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Arthroscopic synovectomy
Arthroscopy: The Journal of Arthroscopic and Related Surgery 1(3): 190-193 @ 1985 Arthroscopy Association of North America
Arthroscopic Synovectomy Carl L. Highgenboten, M.D.
Abstract: Arthroscopic synovectomy of the knee is a technique used for the treatment of the patient whose problems with synovitis and effusion are unsuccessfully treated by nonsurgical means. It offers multiple advantages when compared with open synovectomy but requires attention to detail and the surgeon should follow a set routine. A proven technique and routine are presented.
patient, the surgeon must be prepared to treat correctly any intra-articular lesions encountered in addition to carrying out the synovectomy. The debridement of the rheumatoid knee is often a very time-consuming procedure, even in the hands of the highly skilled arthroscopic surgeon. For these two reasons it is best if the procedures are not undertaken by the surgeon who has only rudimentary arthroscopic skills, or by the infrequent operator. We have used arthroscopic synovectomy for the treatment of patients with rheumatoid arthritis, pigmented villonodular synovitis, synovial osteochondromatosis, and o t h e r synovial disorders since 1977. In the reports on open synovectomy, most authors reported major problems with regaining motion (often requiring manipulation under anesthesia), with prolonged hospitalization, and extensive physical therapy. Most of our patients are able to walk without a limp and regain their preoperative range of motion within 7 to 10 days after their surgery. It is routine in our program to perform arthroscopic debridement of the knee on an outpatient basis; the patients have their physical therapy, which is markedly reduced, as an outpatient. This allows the gainfully employed patients to return to work in a few days. No need has been found for postoperative drains or aspiration, and postoperative pain has not been a problem. Arthroscopic debridement of the knee should be
Synovectomy of the knee was first reported in 1877 by Volkmann for the treatment of tuberculosis, and 23 years later Mignon reported the first synovectomy of the knee for rheumatoid arthritis (1). Because synovectomy of the knee often has a difficult postoperative course, it has remained a controversial method of treatment to the present. With the advent of the technique of arthroscopic synovectomy, many of the difficulties associated with open synovectomy of the knee have been significantly eliminated. When considering treatment for the patient with rheumatoid arthritis, one must remember that rheumatoid arthritis is a chronic, generally progressive disease that no surgical treatment can totally halt or alleviate. Originally involving only the synovium, it ultimately attacks the articular surfaces and other intra-articular structures. In fact, one group of 20 patients d e m o n s t r a t e d involvement o f the menisci in 95% of the knees at the time of arthroscopic debridement for rheumatoid disease. This is extremely important because when arthroscopic treatment is planned for the knee of a rheumatoid
From the Division of Orthopedic Surgery, Department of Surgery, University of Texas Southwestern Medical School and Humana Hospital, Dallas, Texas, U.S.A. Address correspondence and reprint requests to Dr. C. L. Highgenboten at 7777 Forest Lane, Dallas, TX 75230, U.S.A.
190
ARTHROSCOPIC S Y N O V E C T O M Y used to decrease chronic pain and effusion in the knee that does not respond to medical management. The underlying disease is not cured, but arthroscopic debridement can significantly improve the quality of life of the patient. In fact, open synovectomy with its associated difficulties has been shown to be a worthwhile procedure when subjected to a cost-benefit analysis. Therefore, it must be assumed that arthroscopic debridement with its decreased hospitalization and time off work is even more beneficial. The equipment that is needed to carry out the debridement of the rheumatoid knee is basically the same used for all arthroscopic procedures. There are a few special instruments needed in addition to the standard arthroscopic instruments. It is important the procedure not be attempted with less than adequate equipment, as that will change the procedure from difficult to impossible. Equally important is the skill and training of the whole team; they will need to work with the surgeon to carry out the procedure in an efficient manner without excessive tourniquet or anesthesia time.
191
SPECIAL EQUIPMENT I. 2. 3. 4. 5.
Large synovial resector Small synovial resector Large Rosenberg full radius synovial resector Small Rosenberg full radius synovial resector Patience
The technique of arthroscopic debridement of the rheumatoid knee differs from the treatment of other problems because it requires more attention to detailed adherence to a systematic plan of attack. Much must be accomplished in a limited amount of time, and it is easy to overlook areas that need to be dealt with if a plan is not followed. By doing certain parts of the procedure at the correct time, later portions are made much easier. As in all of our cases, a diagnostic arthroscopic examination is carried out as the first stage of the procedure. For the portion of the procedure shown in Fig. 1 the inflow cannula is in the superomedial portal and the arthroscope is initially in the inferolateral portal and later in the superolateral portal. With the arthroscope in the inferolateral portal, the medial compartment, intracondylar notch, and lateral compartment are inspected, respectively. The
STANDARD EQUIPMENT 1. Fluid supply a. Three-liter bags of saline or Ringer's lactate, usually use 4-6 per case b. TURP large bore Y-tubing c. Large inflow cannula 2. Visualization system a. A 4-mm arthroscope, usually 30 degrees but possibly 70 degrees b. High-powered light source c. Television system d. Articulated viewing arm unless using small video camera e. Tourniquet f. Legholder 3. Instruments a. Probe b. Intra-articular knives c. Basket ronguers d. Scissors e. Motorized meniscal cutters f. Arthroplasty system 4. Outflow a. Via the motorized instruments b. Large suction bottle with a built-in straining device
FIG. 1. Anterior-posterior view of right knee with the four routine puncture sites.
Arthroscopy, Vol. 1, No. 3, 1985
192
C. L. HIGHGENBOTEN
arthroscope is then moved to the superolateral portal to provide a better view of the patella and suprapatellar pouch area. During the early stages of the procedure, adequate light may be a problem due to the large amount of synovitis present. After completion of the diagnostic examination, the resection of the synovium is begun with the arthroscope superolateral and the resector inferolateral. With this combination, synovium in the anterior aspect of the joint, including the plica, fatpad, and ligamentum mucosum, is resected. By doing this first, the fluid flow, critical later in the case, is markedly improved in the medial and lateral compartments. When this step is completed it is best to attempt to resect part of the synovium in the suprapatellar pouch and in the medial and lateral gutters. With the arthroscope inferolateral and the resector inferomedial, the rest of the ligamentum mucosum is resected, and the synovium in the medial gutter and anteromedial area just above the meniscus is resected. At this point it may be necessary to deal with medial meniscal or articular surface pathology; however, this should be last in the rare case that will benefit from an abrasion chondroplasty. Using the small resectors, the synovitis along the medial meniscus and in the intracondylar notch should be cleared. In very loose joints it may be possible to do the synovectomy of the posteromedial pouch with this combination. Attention should then be directed to the lateral compartment. First, the anterior synovium is resected and then any work required on the lateral meniscus or articular surfaces is carried out. Prior to quitting this combination of portals, they should be utilized to work in the suprapatellar pouch, peripatellar areas, and in the medial gutter where possible. Next the portals are interchanged with the arthroscope inferomedial and the resector inferolateral. Further debridement of the medial compartment is carried out, particularly inferior to the meniscus, often with the small resectors. Completion of the debridement of the medial meniscus and the medial articular surfaces can be carried out at this time. Following this, debridement of the lateral compartment is continued with particular attention to the area of the popliteus tendon sheath. If possible the posterolateral pouch is debrided and then attention is turned to the lateral gutter. As the last part of this combination any appropriate debridement of the suprapatellar pouch, peripatellar area, and front of the joint possible should be completed. Arthroscopy, Vol. 1, No. 3, 1985
The arthroscope is moved superolateral to complete the debridement of the lateral gutter with the resector left inferolateral. After moving the inflow cannula inferomedial, the resector is moved superomedial leaving the arthroscope superolateral. This combination should allow for the completion of the debridement of the suprapatellar pouch. On rare occasions, secondary, more proximal superolateral and superomedial portals may be required in the chronically distended suprapatellar pouch. After interchanging the portal of the arthroscope and the resector so that the arthroscope is superomedial and the resector is superolateral for any final cleaning of the pouch, the inflow cannula and the resector are interchanged so that the inflow is superolateral and the resector is inferomedialbfor the final cleaning of the medial gutter. If posterior synovectomy is needed and cannot be completed with the previously described portal combinations, posterior portals may be required. The posteromedial portal as is shown in Fig. 2 is initially located by passing an 18-gauge spinal needle into the posteromedial pouch while viewing with an arthroscope passed through the intracondylar notch. Only after this has been successfully
FIG. 2. Medial view of left knee demonstrating site of posteromedial puncture site.
ARTHROSCOPIC SYNOVECTOMY
FIG. 3. Lateral view of left knee demonstrating site of posterolateral puncture site.
carried out is the actual skin incision created. With the arthroscope inferolateral the resector is placed posteromedial and the posteromedial pouch is cleaned. The arthroscope is moved inferomedial and an 18-gauge spinal needle is again used to locate the correct placement for the posterolateral portal. The approximate location of the skin incision for the posterolateral portal is shown in Fig. 3. Once this portal is established the synovial resector is placed into the posterolateral pouch while the scope is used to view the posterolateral pouch via the intracondylar notch. With this combination the posterolateral pouch is cleaned. It may be necessary to use a 70 degree scope for a portion of the posterior debridement. After the completion of the debridement the joint should be reinspected. Although the small synovial resector and the small full radius synovial resector usually do an adequate debridement of the syno-
193
vium along the edge of the articular surfaces, if this has not been possible a small curret can be used. If any further treatment of joint abnormalities is required, such as an abrasion chondroplasty, it should be done at this time. The joint is irrigated with copious amounts of sterile saline and a sterile dressing is applied. No sutures or steri-strips are used. The dressing is made of 4 x 4s, Sterile Webril, and an elastic bandage. The patients are allowed to remove their dressings and shower on the second postoperative day but swimming and tub bathing, a very unsanitary practice anyway, is delayed for 2 weeks. The patients spend approximately 1 hour in the recovery room where they receive IV Sublimaze for pain control. After they leave the recovery room they receive only Tylenol no. 4 or its equivalent for pain control. They usually are discharged from the day surgery unit within 3 to 4 h. All patients are seen the day before their surgery by our physical therapists and instructed in their exercise program and how to use crutches or a walker. They are next seen by the therapist approximately 3 days after their surgery and subsequently on an individualized, as needed basis. Work and other activities may be resumed as soon as the patients feel able to do so. Most are able to resume their usual daily activities within 2 weeks or less. In summary I would like to stress several points. (a) Arthroscopic debridement (synovectomy plus) can be very beneficial to the rheumatoid patient in controlling their pain and swelling and improving the quality of their life. (b) Arthroscopic debridement does not cure the underlying disease process. (c) Arthroscopic debridement, if done correctly, is not a simple procedure and requires a surgeon who will devote the time required to acquire and maintain the needed skills. (d) There is no good reason to carry out an open synovectomy of the knee. REFERENCES 1. Laurin CA, eta]. Surgery o f rheumatoid arthritis. Philadelphia: J. B. Lippincott, 1971.
Arthroseopy, Vol. 1, No. 3, 1985
Arthroscopic Synovectomy Carl L. Highgenboten, M.D.
Abstract: Arthroscopic synovectomy of the knee is a technique used for the treatment of the patient whose problems with synovitis and effusion are unsuccessfully treated by nonsurgical means. It offers multiple advantages when compared with open synovectomy but requires attention to detail and the surgeon should follow a set routine. A proven technique and routine are presented.
patient, the surgeon must be prepared to treat correctly any intra-articular lesions encountered in addition to carrying out the synovectomy. The debridement of the rheumatoid knee is often a very time-consuming procedure, even in the hands of the highly skilled arthroscopic surgeon. For these two reasons it is best if the procedures are not undertaken by the surgeon who has only rudimentary arthroscopic skills, or by the infrequent operator. We have used arthroscopic synovectomy for the treatment of patients with rheumatoid arthritis, pigmented villonodular synovitis, synovial osteochondromatosis, and o t h e r synovial disorders since 1977. In the reports on open synovectomy, most authors reported major problems with regaining motion (often requiring manipulation under anesthesia), with prolonged hospitalization, and extensive physical therapy. Most of our patients are able to walk without a limp and regain their preoperative range of motion within 7 to 10 days after their surgery. It is routine in our program to perform arthroscopic debridement of the knee on an outpatient basis; the patients have their physical therapy, which is markedly reduced, as an outpatient. This allows the gainfully employed patients to return to work in a few days. No need has been found for postoperative drains or aspiration, and postoperative pain has not been a problem. Arthroscopic debridement of the knee should be
Synovectomy of the knee was first reported in 1877 by Volkmann for the treatment of tuberculosis, and 23 years later Mignon reported the first synovectomy of the knee for rheumatoid arthritis (1). Because synovectomy of the knee often has a difficult postoperative course, it has remained a controversial method of treatment to the present. With the advent of the technique of arthroscopic synovectomy, many of the difficulties associated with open synovectomy of the knee have been significantly eliminated. When considering treatment for the patient with rheumatoid arthritis, one must remember that rheumatoid arthritis is a chronic, generally progressive disease that no surgical treatment can totally halt or alleviate. Originally involving only the synovium, it ultimately attacks the articular surfaces and other intra-articular structures. In fact, one group of 20 patients d e m o n s t r a t e d involvement o f the menisci in 95% of the knees at the time of arthroscopic debridement for rheumatoid disease. This is extremely important because when arthroscopic treatment is planned for the knee of a rheumatoid
From the Division of Orthopedic Surgery, Department of Surgery, University of Texas Southwestern Medical School and Humana Hospital, Dallas, Texas, U.S.A. Address correspondence and reprint requests to Dr. C. L. Highgenboten at 7777 Forest Lane, Dallas, TX 75230, U.S.A.
190
ARTHROSCOPIC S Y N O V E C T O M Y used to decrease chronic pain and effusion in the knee that does not respond to medical management. The underlying disease is not cured, but arthroscopic debridement can significantly improve the quality of life of the patient. In fact, open synovectomy with its associated difficulties has been shown to be a worthwhile procedure when subjected to a cost-benefit analysis. Therefore, it must be assumed that arthroscopic debridement with its decreased hospitalization and time off work is even more beneficial. The equipment that is needed to carry out the debridement of the rheumatoid knee is basically the same used for all arthroscopic procedures. There are a few special instruments needed in addition to the standard arthroscopic instruments. It is important the procedure not be attempted with less than adequate equipment, as that will change the procedure from difficult to impossible. Equally important is the skill and training of the whole team; they will need to work with the surgeon to carry out the procedure in an efficient manner without excessive tourniquet or anesthesia time.
191
SPECIAL EQUIPMENT I. 2. 3. 4. 5.
Large synovial resector Small synovial resector Large Rosenberg full radius synovial resector Small Rosenberg full radius synovial resector Patience
The technique of arthroscopic debridement of the rheumatoid knee differs from the treatment of other problems because it requires more attention to detailed adherence to a systematic plan of attack. Much must be accomplished in a limited amount of time, and it is easy to overlook areas that need to be dealt with if a plan is not followed. By doing certain parts of the procedure at the correct time, later portions are made much easier. As in all of our cases, a diagnostic arthroscopic examination is carried out as the first stage of the procedure. For the portion of the procedure shown in Fig. 1 the inflow cannula is in the superomedial portal and the arthroscope is initially in the inferolateral portal and later in the superolateral portal. With the arthroscope in the inferolateral portal, the medial compartment, intracondylar notch, and lateral compartment are inspected, respectively. The
STANDARD EQUIPMENT 1. Fluid supply a. Three-liter bags of saline or Ringer's lactate, usually use 4-6 per case b. TURP large bore Y-tubing c. Large inflow cannula 2. Visualization system a. A 4-mm arthroscope, usually 30 degrees but possibly 70 degrees b. High-powered light source c. Television system d. Articulated viewing arm unless using small video camera e. Tourniquet f. Legholder 3. Instruments a. Probe b. Intra-articular knives c. Basket ronguers d. Scissors e. Motorized meniscal cutters f. Arthroplasty system 4. Outflow a. Via the motorized instruments b. Large suction bottle with a built-in straining device
FIG. 1. Anterior-posterior view of right knee with the four routine puncture sites.
Arthroscopy, Vol. 1, No. 3, 1985
192
C. L. HIGHGENBOTEN
arthroscope is then moved to the superolateral portal to provide a better view of the patella and suprapatellar pouch area. During the early stages of the procedure, adequate light may be a problem due to the large amount of synovitis present. After completion of the diagnostic examination, the resection of the synovium is begun with the arthroscope superolateral and the resector inferolateral. With this combination, synovium in the anterior aspect of the joint, including the plica, fatpad, and ligamentum mucosum, is resected. By doing this first, the fluid flow, critical later in the case, is markedly improved in the medial and lateral compartments. When this step is completed it is best to attempt to resect part of the synovium in the suprapatellar pouch and in the medial and lateral gutters. With the arthroscope inferolateral and the resector inferomedial, the rest of the ligamentum mucosum is resected, and the synovium in the medial gutter and anteromedial area just above the meniscus is resected. At this point it may be necessary to deal with medial meniscal or articular surface pathology; however, this should be last in the rare case that will benefit from an abrasion chondroplasty. Using the small resectors, the synovitis along the medial meniscus and in the intracondylar notch should be cleared. In very loose joints it may be possible to do the synovectomy of the posteromedial pouch with this combination. Attention should then be directed to the lateral compartment. First, the anterior synovium is resected and then any work required on the lateral meniscus or articular surfaces is carried out. Prior to quitting this combination of portals, they should be utilized to work in the suprapatellar pouch, peripatellar areas, and in the medial gutter where possible. Next the portals are interchanged with the arthroscope inferomedial and the resector inferolateral. Further debridement of the medial compartment is carried out, particularly inferior to the meniscus, often with the small resectors. Completion of the debridement of the medial meniscus and the medial articular surfaces can be carried out at this time. Following this, debridement of the lateral compartment is continued with particular attention to the area of the popliteus tendon sheath. If possible the posterolateral pouch is debrided and then attention is turned to the lateral gutter. As the last part of this combination any appropriate debridement of the suprapatellar pouch, peripatellar area, and front of the joint possible should be completed. Arthroscopy, Vol. 1, No. 3, 1985
The arthroscope is moved superolateral to complete the debridement of the lateral gutter with the resector left inferolateral. After moving the inflow cannula inferomedial, the resector is moved superomedial leaving the arthroscope superolateral. This combination should allow for the completion of the debridement of the suprapatellar pouch. On rare occasions, secondary, more proximal superolateral and superomedial portals may be required in the chronically distended suprapatellar pouch. After interchanging the portal of the arthroscope and the resector so that the arthroscope is superomedial and the resector is superolateral for any final cleaning of the pouch, the inflow cannula and the resector are interchanged so that the inflow is superolateral and the resector is inferomedialbfor the final cleaning of the medial gutter. If posterior synovectomy is needed and cannot be completed with the previously described portal combinations, posterior portals may be required. The posteromedial portal as is shown in Fig. 2 is initially located by passing an 18-gauge spinal needle into the posteromedial pouch while viewing with an arthroscope passed through the intracondylar notch. Only after this has been successfully
FIG. 2. Medial view of left knee demonstrating site of posteromedial puncture site.
ARTHROSCOPIC SYNOVECTOMY
FIG. 3. Lateral view of left knee demonstrating site of posterolateral puncture site.
carried out is the actual skin incision created. With the arthroscope inferolateral the resector is placed posteromedial and the posteromedial pouch is cleaned. The arthroscope is moved inferomedial and an 18-gauge spinal needle is again used to locate the correct placement for the posterolateral portal. The approximate location of the skin incision for the posterolateral portal is shown in Fig. 3. Once this portal is established the synovial resector is placed into the posterolateral pouch while the scope is used to view the posterolateral pouch via the intracondylar notch. With this combination the posterolateral pouch is cleaned. It may be necessary to use a 70 degree scope for a portion of the posterior debridement. After the completion of the debridement the joint should be reinspected. Although the small synovial resector and the small full radius synovial resector usually do an adequate debridement of the syno-
193
vium along the edge of the articular surfaces, if this has not been possible a small curret can be used. If any further treatment of joint abnormalities is required, such as an abrasion chondroplasty, it should be done at this time. The joint is irrigated with copious amounts of sterile saline and a sterile dressing is applied. No sutures or steri-strips are used. The dressing is made of 4 x 4s, Sterile Webril, and an elastic bandage. The patients are allowed to remove their dressings and shower on the second postoperative day but swimming and tub bathing, a very unsanitary practice anyway, is delayed for 2 weeks. The patients spend approximately 1 hour in the recovery room where they receive IV Sublimaze for pain control. After they leave the recovery room they receive only Tylenol no. 4 or its equivalent for pain control. They usually are discharged from the day surgery unit within 3 to 4 h. All patients are seen the day before their surgery by our physical therapists and instructed in their exercise program and how to use crutches or a walker. They are next seen by the therapist approximately 3 days after their surgery and subsequently on an individualized, as needed basis. Work and other activities may be resumed as soon as the patients feel able to do so. Most are able to resume their usual daily activities within 2 weeks or less. In summary I would like to stress several points. (a) Arthroscopic debridement (synovectomy plus) can be very beneficial to the rheumatoid patient in controlling their pain and swelling and improving the quality of their life. (b) Arthroscopic debridement does not cure the underlying disease process. (c) Arthroscopic debridement, if done correctly, is not a simple procedure and requires a surgeon who will devote the time required to acquire and maintain the needed skills. (d) There is no good reason to carry out an open synovectomy of the knee. REFERENCES 1. Laurin CA, eta]. Surgery o f rheumatoid arthritis. Philadelphia: J. B. Lippincott, 1971.
Arthroseopy, Vol. 1, No. 3, 1985