Partial Synovectomy Research Articles

The efficacy of intra-articular analgesia after total knee arthroplasty in patients with rheumatoid arthritis and in patients with osteoarthritis

The pain relief provided by intra-articular injection of morphine plus bupivacaine after total knee arthroplasty (TKA) plus partial synovectomy in patients with rheumatoid arthritis was compared with pain relief after TKA alone in patients with osteoarthritis. There were lower pain scores, a much smaller requirement for systemic analgesics, longer duration until the first requirement of systemic analgesics, and improvement in the range of motion of the knee joint in the patients who received intra-articular injection of analgesics. There was more pronounced postoperative analgesia in the patients with rheumatoid arthritis than in the patients with osteoarthritis in the study groups that received intra-articular injection of analgesics.

Hip arthroscopy. Minimal invasive diagnosis and therapy of the diseased or injured hip joint

Arthroscopy of the hip joint has developed into a useful tool for the hip surgeon. Hip joint anatomy, however, makes special demands of the arthroscopist. He needs to be familiar with the arthroscopic anatomy of the hip and its variations. Moreover, he should have practical training in the technique of hip arthroscopy prior to his first intraoperative experience in order to avoid complications. A complete arthroscopic inspection of the hip can be achieved by using a combined procedure: whereas the central hip compartment can be scoped only by distraction of the joint, the periphery can be better seen without traction. Whether to place the patient supine or lateral is dependent on personal experience. No matter which position is used, the positioning technique has to be exact. The literature has shown that most complications are related to traction. Before the first portal is placed, the joint vacuum force should be broken by distension of air or fluid. This leads to maximum distraction of the joint and reduces the risks of damage to labrum and cartilage during first access to the joint. For a diagnostic round through the central compartment, at least two portals have to be placed. The use of a 3-portal technique increases the range of inspection. Due to the relatively thin soft tissue mantle and greater distance to neurovascular structures, the anterolateral or lateral portal should be used as the first portals to the central compartment. In addition, the anterolateral portal is the standard portal to the periphery of the hip. The posterolateral or anterior portal should be used as a supplementary portal. The following indications have been described for an arthroscopic procedure of the hip: loose bodies, labral lesions, synovial diseases such as chondromatosis and pigmented villonodular synovitis, associated lesions in underlying osteoarthritis, ruptures of the teres ligament, malorientation of the acetabulum and proximal femur and, last but not least, "idiopathic" hip pain. The use of hip arthroscopy in infectious arthritis, avascular necrosis of the femoral head, Perthes' disease, osteochondrosis dissecans and complications after total hip replacement is less frequent. Here, in addition to its diagnostic value, operative arthroscopy of the hip offers removal of loose bodies, resection of the labrum and ligaments, synovial biopsy, partial synovectomy, microfracturing, lavage and placement of intraarticular drainage. The first results of arthroscopic procedures in the hip are promising. In addition to its diagnostic value and contribution to the understanding of intraarticular anatomy and pathology, recent studies have demonstrated the advantages of the arthroscopic treatment of the hip.

Osteoarticular Tuberculosis

Tuberculous synovitis frequently presents as a monoarthritis of weight-bearing joints such as the hip, knee, or ankle. Owing to its low incidence in developed countries, the diagnosis is often delayed for months to years. Early diagnosis with a synovial biopsy permits prompt antituberculous therapy and substantially improves the prospect of preservation of joint structure and function. Initial treatment typically includes combination therapy with four drugs (isoniazid, rifampin, pyrazinamide, and streptomycin or ethambutol) because of the frequency of isoniazid resistance. Antimicrobial therapy should be of at least 9 months' duration, longer in immunocompromised hosts. Partial synovectomy and other surgical procedures should be restricted to joints with severe cartilage destruction, large abscesses, joint deformity, multiple drug resistance, or atypical mycobacteria.

Arthroscopic treatment for localized pigmented villonodular synovitis of the knee.

This study investigated 11 patients with localized pigmented villonodular synovitis of the knee that was diagnosed and treated by arthroscopic technique. There were six male and five female patients between the ages of 15 and 59 years (mean, 34.6 years). Seven patients reported extension limitation without joint line tenderness. Four of the 11 patients had a history of trauma before the onset of knee symptoms. All patients were treated by arthroscopic resection with partial synovectomy. The most common involved site was the anteromedial synovium near the anterior horn of the medial meniscus (five patients). The remaining cases were located in the anterior fat pad (two patients), suprapatellar pouch, posteromedial compartment, medial gutter, and the anterior horn of the lateral meniscus. Nine patients had one mass, and the remaining patients each had two or three masses. There was no evidence of recurrence at followup for an average of 29.9 months (range, 24-48 months). Arthroscopy is effective in the diagnosis of localized pigmented villonodular synovitis with minimal morbidity, and complete arthroscopic excision can be considered the definitive treatment for localized pigmented villonodular synovitis.

Primary synovial chondromatosis of the elbow

Very few cases of primary synovial chondromatosis of the elbow have been reported in the literature. This is a study concerning the late outcome of primary synovial chondromatosis in the elbows of 12 patients, 10 men and 2 women, with a mean follow-up of 16 years 10 months. The average age at the time of the initial complaint was 29 years. The histories of 10 patients revealed elbow strain as a consequence of work-related activities. Surgery included removal of loose bodies and partial synovectomy in all patients. A moderate to severe osteoarthritis was found preoperatively in 5 of 12 patients and during follow-up in 7 of 10 patients. The degree of osteoarthritis deteriorated after surgery in 5 of these cases, depending on patient age, length of presurgical history, length of follow-up, and strenuous activities. However, the functional deficiencies were usually moderate and had little significance with respect to the activities of daily living. No recurrence of primary synovial chondromatosis was found. (J Shoulder Elbow Surg 2000;9:319-22.)

Arthroscopic debridement of the shoulder for osteoarthritis

Summary: Twenty-five patients underwent arthroscopic debridement to treat early glenohumeral osteoarthritis. The group consisted of 19 men and 6 women with an average age of 46 years (range, 27 to 72 years.) The operative procedure consisted of lavage of the glenohumeral joint, debridement of labral tears and chondral lesions, loose body removal, and partial synovectomy and subacromial bursectomy. Follow-up averaged 34 months, with a range of 12 to 63 months. Overall, results were rated as excellent in 2 patients (8%), good in 19 patients (72%), and unsatisfactory in 5 (20%). Two patients had complete relief of pain, 18 patients had only occasional mild pain, and 5 had moderate to severe pain postoperatively. Of the 12 patients with marked preoperative stiffness, 10 (83%) had improvement in range of motion postoperatively. Arthroscopic debridement is a reasonable approach for treating early glenohumeral osteoarthritis that has failed to respond to nonoperative treatment, in which the humeral head and glenoid remain concentric, and where there is still a visible joint space on an axillary radiograph. The procedure is not recommended when there is severe joint incongruity or large osteophytes.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 5 (July), 2000: pp 471–476

Factors associated with prognosis for survival and athletic use in foals with septic arthritis: 93 cases (1987–1994)

Objective To identify factors affecting the prognosis for survival and athletic use in foals with septic arthritis. Design Retrospective study. Animals 93 foals with septic arthritis. Procedure Medical records were reviewed to obtain clinical findings, laboratory test results, radiographic findings, treatment method, and outcome. Race records for Thoroughbreds and Standardbreds were evaluated to determine whether foals subsequently raced and whether they raced successfully. Results 43 foals had 1 affected joint, 44 foals had multiple affected joints, and number of affected joints was not recorded for 6 foals. The femoropatellar and tarsocrural joints were most commonly affected. Osteomyelitis or degenerative joint disease were detected in 59% (46/78) of foals. Failure of passive transfer, pneumonia, and enteritis were common. Foals were treated with lavage, lavage and intra-articular administration of antibiotics, lavage and arthroscopic debridement with or without partial synovectomy, or lavage and arthrotomy to debride infected bone and systemic administration of antibiotics. Seventy-three foals survived to be discharged from hospital, and approximately a third raced. Isolation of Salmonella spp from synovial fluid was associated with an unfavorable prognosis for survival and multisystem disease was associated with an unfavorable prognosis for survival and ability to race; other variables were not significantly associated with survival and ability to race. Conclusions and Clinical Relevance With treatment, the prognosis for survival of foals with septic arthritis was favorable, whereas prognosis for ability to race was unfavorable. Multisystem disease, isolation of Salmonella spp from synovial fluid, involvement of multiple joints, and synovial fluid neutrophil count ≥ 95% at admission may be of prognostic value. (J Am Vet Med Assoc 1999;215:973–977)

Arthroscopy for diagnosis and therapy of early osteoarthritis of the hip

Failure to conservative treatment in patients with less advanced radiographic signs of osteoarthritis of the hip (Danielsson grade 2-5) confronts with the decision of further treatment. Since radiographic imaging has not been proved very useful in demonstrating intraarticular structures and results of hip arthroscopies have been promising, arthroscopies have been performed in 17 hips from November 1997 to September 1998. Arthroscopic findings were exceeding preoperative imaging. In addition to cartilage degeneration, concomitant loose bodies, impinging osteophytes, degeneration of the labrum and synovial disease were found. Removal of loose bodies and osteophytes, partial resection of labral tears and partial synovectomy were performed. 1 month after arthroscopy (n = 15), mean Harris-Hip-Score was increased by 13 points und pain reduced by 39 % on average. 6 months after arthroscopy (n = 9), mean Harris-Hip-Score was increased by 14 points and pain reduced by 32 % on average. In addition to its therapeutic benefit, arthroscopy offers direct visualisation of the hip providing important information for the decision of further treatment.

Magnetic Resonance Imaging-guided Focused Ultrasound Synovectomy

Objective. To investigate the feasibility of magnetic resonance imaging (MRI)-guided high power focused ultrasound (FUS) to perform synovectomy noninvasively. Methods. Five New Zealand white male rabbit knees with experimentally induced arthritis underwent MRI-guided thermal surgery by high power (60 W/10 s) sonication. Evidence of tissue coagulation was monitored during the procedure and confirmed by gross and microscopic evaluation and MRI. Results. Partial synovectomy was performed in five animals. Necrotized synovial tissue was observed on gross and microscopic evaluation. Visible signal intensity alterations including high signal intensity on T2-weighted (T2W) images and lack of contrast-enhancement on T1-weighted (T1W) post-contrast, post-sonication images were characteristic and reproducible. Conclusion. Our results demonstrate the ability of high power sonication to destroy synovial tissue in vivo.

Arthroscopic Lavage and Implantation of Gentamicin-impregnated Collagen Sponges for Treatment of Chronic Septic Arthritis in Cattle

SummaryThe object of this retrospective clinical study was to evaluate the efficacy of arthroscopic lavage and debridement, followed by intra-articular implantation of resorbable gentamicin-impregnated collagen sponges (GICS) for treatment of chronic (≥ seven days) septic arthritis in cattle. Fourteen cattle suffering from chronic septic monarthritis refractory to previous treatment were included in this study. Age ranged from one month to 7 years (mean = 34 months) and bodyweight from 58 to 640 kg (mean = 422 kg). The degree of lameness and characteristics of synovial fluid were evaluated before and at days #10 and 20 after the initial operation. The standard surgical procedure consisted of arthroscopic “through-and-through” lavage of the affected joint with a physiological Ringer’s solution, partial synovectomy, and curettage of the articular cartilage when considered necessary, followed by the intra-articular administration of GICS. The aftercare included administration of procaine penicillin, phenylbutazone, and stall confinement. The progress of the cases was monitored at three to 24 months after the initial operation.The tarsocrural joint was affected in six cases, the antebrachiocarpal joint in five and the metacarpophalangeal joint in three cases. The degree of lameness, total nucleated cell count and total protein of synovial fluid significantly (P <.05) decreased within 10 days after the operation. Treatment was successful in 12 of 14 animals (86%). It was therefore concluded that the implantation of GICS after routine “throughand- through” lavage is a valuable alternative technique for the treatment of chronic septic arthritis in cattle. A subsequent second operation for implant removal was not necessary, as GICS are fully absorbable. The tarsocrural joint is associated with the least favourable prognosis of the joints treated in this study.The efficacy of arthroscopic “through-and-through” lavage and debridement, followed by intra-articular implantation of absorbable gentamicin-impreg-nated collagen sponges (GICS) for treatment of chronic (≥ seven days) septic arthritis in cattle was evaluated. Treatment was successful in 12 of 14 cattle (86%). This suggests that the described technique is a valuable alternative to established treatment regimens for prolonged intra-articular administration of gentamicin. When compared to gentamicin-impregnated polymethylmethacrylate beads, GICS have the advantage that a second operation for implant removal is not necessary.

Synovial osteochondromatosis at the elbow producing ulnar and median nerve palsy: Case report and review of the literature

The authors present the case of a 53-year-old woman suffering from synovial osteochondromatosis of her right elbow responsible for ulnar and median nerve entrapment neuropathy. This condition is characterised by the formation of multiple cartilaginous nodules in the metaplastic synovium of otherwise normal joints, bursae or tendon sheaths. Treatment consisted of partial synovectomy, removal of loose bodies and microscopic nerve release. Synovial osteochondromatosis complicated by nerve compression syndromes has been rarely reported, usually with ulnar tunnel syndrome at the elbow. The literature on this subject is reviewed.

Pigmented villonodular synovitis. Case reports and review of the literature

Because this disease is so rare the optimum treatment of pigmented villonodular synovitis (PVNS), in particular the diffuse form differs in the literature. The most important surgical procedures are arthroscopic and open synovectomy. The prevention of disease progression, as well as joint destruction and dysfunction, depends upon the early diagnosis of PVNS. During 1994 and 1995, we treated four cases of PVNS surgically and followed the patients for a time period of more than 12 months. Two patients were treated with complete synovectomy, one patient underwent partial synovial resection, and in the final case an arthrodesis was performed. Our results indicate that an MRI is essential for diagnosis and treatment planning. For the localized form of PVNS, it appears that a partial synovectomy is appropriate. However, in the event of diagnostic uncertainty or obvious diffuse involvement of the synovium, a total synovectomy is indicated because of the high recurrence rate. In our study, all four patients had disease involving secondary bony lesions and, in one case, joint destruction. Based on our findings, it is clear that early surgical therapy is the only recommended curative intervention. The decision regarding the surgical approach, arthroscopic versus open, depends on the form of PVNS, the extent of the disease and secondary changes of the joint.

Total knee arthroplasty in patients who have pigmented villonodular synovitis.

We reviewed the results of all eighteen total knee arthroplasties that had been performed at the Mayo Clinic between 1974 and 1992 for the treatment of pigmented villonodular synovitis. The diagnosis had been confirmed histologically in all patients. Fourteen patients had diffuse disease, which was active in eleven and inactive in three, and four had focal disease. In addition to the arthroplasty, the eleven patients who had active diffuse disease were managed with a complete synovectomy and the four patients who had focal disease had a partial synovectomy. The three remaining patients had a history of diffuse pigmented villonodular synovitis but had no evidence of disease at the time of the arthroplasty, so a synovectomy was not performed. At an average of 9.9 years (range, 3.6 to 20.1 years) after the arthroplasty, fourteen of the eighteen total knee prostheses were well fixed and functioning satisfactorily. The average knee score was 89 points (range, 80 to 99 points) and the average functional score was 77 points (range, 20 to 100 points) for these fourteen patients. The four failures were in patients who had active diffuse disease at the time of the arthroplasty. Three of the failures were due to aseptic loosening, and one was due to recurrence of the disease. Sixteen patients had no evidence of recurrence when they were last seen, at an average of 10.3 years (range, 3.6 to 20.1 years) after the arthroplasty. The two patients who had a recurrence were among the eleven who had active diffuse disease. In one of these patients, the recurrence was diagnosed at the time of a revision arthroplasty performed because of aseptic loosening. The other patient had two recurrences, necessitating an above-the-knee amputation.

Hemophilic Synovitis of the Knee and the Elbow

A prospective study from 1974 to 1996 was done to determine optimal treatment for chronic hemophilic synovitis of the knee and synovitis of the elbow. Sixty-five patients with synovitis affecting 65 knee joints and 40 patients who had synovitis of the elbow (44 elbows), despite a 3-month trial of prophylactic substitution therapy, were treated by synovectomy. Radiation synovectomies (Au-198 synoviorthesis) were done on 38 knees, open surgical synovectomy on 18, and nine had an arthroscopic procedure. Radioactive gold synoviorthesis was performed on 29 elbows, and 15 had a resection of the radial head and partial open synovectomy. Synovectomy (by any method) significantly reduced bleeding episodes, but did not halt the radiographic deterioration of the joints. It is thought that radiation synovectomy is the best choice for patients with persistent synovitis of the knee and synovitis of the elbow unresponsive to a 3-month trial of prophylactic factor replacement. If two to three consecutive synoviortheses with 3 to 6 months intervals had been ineffective, or when the radiographic score is more than two points, an open synovectomy is indicated.

In vivo suppression of early experimental osteoarthritis by interleukin-1 receptor antagonist using gene therapy.

This study explored the therapeutic effect of interleukin-1 receptor antagonist (IL-1Ra), administered by gene transfer, on the progression of osteoarthritic (OA) lesions in an experimental dog model. Seventeen mature mongrel dogs were divided into 3 groups. Group 1 (n = 7) had an anterior cruciate ligament (ACL) section of the right knee through a stab wound incision. Groups 2 and 3 (n = 5 per group), had an ACL section of the right knee and partial synovectomy of the left knee. Each dog's synovium was subjected to enzymatic digestion, and the synovial fibroblasts were propagated in monolayer culture. Synovial cells from each dog were transduced in vitro using the retrovirus MFG with either the Escherichia coli beta-galactosidase (lac Z) gene (group 2) or the human IL-1Ra gene (group 3). Two days after surgery, the dogs received intraarticular injections as follows: group 1 phosphate buffered saline (PBS) (2 ml); group 2 autologous cells (60 x 10(6) cells/2 ml of PBS) transduced with the lac Z gene; group 3 autologous cells transduced with the IL-1Ra gene. Synovial fluid was aspirated at 2 weeks and 4 weeks. All dogs were euthanized at 4 weeks postsurgery. The right knees were dissected, and lesions were scored for macroscopic and microscopic changes. Synovial explants were dissected and representative specimens were used for histology or were cultured for 48 hours. The levels of IL-1Ra in synovial fluid and synovial explant conditioned medium were measured by specific enzyme-linked immunosorbent assay. The level of IL-1Ra in synovial fluid of group 3 was 202.8 +/- 131.5 ng/ml (mean +/- SEM) at 2 weeks and 2.8 +/- 2.2 ng/ml at 4 weeks after surgery. Membrane explants isolated from dogs that received synovial cells transduced with the IL-1Ra gene (group 3) actively produced IL-1Ra (4.0 +/- 2.0 ng/gm of tissue wet weight). The severity of OA cartilage lesions was similar in groups 1 and 2. In contrast, group 3 dogs had a marked reduction in macroscopic lesion severity on the tibial plateaus (P < 0.01 for grade; P < 0.04 for size) and femoral condyles. Moreover, the histologic lesion severity was decreased on both plateaus (P < 0.06) and condyles. This study showed that a local increase in IL-1Ra production in OA knee joints by intraarticular injection of transduced synovial cells can reduce the progression of experimentally induced lesions.

肩関節における滑液包内遊離体の２例

The shoulder joint is a relatively rare site for loose bodies of the synovium. In this study we present two cases with loose bodies in the bursa around the shoulder joint.Case 1: A 42-year-old male who had swelling and discomfort with limitation of motion of the right shoulder. Roentgenogram and CT scan showed destruction of the acromion and retention of fluid on the subacrominal brrsa. Operative findings revealed numerous loose bodies. A definite diagnosis of tuberculous bursitis was revealed by histological examination due to the presence of granulation and caseous necrosis.Case 2: An 88-year-old female had been suffering from right shoulder pain for 7 years. Roentgenogram showed numerous radiodense bodies in the right shoulder joint. CT scan and MRI also revealed the same findings. Numerous loose bodies removed from the shoulder were found to be a combination of cartilage and bony tissue. Histologically, this case was diagnosed as synovial osteochondromatosis.In both cases, the lesion was treated by removal of the loose bodies and a partial synovectomy with satisfactory results. From this study, it can be concluded that in cases with loose bodies around the joints, the final diagnosis can be made after histological examination.

Infection of the intertubercular bursa in horses: four cases (1978-1991)

Objective To determine the clinical outcome of horses treated for infection of the intertubercular bursa (infectious bicipital bursitis). Design Retrospective analysis of case records. Animals Four horses referred for treatment of infectious bicipital bursitis. Procedure Medical records of horses that were severely lame on admission were reviewed. Results In 3 horses, palpation over the bicipital bursa as well as flexion and extension of the scapulohumeral joint were resented. Ultrasonography performed in 1 horse revealed that the bicipital bursa was large and that excessive amounts of fluid containing hyperechoic material were evident within the bicipital bursa. Two horses were treated by the administration of antimicrobial and nonsteroidal antiinflammatory drugs. Both remained lame and failed to resume their former activity. Two horses additionally were treated surgically by means of a partial synovectomy. Both resumed their former activity although a subtle lameness remained in 1 horse. Clinical Implications Partial synovectomy may be useful in the treatment of horses with infectious bicipital bursitis. (J Am Vet Med Assoc 1996;208:1434-1437)

Laser synovectomy of the knee joint. Experimental results on a new approach to joint surgery.

The clinical impact of laser-assisted synovectomy was investigated in a two-part study consisting of a morphological part with morphometric measurements and an in vivo part using an animal model. A continuous wave Nd:YAG laser (lambda = 1064 nm; power density 18-106 W/mm2; exposure 0.5-5 s) and a XeCl excimer laser (lambda = 308 nm; pulsewidth 20 ns; repetition rate 10-70 Hz; energy density 20-45 mJ/mm2; exposure 10-60 s) were employed in combination with a fused silica fiber with diameters of 600 microns and 800 microns, respectively. In vitro study. Under light microscopy, synovium exposed to Nd:YAG laser energy presents a transitional band (with a mean diameter of 2 mm) with three zones: a carbonized area, a vesicular zone, and a coagulated part. In contrast, pulsed UV-laser irradiation leads only to a narrow transitional zone extending 10-70 microns. Scanning electron microscopy reveals a clear-cut surface following excimer synovectomy, whereas Nd:YAG laser irradiation forms an irregular surface with numerous bursts due to vaporizing activity. In vivo study. Partial synovectomy of the knee joint was performed in two groups of 14 New Zealand white rabbits with a 1064-nm Nd:YAG laser and a 308-nm XeCl excimer laser. Another 14 animals synovectomized in a conventional technique served as a control. Morphological examination and histopathological scoring of the synovial membrane were performed 4 days to 6 months after the operation. The progress of synovial regeneration following excimer laser synovectomy did not differ from observations in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Synovectomy and radial head excision in rheumatoid arthritis. 11 patients followed for 14 years.

A radial head excision and partial synovectomy of the elbow through a lateral approach was performed in 24 patients suffering from rheumatoid arthritis. At follow-up examination of 11 patients (12 elbows) 14 years postoperatively, 10 patients were still satisfied with pain reduction and improved elbow motion. 2 elbows had been reoperated on. Radiographic destruction, assessed by the Larsen index, was, on average, 2.9 preoperatively and 3.8 at follow-up.

Arthroscopic treatment of anterior synovitis of the ankle in athletes.

In a retrospective study we analysed the results of arthroscopic treatment of anterior synovitis of the ankle in 35 athletes. Five athletes additionally suffered from anterior osteophytes, and three presented with an anterolateral plica. Their average age was 25 years (SD 8.3), and the follow-up interval was 32.4 months (SD 19.4). Eight patients suffered from additional hyperlaxity of the ankle joint. At the time of follow-up, the patients were examined clinically as well as radiologically. The results were scored according to an ankle index containing the criteria pain, function, athletic activity, walking aids, range of motion and swelling. During surgery a partial synovectomy was performed and removal of anterior osteophytes or anterolateral plica as necessary. The overall score increased non-significantly from 66.2 preoperatively to 78.7 postoperatively (P > 0.05). Comparing the different criteria, the score parameter pain significantly increased after arthroscopy. All other parameters (function, athletic activity, walking aids, range of motion, swelling) showed only slight changes in this patient group. Athletes with a hypermobile joint showed worse results compared with the others. Even after surgery we documented severe restriction concerning athletic activity. Only 9 patients performed their activities at their previous level, 19 had reduced their activity level, and 7 had discontinued their athletic activity. In 6 cases we found temporary iatrogenic neurological damage. Regarding the uncertain clinical outcome and the documented high risk for neurovascular complication, patient selection for arthroscopic partial synovectomy in the athletic population should be extremely carefully performed.(ABSTRACT TRUNCATED AT 250 WORDS)