Technical Note
Office-Based Arthroscopic Synovectomy of the Wrist in Rheumatoid Arthritis Nathan Wei, M.D., Sheila K. Delauter, R.N., Sheila Beard, R.N., Marianne S. Erlichman, R.N., and Denise Henry, L.P.N.
Abstract: We present an office-based technique for performin g arthroscopic synovectomy of the wrist in patients with rheumatoid arthritis. Intra-articular anesthesia as well as subcutaneous portal anesthesia are used. Standard portals are used in the radial carpal and midcarpal joints. Standard instrumentation is used and the synovectomy is accomplished using a motorized shaver. We performed 30 procedures in 21 patients: 1.5 complete synovectomies. 3 radioulnar carpal synovectomies because of only limited disease, and 12 limited synovectomies because these patients were participants in a clinical trial and required only limited synovectomy for investigational purposes.
There were no complications. Office-based arthroscopic synovectomy of the wrist in patients with refractory rheumatoid arthritis can be performed safety and effectively. This technique both a clinical as well as a research setting. Key Words: Synovectomy-Wrist-Office Rheumatoid arthritis-Arthroscopy.
Rh
ecent advances in rheumatoid arthritis therapy ave allowed much better systemic control of disease.1-3 Unfortunately, some patients continue to have active disease, particularly in the small joints of the hand and wrist.4 We have performed 30 office-based arthroscopic wrist synovectomies in 21 patients with rheumatoid arthritis using local anesthetic techniques. Patient acceptance and tolerability have been excellent. The purpose of this report is to describe our technique. TECHNIQUE Anesthesia All patients underwent the following anesthetic protocol: oral diazepam 5 to 10 mg unless contraindicated
From The Arthn’tis and Osteoporosis Center of Maryland. Frederick, Maryland, U.S.A. Address correspondence and reprint requests to Nathan Wei, M.D., The Arthritis and Osteoporosis Center of Maryland, 71 Thomas Johnson Dr, Frederick, MD 21702, U.S.A. E-mail:
[email protected] 0 2001 by the Arthroscopy Association of North America 1526-3231/01/l 708-2663$35.00/O doi:lO. 1053/jars.2001.22404
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Arthroscopy:
The Journal
of Arthroscopic
and Related
is useful in based-
and local povidone iodine and alcohol preparation of the wrist. Anesthesia of wrist portals including the 3-4, 6R, and midcarpal radial portals (Figs l-3) was accomplished with a total of 2.5 mL of 2% lidocaine without epinephrine, 2.5 mL of 0.25% bupivacaine without epinephrine, and 1 mL of 8.4% sodium bicarbonate. Intra-articular anesthesia was administered via a far ulnar (6U) portal located just distal to the tip of the ulnar styloid using a 22-gauge needle attached to a 10 mL syringe containing 2.5 mL of 2% lidocaine without epinephrine and 2.5 mL of 0.25% bupivacaine with epinephrine (Fig 4). Position and Preparation Patients are placed in a supine position with the head of the table elevated 30”. A pillow is placed under the shoulder and upper arm. The patient rests the forearm on an armrest at a 75” angle as described previously for metacarpophalangeal arthroscopy.5 Each patient’s arm is scrubbed initially with an iodine-based soap scrub. A sterile stockinette and elastic bandage wrap are applied extending from the fingertips to the wrist. The hand and arm are then
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OFFICE-BASED
FIGURE
1.
Landmarks
showing
ARTHROSCOPIC
the 3-4, 6R, and far ulnar
portals.
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FIGURE 3. Anesthesia 6R portal site.
of the skin
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and subcutaneous
tissue
at the
inserted through the elasticized opening of a drape sheet with another sterile bandage wrap applied to seal the arm and drape sheet. The stockinette is rolled back past the wrist and the hand is reprepped with an iodine-based solution and alcohol. A 2- X 3-inch section of sterile gauze is wrapped individually around the 2nd and 3rd digits and a double finger trap is applied. The finger traps are then attached to a pulley system with 8 lb of traction applied. An additional 2 mL of lidocaine without epinephrine are used to anesthetize the 3-4 and 6R portals. Approach
FIGURE 2. portal site.
Anesthesia
of the skin
and subcutaneous
tissue
at 3-4
A longitudinal skin incision, 2 mm in length, is made using a No. 11 scalpel blade at the 3-4 portal. The skin and subcutaneous tissue are spread down to the joint capsule using a small mosquito clamp. A short 2.2- or 2.9-mm semiblunt trocar and cannula system are inserted into the joint using gentle steady pressure and a slight twisting motion. The trocar and
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FIGURE 4. Administration ulnar portal.
N. WEI ET AL.
of intra-articular
anesthesia
via the far
cannula are directed in a slightly posterior direction to follow the concave curve of the radial head. During this particular part of the procedure, manual traction is applied by the surgical assistant to the 2nd and 3rd digits in order to ensure adequate distention of the radial carpal joint space. When the capsule is pierced, the cannula is advanced another millimeter. At this point, the cannula tip should move freely. Inflow is established. The type of inflow will depend on the cannula size used. With the larger cannula, we have used the Dyonics InteliJET pump (Dyonics, Andover, MA) for distention. When using the smaller cannula, we have used gravity inflow. The arthroscope, either 1.9-mm or 2.7-mm short is then inserted. A new double coupler (Dyonics) that enlarges the image when using the smaller 1.9-mm arthroscope has greatly enhanced visualization. As a result, we now do all arthroscopic wrist procedures using the smaller cannula and gravity inflow. Visualization, particularly in the rheumatoid wrist, is not always easily achieved at this stage. However,
once the arthroscope is in place, we have then inserted an 18-gauge spinal needle into the wrist via the 6R portal. Once there is fluid return through the needle, visualization is usually achieved. The spinal needle is then used as a probe, with care being used to avoid scuffing of cartilage. A careful diagnostic examination of the radial carpal and ulnar carpal portions of the wrist is performed noting the presence or absence of erosions and also grading the degree of synovial activity. The spinal needle is removed. A 2-mm longitudinal skin incision is made at the 6R portal and the skin and subcutaneous tissue are dissected with a mosquito clamp. A semiblunt trocar and cannula are inserted. They are then removed and a 2.9-mm motorized shaver is introduced. This is used to remove synovial tissue from the ulnar recesses and the ulnar carpal joint space (Fig 5). The arthroscope is then transferred to the 6R portal and the shaver is transferred to the 3-4 portal and synovial tissue is removed from the radial carpal joint and the radial recess. A spinal needle is then inserted into the midcarpal radial portal. The spinal needle is removed and a small 2-mm longitudinal skin incision is made at the metacarpal radial portal and the semiblunt trocar and cannula system are introduced using the same technique as described for the other portals. The arthroscope is introduced and used to perform a diagnostic evaluation. If necessary, the midcarpal ulnar portal is reanesthetized using 1.5 mL of 2% lidocaine without epinephrine. The shaver is then introduced via this portal as described previously. When the procedure is completed, all instruments are removed and no sutures are required.
FIGURE traction.
5.
Wrist
arthroscopy
procedure
using
finger
trap to pulley
OFFICE-BASED
Postoperative
ARTHROSCOPIC
Instructions
Patients have their hand and wrist dressed with a sterile pressure bandage. The following day, they may remove the bandage and use small adhesive bandages. The patients are seen for follow-up after 1 week. RESULTS The procedure was successfully completed in all 30 patients. Preliminary data are encouraging. Twelvemonth data are available for 17 cases. Of these, 13 had good to excellent results. 3 had fair results, and 1 had a poor result. DISCUSSION Arthroscopic synovectomy of the wrist has been described by others6-ia An excellent technique guide has also been published. II To our knowledge, a detailed description of this technique as an office-based procedure using local anesthetic only has not been published. We have found the short-term (12-month) results and patient acceptance of this procedure to be exceptional. Our procedure time is currently about 30 minutes. We have encountered the following difficulties with the procedure. Because synovial tissue is extremely vascular, visualization is occasionally hampered by excessive bleeding in the joint. This problem has been less of an issue when we have been able to use the fluid management pump than when we have used gravity inflow. In some patients where synovitis is extreme, visualization remains difficult. These patients require much gentler manipulation of the wrist and the procedure time can be significantly longer (45 to 60 minutes). This procedure has been beneficial not only in the clinic but also in the research setting where the wrist provides an excellent site for tissue acquisition in the evaluation of the effectiveness of biologic agents. In addition, the procedure has been useful in diagnosis as well as treatment. Two of the patients initially thought
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to have polymyalgia rheumatica were found to have erosive lesions and synovial patterns consistent with rheumatoid arthritis. The long-term efficacy of arthroscopic wrist synovectomy still remains to be determined. However, we believe this procedure to be useful for those patients who still have active wrist disease despite aggressive and appropriate systemic therapy. CONCLUSION After our experience we have reached the following conclusions: (1) Office-based arthroscopic synovectomy of the wrist using local anesthetic is technically feasible. (2) Patient acceptance and tolerability are excellent. (3) Short-term (12-month) results are promising. (4) This is an excellent procedure for harvesting tissue for clinical trials in rheumatoid arthritis. REFERENCES 1. Koopman WJ, Moreland LW. Rheumatoid arthritis: Anticytokine therapies on the horizon. Ann Intern Med 1998;128:231233. 2. Moreland LW, Heck LW, Koopman WJ. Biologic agents for treating rheumatoid arthritis. Arthritis Rheum 1997;40:397406. 3. Moreland LW, Schiff MH. Baumgartner SW. Etanercept therapy in rheumatoid arthritis. Ann Intern Med 1999;130:478486. 4. Ostendorf B, Dann P, Wedekind F. Miniarthroscopy of metacarpophalangeal joints in rheumatoid arthritis. Rating of diagnostic value in synovitis staging and efficiency of synovial biopsy. J Rheum 1999;26:1901-1908. 5. Wei N, Delauter SK, Erlichman MS, Rozmaryn LM, Beard SJ, Henry DL. Arthroscopic synovectomy of the metacarpophalangeal joint in refractory rheumatoid arthritis: A technique. Arthroscopy 1999:15:265-268. 6. Adolfsson L, Nylander G. Arthroscopic synovectomy of the rheumatoid wrist. J Hand Surg [Br] 1993;18:92-96. L, Frisen M. Arthroscopic synovectomy of the 7. Adolfsson rheumatoid wrist. J Hand Surg [Br] 1997;22:71 l-713. in arthritis. Hand 8. Bain GI, Roth JH. The role of arthroscopy C/in 1995;11:51-58. “ectomy” surgery of the 9. Roth JH, Poehling GG. Arthroscopic wrist. Arthroscopy 1990;6:141-147. 10. Rettig ME, Amadio PC. Wrist arthroscopy. J Hand Surgery [Br] 1994;19:774-777. 11. Poehling GG, Ruth DS. Arthroscopic surgery ofrhe wrist. A monograph of The Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC, 1997.