Joint synovectomy

In the absence of results of conservative treatment of certain diseases of the joints, an operation is performed to remove the damaged part or all of the synovial membrane lining the articular capsule - synovectomy.

Removing abnormal tissue can reduce symptoms and slow the destruction of articular cartilage. [1]

Indications for the procedure

In orthopedic surgery, synovectomy is used when symptoms of alteration of the synovial membrane of the joint, such as severe pain and limited mobility threatening disability, do not respond to either drug treatment or physiotherapy for at least 10-12 months. [2]

And the main indications for the removal of synovial tissue are the presence of radiographically confirmed patients in patients:

• rheumatoid arthritis; [3]
• seronegative spondyloarthropathies , including reactive and psoriatic arthritis;
• septic arthritis ;
• post-infectious or trauma-related monoarthritis;
• synovitis  (including infectious);
• synovial tumor - pigmented villonodular (villous-nodular) synovitis;
• recurrent hemarthrosis (developing joint damage in patients with hemophilia); [4]
• chronic form of aseptic bursitis.

Limited, and sometimes total synovectomy is used for relapses of primary synovial osteochondromatosis (the formation of osteochondral bodies in the synovial membrane).

As for synovectomy for rheumatoid arthritis, then, as noted by foreign experts, this procedure can be used to relieve pain in case of damage to the knee or elbow joint (accompanied by synovitis), provided there is slight destruction of bone or cartilage. But if the cartilage is severely damaged and joint destruction progresses rapidly, synovectomy will not help. In such cases, joint replacement ( arthroplasty ) is required.

Preparation

In the process of preparing for the synovectomy, the surgeon examines the patient's medical history and the available images of the affected joint, conducts a physical examination, and also prescribes instrumental examinations: X-rays, computed tomography (CT) and MRI scans to confirm the existing disease, as well as detailed visualization of all bone and connective tissue structures of the joint and periarticular tissues at the time of surgery.

Routine laboratory tests before surgery include a coagulogram - a blood clotting test.

Technique synovectomy

The technique of performing depends on the method by which the synovectomy is performed, and the choice of the method is determined by the specificity and degree of joint damage and its localization.

So, on the upper limbs (most often with arthritis), synovectomy of the wrist, elbow and shoulder joints is performed; on the lower extremities - synovectomy of the ankle, knee and hip joint (especially the acetabulum).

According to clinics, most patients undergo knee synovectomy, followed by elbow synovectomy.

Open surgical (arthrotomy) and arthroscopic are the two main methods for removing synovial tissue, and both are performed under general anesthesia. [5]

In open surgery to remove the synovium, an incision is made over the affected joint, the bursa is exposed and dissected, and the inflamed or pathologically altered synovial membrane is scraped off or excised, and the effusion is removed. In cases of bone infection, the joint is sanitized. Sutures are applied to the incisions, and a bandage is placed on top of the joint.

In arthroscopic synovectomy, several small percutaneous incisions (portals) are made with trocars around the joint perimeter, through which an arthroscope (a flexible tube equipped with a light guide and a video camera) and miniature surgical instruments are inserted. Before removing the synovium, a sterile solution is injected into the joint capsule through a cannula. The surgeon performs all manipulations looking at the enlarged image obtained from the arthroscope camera on the monitor. At the end of the procedure, all surgical devices are removed and a bandage is applied to the incisions. [6]

Experts note such obvious advantages of the arthroscopic technique (especially for synovectomy of the shoulder and knee joints), such as minimal trauma to the periarticular tissues, absence of kinesthesia disorders, less pronounced postoperative pain and faster recovery of patients. [7]

Although arthroscopy is less invasive than open surgery, the technique is more complicated and the procedure takes longer.

Contraindications to the procedure

Synovectomy is not performed:

• with osteoarthritis and ostearthritis;
• in the acute stage of joint inflammation of an infectious etiology;
• in the presence of progressive rheumatoid arthritis with radiologically determined high degree of destruction of the joint (subchondral bone and / or articular cartilage);
• in cases of severe joint instability;
• with ankylosis.

Also on the list of contraindications is severe coronary heart disease, pregnancy and the period of breastfeeding.

Consequences after the procedure

Since with standard synovectomy, the synovial membrane of the joint regenerates over time (due to the formation of connective tissue during maturation of fibroblasts), the most common consequence after the procedure is the recurrence of synovitis or chondromatosis and even their progression. - with the need for reoperation. [8]

According to some reports, almost 15-20% of patients who underwent arthroscopic synovectomy of the hip joint have recurrences of synovial chondromatosis during the first two to three years after the procedure.

Complications after the procedure

The main complications after synovectomy are associated with a negative reaction to anesthesia, infection and the development of an inflammatory process, damage to blood vessels and bleeding, damage to nerves, as well as the surfaces of the articulating bones. [9]

Clinical experience shows that there is a high risk of nerve damage during elbow synovectomy; with open synovectomy of the shoulder joint, the coordination of the muscles of the shoulder and shoulder girdle may be impaired; in some patients after synovectomy of the ankle joint due to scars and contracture, the mobility of the limb in the ankle is significantly reduced.

At the same time, open synovectomy often arthroscopic leads to postoperative rigidity of the joint and a decrease in the range of its motion.

Care after the procedure

Postoperative care and subsequent rehabilitation are carried out according to the instructions and recommendations of the operating surgeon. In particular, with regard to the limitations of joint movement (turns, straightening-flexion, etc.) and the optimal position of the limb: the elbow joint is kept bent (using an orthosis), after knee surgery, its immobilization is provided by a removable plaster cast, and the leg should be kept slightly bent (for which a roller or small pillow is placed under the knee). [10]

With swelling of the joint, cold is applied; pain relievers are prescribed for pain, heparin is used to prevent blood clots, and nonsteroidal anti-inflammatory drugs (NSAIDs) are used to prevent ossification.

Postoperative rehabilitation consists in performing a set of exercises, determined in each specific case by a specialist (rehabilitologist or physiotherapist), taking into account the balance of active and passive movement - to develop joint mobility and restore its functions. And physiotherapy can begin two days after the operation and should continue for at least two, or even three months. [11]

Although the total rehabilitation time depends on the patient's condition and the degree of joint damage. So, the pain after synovectomy disappears, on average, after three to three and a half weeks; swelling subsides and joint mobility improves noticeably in a month and a half.