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ROLE OF ARTHROSCOPIC
SYNOVECTOMY OF KNEE JOINT IN
PATIENTS WITH RHEUMATOID
ARTHRITIS
-BY
Dr. Prakhar Chhawchharia
Orthopaedic surgeon
Fellowship in Arthroscopy
9/18/2016 Dr. Prakhar Chhawchharia 1
INTRODUCTION
• INFLAMMATORY SYNOVITIS
• MONOARTICULAR OR POLYARTICULAR
• KNEE SYNOVIUM COMMONLY INVOLVED
• FEMALES :MALE RATIO 3:1
9/18/2016 Dr. Prakhar Chhawchharia 2
CLINICAL FEATURES OF KNEE JOINT
SYNOVITIS
• PAIN
• SWELLING DUE TO EFFUSION
• WARMTH
• DECREASED ROM DUE TO PAIN, EFFUSION
• STIFFNESS
9/18/2016 Dr. Prakhar Chhawchharia 3
CLINICAL EXAMINATION
• SWELLING
• ERYTHEMA
• WARMTH
• PATELLA BALLOTING
• PATELLA TAP
• TENDERNESS OVER SOFT TISSUE
STRUCTURES
• ROM- ACTIVE & PASSIVE
• VARUS/VALGUS STRESS TEST
9/18/2016 Dr. Prakhar Chhawchharia 4
PATHOPHYSIOLOGY
• IMMUNE MEDIATED INFLAMMATORY DISEASE
9/18/2016 Dr. Prakhar Chhawchharia 5
ANTIGEN BINDS
WITH MHC
C28 MOLECULE
ACTIVATES
T -CELL
PROLIFERATE AND
SECRETE IL-2,
IFN,TNF,IL-4
B CELLS GET
ACTIVATED
SECRETE CYTOKINES,
BECOME ANTIGEN
PRESENTING CELL TO
T LYMPHOCYTES
PLASMA CELLS
RELEASE RF, anti-
CCP,ACPA
PATHOPHYSIOLOGY OF SYNOVIUM
• INTIMAL LAYER(1-3 CELLS THICK)
HYPERTROPHIED-FILLED WITH FIBROBLASTS
AND MACROPHAGES
• SUBINTIMAL LAYER- (VASCULAR LAYER)
HEAVILY INFILTERATED WITH T & B CELLS,
MACROPHAGES, OSTEOCLASTS,
ANGIOGENESIS
• THIS IS CALLED PANNUS-HYPERTROPHIED
SYNOVIUM
• PANNUS INVADES AND ERODES THE
CONTIGOUS CARTILAGE AND BONE
9/18/2016 Dr. Prakhar Chhawchharia 6
INVESTIGATIONS/DIAGNOSIS
• HAEMATOLOGY- RA FACTOR, anti-CCP, ANCP,
ESR, C-RP
• RADIOLOGY- XRAY, MRI
• BIOCHEMISTRY- SYNOVIAL FLUID ANALYSIS
• HISTOPATHOLOGY- SYNOVIAL TISSUE BIOPSY
9/18/2016 Dr. Prakhar Chhawchharia 7
TREATMENT
• MEDICAL LINE OF MANAGEMENT
• NSAID’S
• DMARD’S
9/18/2016 Dr. Prakhar Chhawchharia 8
CONVENTIONAL BIOLOGICS
METHOTREXATE ETARNECEPT
LEFLUNOMIDE INFLIXIMAB
SULFASALAZINE ADALIMUNAB
HYDROXYCHLOROQUINE ABATACEPT
AZATHIOPRINE RITUXIMAB
CYCLOSPORIN ANAKINRA
TREATMENT
• SURGICAL- ARTHROSCOPIC SYNOVECTOMY,
TOTAL KNEE REPLACEMENT
• INDICATIONS OF ARTHROSCOPIC
SYNOVECTOMY
1. ACUTE INFLAMMATION
2. CHRONIC INFLAMMATION NOT RESPONDING
TO DMARD’S
3. EARLY STAGE OF DISEASE
4. NO ADVANCED BONY CHANGES
5. TO DELAY TKR IN YOUNG OR WITH OTHER
CO- MORBITIES
9/18/2016 Dr. Prakhar Chhawchharia 9
ATHROSCOPIC SYNOVECTOMY
• ADVANTAGES
1. SIGNIFICANT IMPROVEMENT IN PAIN SCORES
2. COMPLETE REMISSION OF DISEASE IN A JOINT
3. CAN BE MANAGED WITH SINGLE DMARD
4. MORE ACCURATE DIAGNOSIS VIA SYNOVIAL
BIOPSY AND SYNOVIAL FLUID ANALYSIS
5. NEAR COMPLETE REMOVAL OF SYNOVIUM
UNDER VISUALISATION
6. DIMUNITION OF JOINT STIFFNESS POST
SURGERY
7. SHORT HOSPITAL STAY
9/18/2016 Dr. Prakhar Chhawchharia 10
ARHTROSCOPIC SYNOVECTOMY-
MATERIALS AND METHOD
1. STANDARD 5MM SCOPE
2. 5.5 MM RESECTOR/SHAVER
3. PUNCH BIOPSY FORCEPS
4. BITE FORCEPS
5. GRASPER
9/18/2016 Dr. Prakhar Chhawchharia 11
ARHTROSCOPIC SYNOVECTOMY-
MATERIALS AND METHOD
• PORTALS
9/18/2016 Dr. Prakhar Chhawchharia 12
ARHTROSCOPIC SYNOVECTOMY-
MATERIALS AND METHOD
• SEQUENCE OF PERFORMING A TOTAL SYNOVECTOMY
1. INTERCONDYLAR NOTCH,
2. POSTEROLATERAL COMPARTMENT,
3. POSTEROMEDIAL COMPARTMENT,
4. MEDIAL COMPARTMENT,
5. LATERAL COMPARTMENT,
6. SUPRAPATELLAR COMPARTMENT,
7. RETROPATELLAR COMPARTMENT.
8. UNDERSURFACE OF EACH MENISCUS IS CAREFULLY
EXAMINED
9. ANY POPLITEAL CYST, FOREIGN BODY & PLICA REMOVED
10. AFTER RELEASING THE TOURNIQUET, BLEEDERS ARE
CAUTERIZED BY RF ABLATION PROBE,DRAIN KEPT AND
COMPRESSION BANDAGE GIVEN
9/18/2016 Dr. Prakhar Chhawchharia 13
ATHROSCOPIC SYNOVECTOMY
-POST OPERATIVE CARE
• DRAIN REMOVAL AT 24 HRS
• STATIC QUADRICEPS AND PASSIVE ROM
STARTED IN IMMEDIATE POST OP PERIOD
• PHYSIOTHERAPY REHAB PROTOCOL FOR
QUADRICEPS AND HAMSTRING
STRENGTHENING
• ACTIVE ROM EXERCISES
• MODALITIES TO DECREASE PAIN, SWELING,
STIFFNESS IN POST OP PERIOD
9/18/2016 Dr. Prakhar Chhawchharia 14
9/18/2016 Dr. Prakhar Chhawchharia 15

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Role of arthroscopic synovectomy of knee joint in ra

  • 1. ROLE OF ARTHROSCOPIC SYNOVECTOMY OF KNEE JOINT IN PATIENTS WITH RHEUMATOID ARTHRITIS -BY Dr. Prakhar Chhawchharia Orthopaedic surgeon Fellowship in Arthroscopy 9/18/2016 Dr. Prakhar Chhawchharia 1
  • 2. INTRODUCTION • INFLAMMATORY SYNOVITIS • MONOARTICULAR OR POLYARTICULAR • KNEE SYNOVIUM COMMONLY INVOLVED • FEMALES :MALE RATIO 3:1 9/18/2016 Dr. Prakhar Chhawchharia 2
  • 3. CLINICAL FEATURES OF KNEE JOINT SYNOVITIS • PAIN • SWELLING DUE TO EFFUSION • WARMTH • DECREASED ROM DUE TO PAIN, EFFUSION • STIFFNESS 9/18/2016 Dr. Prakhar Chhawchharia 3
  • 4. CLINICAL EXAMINATION • SWELLING • ERYTHEMA • WARMTH • PATELLA BALLOTING • PATELLA TAP • TENDERNESS OVER SOFT TISSUE STRUCTURES • ROM- ACTIVE & PASSIVE • VARUS/VALGUS STRESS TEST 9/18/2016 Dr. Prakhar Chhawchharia 4
  • 5. PATHOPHYSIOLOGY • IMMUNE MEDIATED INFLAMMATORY DISEASE 9/18/2016 Dr. Prakhar Chhawchharia 5 ANTIGEN BINDS WITH MHC C28 MOLECULE ACTIVATES T -CELL PROLIFERATE AND SECRETE IL-2, IFN,TNF,IL-4 B CELLS GET ACTIVATED SECRETE CYTOKINES, BECOME ANTIGEN PRESENTING CELL TO T LYMPHOCYTES PLASMA CELLS RELEASE RF, anti- CCP,ACPA
  • 6. PATHOPHYSIOLOGY OF SYNOVIUM • INTIMAL LAYER(1-3 CELLS THICK) HYPERTROPHIED-FILLED WITH FIBROBLASTS AND MACROPHAGES • SUBINTIMAL LAYER- (VASCULAR LAYER) HEAVILY INFILTERATED WITH T & B CELLS, MACROPHAGES, OSTEOCLASTS, ANGIOGENESIS • THIS IS CALLED PANNUS-HYPERTROPHIED SYNOVIUM • PANNUS INVADES AND ERODES THE CONTIGOUS CARTILAGE AND BONE 9/18/2016 Dr. Prakhar Chhawchharia 6
  • 7. INVESTIGATIONS/DIAGNOSIS • HAEMATOLOGY- RA FACTOR, anti-CCP, ANCP, ESR, C-RP • RADIOLOGY- XRAY, MRI • BIOCHEMISTRY- SYNOVIAL FLUID ANALYSIS • HISTOPATHOLOGY- SYNOVIAL TISSUE BIOPSY 9/18/2016 Dr. Prakhar Chhawchharia 7
  • 8. TREATMENT • MEDICAL LINE OF MANAGEMENT • NSAID’S • DMARD’S 9/18/2016 Dr. Prakhar Chhawchharia 8 CONVENTIONAL BIOLOGICS METHOTREXATE ETARNECEPT LEFLUNOMIDE INFLIXIMAB SULFASALAZINE ADALIMUNAB HYDROXYCHLOROQUINE ABATACEPT AZATHIOPRINE RITUXIMAB CYCLOSPORIN ANAKINRA
  • 9. TREATMENT • SURGICAL- ARTHROSCOPIC SYNOVECTOMY, TOTAL KNEE REPLACEMENT • INDICATIONS OF ARTHROSCOPIC SYNOVECTOMY 1. ACUTE INFLAMMATION 2. CHRONIC INFLAMMATION NOT RESPONDING TO DMARD’S 3. EARLY STAGE OF DISEASE 4. NO ADVANCED BONY CHANGES 5. TO DELAY TKR IN YOUNG OR WITH OTHER CO- MORBITIES 9/18/2016 Dr. Prakhar Chhawchharia 9
  • 10. ATHROSCOPIC SYNOVECTOMY • ADVANTAGES 1. SIGNIFICANT IMPROVEMENT IN PAIN SCORES 2. COMPLETE REMISSION OF DISEASE IN A JOINT 3. CAN BE MANAGED WITH SINGLE DMARD 4. MORE ACCURATE DIAGNOSIS VIA SYNOVIAL BIOPSY AND SYNOVIAL FLUID ANALYSIS 5. NEAR COMPLETE REMOVAL OF SYNOVIUM UNDER VISUALISATION 6. DIMUNITION OF JOINT STIFFNESS POST SURGERY 7. SHORT HOSPITAL STAY 9/18/2016 Dr. Prakhar Chhawchharia 10
  • 11. ARHTROSCOPIC SYNOVECTOMY- MATERIALS AND METHOD 1. STANDARD 5MM SCOPE 2. 5.5 MM RESECTOR/SHAVER 3. PUNCH BIOPSY FORCEPS 4. BITE FORCEPS 5. GRASPER 9/18/2016 Dr. Prakhar Chhawchharia 11
  • 12. ARHTROSCOPIC SYNOVECTOMY- MATERIALS AND METHOD • PORTALS 9/18/2016 Dr. Prakhar Chhawchharia 12
  • 13. ARHTROSCOPIC SYNOVECTOMY- MATERIALS AND METHOD • SEQUENCE OF PERFORMING A TOTAL SYNOVECTOMY 1. INTERCONDYLAR NOTCH, 2. POSTEROLATERAL COMPARTMENT, 3. POSTEROMEDIAL COMPARTMENT, 4. MEDIAL COMPARTMENT, 5. LATERAL COMPARTMENT, 6. SUPRAPATELLAR COMPARTMENT, 7. RETROPATELLAR COMPARTMENT. 8. UNDERSURFACE OF EACH MENISCUS IS CAREFULLY EXAMINED 9. ANY POPLITEAL CYST, FOREIGN BODY & PLICA REMOVED 10. AFTER RELEASING THE TOURNIQUET, BLEEDERS ARE CAUTERIZED BY RF ABLATION PROBE,DRAIN KEPT AND COMPRESSION BANDAGE GIVEN 9/18/2016 Dr. Prakhar Chhawchharia 13
  • 14. ATHROSCOPIC SYNOVECTOMY -POST OPERATIVE CARE • DRAIN REMOVAL AT 24 HRS • STATIC QUADRICEPS AND PASSIVE ROM STARTED IN IMMEDIATE POST OP PERIOD • PHYSIOTHERAPY REHAB PROTOCOL FOR QUADRICEPS AND HAMSTRING STRENGTHENING • ACTIVE ROM EXERCISES • MODALITIES TO DECREASE PAIN, SWELING, STIFFNESS IN POST OP PERIOD 9/18/2016 Dr. Prakhar Chhawchharia 14
  • 15. 9/18/2016 Dr. Prakhar Chhawchharia 15