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
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2. INTRODUCTION
• INFLAMMATORY SYNOVITIS
• MONOARTICULAR OR POLYARTICULAR
• KNEE SYNOVIUM COMMONLY INVOLVED
• FEMALES :MALE RATIO 3:1
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3. CLINICAL FEATURES OF KNEE JOINT
SYNOVITIS
• PAIN
• SWELLING DUE TO EFFUSION
• WARMTH
• DECREASED ROM DUE TO PAIN, EFFUSION
• STIFFNESS
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4. CLINICAL EXAMINATION
• SWELLING
• ERYTHEMA
• WARMTH
• PATELLA BALLOTING
• PATELLA TAP
• TENDERNESS OVER SOFT TISSUE
STRUCTURES
• ROM- ACTIVE & PASSIVE
• VARUS/VALGUS STRESS TEST
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5. PATHOPHYSIOLOGY
• IMMUNE MEDIATED INFLAMMATORY DISEASE
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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
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8. TREATMENT
• MEDICAL LINE OF MANAGEMENT
• NSAID’S
• DMARD’S
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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
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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
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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
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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
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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
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