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Arthroscopic synovectomy in the management of painful localized post-traumatic synovitis of the knee joint
Arthroscopic Synovectomy in the Management of Painful Localized Post-traumatic Synovitis of the Knee Joint Jos6 A. Comin, M.D. and E. C. Rodriguez-Merchfin, M.D., Ph.D.
Summary: Seventy-four patients were operated on by arthroscopic synovectomy after being diagnosed with symptomatic localized post-traumatic synovitis in a 5year period. Sixty-six patients (69 knees) could be evaluated at the end of the follow-up. The indication for surgery was severe mechanical type pain (score 3) after an evident injury nonresponding to 3 months of conservative treatment. Any other source of pain was preoperatively excluded by means of radiographs and magnetic resonance imaging, and intraoperatively by means of arthroscopic examination. The results were assessed according to a pain scale (score 0-3). Preoperatively all patients had severe pain (score 3). After a mean follow-up of 2.8 years (range, 1 to 6 years) there were 43 patients without pain (score 0), 15 with mild pain (score 1), 8 with moderate pain (score 2), and 3 with severe pain (score 3). In summary, this retrospective study appears to show that arthroscopic synovectomy should be taken into account when facing patients with painful localized post-traumatic synovitis of the knee joint. This is a diagnosis of exclusion as other internal derangements have been eliminated by magnetic resonance imaging and arthroscopic examination. Key Words: Arthroscopy--Synovectomy--Synovitis-- Post-traumatic.
Ynovectomy continues to be a useful option for treating selected patients with rheumatoid arthritis, l pigmented villonodular synovitis, 2 and hemophilic synovitis. 3 Synovectomy decreases, at least temporarily, the pain and synovitis of the knees affected by these conditions. The advantages of arthroscopic synovectomy are low morbidity, decreased risk of infection, and minimal loss of motion postoperatively. It is well known that, after an injury, a reactive synovitis can take place. Such a synovitis used to be associated with several conditions: acute rupture of the anterior cruciate ligament, patellar dislocation, meniscal tear, or an articular contusion (in which case, the synovitis sometimes does not dissapear spontane-
S
From private practice in orthopaedic surgery (J.A.C.), and the Service of Traumatology and Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain (E.C.R.M.). Address correspondence and reprints requests to E. C. Rodrfguez-Merchdn, M.D., Ph.D., Capitdn Blanco Argibay 21-G3A, 28029-Madrid, Spain. © 1997 by the Arthroscopy Association of North America 0749-8063/97/1305-155353.00/0
606
ously4). This article presents the authors' experience in treating a group of patients suffering from symptomatic localized post-traumatic synovitis.
MATERIALS AND METHODS In the 5-year period between January 1989 and December 1993, 215 patients were seen with severe mechanical type pain (score 3, Table 1) resulting from trauma to the anteromedial aspect of the knee. Patients had pain only with specific motions or positions, and otherwise they had no pain. They had no pain at rest, and they had very localized symptoms. They did not complain of nonmechanical type pain; that is, burning, constant pain, or pain that kept them awake at night. Seventy-four (25.6%) of these patients did not respond to a 3-month period of conservative treatment (relative rest and nonsteroidal anti-inflammatory drugs); 8 were lost at follow-up. Sixty-six patients (69 knees) were included in this retrospective study; 37 were male and 29 female. The right knee was involved
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 13, No 5 (October), 1997: pp 606-608
LOCALIZED POST-TRAUMATIC SYNOVITIS OF THE KNEE
TABLE 1. Assessment of Results in This Study 0: No mechanical pain (excellent result). 1: Mild mechanical pain (good result). Does not interfere with occupation nor with ADL 2: Moderate mechanical pain (fair result). Partial or occasional interference with occupation or ADL. 3: Severe mechanical pain (poor result). Interferes with occupation or ADL.
43 cases 15 cases 8 cases
607
no pain at all (score 0) or mild pain (score 1). Only 11 patients (16%) had moderate or severe mechanical type pain interfering with occupation or activities of daily living (scores 2 and 3). No complications were found in this series (e.g., flexion contracture). The patients with poor results were offered a new arthroscopic examination but all of them declined to do so.
3 cases
NOTE. Assessment of mechanical type pain: patients have pain with specific motions or positions, score 0-3. Abbreviation: ADL, activities of daily living.
in 39 cases and the left knee in 30 patients. The mean age of the patients was 33 years (range, 8 to 66 years). The follow-up was 2.85 years on average (range, 1 to 5 years). The indication for surgery was a knee that had mechanical symptoms (pain score 3) with an evident previous injury nonresponding to 3 months of conservative treatment. Other diagnoses, mainly a rupture of the anterior cruciate ligament, a meniscal tear, or osteoarthritic changes, were excluded by magnetic resonance imaging and were ruled out during arthroscopic examination. In every patient, the operations were carried out looking for the source of pain. In all of them, the only common finding was the presence of a localized synovitis producing an impaction area approximately 2 x 2 cm on the medial femoral condyle near the intercondylar notch; this was the main indication for an arthroscopic partial synovectomy. No other articular cartilage defects were found in the arthroscopic examination. The synovium in question was not the medial symptomatic plica (medial shelf syndrome). The operations were carried out under general anesthesia with the lower limb under tourniquet control. In every case a histopathologic examination excluded other diagnoses for the existing synovitis, i.e., rheumatoid arthritis. The results were assessed by means of a pain scale (score 0 to 3 points) (Table 1).
RESULTS A full range of motion was seen in every patient preoperatively, intraoperatively and postoperatively; no hyperextension was present. All patients had severe mechanical type pain (score 3) before arthroscopic synovectomy. At follow-up, 43 knees had an excellent result (no pain, score 0), 15 had a good result (mild pain, score 1), 8 patients had a fair result (moderate pain, score 2), and 3 patients had a poor result (severe pain, score 3). Thus, at follow-up, 84% of patients had
DISCUSSION The sources of a monoarticular knee synovitis commonly are mechanical disorder, infection, gout or pseudogout, bone necrosis or hemarthrosis, and trauma. 4 Direct blunt trauma to the anteromedial aspect of the knee may irritate the synovium, resulting in inflammation, localized synovitis, and subsequent fibrosis. Patients may complain of joint line tenderness, meniscallike symptoms, and rotational findings. Most patients respond to conservative care. In patients with persistent mechanical type pain who have not responded to the conservative modalities of ice, activity modification, and anti-inflammatory medication, arthroscopic debridement may be warranted. 5 According to Poehling (personal communication, 1997), patients who have pain at the knee and nothing else can usually be divided into two groups. One group of patients has mechanical type symptoms, that is, only with specific motions or positions. These patients seem to respond to surgery in a much higher percentage that patients who have nonmechanical symptoms. Nonmechanical symptoms are constant burning pain, pain that is present at all time (even at rest), and pain that keeps them awake at night even if they have not been active. These patients have an extremely low incidence of improvement after surgery. Typically they state that every time an arthroscopy is performed, they get worse. When, after 3 months of conservative treatment, mechanical type pain does not subside and no other sources for synovitis can be found, reactive localized post-traumatic synovitis should be suspected and arthroscopy can be useful to control the pain. In the authors' opinion, the pathogenesis of pain is the entrapment of the hypertrophic synovium in the joint space, and the removal of such a synovium will alleviate the symptoms and may avoid further cartilaginous involvement on the medial femoral condyle. Although we have considered hyperextension of the knee with impaction of the meniscus/tibia as a possible cause, we believe that our diagnosis was correct and that this was not a hyperextension/meniscal syndrome. We also believe that the synovitis was the primary cause of
608
J. A. C O M [ N A N D E. C. R O D R [ G U E Z - M E R C H A N
s y m p t o m s and was not secondary to a trochlear cartilage injury. W e have carried out a thorough review o f the English language literature concerning s y n o v e c t o m y and no other reports have been published on this subject. W e have no explanation for the 16% rate o f poor results in this series.* Since the major s y m p t o m o f this condition is mechanical type pain, we thought that an evaluation that emphasizes this s y m p t o m would be a g o o d indication of the outcome. The results of this study appear to show that arthroscopic partial s y n o v e c t o m y is a proce-
*It is possible that some of the 16% with poor results could have had unrecognized nonmechanical pain.
dure to be considered in solving painful localized posttraumatic synovitis o f the knee joint.
REFERENCES 1. Doets HC, Bierman BT, Soesbergen RM. Synovectomy of the rheumatoid knee does not prevent deterioration: 7-year followup of 83 cases. Acta Orthop Scand 1989;60:523-525. 2. Ogilvie-Harris DJ, McLean J, Zarnett ME. Pigmented villonodular synovitis of the knee. J Bone Joint Surg Am 1992;74:119123. 3. Rodriguez-Merchfin EC, Galindo E, Ladreda JMM, Pardo JA. Surgical synovectomy in haemophilic arthropathy of the knee. Int Orthop 1994; 18:38-41. 4. Christian CL. Knee synovitis. In: Insall JN, ed. Surgery of the knee. Ed. 2. New York: Churchill Livingstone, 1993;595-607. 5. Bach BR Jr. Knee and leg: Soft tissue-trauma. In: Kasser JR, ed. AAOS orthopaedic knowledge update 5. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1996;463-480.
Summary: Seventy-four patients were operated on by arthroscopic synovectomy after being diagnosed with symptomatic localized post-traumatic synovitis in a 5year period. Sixty-six patients (69 knees) could be evaluated at the end of the follow-up. The indication for surgery was severe mechanical type pain (score 3) after an evident injury nonresponding to 3 months of conservative treatment. Any other source of pain was preoperatively excluded by means of radiographs and magnetic resonance imaging, and intraoperatively by means of arthroscopic examination. The results were assessed according to a pain scale (score 0-3). Preoperatively all patients had severe pain (score 3). After a mean follow-up of 2.8 years (range, 1 to 6 years) there were 43 patients without pain (score 0), 15 with mild pain (score 1), 8 with moderate pain (score 2), and 3 with severe pain (score 3). In summary, this retrospective study appears to show that arthroscopic synovectomy should be taken into account when facing patients with painful localized post-traumatic synovitis of the knee joint. This is a diagnosis of exclusion as other internal derangements have been eliminated by magnetic resonance imaging and arthroscopic examination. Key Words: Arthroscopy--Synovectomy--Synovitis-- Post-traumatic.
Ynovectomy continues to be a useful option for treating selected patients with rheumatoid arthritis, l pigmented villonodular synovitis, 2 and hemophilic synovitis. 3 Synovectomy decreases, at least temporarily, the pain and synovitis of the knees affected by these conditions. The advantages of arthroscopic synovectomy are low morbidity, decreased risk of infection, and minimal loss of motion postoperatively. It is well known that, after an injury, a reactive synovitis can take place. Such a synovitis used to be associated with several conditions: acute rupture of the anterior cruciate ligament, patellar dislocation, meniscal tear, or an articular contusion (in which case, the synovitis sometimes does not dissapear spontane-
S
From private practice in orthopaedic surgery (J.A.C.), and the Service of Traumatology and Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain (E.C.R.M.). Address correspondence and reprints requests to E. C. Rodrfguez-Merchdn, M.D., Ph.D., Capitdn Blanco Argibay 21-G3A, 28029-Madrid, Spain. © 1997 by the Arthroscopy Association of North America 0749-8063/97/1305-155353.00/0
606
ously4). This article presents the authors' experience in treating a group of patients suffering from symptomatic localized post-traumatic synovitis.
MATERIALS AND METHODS In the 5-year period between January 1989 and December 1993, 215 patients were seen with severe mechanical type pain (score 3, Table 1) resulting from trauma to the anteromedial aspect of the knee. Patients had pain only with specific motions or positions, and otherwise they had no pain. They had no pain at rest, and they had very localized symptoms. They did not complain of nonmechanical type pain; that is, burning, constant pain, or pain that kept them awake at night. Seventy-four (25.6%) of these patients did not respond to a 3-month period of conservative treatment (relative rest and nonsteroidal anti-inflammatory drugs); 8 were lost at follow-up. Sixty-six patients (69 knees) were included in this retrospective study; 37 were male and 29 female. The right knee was involved
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 13, No 5 (October), 1997: pp 606-608
LOCALIZED POST-TRAUMATIC SYNOVITIS OF THE KNEE
TABLE 1. Assessment of Results in This Study 0: No mechanical pain (excellent result). 1: Mild mechanical pain (good result). Does not interfere with occupation nor with ADL 2: Moderate mechanical pain (fair result). Partial or occasional interference with occupation or ADL. 3: Severe mechanical pain (poor result). Interferes with occupation or ADL.
43 cases 15 cases 8 cases
607
no pain at all (score 0) or mild pain (score 1). Only 11 patients (16%) had moderate or severe mechanical type pain interfering with occupation or activities of daily living (scores 2 and 3). No complications were found in this series (e.g., flexion contracture). The patients with poor results were offered a new arthroscopic examination but all of them declined to do so.
3 cases
NOTE. Assessment of mechanical type pain: patients have pain with specific motions or positions, score 0-3. Abbreviation: ADL, activities of daily living.
in 39 cases and the left knee in 30 patients. The mean age of the patients was 33 years (range, 8 to 66 years). The follow-up was 2.85 years on average (range, 1 to 5 years). The indication for surgery was a knee that had mechanical symptoms (pain score 3) with an evident previous injury nonresponding to 3 months of conservative treatment. Other diagnoses, mainly a rupture of the anterior cruciate ligament, a meniscal tear, or osteoarthritic changes, were excluded by magnetic resonance imaging and were ruled out during arthroscopic examination. In every patient, the operations were carried out looking for the source of pain. In all of them, the only common finding was the presence of a localized synovitis producing an impaction area approximately 2 x 2 cm on the medial femoral condyle near the intercondylar notch; this was the main indication for an arthroscopic partial synovectomy. No other articular cartilage defects were found in the arthroscopic examination. The synovium in question was not the medial symptomatic plica (medial shelf syndrome). The operations were carried out under general anesthesia with the lower limb under tourniquet control. In every case a histopathologic examination excluded other diagnoses for the existing synovitis, i.e., rheumatoid arthritis. The results were assessed by means of a pain scale (score 0 to 3 points) (Table 1).
RESULTS A full range of motion was seen in every patient preoperatively, intraoperatively and postoperatively; no hyperextension was present. All patients had severe mechanical type pain (score 3) before arthroscopic synovectomy. At follow-up, 43 knees had an excellent result (no pain, score 0), 15 had a good result (mild pain, score 1), 8 patients had a fair result (moderate pain, score 2), and 3 patients had a poor result (severe pain, score 3). Thus, at follow-up, 84% of patients had
DISCUSSION The sources of a monoarticular knee synovitis commonly are mechanical disorder, infection, gout or pseudogout, bone necrosis or hemarthrosis, and trauma. 4 Direct blunt trauma to the anteromedial aspect of the knee may irritate the synovium, resulting in inflammation, localized synovitis, and subsequent fibrosis. Patients may complain of joint line tenderness, meniscallike symptoms, and rotational findings. Most patients respond to conservative care. In patients with persistent mechanical type pain who have not responded to the conservative modalities of ice, activity modification, and anti-inflammatory medication, arthroscopic debridement may be warranted. 5 According to Poehling (personal communication, 1997), patients who have pain at the knee and nothing else can usually be divided into two groups. One group of patients has mechanical type symptoms, that is, only with specific motions or positions. These patients seem to respond to surgery in a much higher percentage that patients who have nonmechanical symptoms. Nonmechanical symptoms are constant burning pain, pain that is present at all time (even at rest), and pain that keeps them awake at night even if they have not been active. These patients have an extremely low incidence of improvement after surgery. Typically they state that every time an arthroscopy is performed, they get worse. When, after 3 months of conservative treatment, mechanical type pain does not subside and no other sources for synovitis can be found, reactive localized post-traumatic synovitis should be suspected and arthroscopy can be useful to control the pain. In the authors' opinion, the pathogenesis of pain is the entrapment of the hypertrophic synovium in the joint space, and the removal of such a synovium will alleviate the symptoms and may avoid further cartilaginous involvement on the medial femoral condyle. Although we have considered hyperextension of the knee with impaction of the meniscus/tibia as a possible cause, we believe that our diagnosis was correct and that this was not a hyperextension/meniscal syndrome. We also believe that the synovitis was the primary cause of
608
J. A. C O M [ N A N D E. C. R O D R [ G U E Z - M E R C H A N
s y m p t o m s and was not secondary to a trochlear cartilage injury. W e have carried out a thorough review o f the English language literature concerning s y n o v e c t o m y and no other reports have been published on this subject. W e have no explanation for the 16% rate o f poor results in this series.* Since the major s y m p t o m o f this condition is mechanical type pain, we thought that an evaluation that emphasizes this s y m p t o m would be a g o o d indication of the outcome. The results of this study appear to show that arthroscopic partial s y n o v e c t o m y is a proce-
*It is possible that some of the 16% with poor results could have had unrecognized nonmechanical pain.
dure to be considered in solving painful localized posttraumatic synovitis o f the knee joint.
REFERENCES 1. Doets HC, Bierman BT, Soesbergen RM. Synovectomy of the rheumatoid knee does not prevent deterioration: 7-year followup of 83 cases. Acta Orthop Scand 1989;60:523-525. 2. Ogilvie-Harris DJ, McLean J, Zarnett ME. Pigmented villonodular synovitis of the knee. J Bone Joint Surg Am 1992;74:119123. 3. Rodriguez-Merchfin EC, Galindo E, Ladreda JMM, Pardo JA. Surgical synovectomy in haemophilic arthropathy of the knee. Int Orthop 1994; 18:38-41. 4. Christian CL. Knee synovitis. In: Insall JN, ed. Surgery of the knee. Ed. 2. New York: Churchill Livingstone, 1993;595-607. 5. Bach BR Jr. Knee and leg: Soft tissue-trauma. In: Kasser JR, ed. AAOS orthopaedic knowledge update 5. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1996;463-480.