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Arthroscopic synovectomy
Arthroscopy: The Journal of Arthroscopic and Related Surgery 6(1):1%23
Published by Raven Press, Ltd. 8 1990Arthroscopy Association of North America
Arthroscopic Synovectomy Paul Smiley, M.D. and Stephen A. Wasilewski,
M.D.
Summary: This study was undertaken to evaluate the efficacy of knee synovectomy with arthroscopic technique. Nineteen patients with 25 operated knees were studied. All 25 knees had 6-month follow-up, 21 knees had 2-year follow-up, and 14 knees were evaluated at least 4 years after operation. After operation, patients were evaluated using clinical data including pain relief, functional capacity, range of motion, recurrent synovitis, and presence of effusion. Preoperative as well as follow-up weight-bearing radiographs were also studied to assess the results of this procedure. At 6 months’ postoperative clinical evaluation, 96% of patients showed good results. At 2 years, 90% of patients were considered to have good results, and at 4 years, 57% of patients continued to do well. Of those knees studied radiographically, 81% showed no progressive radiographic changes at 2 years and 61.5% showed no deterioration at 4 years. Clinical results correlated well with radiographic results. Arthroscopic synovectomy yielded results similar to those previously published for open synovectomy, with less operative and postoperative morbidity. Key Words: Rheumatoid arthritis-Knee synovectomy.
Open synovectomy of the knee was first performed in the United States in 1900 by Goldthwait (l), and to date several long-term studies have been reported on patients who have had open total and partial synovectomy of the knee (2-7). The results reported for open total synovectomy of the knee for rheumatoid arthritis have been relatively consistent. In 1972, Ranawat et al. (5) reported that 73% of their patients with rheumatoid arthritis showed improvement an average of 2.8 years after synovectomy. Marmor (6) found good results in 75% of his patients who had only early preoperative radiographic changes before synovectomy. However, in his entire group of patients, only 53% had good results. Taylor (4) in 1979 came to the conclusion that synovectomy, if performed early,
before radiographic changes were evident, was more useful and appeared to retard the development of further changes. The consensus of most of these studies appears to be that if performed during the early stages of the disease before severe joint destruction is present, open synovectomy for rheumatoid arthritis served to slow down, and in some patients halt, the progression of the disease (4). However, not all authors believe in the effectiveness of synovectomy. McEwen (8), in a multicenter study published in 1988, found that surgical synovectomy had little long-term value in the general treatment of rheumatoid arthritis or in the prevention of recurrence of disease activity or progressive articular damage. In 1988, Klein and Jensen (9) published a report on arthroscopic synovectomy of the knee with an average follow-up of 2.7 years. These authors described the surgical technique and discussed the feasibility of performing arthroscopic synovectomy for hypertrophic synovitis of the knee joint. They reported promising short-term results, as good if not better than those reported for conventional open synovectomy. However, there has not yet
From the Department of Orthopaedic Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts, U.S.A. Address correspondence and reprint requests to Dr. S. A. Wasilewski, Department of Orthopaedic Surgery, Lahey Clinic Medical Center, 41 Mall Road, Burlington, MA 0180.5, U.S.A. Results of this study were presented at the 1989 Annual Meeting of the Arthroscopy Association of North America, April 1316, Seattle, Washington, U.S.A.
18
ARTHROSCOPIC TABLE 1. Grading of weight-bearing Grade I II
III IV
radiographs
Criteria No evidence of radiographic degenerative changes Radiographic evidence of osteoporosis. Slight destruction of articular cartilage may be present with 40% loss of joint space Loss of joint space 350% Complete loss of joint space
been a study that looks at the patients’ clinical results and radiographic changes over a long period. This study evaluated patients who had undergone arthroscopic synovectomy of the knee at 6 months, 2 years, and 4 years after operation. We correlated preoperative and postoperative radiographic evaluation of the knee with the patient’s clinical results and compared our results of synovectomy using the arthroscopic technique with the previously published results for the conventional open procedure. MATERIALS AND METHODS This study is a retrospective review of 19 patients with 25 operated knees who underwent arthroscopic synovectomy of the knee at the Lahey Clinic between 1983 and 1988. These patients were evaluated at 6 months, 2 years, and 4 years after operation. All patients had appreciable pain and swelling that persisted despite a minimum of 6 months to a maximum of 10 years of medical management and were referred by their rheumatologist for consideration for synovectomy. Synovectomy was offered as symptomatic and not prophylactic treatment. At the time of operation, the ages of the patients ranged from 16 to 66 years, with a median age of 42 years. Fourteen patients were female and five were male. Twenty-two of the knees were involved by rheumatoid arthritis or variants of rheumatoid disease, two by psoriatic arthritis, and one by pigmented villonodular synovitis. The median followup at the time of this review was 55 months with a range of 6-72 months. The surgical technique employed involved a systematic approach to the synovial pouch of the knee joint. All operations were done with patients under either general or spinal anesthesia. Each procedure was performed with a pneumatic tourniquet inflated on the thigh. If the operative procedure lasted longer than 2 h, the tourniquet was released and then reinflated after 8 to 10 min. All operations were
19
SYNOVECTOMY
accomplished using an arthroscopic leg holder allowing flexion of the knee to 90”. Surgical technique The synovial pouch was divided into seven sections. Routinely, five to six skin portals were used to perform an entire synovectomy including the posterior compartment. The technique of arthroscopic synovectomy has been described previously by Highgenboten in 1982 (10) and 1985 (11) and by Klein and Jensen in 1988 (9). We have found that the following points need to be stressed. 1. Menisci, if at all possible, need to be preserved. In our study, one patient had a coexistent tear of the lateral meniscus and underwent a partial lateral meniscectomy, and one patient had undergone a previous medial meniscectomy. In all other patients, both menisci were left intact. 2. Synovial ingrowth into the cruciate ligaments, especially the anterior cruciate, should be resected carefully to preserve these structures. 3. Pannus formation in the medial and lateral aspects of the knee should be carefully stripped off the junction of the synovium and the articular cartilage. 4. Frequent repositioning of the arthroscope and power instruments in the various portals is important to avoid iatrogenic damage to the articular cartilage. 5. The use of a posteromedial portal is essential to perform a synovectomy of the posterior compartment. A 70” arthroscope is inserted through the intercondylar notch to visualize the posterior compartment. The synovectomy is performed through the posteromedial portal and if necessary, through an additional posterolateral portal. Occasionally a second posteromedial portal is used to provide additional inflow. A posterior synovectomy was performed in all patients. After operation, the patients were placed in a modified Jones dressing and were discharged with instructions to bear weight as tolerated with crutches. They were instructed to begin immediate range-of-motion (ROM) and quadriceps exercises. Patients were seen a week after operation, at which time most were able to walk without crutches. Sutures were removed, and patients were begun on a supervised physical therapy program of active assisted ROM exercises. At follow-up, patients were evaluated clinically using the subjective and objective criteria of pain relief, level of activity, presence or absence of efArthroscopy,
Vol. 6, No. 1. 1590
1 A,B
1 C,D
ARTHROSCOPIC
21
SYNOVECTOMY
FIG. 1. Grading of weight-bearing radiographs. A: Grade I. B: Grade II. C: Grade III. D: Grade IV.
fusion, and ROM of the knee joint. A good result was defined as little or no pain, no recurrent effusion, unchanged or improved ROM, and little or no limitation of activity. A poor result was defined as persistent knee pain, effusion, limitation of activity, or loss of motion of the knee. Preoperative weight-bearing radiographs were obtained in all patients and were graded I-IV according to the grading system outlined in Table 1 and illustrated by Fig. 1. RESULTS We found that the average surgical time decreased from 2 h 30 min for the cases before 1985 to 1 h 55 min since then because of both improved surgical technique and the development of more sophisticated arthroscopic power tools. The average hospital stay after operation was 2.7 days, with a range of 6 h to 8 days. Twenty percent of the procedures were performed as outpatient surgery. There were no operative complications. Three patients eventually underwent total knee arthroplasty, and one more is currently being evaluated for arthroplasty. One patient fell 2 months after operation and required a closed manipulation of the knee for decreased motion. One year after operation, this same patient underwent a repeat arthroscopy, patella chondroplasty, and removal of loose bodies. There was no evidence of recurrent synovitis. No other patients lost motion in their knees. One patient underwent repeat arthroscopy at another center for persistent swelling 9 months after the original operation, which reportedly showed no recurrent synovitis. All 25 knees were evaluated clinically at 6 months after operation. Subsequently, 21 knees were examined at 2-4 years, and 14 of these 21 knees were evaluated at 4-6 years after operation. At the 6-month postoperative evaluation, 24 of the 25 knees (96%) showed good results. Of the 16 patients with 21 operated knees evaluated at 24 years, 19 of the knees (90%) were considered to have good results. Two of the knees (10%) demonstrated poor clinical results at 2-year follow-up. One of these knees underwent total knee arthroplasty 11 months after operation after showing a one-grade radiographic deterioration (grades II-III). The other knee demonstrated a two-grade radiographic deterioration (grades II-IV) before un-
dergoing total knee arthroplasty at 47 months after initial synovectomy. Eleven patients with 14 operated knees were evaluated at least 4 years after operation. Clinically, eight knees (57%) continued to do well, and six knees (43%) showed progressive clinical deterioration (Fig. 2). One of these knees underwent total knee arthroplasty at 47 months, one at 64 months, and one knee is currently undergoing consideration for total knee arthroplasty. Twenty-four of the 25 knees showed either grade I or grade II radiographic changes before operation. One knee showed grade III preoperative changes (Fig. 3). Weight-bearing radiographs of 16 knees were evaluated at 2-year follow-up and of 13 knees at 4-year follow-up using the same grading system. Of the 16 knees evaluated by radiography at 2 years, 13 knees (81%) showed no progressive radiographic deterioration and 3 knees (1%) showed progression of one grade as compared with preoperative films (Fig. 4). In the 10 patients with 13 operated knees evaluated by radiography at 4-year follow-up, 8 knees (62%) showed no progressive radiographic changes and 5 knees (38%) showed progressive radiographic deterioration. One knee progressed one grade, one knee progressed two grades, and three knees showed a three-grade radiographic deterioration (Fig. 5). None of the knees that continued to show good clinical results at 4 years had evidence of radiographic deterioration of disease when compared with their preoperative radiographs . Good Poor
6 months
clinical clinical
results m results
4 years Follow - up
2 years Postoperative
FIG. 2. Postoperative
follow-up.
Arthroscopy,
Vol. 6, No. I, 1990
22
P. SMILEY
AND
S. A. WASILEWSKI
Preoperative
Grade
I Preoperative
II X
III
m
IV
ray Grades
FIG. 3. Radiographic changes before operation.
Grade
I
II X - ray Grades
FIG. 5. Radiographic progression
Ill
IV
4 years after operation.
DISCUSSION Table 2 reviews the results of major studies on open and arthroscopic knee synovectomy. In our study, 96% of the operated knees showed good results at 6 months, 90% showed good clinical results at 2 years after arthroscopic synovectomy, and 57% of the knees continued to show improvement after 4 years. These data compare favorably with the published results of conventional open knee synovectomy as well as with the results of arthroscopic synovectomy published by Klein and Jensen (9). The presence or absence of clinical deterioration of the knees in this review correlates well with the presence or absence of radiographic deterioration of the disease at 2- and 4-year follow-up (Table 3). Fifty-seven percent of the knees studied continued to show clinical improvement at 4 years, and 62% of
the knees evaluated at 4 years showed no radiographic deterioration. In our experience, arthroscopic synovectomy proved to have fewer operative complications and decreased postoperative morbidity than that reported for conventional open synovectomy. Graham and Checketts (7) reported that 31% of their patients who underwent open synovectomy had decreased postoperative ROM. In the study of Paradies (3), 64% of patients lost motion and 46% required manipulation while they were under anesthesia. The hospital stay for patients in the study reported by Ranawat et al. (5) ranged from 3 to 6 weeks, and 46% of their patients required postoperative manipulation while they were under anesthesia to increase ROM. During the past 6 years, we have found that the
TABLE 2. Open and arthroscopic
Preoperative 2-y
follows
;,
up
synovectomy
Year 1972 1973 1973
I
Grade
II
Ill X-ray
Vol.
6, No.
1, 1990
1979
Ranawat et al. (5) Marmor (6) Graham and Checketts (7) Taylor (4)
1988 1989
Klein and Jensen (9) Present study
IV
Grades
FIG. 4. Radiographic progression 2 years after operation.
Arthroscopy.
Author
(1Average follow-up.
knee
studies Clinical results (% good)
Length of follow-up (yr)
73 53 5.5
2.8“ 4” 5-9
74 59 44 28 78 96 90 57
1 3 6 9 2.7” 6mo 2 4
ARTHROSCOPIC TABLE 3. Follow-up intervals
Good clinical results
No radiographic deterioration
2 yr
4 yr
90% 81%
57% 62%
technique of arthroscopy has improved our ability to perform a complete synovectomy of the knee. In particular, the use of the arthroscope has enabled us to do a complete posterior synovectomy easily. It has allowed us to perform an extensive synovectomy while preserving the menisci. Krause et al. (12) showed that menisci perform a load-transmitting and energy-absorbing function in the knee joint and that the stress acting across the joint increases appreciably after meniscectomy. This increased stress has been shown to increase the possibility of degeneration of the joint (13,14). In both of the studies reported on by Ranawat et al. (5) and Paradies (3), the menisci were removed to complete the total synovectomy. As compared with conventional open synovectomy, we have been able to shorten appreciably the patient’s hospital stay. Operative complications and the need for postoperative manipulations have also been nearly eliminated. In addition to these benefits, we have found that the results of arthroscopic synovectomy of the knee are at least as good at 2 and 4 years after operation as those published with conventional open synovectomy. Our 2-year data also correspond fairly well with the data published by Klein and Jensen (9) for arthroscopic synovectomy. CONCLUSION Synovectomy of the knee for rheumatoid arthritis has been shown by many to be beneficial in patients who demonstrate only minor radiographic deterioration and who do not respond to conservative medicaI management. Arthroscopy has enabled us to perform a complete synovectomy, including the posterior compartment, while preserving the menisci. The results
23
SYNOVECTOMY
obtained after arthroscopic synovectomy are comparable with those obtained after open synovectomy. In addition, the arthroscopic procedure is less stressful for the patient, with significantly lessened operative and postoperative morbidity. This study, however, shows that these initial beneficial effects deteriorate with time, not only clinically but radiographically. It must be stressed that this procedure provides symptomatic and not prophylactic treatment. Some of these patients may eventually require total knee arthroplasties, but in many instances, a total synovectomy can provide pain relief, increase motion, decrease effusion, and improve quality of life. REFERENCES 1. Goldthwait JE. Knee joint surgery for nontubercular conditions. Boston Med Surg .I 1900;143:286-90. 2. Laurin CA, Desmarchais J, Daziano L, Gari6py R, Derome A. Long-term results of synovectomy of the knee in rheumatoid patients. J Bone Joinf Surg [Am] 1974;56:521-31. 3. Paradies LH. Synovectomy for rheumatoid arthritis of the knee. J Bone Joint Surg [Am] 1975;57:95-100. 4. Taylor AR. Synovectomy of the knee in rheumatoid arthritis: long-term results [Abstract]. J Bone Joint Surg [Br] 1979;61:121. 5. Ranawat CS, Ecker ML, Straub LR. Synovectomy and debridement of the knee in rheumatoid arthritis (a study of 60 knees). Arthritis Rheum 1972;15:571-81. 6. Marmor L. Surgery of the rheumatoid knee: synovectomy and debridement. J Bone Joint Surg [Am] 1973;55:5354l. 7. Graham J, Checketts RG. Synovectomy of the knee-joint in rheumatoid arthritis. A long-term follow-up. J Bone Joint Surg [Br] 1973;55:786-95.
8. McEwen C. Multicenter evaluation of synovectomy in the treatment of rheumatoid arthritis. A report of results at the end of five years. J Rheumatol 1988;15:764-9. 9. Klein W, Jensen KU. Arthroscopic synovectomy of the knee joint: indications, technique and follow-up results. Arthroscopy 1988;4:63-7 1. 10. Highgenboten CL. Arthroscopic synovectomy. Orthop Clin North Am 1982;13:399-405. 11. Highgenboten CL. Arthroscopic synovectomy. Arthroscopy 1985;1:190-3.
12. Krause WR, Pope MH, Johnson RJ, Wilder DG. Mechanical changes in the knee after meniscectomy. J Bone Joint Surg [Am] 1976;58:599-604.
13. Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Sura lAm1 1%9:51:517-26.
14. Johnson RJ, Ketilekamp DB; Clark W, Leaverton P. Factors affecting late results after meniscectomy. J Bone Joint Surg [Am] 1974;56:7&29.
Arthroscopy, Vol. 6, NO. I, 1990
Published by Raven Press, Ltd. 8 1990Arthroscopy Association of North America
Arthroscopic Synovectomy Paul Smiley, M.D. and Stephen A. Wasilewski,
M.D.
Summary: This study was undertaken to evaluate the efficacy of knee synovectomy with arthroscopic technique. Nineteen patients with 25 operated knees were studied. All 25 knees had 6-month follow-up, 21 knees had 2-year follow-up, and 14 knees were evaluated at least 4 years after operation. After operation, patients were evaluated using clinical data including pain relief, functional capacity, range of motion, recurrent synovitis, and presence of effusion. Preoperative as well as follow-up weight-bearing radiographs were also studied to assess the results of this procedure. At 6 months’ postoperative clinical evaluation, 96% of patients showed good results. At 2 years, 90% of patients were considered to have good results, and at 4 years, 57% of patients continued to do well. Of those knees studied radiographically, 81% showed no progressive radiographic changes at 2 years and 61.5% showed no deterioration at 4 years. Clinical results correlated well with radiographic results. Arthroscopic synovectomy yielded results similar to those previously published for open synovectomy, with less operative and postoperative morbidity. Key Words: Rheumatoid arthritis-Knee synovectomy.
Open synovectomy of the knee was first performed in the United States in 1900 by Goldthwait (l), and to date several long-term studies have been reported on patients who have had open total and partial synovectomy of the knee (2-7). The results reported for open total synovectomy of the knee for rheumatoid arthritis have been relatively consistent. In 1972, Ranawat et al. (5) reported that 73% of their patients with rheumatoid arthritis showed improvement an average of 2.8 years after synovectomy. Marmor (6) found good results in 75% of his patients who had only early preoperative radiographic changes before synovectomy. However, in his entire group of patients, only 53% had good results. Taylor (4) in 1979 came to the conclusion that synovectomy, if performed early,
before radiographic changes were evident, was more useful and appeared to retard the development of further changes. The consensus of most of these studies appears to be that if performed during the early stages of the disease before severe joint destruction is present, open synovectomy for rheumatoid arthritis served to slow down, and in some patients halt, the progression of the disease (4). However, not all authors believe in the effectiveness of synovectomy. McEwen (8), in a multicenter study published in 1988, found that surgical synovectomy had little long-term value in the general treatment of rheumatoid arthritis or in the prevention of recurrence of disease activity or progressive articular damage. In 1988, Klein and Jensen (9) published a report on arthroscopic synovectomy of the knee with an average follow-up of 2.7 years. These authors described the surgical technique and discussed the feasibility of performing arthroscopic synovectomy for hypertrophic synovitis of the knee joint. They reported promising short-term results, as good if not better than those reported for conventional open synovectomy. However, there has not yet
From the Department of Orthopaedic Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts, U.S.A. Address correspondence and reprint requests to Dr. S. A. Wasilewski, Department of Orthopaedic Surgery, Lahey Clinic Medical Center, 41 Mall Road, Burlington, MA 0180.5, U.S.A. Results of this study were presented at the 1989 Annual Meeting of the Arthroscopy Association of North America, April 1316, Seattle, Washington, U.S.A.
18
ARTHROSCOPIC TABLE 1. Grading of weight-bearing Grade I II
III IV
radiographs
Criteria No evidence of radiographic degenerative changes Radiographic evidence of osteoporosis. Slight destruction of articular cartilage may be present with 40% loss of joint space Loss of joint space 350% Complete loss of joint space
been a study that looks at the patients’ clinical results and radiographic changes over a long period. This study evaluated patients who had undergone arthroscopic synovectomy of the knee at 6 months, 2 years, and 4 years after operation. We correlated preoperative and postoperative radiographic evaluation of the knee with the patient’s clinical results and compared our results of synovectomy using the arthroscopic technique with the previously published results for the conventional open procedure. MATERIALS AND METHODS This study is a retrospective review of 19 patients with 25 operated knees who underwent arthroscopic synovectomy of the knee at the Lahey Clinic between 1983 and 1988. These patients were evaluated at 6 months, 2 years, and 4 years after operation. All patients had appreciable pain and swelling that persisted despite a minimum of 6 months to a maximum of 10 years of medical management and were referred by their rheumatologist for consideration for synovectomy. Synovectomy was offered as symptomatic and not prophylactic treatment. At the time of operation, the ages of the patients ranged from 16 to 66 years, with a median age of 42 years. Fourteen patients were female and five were male. Twenty-two of the knees were involved by rheumatoid arthritis or variants of rheumatoid disease, two by psoriatic arthritis, and one by pigmented villonodular synovitis. The median followup at the time of this review was 55 months with a range of 6-72 months. The surgical technique employed involved a systematic approach to the synovial pouch of the knee joint. All operations were done with patients under either general or spinal anesthesia. Each procedure was performed with a pneumatic tourniquet inflated on the thigh. If the operative procedure lasted longer than 2 h, the tourniquet was released and then reinflated after 8 to 10 min. All operations were
19
SYNOVECTOMY
accomplished using an arthroscopic leg holder allowing flexion of the knee to 90”. Surgical technique The synovial pouch was divided into seven sections. Routinely, five to six skin portals were used to perform an entire synovectomy including the posterior compartment. The technique of arthroscopic synovectomy has been described previously by Highgenboten in 1982 (10) and 1985 (11) and by Klein and Jensen in 1988 (9). We have found that the following points need to be stressed. 1. Menisci, if at all possible, need to be preserved. In our study, one patient had a coexistent tear of the lateral meniscus and underwent a partial lateral meniscectomy, and one patient had undergone a previous medial meniscectomy. In all other patients, both menisci were left intact. 2. Synovial ingrowth into the cruciate ligaments, especially the anterior cruciate, should be resected carefully to preserve these structures. 3. Pannus formation in the medial and lateral aspects of the knee should be carefully stripped off the junction of the synovium and the articular cartilage. 4. Frequent repositioning of the arthroscope and power instruments in the various portals is important to avoid iatrogenic damage to the articular cartilage. 5. The use of a posteromedial portal is essential to perform a synovectomy of the posterior compartment. A 70” arthroscope is inserted through the intercondylar notch to visualize the posterior compartment. The synovectomy is performed through the posteromedial portal and if necessary, through an additional posterolateral portal. Occasionally a second posteromedial portal is used to provide additional inflow. A posterior synovectomy was performed in all patients. After operation, the patients were placed in a modified Jones dressing and were discharged with instructions to bear weight as tolerated with crutches. They were instructed to begin immediate range-of-motion (ROM) and quadriceps exercises. Patients were seen a week after operation, at which time most were able to walk without crutches. Sutures were removed, and patients were begun on a supervised physical therapy program of active assisted ROM exercises. At follow-up, patients were evaluated clinically using the subjective and objective criteria of pain relief, level of activity, presence or absence of efArthroscopy,
Vol. 6, No. 1. 1590
1 A,B
1 C,D
ARTHROSCOPIC
21
SYNOVECTOMY
FIG. 1. Grading of weight-bearing radiographs. A: Grade I. B: Grade II. C: Grade III. D: Grade IV.
fusion, and ROM of the knee joint. A good result was defined as little or no pain, no recurrent effusion, unchanged or improved ROM, and little or no limitation of activity. A poor result was defined as persistent knee pain, effusion, limitation of activity, or loss of motion of the knee. Preoperative weight-bearing radiographs were obtained in all patients and were graded I-IV according to the grading system outlined in Table 1 and illustrated by Fig. 1. RESULTS We found that the average surgical time decreased from 2 h 30 min for the cases before 1985 to 1 h 55 min since then because of both improved surgical technique and the development of more sophisticated arthroscopic power tools. The average hospital stay after operation was 2.7 days, with a range of 6 h to 8 days. Twenty percent of the procedures were performed as outpatient surgery. There were no operative complications. Three patients eventually underwent total knee arthroplasty, and one more is currently being evaluated for arthroplasty. One patient fell 2 months after operation and required a closed manipulation of the knee for decreased motion. One year after operation, this same patient underwent a repeat arthroscopy, patella chondroplasty, and removal of loose bodies. There was no evidence of recurrent synovitis. No other patients lost motion in their knees. One patient underwent repeat arthroscopy at another center for persistent swelling 9 months after the original operation, which reportedly showed no recurrent synovitis. All 25 knees were evaluated clinically at 6 months after operation. Subsequently, 21 knees were examined at 2-4 years, and 14 of these 21 knees were evaluated at 4-6 years after operation. At the 6-month postoperative evaluation, 24 of the 25 knees (96%) showed good results. Of the 16 patients with 21 operated knees evaluated at 24 years, 19 of the knees (90%) were considered to have good results. Two of the knees (10%) demonstrated poor clinical results at 2-year follow-up. One of these knees underwent total knee arthroplasty 11 months after operation after showing a one-grade radiographic deterioration (grades II-III). The other knee demonstrated a two-grade radiographic deterioration (grades II-IV) before un-
dergoing total knee arthroplasty at 47 months after initial synovectomy. Eleven patients with 14 operated knees were evaluated at least 4 years after operation. Clinically, eight knees (57%) continued to do well, and six knees (43%) showed progressive clinical deterioration (Fig. 2). One of these knees underwent total knee arthroplasty at 47 months, one at 64 months, and one knee is currently undergoing consideration for total knee arthroplasty. Twenty-four of the 25 knees showed either grade I or grade II radiographic changes before operation. One knee showed grade III preoperative changes (Fig. 3). Weight-bearing radiographs of 16 knees were evaluated at 2-year follow-up and of 13 knees at 4-year follow-up using the same grading system. Of the 16 knees evaluated by radiography at 2 years, 13 knees (81%) showed no progressive radiographic deterioration and 3 knees (1%) showed progression of one grade as compared with preoperative films (Fig. 4). In the 10 patients with 13 operated knees evaluated by radiography at 4-year follow-up, 8 knees (62%) showed no progressive radiographic changes and 5 knees (38%) showed progressive radiographic deterioration. One knee progressed one grade, one knee progressed two grades, and three knees showed a three-grade radiographic deterioration (Fig. 5). None of the knees that continued to show good clinical results at 4 years had evidence of radiographic deterioration of disease when compared with their preoperative radiographs . Good Poor
6 months
clinical clinical
results m results
4 years Follow - up
2 years Postoperative
FIG. 2. Postoperative
follow-up.
Arthroscopy,
Vol. 6, No. I, 1990
22
P. SMILEY
AND
S. A. WASILEWSKI
Preoperative
Grade
I Preoperative
II X
III
m
IV
ray Grades
FIG. 3. Radiographic changes before operation.
Grade
I
II X - ray Grades
FIG. 5. Radiographic progression
Ill
IV
4 years after operation.
DISCUSSION Table 2 reviews the results of major studies on open and arthroscopic knee synovectomy. In our study, 96% of the operated knees showed good results at 6 months, 90% showed good clinical results at 2 years after arthroscopic synovectomy, and 57% of the knees continued to show improvement after 4 years. These data compare favorably with the published results of conventional open knee synovectomy as well as with the results of arthroscopic synovectomy published by Klein and Jensen (9). The presence or absence of clinical deterioration of the knees in this review correlates well with the presence or absence of radiographic deterioration of the disease at 2- and 4-year follow-up (Table 3). Fifty-seven percent of the knees studied continued to show clinical improvement at 4 years, and 62% of
the knees evaluated at 4 years showed no radiographic deterioration. In our experience, arthroscopic synovectomy proved to have fewer operative complications and decreased postoperative morbidity than that reported for conventional open synovectomy. Graham and Checketts (7) reported that 31% of their patients who underwent open synovectomy had decreased postoperative ROM. In the study of Paradies (3), 64% of patients lost motion and 46% required manipulation while they were under anesthesia. The hospital stay for patients in the study reported by Ranawat et al. (5) ranged from 3 to 6 weeks, and 46% of their patients required postoperative manipulation while they were under anesthesia to increase ROM. During the past 6 years, we have found that the
TABLE 2. Open and arthroscopic
Preoperative 2-y
follows
;,
up
synovectomy
Year 1972 1973 1973
I
Grade
II
Ill X-ray
Vol.
6, No.
1, 1990
1979
Ranawat et al. (5) Marmor (6) Graham and Checketts (7) Taylor (4)
1988 1989
Klein and Jensen (9) Present study
IV
Grades
FIG. 4. Radiographic progression 2 years after operation.
Arthroscopy.
Author
(1Average follow-up.
knee
studies Clinical results (% good)
Length of follow-up (yr)
73 53 5.5
2.8“ 4” 5-9
74 59 44 28 78 96 90 57
1 3 6 9 2.7” 6mo 2 4
ARTHROSCOPIC TABLE 3. Follow-up intervals
Good clinical results
No radiographic deterioration
2 yr
4 yr
90% 81%
57% 62%
technique of arthroscopy has improved our ability to perform a complete synovectomy of the knee. In particular, the use of the arthroscope has enabled us to do a complete posterior synovectomy easily. It has allowed us to perform an extensive synovectomy while preserving the menisci. Krause et al. (12) showed that menisci perform a load-transmitting and energy-absorbing function in the knee joint and that the stress acting across the joint increases appreciably after meniscectomy. This increased stress has been shown to increase the possibility of degeneration of the joint (13,14). In both of the studies reported on by Ranawat et al. (5) and Paradies (3), the menisci were removed to complete the total synovectomy. As compared with conventional open synovectomy, we have been able to shorten appreciably the patient’s hospital stay. Operative complications and the need for postoperative manipulations have also been nearly eliminated. In addition to these benefits, we have found that the results of arthroscopic synovectomy of the knee are at least as good at 2 and 4 years after operation as those published with conventional open synovectomy. Our 2-year data also correspond fairly well with the data published by Klein and Jensen (9) for arthroscopic synovectomy. CONCLUSION Synovectomy of the knee for rheumatoid arthritis has been shown by many to be beneficial in patients who demonstrate only minor radiographic deterioration and who do not respond to conservative medicaI management. Arthroscopy has enabled us to perform a complete synovectomy, including the posterior compartment, while preserving the menisci. The results
23
SYNOVECTOMY
obtained after arthroscopic synovectomy are comparable with those obtained after open synovectomy. In addition, the arthroscopic procedure is less stressful for the patient, with significantly lessened operative and postoperative morbidity. This study, however, shows that these initial beneficial effects deteriorate with time, not only clinically but radiographically. It must be stressed that this procedure provides symptomatic and not prophylactic treatment. Some of these patients may eventually require total knee arthroplasties, but in many instances, a total synovectomy can provide pain relief, increase motion, decrease effusion, and improve quality of life. REFERENCES 1. Goldthwait JE. Knee joint surgery for nontubercular conditions. Boston Med Surg .I 1900;143:286-90. 2. Laurin CA, Desmarchais J, Daziano L, Gari6py R, Derome A. Long-term results of synovectomy of the knee in rheumatoid patients. J Bone Joinf Surg [Am] 1974;56:521-31. 3. Paradies LH. Synovectomy for rheumatoid arthritis of the knee. J Bone Joint Surg [Am] 1975;57:95-100. 4. Taylor AR. Synovectomy of the knee in rheumatoid arthritis: long-term results [Abstract]. J Bone Joint Surg [Br] 1979;61:121. 5. Ranawat CS, Ecker ML, Straub LR. Synovectomy and debridement of the knee in rheumatoid arthritis (a study of 60 knees). Arthritis Rheum 1972;15:571-81. 6. Marmor L. Surgery of the rheumatoid knee: synovectomy and debridement. J Bone Joint Surg [Am] 1973;55:5354l. 7. Graham J, Checketts RG. Synovectomy of the knee-joint in rheumatoid arthritis. A long-term follow-up. J Bone Joint Surg [Br] 1973;55:786-95.
8. McEwen C. Multicenter evaluation of synovectomy in the treatment of rheumatoid arthritis. A report of results at the end of five years. J Rheumatol 1988;15:764-9. 9. Klein W, Jensen KU. Arthroscopic synovectomy of the knee joint: indications, technique and follow-up results. Arthroscopy 1988;4:63-7 1. 10. Highgenboten CL. Arthroscopic synovectomy. Orthop Clin North Am 1982;13:399-405. 11. Highgenboten CL. Arthroscopic synovectomy. Arthroscopy 1985;1:190-3.
12. Krause WR, Pope MH, Johnson RJ, Wilder DG. Mechanical changes in the knee after meniscectomy. J Bone Joint Surg [Am] 1976;58:599-604.
13. Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Sura lAm1 1%9:51:517-26.
14. Johnson RJ, Ketilekamp DB; Clark W, Leaverton P. Factors affecting late results after meniscectomy. J Bone Joint Surg [Am] 1974;56:7&29.
Arthroscopy, Vol. 6, NO. I, 1990