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Hip Arthroscopic Synovectomy and Labral Repair in a Patient With Rheumatoid Arthritis With a 2-Year Follow-up
Hip Arthroscopic Synovectomy and Labral Repair in a Patient With Rheumatoid Arthritis With a 2-Year Follow-up Nobuyuki Watanabe, M.D., Ph.D., Hirotaka Iguchi, M.D., Ph.D., Hiroto Mitsui, M.D., Ph.D., Kaneaki Tawada, M.D., Satona Murakami, M.D., Ph.D., and Takanobu Otsuka, M.D., Ph.D.
Abstract: The arthroscopic surgical procedures reported previously for a rheumatic hip joint have been primarily performed as diagnostic procedures. Only a few studies have reported the success of arthroscopic surgery in hip joint preservation. We encountered a special case in which joint remodeling was seen in a patient with rheumatoid arthritis treated with biological drugs after hip arthroscopic synovectomy and labral repair. We report the case of a 39-year-old woman with rheumatism, which was controlled with tocilizumab, prednisolone, and tacrolimus. The hip joint showed Larsen grade 3 destruction, and the Harris Hip Score was 55 points. Because of the patient’s strong desire to undergo a hip preservation operation, we performed hip arthroscopic synovectomy and repair of a longitudinal labral tear. After 2.5 years, the joint space had undergone rebuilding with improvement to Larsen grade 2, and the Harris Hip Score had improved to 78 points; the patient was able to return to work with the use of 1 crutch. It is possible to perform hip arthroscopic surgery for rheumatoid arthritis with a hip preservation operation with biological drugs.
T
he number of hip arthroscopic surgical procedures performed has been on the rise. This is because of the widespread recognition of the concept of femoroacetabular impingement.1 Subsequently, not only surgery for femoroacetabular impingement but also hip arthroscopic surgery for the initial degenerative symptoms of the hip joint and its effects became acceptable.2,3 Several studies have reported on hip arthroscopic surgery as a diagnostic procedure for the rheumatic hip joint, but very few have reported it as a treatment procedure. There is much debate on the use of arthroscopy in the treatment of rheumatoid arthritis (RA). Previous reports have not enumerated the advantages of this operation in the prevention of progression of hip joint degeneration.4
From the Department of Orthopedics, Tosei General Hospital (N.W.), Seto; Departments of Arthroplastic Medicine (H.I.) and Orthopedic Surgery (H.M., S.M., T.O.), Graduate School of Medical Sciences, Nagoya City University, Nagoya; and Department of Orthopedics, Komaki Municipal Hospital (K.T.), Komaki, Japan. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received May 10, 2014; accepted June 3, 2014. Address correspondence to Nobuyuki Watanabe, M.D., Ph.D., Department of Orthopedics, Tosei General Hospital, Nishioiwake 160, Seto, Aichi Prefecture 489-0065, Japan. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/14401/$36.00 http://dx.doi.org/10.1016/j.eats.2014.06.001
We report the case of a patient with RA who underwent hip arthroscopy that resulted in good cartilage remodeling.
Case Description A 39-year-old woman with RA presented with severe pain and limited range of motion in the right hip. She had undergone treatment with 480 mg of tocilizumab every 4 weeks, 5 mg of prednisolone, and 2 mg of tacrolimus. She was classified as stage II and class II according to the Steinbrocker classification, and the Disease Activity Score was 2.12. The hip joint was classified as Larsen grade 3, and the Harris Hip Score at the first visit was 55 points (Fig 1, A and B). T1weighted magnetic resonance imaging showed bone marrow edema of the femoral head (Fig 2A). A radial scan on magnetic resonance imaging showed a labral tear from the 12-o’clock position to the 2-o’clock position (Fig 2B). Because the patient wanted to avoid arthroplasty and instead had a strong desire to undergo hip preservation surgery, we performed hip arthroscopy to confirm and improve her hip condition.
Surgical Technique The patient was placed on the fracture table in the supine position by use of post padding (Philippon Post Pad; Bledsoe, Grand Prairie, TX). Hip flexion was 10 , abduction was 15 , and internal rotation was 30 . We used anterolateral and mid-anterior portals. A hip
Arthroscopy Techniques, Vol 3, No 4 (August), 2014: pp e523-e526
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Fig 1. Preoperative (A) anteroposterior and (B) Lauenstein radiographs. The hip condition was classified as Larsen grade 3. Postoperative (C) anteroposterior and (D) Lauenstein radiographs showed joint remodeling. The Larsen grade improved to grade 2.
arthroscopy system (Smith & Nephew, Andover, MA) was adapted for use in this operation. A 70 arthroscope was used during the operation. The patient’s cartilage condition was classified as Outerbridge grade 3 and International Cartilage Repair Society grade 3 on the femoral head side and Outerbridge grade 2 and International Cartilage Repair Society grade 2 on the acetabular side (Fig 3A). By use of a shaver (Dyonics; Smith & Nephew) and flexible radiofrequency probes (Eflex; Smith & Nephew), synovectomy with a
degenerative capsule was performed with portal changing including around the ligamentum teres (Fig 3B). Many rice bodies were recognized; these were removed with a shaver and punches (Fig 3C). During synovectomy around the labrum, we detected a longitudinal labral tear from the 12-o’clock position to the 2-o’clock position (Fig 3D). The labral damage was classified as detachment type according to the classification of Beck et al.5 We performed total arthroscopic synovectomy of the hip joint and labral repair with a
Fig 2. A radial scan was performed by magnetic resonance imaging with a diagnostic hip injection. (A) Damaged cartilage and bone marrow edema of the femoral head were seen on magnetic resonance imaging. (B) A retrospective observation showed that there was a labral tear from the 12-o’clock position to the 2-o’clock position (arrow).
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SYNOVECTOMY AND LABRAL REPAIR IN RA
Fig 3. Intraoperative arthroscopic view from anterolateral portal in spine. (A) Cartilage damage was seen on both the femoral head side and acetabular side. (B) Synovectomy around the ligamentum teres was performed with a radiofrequency probe. (C) Rice bodies (arrow) were removed with a grasper. Fibrillation and degeneration were noted on the acetabular cartilage. (D) A longitudinal labral tear from the 12-o’clock position to the 2-o’clock position (arrow) was present. (E) Labral suturing was performed to repair the torn labrum using a suture anchor.11 (F) Two single-knot labral sutures were placed (arrows). (A, acetabulum; AC, acetabular cartilage; FH/H, femoral head; L, labrum.)
single suture and 2 suture anchors (Bioraptor 2.3 PK; Smith & Nephew) (Fig 3, E and F), and we tried to avoid causing a microfracture of the surface of the femoral head, which was a possibility because of the poor bone quality (Video 1 and Table 1). Physical therapy was initiated on the first postoperative day, but partial weight bearing was not permitted for 3 weeks. At 2.5 years after the operation, the patient’s Harris Hip Score improved to 78 points. The Larsen grade also improved, from grade 3 to grade 2 (Fig 1, C and D). The patient was able to resume her job within 1 year of the operation with 1 crutch.
Discussion Recent developments in biological agents can help in the successful treatment of patients with active RA; however, we observe bony destruction in some cases despite the availability of these agents. Although total hip arthroplasty is the gold standard treatment for severe hip arthritis, we propose arthroscopic hip joint
surgery in patients with RA to allow immediate improvement in their quality of life and to increase the preparation period before total joint replacement. Holgersson et al.6 reported the first hip arthroscopy in RA patients in 1981 as a diagnostic procedure. In 1988 Gonadolph-Zink et al.7 published the first study on hip arthroscopic synovectomy, performed in 6 cases. Then, Ide et al.8 reported performing arthroscopic synovectomy in 3 patients (6 hips) with RA, among 196 patients, in 1991. The most recent report is from China. Zhou et al.9 reported hip arthroscopic debridement with inflammatory arthritis in 36 patients (40 hips), which included 11 RA patients. According to the results, excellent, good, fair, and poor outcomes were found in 8, 17, 8, and 3 patients, respectively; however, the results of RA patients were not specified. A Japanese publication reported a long-term follow-up of RA hip synovectomy: Takayama et al.10 reported the results of a 4-year follow-up of 6 patients (6 hips) after arthroscopic
Table 1. Indication, Contraindication, Pearls, and Pitfalls Indication Tightly controlled RA with biological drugs Round femoral head is preserved
Both the patient and family understand that the procedure is just an option for time saving
Pearls
Pitfalls
Poorly controlled RA
Contraindication
Pathologic diagnosis (optional)
Severely degenerated hip
Synovectomy with degenerated capsule using shaver and radiofrequency probe Preserve labrum, with use of good suture technique
No osteochondroplasty if bone and cartilage quality are poor Synovectomy with enough traction is technically demanding
Patient deserves immediate/ complete pain relief
Possible degenerative change immediately after operation
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synovectomy of the hip. The preoperative Larsen grade was 1 in 1 patient, 3 in 1 patient, and 4 in 4 patients. The mean Japanese Orthopaedic Association score changed from 45.3 preoperatively to 56.5 at discharge. The hip joint was preserved in 4 cases. Biological drugs had been prescribed to the patients after the operation, but they had not stopped the destructive changes in the patients’ hips. Regarding the joint preservation efficacy of biological drugs, Takeuchi et al.11 reported the clinical, radiographic, and functional effectiveness of tocilizumab in RA patients. In their study, 149 RA cases were treated with tocilizumab for 52 weeks. The van der Heijde (vDH)-Sharp score, erosion score, and joint space narrowing score did not show a significant change. In our case, the hip joint line was detectable on radiography after arthroscopic surgery. The hip joint condition seemed to be a combined effect of biological agents and arthroscopic surgery. We have reported the case of a patient who underwent hip arthroscopic surgery for preservation of the hip joint. The results showed a good course over a 2year follow-up. We conclude that the arthroscopic surgical procedure in the hip combined with labral repair, use of biological agents for RA, and use of a crutch in a patient with RA produces a good result. The operative hip will show deterioration over time because of the RA diagnosis and a crutch gait. Long-term follow-up is therefore important.
Acknowledgment The authors thank Hironari Sakurai, Chief of the Department of Orthopedics, Tosei General Hospital.
References 1. Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy 2013;29:661-665. 2. Matsuda DK. Protrusio acetabuli: Contraindication or indication for hip arthroscopy? And the case for arthroscopic treatment of global pincer impingement. Arthroscopy 2012;28:882-888. 3. Lubowitz JH, Provencher MT, Poehling GG. Hip arthroscopy in patients with early arthritis. Arthroscopy 2012;28: 743-744. 4. Chalmers PN, Sherman SL, Raphael BS, Su EP. Rheumatoid synovectomy: Does the surgical approach matter? Clin Orthop Relat Res 2011;469:2062-2071. 5. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br 2005;87:1012-1018. 6. Holgersson S, Brattstrom H, Mogensen B, Lidgren L. Arthroscopy of the hip in juvenile chronic arthritis. J Pediatr Orthop 1981;1:273-278. 7. Gonadolph-Zink B, Puhl W, Noack W. Semiarthroscopic synovectomy of the hip. Int Orthop 1988;12:31-35. 8. Ide T, Akamatsu N, Nakajima I. Arthroscopic surgery of the hip joint. Arthroscopy 1991;7:204-211. 9. Zhou M, Li ZL, Wang Y, et al. Arthroscopic debridement and synovium resection for inflammatoryhip arthritis. Chin Med Sci J 2013;28:39-43. 10. Takayama Y, Koyama K, Sugiyama H, Haro H. Arthroscopic synovectomy in rheumatoid hip; six cases followed for more than 4 years. Jpn J Joint Dis 2010;29:505-508 [in Japanese]. 11. Takeuchi T, Tanaka Y, Amano K, et al. Clinical, radiographic and functional effectiveness of tocilizumab for rheumatoid arthritis patientsdREACTION 52-week study. Rheumatology (Oxford) 2011;50:1908-1915.
Abstract: The arthroscopic surgical procedures reported previously for a rheumatic hip joint have been primarily performed as diagnostic procedures. Only a few studies have reported the success of arthroscopic surgery in hip joint preservation. We encountered a special case in which joint remodeling was seen in a patient with rheumatoid arthritis treated with biological drugs after hip arthroscopic synovectomy and labral repair. We report the case of a 39-year-old woman with rheumatism, which was controlled with tocilizumab, prednisolone, and tacrolimus. The hip joint showed Larsen grade 3 destruction, and the Harris Hip Score was 55 points. Because of the patient’s strong desire to undergo a hip preservation operation, we performed hip arthroscopic synovectomy and repair of a longitudinal labral tear. After 2.5 years, the joint space had undergone rebuilding with improvement to Larsen grade 2, and the Harris Hip Score had improved to 78 points; the patient was able to return to work with the use of 1 crutch. It is possible to perform hip arthroscopic surgery for rheumatoid arthritis with a hip preservation operation with biological drugs.
T
he number of hip arthroscopic surgical procedures performed has been on the rise. This is because of the widespread recognition of the concept of femoroacetabular impingement.1 Subsequently, not only surgery for femoroacetabular impingement but also hip arthroscopic surgery for the initial degenerative symptoms of the hip joint and its effects became acceptable.2,3 Several studies have reported on hip arthroscopic surgery as a diagnostic procedure for the rheumatic hip joint, but very few have reported it as a treatment procedure. There is much debate on the use of arthroscopy in the treatment of rheumatoid arthritis (RA). Previous reports have not enumerated the advantages of this operation in the prevention of progression of hip joint degeneration.4
From the Department of Orthopedics, Tosei General Hospital (N.W.), Seto; Departments of Arthroplastic Medicine (H.I.) and Orthopedic Surgery (H.M., S.M., T.O.), Graduate School of Medical Sciences, Nagoya City University, Nagoya; and Department of Orthopedics, Komaki Municipal Hospital (K.T.), Komaki, Japan. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received May 10, 2014; accepted June 3, 2014. Address correspondence to Nobuyuki Watanabe, M.D., Ph.D., Department of Orthopedics, Tosei General Hospital, Nishioiwake 160, Seto, Aichi Prefecture 489-0065, Japan. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/14401/$36.00 http://dx.doi.org/10.1016/j.eats.2014.06.001
We report the case of a patient with RA who underwent hip arthroscopy that resulted in good cartilage remodeling.
Case Description A 39-year-old woman with RA presented with severe pain and limited range of motion in the right hip. She had undergone treatment with 480 mg of tocilizumab every 4 weeks, 5 mg of prednisolone, and 2 mg of tacrolimus. She was classified as stage II and class II according to the Steinbrocker classification, and the Disease Activity Score was 2.12. The hip joint was classified as Larsen grade 3, and the Harris Hip Score at the first visit was 55 points (Fig 1, A and B). T1weighted magnetic resonance imaging showed bone marrow edema of the femoral head (Fig 2A). A radial scan on magnetic resonance imaging showed a labral tear from the 12-o’clock position to the 2-o’clock position (Fig 2B). Because the patient wanted to avoid arthroplasty and instead had a strong desire to undergo hip preservation surgery, we performed hip arthroscopy to confirm and improve her hip condition.
Surgical Technique The patient was placed on the fracture table in the supine position by use of post padding (Philippon Post Pad; Bledsoe, Grand Prairie, TX). Hip flexion was 10 , abduction was 15 , and internal rotation was 30 . We used anterolateral and mid-anterior portals. A hip
Arthroscopy Techniques, Vol 3, No 4 (August), 2014: pp e523-e526
e523
e524
N. WATANABE ET AL.
Fig 1. Preoperative (A) anteroposterior and (B) Lauenstein radiographs. The hip condition was classified as Larsen grade 3. Postoperative (C) anteroposterior and (D) Lauenstein radiographs showed joint remodeling. The Larsen grade improved to grade 2.
arthroscopy system (Smith & Nephew, Andover, MA) was adapted for use in this operation. A 70 arthroscope was used during the operation. The patient’s cartilage condition was classified as Outerbridge grade 3 and International Cartilage Repair Society grade 3 on the femoral head side and Outerbridge grade 2 and International Cartilage Repair Society grade 2 on the acetabular side (Fig 3A). By use of a shaver (Dyonics; Smith & Nephew) and flexible radiofrequency probes (Eflex; Smith & Nephew), synovectomy with a
degenerative capsule was performed with portal changing including around the ligamentum teres (Fig 3B). Many rice bodies were recognized; these were removed with a shaver and punches (Fig 3C). During synovectomy around the labrum, we detected a longitudinal labral tear from the 12-o’clock position to the 2-o’clock position (Fig 3D). The labral damage was classified as detachment type according to the classification of Beck et al.5 We performed total arthroscopic synovectomy of the hip joint and labral repair with a
Fig 2. A radial scan was performed by magnetic resonance imaging with a diagnostic hip injection. (A) Damaged cartilage and bone marrow edema of the femoral head were seen on magnetic resonance imaging. (B) A retrospective observation showed that there was a labral tear from the 12-o’clock position to the 2-o’clock position (arrow).
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SYNOVECTOMY AND LABRAL REPAIR IN RA
Fig 3. Intraoperative arthroscopic view from anterolateral portal in spine. (A) Cartilage damage was seen on both the femoral head side and acetabular side. (B) Synovectomy around the ligamentum teres was performed with a radiofrequency probe. (C) Rice bodies (arrow) were removed with a grasper. Fibrillation and degeneration were noted on the acetabular cartilage. (D) A longitudinal labral tear from the 12-o’clock position to the 2-o’clock position (arrow) was present. (E) Labral suturing was performed to repair the torn labrum using a suture anchor.11 (F) Two single-knot labral sutures were placed (arrows). (A, acetabulum; AC, acetabular cartilage; FH/H, femoral head; L, labrum.)
single suture and 2 suture anchors (Bioraptor 2.3 PK; Smith & Nephew) (Fig 3, E and F), and we tried to avoid causing a microfracture of the surface of the femoral head, which was a possibility because of the poor bone quality (Video 1 and Table 1). Physical therapy was initiated on the first postoperative day, but partial weight bearing was not permitted for 3 weeks. At 2.5 years after the operation, the patient’s Harris Hip Score improved to 78 points. The Larsen grade also improved, from grade 3 to grade 2 (Fig 1, C and D). The patient was able to resume her job within 1 year of the operation with 1 crutch.
Discussion Recent developments in biological agents can help in the successful treatment of patients with active RA; however, we observe bony destruction in some cases despite the availability of these agents. Although total hip arthroplasty is the gold standard treatment for severe hip arthritis, we propose arthroscopic hip joint
surgery in patients with RA to allow immediate improvement in their quality of life and to increase the preparation period before total joint replacement. Holgersson et al.6 reported the first hip arthroscopy in RA patients in 1981 as a diagnostic procedure. In 1988 Gonadolph-Zink et al.7 published the first study on hip arthroscopic synovectomy, performed in 6 cases. Then, Ide et al.8 reported performing arthroscopic synovectomy in 3 patients (6 hips) with RA, among 196 patients, in 1991. The most recent report is from China. Zhou et al.9 reported hip arthroscopic debridement with inflammatory arthritis in 36 patients (40 hips), which included 11 RA patients. According to the results, excellent, good, fair, and poor outcomes were found in 8, 17, 8, and 3 patients, respectively; however, the results of RA patients were not specified. A Japanese publication reported a long-term follow-up of RA hip synovectomy: Takayama et al.10 reported the results of a 4-year follow-up of 6 patients (6 hips) after arthroscopic
Table 1. Indication, Contraindication, Pearls, and Pitfalls Indication Tightly controlled RA with biological drugs Round femoral head is preserved
Both the patient and family understand that the procedure is just an option for time saving
Pearls
Pitfalls
Poorly controlled RA
Contraindication
Pathologic diagnosis (optional)
Severely degenerated hip
Synovectomy with degenerated capsule using shaver and radiofrequency probe Preserve labrum, with use of good suture technique
No osteochondroplasty if bone and cartilage quality are poor Synovectomy with enough traction is technically demanding
Patient deserves immediate/ complete pain relief
Possible degenerative change immediately after operation
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N. WATANABE ET AL.
synovectomy of the hip. The preoperative Larsen grade was 1 in 1 patient, 3 in 1 patient, and 4 in 4 patients. The mean Japanese Orthopaedic Association score changed from 45.3 preoperatively to 56.5 at discharge. The hip joint was preserved in 4 cases. Biological drugs had been prescribed to the patients after the operation, but they had not stopped the destructive changes in the patients’ hips. Regarding the joint preservation efficacy of biological drugs, Takeuchi et al.11 reported the clinical, radiographic, and functional effectiveness of tocilizumab in RA patients. In their study, 149 RA cases were treated with tocilizumab for 52 weeks. The van der Heijde (vDH)-Sharp score, erosion score, and joint space narrowing score did not show a significant change. In our case, the hip joint line was detectable on radiography after arthroscopic surgery. The hip joint condition seemed to be a combined effect of biological agents and arthroscopic surgery. We have reported the case of a patient who underwent hip arthroscopic surgery for preservation of the hip joint. The results showed a good course over a 2year follow-up. We conclude that the arthroscopic surgical procedure in the hip combined with labral repair, use of biological agents for RA, and use of a crutch in a patient with RA produces a good result. The operative hip will show deterioration over time because of the RA diagnosis and a crutch gait. Long-term follow-up is therefore important.
Acknowledgment The authors thank Hironari Sakurai, Chief of the Department of Orthopedics, Tosei General Hospital.
References 1. Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy 2013;29:661-665. 2. Matsuda DK. Protrusio acetabuli: Contraindication or indication for hip arthroscopy? And the case for arthroscopic treatment of global pincer impingement. Arthroscopy 2012;28:882-888. 3. Lubowitz JH, Provencher MT, Poehling GG. Hip arthroscopy in patients with early arthritis. Arthroscopy 2012;28: 743-744. 4. Chalmers PN, Sherman SL, Raphael BS, Su EP. Rheumatoid synovectomy: Does the surgical approach matter? Clin Orthop Relat Res 2011;469:2062-2071. 5. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br 2005;87:1012-1018. 6. Holgersson S, Brattstrom H, Mogensen B, Lidgren L. Arthroscopy of the hip in juvenile chronic arthritis. J Pediatr Orthop 1981;1:273-278. 7. Gonadolph-Zink B, Puhl W, Noack W. Semiarthroscopic synovectomy of the hip. Int Orthop 1988;12:31-35. 8. Ide T, Akamatsu N, Nakajima I. Arthroscopic surgery of the hip joint. Arthroscopy 1991;7:204-211. 9. Zhou M, Li ZL, Wang Y, et al. Arthroscopic debridement and synovium resection for inflammatoryhip arthritis. Chin Med Sci J 2013;28:39-43. 10. Takayama Y, Koyama K, Sugiyama H, Haro H. Arthroscopic synovectomy in rheumatoid hip; six cases followed for more than 4 years. Jpn J Joint Dis 2010;29:505-508 [in Japanese]. 11. Takeuchi T, Tanaka Y, Amano K, et al. Clinical, radiographic and functional effectiveness of tocilizumab for rheumatoid arthritis patientsdREACTION 52-week study. Rheumatology (Oxford) 2011;50:1908-1915.