gave the method a good reputation that it became a widely used procedure (see Geens”). The disadvantages accompanying its popularization soon became ap- parent as the indications grew wider and consequently the results were so variable that by the 1940s synovectomy had come into great disrepute.

A period of low surgical activity lasted for some 20 yr, but in the mid-1960s a more optimistic and enthusiastic approach was noted among orthopedic surgeons all over the world. Short-term reports of good results following syno-

SYNOVECTOMY 221

vectomy for rheumatoid arthritis appeared (see Geens”), and during the past 2

yr long-term results that are encouraging are appearing.49,6’9’00

SYNOVIAL MICROANATOMY

Before answering the questions raised earlier, it appears necessary to analyze the structure and function of synovial tissues both under normal conditions and in rheumatoid arthritis. A diarthrodial joint is encapsulated by two layers

of tissue, one of which is more fibrous and constitutes the outer layer. The inner layer is the synovial tissue, which is a separate structure built up by cells of different types and which contains an independent vascular network. Macro- scopically, the synovial tissue much resembles a glossy membrane studded with

folds and villi that vary in form and size. In scanning electron microscopy, the normal synovial surface is slightly fur-

rowed (Fig. 1) and demonstrates only an occasional villus or folding. Numerous

surface pores approximately 10,000 A (1 P) in diameter can be observed, and they are probably openings to intercellular channels. Synovial fluid deposits are often seen on the surface.‘32 The synovial tissue is both areolar and fibrous (Fig. 2). The cells of synovial tissue (synoviocytes) were originally fibroblasts that have since become differentiated. There are two types: Type A has phago- cytic properties and contains filopodia, Golgi’s complex, fibrils, and vacuoles (Fig. 3); Type B has secretory properties (elaborates hyaluronic acid protein complex) and contains vacuoles, mitochondria, and ergastoplasm (Fig. 3). The vascular supply of the synovial tissue is characterized by a network of capil- laries having a coil-like appearance reminiscent of glomerular vessels (Fig. 4).

Fig. 1. Surface of normal synovial membrane x 1250; furrowed articular surface (Redler and Zimmy’32).

IAN F. GOLDIE

Fig. 2. Synovial tissue from rheumatoid knee joint: above, areolar type; below, fibrous; H an stain; x 200.

id E

Fig. 3. Synoviocytes of different types, x 7600; A cell: filopodia, Golgi’s complex, Abrils, and vacuoles; B cell: vacuoles, mito- chondria, and ergastoplasm (garland, Novikoff, Hammerman, 1962).

Fig. 4. Glomerular-like vascular arrangement in synovial villus in normal synovial membrane (the same appearance is also seen in osteoarthritis); freeze-fixation and clearing; x60.

224 IAN F. GOLDIE

Fig. 5. Sectional magnification of region of hypervarcularity in bone-cartilage zone where synovial tissue is attached; AC = articular cartilage, gM = bone marrow, SA = synovial attach- ment with connecting vessels; x36.

Via intraosseous channels in the bone-cartilage region there is an intimate con-

nection between the vascular system of the bone marrow and the vessels of the synovial tissue (Fig. 5); there is thus a direct connection between the bone mar- row and the joint cavity.

SYNOVIAL ANATOMY IN RHEUMATOID ARTHRITIS

“There is no lesion which is absolutely pathognomonic for rheumatoid

arthritis.“3’ The lesions in synovium are believed to occur by the interaction of the minute vessels with dilated venules or fibrinoid necrosis in the vascular

walls, or both. 85~‘2g*144 Because of the insidious onset of the disease and its pre- dilection for beginning in small joints, only scant information is available about

morphologic changes in the earliest phases. Hench63 demonstrated in 1944 the presence of coagulated material in the

joint cavity and neutrophilic infiltration of the synovium in a case of only 24 hr duration. Kulka et al.*4 found in lesions of 7 days duration generalized pro- liferative synovitis, intimal hyperplasia, focal and juxtavascular cell infiltra- tions, numerous lymphocytes, plasma cells, and lymphocytic nodules. Cruick- shank35 found major histopathologic variations between normal and adjacent areas from the same region. Similar observations without special correlation to the duration of the disease have previously been made.3’7’81,‘33,‘37,‘~~‘46

In rheumatoid arthritis, villi are often present as broad-based edematous synovial projections the tips of which become ischemic and appear as a jellylike cap on the villus (Fig. 6). “,‘* In 1954 Cruickshank36 found at autopsy signs of

SYNOVECTOMY 225

Fig. 6. Villi of vary- ing size and form from synovial tissue in rheu- matoid arthritis; note

the gelatinous appear- ance of villur to the left; natural size.

active or healed arteritis in 252; of cases with rheumatoid arthritis. This figure might be higher, as the localization of vascular changes is most irregular.”

Virtamals6 found in arteriographic studies in the digital arteries of the hand

local obliterations of the arterial trunks, especially in the vicinity of the affected

joint spaces, as well as local poststenotic shuttle-like dilations of the arteries and hypervascularization and dilation of the arterioles close to erosions of bone. SokolofF has described an arteritis principally affecting small segments

of terminal arteries 35 to 40 p in diameter. The lesions are chronic and they lack distinctive histologic characteristics.

Kulka85 believes that the injurious process involves the venular and capillary systems. He ascertained that the lesions in the synovial tissue are a consequence of deranged blood-tissue interchange. This is due to a focal capillary-venular

dilation with abnormal leakage. Areas of fibrinoid necrosis can be seen in the vessel wall. Progressive microcirculatory impairment maintains the lesions of the connective tissue.

Using vital microscopic methods, Branemark et a1.20 found typical changes in capillaries and venules such as dilation, varying caliber, and slow, almost stag- nated corpuscular flows. There appeared a correlation between capillary lesions and the patchy distribution of the connective-tissue changes.

In an electron microscopic study, Hirohata and Kobayashi6’ found an in- crease in height of vascular endothelial cells, cytoplasmic processes into the vascular lumen causing obstruction, and widening of intercellular space and thickening of the basement membrane. In another study with electron micro- scopy, these findings could not be verified. *’ The ultrastructural pattern of vessels in normal synovial tissue did not deviate from that in rheumatoid disease.

226 IAN F. GOLDIE

The microvascular system thus no doubt becomes involved, but as yet it is uncertain to what extent the vascular network is engaged. In one investigation58 it was found that in rheumatoid arthritis two types of synovial tissue were en- countered, one being hypertrophic and the other hypotrophic.

Hypertrophic. Clinically these joints as a rule exhibited capsular swelling and hydrops. The synovial tissue was congested and had a glossy surface covered by what was established at microscopy as a fibrin layer (Fig. 7). Hyper- vascularization was common, and pannus formation, i.e., granulation tissue flattened out over the articular cartilage, was frequently seen.

Microscopically, there were strong indications of the synovial tissue being edematous, though this is difficult to confirm in histologic sections due to the technical procedures specimens are subjected to. There was a heavy infiltration of inflammatory cells, predominantly lymphocytes that either occurred irregu- larly scattered or assembled like infiltrates almost resembling nodules. The lymphocytes were often assembled around vessels that were of either arteriolar or venular origin (Figs. 8 and 9). Plasma cells were common, but neutrophils scant. The surface was often covered by fibrin. Small scattered areas of fibrinoid necrosis were seen, and iron pigmentation was common. In some samples, tufts of granulation tissue invaded the osseous structures, creating the cavity called “snail” by Moberg et al. i13 (Fig. 10). The synovium was highly vascularized, with a predominance of venules that were dilated and congested.

Hypotrophic. The hypotrophic variety occurred in those joints that in clin- ical language are often called dry joints. The synovial tissue appeared as a white, almost leathery, membrane without edema or any richness of vessels. No

Fig. 7. Rheumatoid arthritis in right knee joint opened from the medial aspect; erosions in cartilage-bone barrier with osteophytes; edematous synovium with small broad-based villi to the left.

SYNOVECTOMY 227

Fig. 8. Synovial tissue from rheumatoid knee joint; nodular infiltrates of plasma cells lymphocytes; some thin-walled vessels are seen; H and E stain; x200.

and

Fig. 9. infiltration of lymphocytes and round cells about arterioles, but especially venules, which are thin-walled and dilated; synovium from rheumatoid knee joint; H and E stain; x250.

228 IAN F. GOLDIE

Fig. 10. Invasion of granulation tuft into bone in rheumatoid arthritis; H and E stain; x200.

proper villi occurred-only small elevations. Granulation tissue was absent.

Microscopically, the cellular infiltration resembled that of the hypertrophic variety, though it was much more sparse. The predominant feature was hyalino-

fibrosis. Focal necrotic areas occurred, and fibrin flakes were apparent on the surface.

PATHOPHYSIOLOGIC REMARKS

There is a fibrinoid necrosis in the vascular walls, mostly located to the media. A swelling of the endothelial cells of the capillaries causes a stagnation of the blood flow, and a diapedesis of the various blood elements occurs. The

synovial tissue becomes congested. There is an exudation of fibrin, which, due to its antigenic properties, sustains inflammation. This is further augmented by the phagocytic properties of the A cells. When they ingest foreign particles, the so-called lysosomes-organelles housed in the A cells-disrupt and release hydrolytic enzymes that destroy both cartilage and bone. Besides the destructive effects of the lymphocytes on cartilage, it appears probable that they can cause focal destruction of synovium.

Synoviocytes are capable of both phagocytosis and secretion. It has there- fore been suggested that rheumatoid arthritis may be due to secretion from the B cells of hyaluronate protein, which is rendered antigenic by the incorporation in it of molecular fragments of microorganisms taken up by the cell producing this protein. The focal inflammation so characteristic of the disease would thus be explicable on the basis of an immune response to abnormal hyaluronate protein.

SYNOVECTOMY 229

REGENERATION OF SYNOVIAL TISSUE

It is known from rabbit experiments that a new synovial tissue is formed by metaplasia of the underlying connective tissue within 60 days after complete

excision. *O According to Marmor,99 Pau1,‘26 and Preston,129 this also occurs in man, and after synovectomy for rheumatoid arthritis, normal synovium recurs.

In an electron microscopic study on regenerated synovium 3 wk to 6 yr after synovectomy in cases with early rheumatoid arthritis, Mitchell and Shepard”’

found A and B cells in a lining cell layer, a disappearance of the subsynovial inflammatory infiltrations characteristic of rheumatoid disease, and a gradual

improvement in the morphology of the chondrocytes.

The findings related above are in some contradiction to the observations in a study by Goldie58 in which it was shown that regenerated synovium housed features identical to those present in the originally removed synovial tissue.

Regenerated tissue was obtained from 26 knee joints in patients who had under- gone synovectomy from 1 to 3 yr prior to the second sampling. In 14 patients an exploratory arthrotomy was done; in 12 patients a biopsy according to Parker and Pearson’24 was carried out. The synovium was glossy and thin with

minor edema. There was a richness of vessels, and folds were present that ap- peared as small broad-based villi. No jellified tips were observed. Granulation tissue was scant. The regenerated synovium could easily be pealed off from the fibrous capsule, and there was no evidence of scar tissue.

At histologic examination it was impossible to find any difference in the re- generated tissues from joints with hypertrophic or hypotrophic synovium at the

Fig. 1 I. Regenerated synovial tissue 14 mo after synovectomy with intense lymphocyte and

plasma cell invasion; H and E stain; x350.

230 IAN F. GOLDIE

first synovectomy. Synoviocytes appeared in layers but were somewhat flat-

tened, and there was an inflammatory reaction with predominantly lympho- cytes either assembled juxtavascularly or aggregated in infiltrates. Plasma cells were common. Hyalinosclerosis was occasionally seen. Granulation tissue was

sparsely observed (Fig. 11). Fibrinoid necrosis was detected, and there was a richness of vessels both arteriolar and venular. The same observations described above have been made by Patzakis et a1.‘25 and Mellors.“’

PRESENCE OF NERVES

The soft tissues surrounding a joint, i.e., fibrous capsule and mesenchymal lining, are richly supplied with nerve elements that may conduct pain.9~47@*‘2s

The fibrous capsule contains both encapsulated, complex unencapsulated, and free nerve endings that are believed to be pressure-sensitive and responsible

for stereotaxis and sensibility, such as, e.g., the Ruffini, Vater-Paccinian, and Golgi-Mazzoni endings.15,39,95*142 Th e mesenchymal lining, which is the synovial tissue, contains nervous elements,9~47.48 which are very scarce in contrast to the richly endowed fibrous capsule.

It has been possible to demonstrate nervous structures” in original as well as

in regenerated synovial tissues (Fig. 12). The presence of nerve fibers in the re- generated tissue was established 1 yr after synovectomy. Free fiber endings and complex unencapsulated nerve endings were observed; of these, the former are

assumed to conduct pain. It now seems appropriate to attempt an answer to the first question raised

earlier: Why should synovectomies be performed? Despite rheumatoid arthritis

being a generalized mesenchymal disease, there seems to be a predilection for the synovial tissue of joints. The rheumatoid granulation tissue with invading

microvessels destroys cartilage and bone in the joint with a focus at the bone- cartilage border. The granulation tissue in many ways behaves as a local in- vasive and destructive-but nonmalignant-agent. Without intervention, the final result in many cases is a stiff joint or a joint with very restricted movement.

Fig. 12. Free fiber ending with “varicosities”; some terminal expansions; from rheumatoid synovium; methylene blue; x200.

SYNOVECTOMY 231

Before this final stage is reached, which as a rule takes many years, the pa-

tient has also been disabled by intense pain from the pathologic process in the synovium. Thus removal of the synovial tissue appears indicated with respect to removal of a pathologic destructive local tissue process as well as to reducing

the discomfort of the patient. It is likely that the denervation, which accom- panies synovectomy, is a pain-relieving factor promoting the mobility of the

joint.

FUNCTION OF REGENERATED SYNOVIAL TISSUE

The postsynovectomy function can be appraised clinically by observing the

patients’ local joint condition. This carries many subjective and emotional evaluations that can distort the true condition, and therefore an attempt has

been made to make investigations53m57 as objective as possible by employing

measuring instruments excluding the subjective influence. For the functional appraisal of synovectomy the following methods have been used: (1) direct

intraarticular temperature recordings--use of thermistors; (2) indirect measure-

ments of joint temperatures-thermography: (3) estimation of hydrogen ion concentration--intravital pH measurements; (4) demonstration of the presence of rheumatoid factor in the synovial fluid; (5) observation of iron deposition

in synovial tissues; and (6) radiologic evaluation of the cartilaginous and osseous structures.

(1) By recording the temperature of a tissue, an indicator can be obtained of its functional condition resulting from metabolic or circulatory mechanisms.

Intraarticular temperatures were studied’9*s3 on the assumption that a connec- tion might exist between activity of disease and recorded temperature. The

intraarticular temperatures were registered before and after synovectomy. The

temperatures were registered with needle thermistors for multi-point measure-

ments with four to five thermistors in each needle, thus allowing measurements

at different zones of the joint.

The temperatures were recorded with and without caloric stimulation. There

was a typical pattern of reaction in rheumatoid arthritis (Fig. 13) in contrast to healthy joints. Thus when a hot pack was applied over the patellar region in a

normal joint, there was an immediate increase in the intraarticular temperature,

and if a cold pack was applied there was an immediate decrease in temperature. In patients with rheumatoid disease affecting the knee joints, there was a rever-

sal of this reaction, so that after the hot pack there was a short but significant decrease in intraarticular temperature and after cold pack a short period of in-

creased temperature.

After synovectomy temperature recordings revealed a normal reaction pat- tern, and it was thus obvious that synovectomy had had a beneficial effect.

(2) Every object with a temperature above absolute zero radiates from its surface electromagnetic waves. These appear within the infrared sector of the

spectrum. This self-emitted energy can be collected optically and transformed into proportional electrical impulses. These in turn can be converted into visible light to form a picture, a so-called thermogram.12 A thermogram is thus a pic- torial representation of the temperature contours of an observed surface.

In short, the working concept of a thermograph is that it attracts the emitted heat rays, the vertical rays being transferred via a plane mirror and the hori-

232 IAN F. GOLDIE

7’ H

Fig. 13. Temperature reaction in normal joints (solid line) and in rheumatoid joints (broken line) to hot pack (H) and cold pack (C); top: 3-min ap- plication of heat above 50°C; bottom: application for 3 min of cold pack of 4°C; 6 mo following syno-

5 10 15 20 25& vectomy, the rheumatoid joint behaves almost normally as regards temperature reactions.

zontal rays by a rotating prism to a photoconductive detector of indium anti- monide. The sensitivity of this apparatus is increased by cooling with liquid

nitrogen. The detector signal is then fed to a display unit where a television-like

picture is obtained on a screen. This picture can be adjusted for contrast (tem-

perature range) and brightness (temperature level) by controls on the display

unit. It thus becomes possible to model out the pictorial registration of the emitted heat, and temperature differences down to 0.2” C can be revealed.”

In 27 knee joints, repeated postoperative thermograms showed that in all

patients a decrease in heat emission followed synovectomy (Fig. 14). This was

interpreted as an amelioration of the inflammatory state of the joint. Clinically,

an improvement followed that paralleled the lessened intensity of heat emission.

(3) Inflammatory reactions are among other characteristics distinguished by a local acidosis. This varies in relation to the intensity of the inflammatory state. For example, in the initial stages when there is a predominance of polymor- phonuclear leucocytes, the hydrogen ion concentration is relatively low and the

pH ranges around 7.4. With further development of inflammation, correlated to this, a change in the cellular morphology toward the mononuclear phagocytic

type occurs. The alkalinity subsides and there is a drop in pH to levels around

6.5.‘08 Using an intravital method, the hydrogen ion concentration was measured in

synovial fluids of normal rheumatoid and synovectomized rheumatoid knee joints.s4 Normal knee joints had a pH of 7.3, rheumatoid joints had a value of 6.6, and rheumatoid joints at varying times after synovectomy had a value of 6.8, with a statistically significant difference between the first and the two latter groups (Table 1). The observations coincide with current ideas of an increased hydrogen ion concentration being paralleled by tissue changes of the chronic intlammatory type that characterize synovial tissues in rheumatoid arthritis before and after synovectomy.

SYNOVECTOMY 233

Fig. 14. Thermography,

i.e., registration of heat emission from capsular region of rheumatoid knee joint; right knee from the lateral aspect;

top: before synovectomy; mid- dle: 2 mo after synovectomy, wmewhat incraawd due to healing reaction; bottom: 6 mo after synovectomy. The emission pattern now con- farms to that of a normal knee joint. Note the increase from the Hoffa fat pad region.

(4) In rheumatoid arthritis, immunologic changes have been demonstrated in

both synovial fluid and serum.‘3.34*62,106 The presence of rheumatoid factor in synovial fluid before and after syno-

vectomy has been investigated. 56 The sensitized sheep cell test and acryl fixation test were used. Fourteen patients representing 18 knee joints in which synovec- tomy was performed showed the same immunologic conditions of synovial fluid

Table 1. Some pH Values in Synovial Fluid From Normal and Rheumatoid Knees and

Rheumatoid Synovectomized Knees.

Normal Knee5

Rheumatoid Ktl.%?S

Rheumatoid Synovectomized

Knee5

MeCln 7.30 6.61 6.79

SD2 0.033 0.214 0.098

T statistic _ tdiff = 4.42 - - tdiff = 0.95 -

,- t&e = 4.01 -

234 IAN F. GOLDIE

before and after the surgical procedure. Observations of the same kind have

been published by Cracchiolo et al. 34 It thus appears that synovectomy does not

have any influence on the immunologic reactions in the diseased joint. (5) The deposition of iron in rheumatoid synovial tissues interests the physi-

cian in that damage is assumed to occur locally in the synovium and generally

in the hematologic equilibrium. It is believed that the ingestion of iron particles

in rheumatoid arthritis may cause a relief of lysosomal hydrolytic enzymes, thus destroying the joint tissues. The magnitude of iron deposits in the synovium may partly explain the anemia of rheumatoid arthritis.“5~‘16~‘3’~‘34 Normal syn- ovial tissues contain hardly any iron at all. In one studyS7 it was demonstrated

that synovectomy did not alter the deposition of iron in the synovium (Fig. 15).

(6) A matter of concern has been the possible effect synovectomy might have on the cartilaginous and osseous structures of the joint. There is general agree- ment that the types of radiologic changes encountered in rheumatoid arthritis

include soft-tissue changes, bone rarefaction, narrowed joint space, erosions, cysts, and periosteal elevations. 24.26,41,72,77,88.9l.10l,l18,120.121,140,143.152

It is becoming apparent that the evaluation of radiologic changes following

synovectomy is most dependent on the time after the procedure that the evalua-

tion is carried out. In a radiologic study55 on 30 synovectomized rheumatoid knees with an observation time of 2.2 yr post synovectomy, it was found that

(1) synovectomy did not appear to destroy an intact joint, (2) no increase in already existing destructions occurred, and (3) no reaction was released that

could further destroy the articular cartilage. In 1972 Gschwend6’ presented a well-controlled study involving among other

Fig. 15. Rheumatoid synovial tissue; clusters of iron ore found around vessels with small isolated granules in wall of center vessel; turnbull blue; x200.

SYNOVECTOMY 235

Fig. 16. Anteroposterior radiogram of right rheumatoid knee joint; narrowing of joint space,

rarefaction, cysts, erosions, and periosteal elevations.

things a radiologic examination 7 yr post synovectomy. His conclusion was that

with time synovectomy might create some damage to the articular structures. Further long-term studies are required to elucidate this problem.

An attempt will now be made to answer the two questions: What is the bio- logic rationale behind synovectomy? and When in the course of the disease is

the time of choice for synovectomy? The important question is whether removal of the synovial tissue in one or

several joints may beneficially influence the rheumatoid disease of the mesen- chymal tissue in the patient as a whole. There may be a local cell-perpetuating tissue injury mechanism of the local autoimmune reaction type in the diseased

236 IAN F. GOLDIE

joint, as previously stated. If the synovium could be completely removed, to-

gether with all the patchy distributed areas of rheumatoid granulation tissue,

and if the early-regenerating synovium were of normal structure and function,

synovectomy of this kind might temporarily improve the joint. However, the joint is a part of the body connected to the general circulation, and thus cir-

culating factors in the blood may influence the synovium under formation and

directed toward a pathologic tissue, as claimed by certain observers previously cited. Furthermore, it is not possible technically to remove the synovium com-

pletely; thus there may be pathologic areas left behind in the synovium that

might by cellular or humoral factors influence the regenerating tissue and add

to the pathomorphologic features arising in the tissue during its re-formation. Thus removal of the synovial tissue in rheumatoid arthritis may reduce the

activity of the disease by reducing the amount of the diseased tissue in the body

and possibly by reducing the amount of different factors produced from the synovium and circulated in the blood. But even if a complete synovectomy could be performed in a joint, it is still very important to remember that circu-

lating factors may exist that can influence the newly formed tissue.

So far, it has been accepted that synovectomy does not cause recognizable

damage to the joint. As the granulation tissue components have a tendency to rapid destruction of the articulating surfaces of the joint, it appears logical

to perform synovectomy as early as possible in the disease, especially during the phase when there is evidence of the synovial tissue being of the dynamic and active hypertrophic type. An indication of this is the swollen joint with effusion

and a palpable thickening of the joint capsule. The question arises whether the

term early should not be replaced by the term prophylactic.

SYNOVECTOMY-SURVEY OF CLINICAL EXPERIENCE

Synovectomy need not necessarily be surgical-it may also be chemical.

Synovectomy is as a rule carried out in adult rheumatoid patients, but can also be performed in children suffering from juvenile rheumatoid arthritis.

Chemical Synovectomy Various drugs have a direct antiinflammatory effect by intervening with the

blood flow and suppressing the plasma cells and lymphocytes.lo3 Osmic acid has been commonly used in Scandinavian countries’0*‘s~155~‘5* with clinically good

results. Experimental application of osmic acid in rabbit knee jointsg3 showed that: (1) blood flow in the synovial vessels became arrested up to 4 hr, after

which time a slow flow was reinstituted, (2) 1 to 5 mo following the osmic acid

injection, normal vascular architecture could be observed, and (3) osmic acid was lodged in the intimal synovial layer perivascularly.

Mitchell reported in 1972 that osmic acid created chondrocyte destruction of healthy rabbit knee joints, as studied by electron microscopy. The flare-up that

follows the application of osmic acid can be dampened by adding hydro- cortisone to the injection, as suggested by Berglof.” In more than 50% of his

cases lasting improvement was noted. In a personal communication, Brattstriim” mentioned that following the

administration of osmic acid, patients improved so much that it was almost

SYNOVECTOMY 237

impossible to offer the patient an acceptable reason for a later surgical syno-

vectomy. Brattstrijm finds an advantage in using osmic acid preoperatively, as

the brown coloring of the synovium makes the removal of synovial tissue easier.

Other alkylating agents have been used, such as Thiotepa (n, n’, n”, -triethy-

lenethiophosphoramide),44 radioactive gold, and alcohol. Nitrogen mustard

has been used by Paul et a1.1z6 with comparatively good results, and Scherbel

et al.‘38 reported that joint inflammation disappeared for 1 to 2 yr in 37 of 106

cases and for 6 to 9 mo in another additional 35 cases. On the whole, however,

the results are conflicting.

The therapeutic effects of chemical synovectomy might in some cases be due

to a denervation of the intimal tissue instead of to a genuine synovectomy.22

Synovectomy in Juvenile Rheumatoid Arthritis

Chemical synovectomy is used in juvenile rheumatoid arthritis, but the re-

sults are as conflicting as in adults, wherefore the young child ultimately be- comes a candidate for surgical synovectomy. Experience is as yet rather lim-

ited,16 and the reports mainly deal with short-term observations. As these are

very optimistic,40,42,89,‘05 surgical intervention might be supported as a treatment

more frequently to be used. Kampner et a1.78 reported on 117 closely observed patients varying in age

from 2 to 18 yr with a follow-up period of 8.3 yr. Of these 117 patients, 25

underwent synovectomy following failure to be controlled by more conservative

measures. The results were not overwhelmingly good, but were acceptable to the degree that synovectomy will no doubt maintain such a position in the treat- ment of juvenile rheumatoid arthritis that in many cases it will be the procedure

to follow rather than to watch the joint slowly destroy itself while being man-

aged on conservative medical therapy.

Surgical Synovectomy in Different Joint Systems

Metacarpophalangeal Joints. Edstrijm38 maintained in 1961 that “15 or 20

years ago the commonest cause of disability in rheumatoid arthritis in Sweden was flexion contractures in the knees with incapacity to walk and stand. Today

the commonest of these causes is deformed hands with incapacity to grip and

pinch. From an economic point of view the function of the hands is very im-

portant. A blind or a deaf man is often less disabled than one who has lost the

use of his hands.” Kessler et al.79 reported on a series of 250 patients with 330 hands involved;

the hands were the site of the first onset of the disease in 30%.

Soft-tissue changes occur in the flexor and extensor tendons and also in the synovial membranes of the interphalangeal joints. The distribution is roughly

60”,, in the extensor tendor, 402) in the flexors, and 6.5”/, in the thumb.13’ These changes can be accompanied by instability in the metacarpophalangeal joint in roughly 45% and in the distal interphalangeal joint in 1O%.‘3o

Bunnell23 stated in 1948 that surgery should be used only on “burned out” cases, but it has become evident that the earlier the treatment the better the results. It is essential at these operations to remove all synovial tissue from

238 IAN F. GOLDIE

the tendon sheaths and from the joints, and it has been shown conclusively that the most important sites are the bone cartilage barrier and also where the collateral ligaments insert. Due to granulations, which erode the bone and the

insertion of the ligaments, a total or partial rupture of the ligamentous inser- tion can occur with a consequent instability of the joint.45 It is essential to

clean synovial granulations out of the site of insertion of the collateral liga-

ments. Total synovectomy is, however, not necessary, and in large series it has

been proved that it is sufficient to remove roughly 85% of the synovial tissue.45 As a rule, the remaining 15% is located in the volar area, which offers some

technical difficulties to removal. As has been previously stated, the results are

good, and an Anglo-American authority (Flatt) has said “I have yet to see a

true recurrence of a synovitis in a joint in which I have done a synovectomy. I

add the qualification yet because any surgeon who says never can only be young

and foolish and I am no longer young.”

Savi11’36 reported in 1969 on 98 metacarpophalangeal joints with a follow-up

time ranging from 1 to 6 yr; the majority, 61, were 4 to 5 yr. The pain had disappeared in 66 and was less in 26. Swelling remained in 8, and erosions were the same in 49 and had increased in 55. With these figures as a background,

Savill suggests that synovectomy of the metacarpophalangeal joints should be

carried out in order to relieve pain and control swelling. In 1972 Gschwend6’ voiced the same opinion based on a well-controlled study with somewhat sim-

ilar results, and equally good results have simultaneously been claimed.25q99*149*152

In an English study’36 on 30 patients with engagement of both hands, opera-

tions were performed in the more destroyed hand. The strength of grip in the

operated hand was stronger than in the nonoperated. Range of motion in- creased and pain was completely relieved. Two years later there were no re-

currences. In summary, it can then be said that synovectomy of the metacarpophalan-

geal joint is an accepted method, the aim of which is to eliminate diseased

tissue, restore movement, improve function, and maintain stability, resulting

in reduction of pain and swelling.

The Wrist. This is one of the more frequent predilections for rheumatoid changes. Many structures are involved in one functional unit, the efficiency of which can be jeopardized by involvement of only one single structure, or, what

is more common, by a combination of many. The structures involved are the

radiocarpal, intercarpal, and carpometacarpal joints, the inferior radio-ulnar joint, the long extensor tendons of the thumb and fingers, the radial and ulnar

carpal extensor tendons, and the flexor tendons in the carpal tunnel. Disabling symptoms in the wrist are often related to the tendons and to the

inferior radio-ulnar joint. Pain in this region is usually relieved by surgical

intervention of these structures. Savill’36 has reported a series of 299 operations being performed at the wrist, and during 7 yr arthrodesis had to be performed only in 15 instances. Savill does not believe that a synovectomy can adequately be performed in the wrist, and he therefore suggests synovectomy only of the inferior radio-ulnar joint combined with resection of the ulnar head.

Looking at the problem more systematically, however, one might say that the

synovitis can be divided into three stages: 25 The first features an increased pro-

SYNOVECTOMY 239

duction of synovial fluid, which does not interfere with the joint cartilage but

only increases the volume and puts the joint capsule and ligaments under ten-

sion. In 22 cases synovectomy gave excellent results in all, with a checkup time of 3 to 6 yr. The second shows the synovial tissue to be more hypertrophic, and the synovial fluid is more viscous, which adds to decreasing the mobility of the joint, but still the joint structures are not interfered with and the pathology is

limited only to tendons and tendon sheaths. The third stage is that in which

there is a formation of pannus, which invades the joint cartilage and erodes the

osseous structure. Synovectomy around the ulnar head without resection of the head gives a great number of recurrences, whereas with resection of the ulnar

head there are no recurrences. Synovectomy in the radiocarpal joint is techni-

cally rather difficult, and the results are not satisfying. Synovectomy around the

extensor tendon with division of the retinaculum gives a surprisingly large

number of recurrences. A careful analysis therefore becomes necessary before surgery.

The Elbow Joint. Wilkinson and Lowrylm mentioned that of 103 operations

for rheumatoid arthritis during one year, 6.8% were synovectomies of the elbow joint, as compared to 50.5% on the knee, 14% on the wrist, and 20% on the

hand. In a series of 19 1 patients*’ with generalized rheumatoid arthritis, two-thirds

had an involvement of the elbow. As a rule, elbow involvement is most fre-

quently seen in younger patients; in about 70% radiological changes can be demonstrated.” Operation should be carried out as early as possible, if neces- sary when crepitations are palpated over the radial head. The operation in- volves a synovectomy and extirpation of the radial head. Access to the joint is best achieved through medial and lateral incisions. Division of the olecranon is

unnecessary. 16’ At the same time, it has been recommended that a transposition of the ulnar nerve should be carried out.‘” Others”j’ suggest, however, that the

ulnar nerve be transposed only when symptoms from the nerve have been ob- served prior to operation. Synovectomy with extirpation of the radial head is a

most satisfactory procedure in the elbow joint, and more than 80% of these have good results.*’

Nevertheless, Merle d’Aubigne and Delbarrelog felt prepared to denounce

synovectomy, as only two out of four patients were satisfied in a short-term follow-up of a maximum of 11 mo. Inglis, Ranawat, and Straub” have reported on 28 synovectomies and debridement of the elbow joint with an average

follow-up time of 33 yr; 25 were improved in terms of relief of pain and ex- tended range of motion. Correspondingly good results have been reported by Marmor99 and Wilson et al. 16’ It therefore seems logical to suggest that total synovectomy plus the necessary amount of joint debridement with or without resection of the radial head still results in an adequate improvement.

The Shoulder Joint, This joint very often becomes engaged early in the rheu- matoid disease process. Besides pain there is a restriction in movement, which

ultimately can lead to the frozen-shoulder syndrome. The tendon sheaths as well as the numerous bursae around the shoulder joint become engaged, and difficulties arise in deciding which structures to deal with.

HerscheF has suggested that synovectomy should be combined with more

240 IAN F. GOLDIE

extensive procedures such as resection of the coraco-acromial ligament, acromiectomy with excision of the subacromial bursae, and intrinsic release of

the short rotators combined with release of the inferior capsule. The procedure

has been performed with acceptable results in only three cases. Ansell and Arden’ have reported five instances in which the subacromial bursa was re-

moved, with excellent results in four; the fifth case had a fair result.

The Foot. The engagement of the foot in the rheumatoid process gives the patient great disability and has a dominating position in the symptomatology of the rheumatoid patient. The hind-foot as a rule is only engaged 10 to 15% as

often as the fore-foot.30 Attempts at synovectomy in the various joints of the hind-foot have not yielded such results that the procedure is justified.99v141 Clay-

ton3’ as are most other authors, is of the opinion that arthrodesis should be

carried out. As for the fore-foot, however, the situation is entirely different. The patient

very often has great pain from the fore-foot when walking. The synovitis in the metatarsophalangeal joints no doubt creates a greater part of the symptomatol-

ogy, but other factors make an important contribution, such as hallux valgus, subluxations of the metatarsophalangeal joint, hammer toes, and bursitis. The transverse arch falls down and becomes completely flat, and painful callosities arise. According to Brown,‘62 meticulous synovectomy in the metatarsophalan- geal joints gave excellent results in 50 patients. Marmor99 and Clayton3’ have

found that resection of the metatarsophalangeal joint is the supreme remedy for

this condition; in 110 feet, excellent results had been recorded and no recur- rences had been observed. Either a plantar incision going across the metatarsal

heads can be used or two or three longitudinal incisions above the metatarsal head on the dorsal aspect of the foot. The ideal is to remove all the five meta- tarsal heads and corresponding basis of the first phalanx. But the custom varies,

and in many places only metatarsophalangeal joints 2 to 5 are resected.

An interesting study is being carried out by Brattstrom of Lund, Sweden, who at present is comparing the results of synovectomy in metatarsophalangeal joints with conservative treatment implying the use of an orthopedic shoe.

Synovectomy is done on one foot, and the other foot is used as a control. Both feet are checked annually with x-rays5 various activity tests, evaluation of pain, and analysis of weight-bearing by the use of foot plates. A 3-yr follow-up has

been published,17 and the results in 32 of 42 operated feet are much more satis-

factory than those of the nonoperated feet. The investigation is still running, and a new report is expected to be published after 5 yr.

The Knee Joint. This joint has attracted great interest from an orthopedic

point of view, as it is technically easily accessible and the results after syno- vectomy can be recorded without difficulty. The general approach to the joint is via a medial parapatellar incision that is extended into the rectus tendon so that the patella without effort can be everted over onto the lateral side, giving good access to the lateral joint compartment. 3~‘4~27~‘M)~‘04~‘35~‘47 Lateral incisions only, or a combination of lateral and medial, have also been used like transverse, horse- shoe-shaped, L- or J-shaped, and vertical transpatellar, the advantages of which do not seem to be so great as to justify their use in preference to the medial

approach. Patellectomy as part of the procedure has been advocated by

SYNOVECTOMY 241

some 49,‘23,‘35 but due to the later lag in the extensor mechanism, removal of the

patel;a is mostly refrained from. Marmor9s*‘oo leaves the suprapatellar pouch intact, with the motivation that

it facilitates the knee mobility and counteracts the formation of adhesions that

would impair function. The results do not seem to become worse in leaving diseased tissue behind. Degenerated menisci should be removed whenever they

are involved in the disease process. 30~83~123~‘35~‘53 The cruciate ligaments remain

surprisingly uninvolved by the rheumatoid disease, but often they are covered

by granulations that should be removed. The rule is that as much synovium as possible should be removed, but most

surgeons refrain from doing a posterior synovectomy.98,‘00 The excision of bony spurs and osteophytes in the bone-cartilage region has been ascribed some im-

portance96 and should routinely be done. It has been thought important for the knee joint to be immobilized in a plas-

ter cast for some 2 to 3 wk postoperatively, after which time the knee is manipu-

lated.61,85,‘02,‘35 Today, however, patients are immediately mobilized, i.e., the day

ofor the day after operation, and permitted out of bed as soon as they have con- trol of their quadriceps mechanism. Weight-bearing can be permitted 3 to 4

Table 2.

Year Author No. of Knees lmoroved P00r FOllOW.UO

1923 JOIVS 2 2 0

1924 Speed 3 2 1

1926 Swett 32 25 7

1929 Allison et al. 19 14 5

1930 BOOll.ltt 41 25 16

1933 Bernstein 25 22 3

1938 lnge 26 16 10

1941 Ghormley et al. 47 26 21

1955 London 32 22 10

1961 Lelik 27 23 4

1964 Aidem et al. 26 24 2

1965 Torppi et al. 24 22 2

1965 Jokubowsky 40 30 10

1966 Gariipy 56 44 12

1966 Mormor 34 34 0

1966 Stevens et al. 100 91 9

1967 Conoty et al. 38 31 7

1967 Platt 42 38 4

1967 Freilinger 9 6 3 1967 Arden 29 19 10

1967 Barnes et al. 53 40 13

1969 28 22 6

1969 Parodies 48 40 8

1972 Drabltis 120 20

1973 MClrm0r 175

94

(6 not recorded)

93 82

1-l yr

l-5 yr

3 Y’

4 Yr

2 Y' a-3 yr

(11 mow.)

i-2 yr

3-29 mo

3-21 mo

2.7 yr

17.6 mo

(2-48 mo)

23

(7-49 mo)

18 mo

(2 mo-5 yr)

2

(6 mo-7 yr)

49.4 mo

242 IAN F. GOLDIE

days postoperatively, and discharge from the hospital between 10 and 14 days. 30~9*~‘oo~‘47~‘53 Results of synovectomy have been compiled in Table 2, which in part has been taken from Geens.%

The follow-ups deserve special comment. Barnes et al.* found that flexion deteriorated in 50% of the patients. This was related to the length of the follow- up, but the patients did not regard the loss of flexion as important. Full exten- sion was improved in 50% and deteriorated in 15%. Preoperative flexion con- tracture up to 20 degrees did not predispose to a bad result. Stability of the knee joint was unchanged by synovectomy.

Continued deterioration in radiographic appearance occurred in 18 of 41 knees. The radiologic deterioration in 23 of 41 knees was, however, less than would be anticipated had the operation not been performed. There was no correlation between preoperative duration of disease and result of operation (N.B., this does not refer to duration of disease in the target joint). There was some evidence that the patient’s assessment of the result of the operation de- teriorated with the length of the follow-up. The same observation has been made by Gariepy et a1.49 and Paradies.“’

Long-term clinical follow-ups, e.g., as reported by London,% indicate that following synovectomy the regenerated synovium will eventually become dis- eased and symptoms will recur if the patient’s systemic disease remains active. Gariepy et al!’ have stated that they observed no systemic exacerbation of disease in 127 cases of synovectomy, but in 56 knees there was 6% recurrence with an average follow-up time of 6.5 yr.

The frequency of recurrence varies from zero (Marmor,” but in a later study from 1973’O” there were 82 failures of 175 synovectomies) to 54x.” The great variation may be due to the fact that the reports are based on patients with different disease activities, e.g., a monarticular engagement as compared to a classic severe form of rheumatoid arthritis. Moreover, there is some divergence in the concept of recurrence: Is it a hydrops only or hydrops with pain and swollen paraarticular tissues?

Earlier in this article, early-or rather prophylactic-synovectomy is advo- cated on purely pathophysiologic grounds. To some extent this is substantiated by clinical experience; many failures are believed to be the result of the opera- tion being performed at a late stage of the disease, as well as to the duration of the disease (despite the observations of Barnes et a1.8) and the duration of joint engagement. Thus Gariepy et a1.49 stated that poor results were the result of patients being operated on late in the course of their disease and that little ben- efit could be provided by the operation when performed at later stages of arthri- tis when the disease had already progressed beyond the synovial tissue.

Geens 5o however, reached quite an opposite conclusion, which is worth quoting: “85 per cent of the procedures in adults were performed in late stages of destruction. All adult patients had classic rheumatoid arthritis with multiple joint involvement. 79 per cent of the knees were rated improved by the patient as compared with 65 per cent rated improved by the examinor. In 46.5 per cent definite or probable recurrence was found.”

According to MarmorlW in his study of 1973, the major cause of failure was advanced destruction of the joint and loss of articular cartilage present in the

SYNOVECTOMY 243

preoperative roentgenogram and recorded at the surgical procedure. The aver-

age patient of the failure group did well for several years following surgery, but gradually the poor joint surface was associated with pain on walking and

further deterioration in the patient’s joint condition.

In the light of the above information it therefore seems unacceptable to with-

hold synovectomy in hope of the occurrence of remission, and synovectomy appears to be done best when done early and radically.

The Hip Joint. Synovectomy has been done,46 but the results have not been

encouraging. Of late, total hip replacement has become the procedure of choice

(for lower age groups as well), and good results have hitherto been reported.29,33 The last two questions raised at the beginning of this article (What are the

long-term results? and What are the indications and contraindications?) seem to

be so interrelated that difficulties arise in answering each question separately.

It has become evident that good results recorded early deteriorate with time*~‘00~‘22 and that this may depend on the stage of activity of disease and

joint engagement when the operation is performed. The following indications may therefore be suggested:8~50~122

I. active disease in the target joint

2. disease duration in the target joint of less than 5 yr

3. slight or mild radiologic change

4. significant pain in the target joint prior to operation 5. effusion

6. palpable synovial thickening

7. tendency toward contracture

8. advanced stages of destruction where the aim of synovectomy is tempo- rary relief of pain and functional improvement

9. negative tests for rheumatoid factor 10. for knees: persistent involvement of short duration in one knee when there

is advanced joint destruction of the opposite side.

The following contraindications are suggested: 1. disease duration of more than 5 yr in target joint

2. severe preoperative radiological changes

3. absence of pain

4. severe instability and loss of articular cartilage

5. strongly positive serological tests for rheumatoid factor 6. the joint that in clinical colloquy is called a dry joint.

PSYCHOLOGIC ASPECTS OF SYNOVECTOMY

According to Weintraub, Is9 the rheumatoid patient struggles with himself and fights his own battle. He seems independent of moral assistance from others; he is patient, fatalistic, and unapproachable. He devotes much of his life to others and requires little for himself.

Lichtwitz,” in describing the sick history of one of his patients, Anna Schede, wrote, “Women, in the later stadium of deforming arthritis resemble Anna Schede. There are not any friendlier and more forebearing patients than these. If nothing helps or if everything fails they do not complain, they make no reproaches. I am always under the impression that they want to console the

244 IAN F. GOLDIE

doctor and ask for forgiveness that his endeavours remain unsuccessful. They never lose confidence, greet you every morning with the same quiet smile and

seem to be happy when the doctor admires the handiwork done by their poor

hands.”

It is supposed that rheumatoid patients fail to observe’the needs of their

physical existence and that the onset of rheumatoid arthritis marks the end of a

premorbid phase that has led to vegetative exhaustion. This exhaustion requires

somatic as well as psychic treatment, and it is suggested that these patients will undergo any operation with patience and fatalism and give their active coopera- tion.ls9

SYNOVECTOMY-AN 8-YR FOLLOW-UP OF 51 OPERATED KNEES

At the Department of Orthopedic Surgery II, Sahlgren Hospital, Giiteborg,

Sweden, synovectomy for rheumatoid arthritis became popular during the mid- 1960’s. The procedure was systematically carried out from 1965 in all rheuma-

toid patients suited for surgery. This presentation will deal only with those in

whom synovectomy of the knee was performed. Most patients were referred

from the Department of Rheumatology, but some came spontaneously to the orthopedic surgeon as the procedure became more widely known among the

rheumatoid patients.

Operation

After admission and workup for surgery, operation was carried out via a medial parapatellar

incision, which was extended into the rectus tendon. In this way the patella could easily be brought

over the lateral femoral condyle, thus giving ample access to the lateral joint compartment. All

accessible synovium, including the suprapatellar pouch, was excised. As a rule, the menisci were

removed. Great care was taken to excise granulation tissue from the bone-cartilage zone of the

condyles and of the patella. Granulations around the cruciates were removed. Posterior syno-

vectomy was never done. A suction drainage was applied, which remained for 2 days. The fibrous

capsule was sutured with silk and the skin with nylon. A modified Robert Jones dressing was ap-

plied. On the day of operation, passive flexions of the knee to 45 degrees were instituted. The day

after operation and onward, active movements were encouraged. As soon as the patient had con-

trol of her quadriceps, she was allowed out of bed, walking without weight-bearing. On day 7 the

bandage was removed, and if the knee looked satisfactory, weight-bearing was permitted. Sutures

were removed on day 14. Hospitalization lasted 10 to I4 days. Postoperative checkups were done

monthly for 3 to 4 mo, and then every year.

Material

During 1965 and 1966,44 patients underwent synovectomy of one or both knees. In 7 cases the

operation was performed on both knees, thus providing a total of 51 knees. There were 28 women

and I6 men whose ages at operation varied from I7 to 78 yr, with a mean of 57.8 yr (women: range

I7 to 76 yr, mean 58.7 yr; men: range 35 to 78 yr, mean 57 yr). The duration of disease from onset

until operation varied from 1 to 38 yr (mean I I. I yr) and in the affected knee from I to 20 yr (mean

4.5 yr).

Pain was graded according to a numerical system: 0 = none, I = occasional, 2 = mild, 3 = mod-

erate, 4 = severe. Range of motion was determined in all knees with 0 degrees as full extension

and 90 degrees flexion regarded as normal. Radiology was graded according to the scale described

in the Atlas of Standard Radiographs of Arthritis, Manchester Royal Infirmary, 1960: 0 = none,

I = doubtful, 2 = mild, 3 = moderate, 4 = severe.

All patients were seropositive and classified into stages I to IV as suggested by the American

Rheumatism Association (Table 3). The material is more systematically presented in Table 4.

SYNOVECTOMY 245

Table 3. American Rheumatism Association Classification of Anatomical Stages

Stage I, Early

* 1. No destructive changes roentgenographically

2. Roentgenogrophic evidence of osteoporosis moy be present

Stage II, Moderate

*l. Roentgenographic evidence of osteoporosis, with or without bone destruction; slight

cartilage destruction may be present

*2. No joint deformities, although limitation of ioint mobility may be present

Stage III, Severe

* 1. Roentgenographic evidence of cartilage and bone destruction, in addition to osteoporosis

*2. Joint deformity, such 0s subluxation, ulnar deviation, or hyperextension, without fibrous or

bone ankylosis

3. Extensive muscle atrophy

4. Extra-articulor soft-tissue lesions, such OS nodules and tenovoginitis, may be present

Stage IV, Terminal

* 1. Fibrous or bone onkylosis

2. Criteria 0s in Stage Ill

*Must be present to permit classification of o patient in any particular stage.

Follow-up

In the spring of 1973 a follow-up was carried out by personal interrogation and examination.

The duration from operation to follow-up was at most 8 yr (16 patients) and at least 7 yr (24

patients). Four patients had died due to intercurrent disease, thus leaving 40 patients representing

47 knees at follow-up. Of these, however, there were some failures that ultimately were excluded.

Four patients had an arthrodesis within 1 to 2 yr following synovectomy. In one patient both knees

were arthrodeses. Four patients developed an ankylosis. Three patients representing 6 knees had

an arthroplasty (McIntosh, total knee replacement) carried out within 3 yr following synovectomy.

A summary of the three A’s for failures is presented in Table 5. Thus for follow-up, 29 patients

representing 32 knees remained. The results of the follow-up presented in Tables 6 and 7. The

tables are self-explanatory and hardly need any comment. Very few complications arose in connec-

tion with surgery. In three knees, infection developed that was successfully treated within 1 mo

with antibiotics. No clinical thrombosis or thrombophlebitis was diagnosed. No deaths occurred.

One patient was resynovectomized within 1 yr following the first procedure because of excruciating

pain; it was completely relieved. The overall results as judged by the patients disclosed in 32 knees:

good: 24; bad: 8. To the question whether synovectomy is a procedure to be recommended the

answers were: yes: 22; no: 7.

Table 4. Presentation of Material Synovectomized in the Knee Joint for Rheumatoid Arthritis.

stage I stage II stage III stage IV

Women

Men

Total knees

Mean age, yr

Duration of rheumatic disease, yr

Duration of ioint affection, yr

Grade of pain

Extension defect, degrees

Flexion defect, degrees

Stability

Radiology

3

4

7

47.5

5.3

3.1

2.3

5

Ye=

14 8 4 8

21 20

59 61.2

11.5 14.7

5 5.9

2.8 3.4

10 15

5 10

ye= “0

2 3.1

3

3

65.6

8

4.3

3.3

20

31.6

“0

4

246 IAN F. GOLDIE

Table 5. The Three A’s for Failure of Synovectomy in the Rheumatoid Knee Joint.

No. of Knees

Arthrodesis 5

Ankylosis 4

Arthroplasty 6

Total 15

Table 6. Results of Follow-up of Synovectomy in Rheumatoid Knee Joints

7 to 8 yr Post Synovectomy.

stage I II Ill IV

Number of knees Grade of pain Extension defect, degrees Flexion defect, degrees Stability Radiology

7 0 5 0

‘2’

13 1.5 5 5

Yes 2.5

10 1.2

15 5

yes 4

2 1.5

15 10 no 4

Note: Number of patients: 29; number of knees: 32.

Table 7. Change in Grade of Pain Before Operation and at Follow-up

Examination in 32 Knees Synovectomized for Rheumatoid Arthritis.

Preoperative Pain

Grading O-4

0 1

2

3

4

0

Cl 3

5

7

2

Postoperative Pain Grading O-4

1 2 3 4

0

1 lzl

2 2 [II

5 1 0

Note: Below and left to boxes, improvement; boxes, no change; in cases of deterioration, the

grading would have filled the columns to the right of the boxes.

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SYNOVECTOMY 247

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