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Arthroscopic Knee Synovectomy is a safe and effective method, it has major potential advantages over open surgical techniques, including:
- improved visualization of the knee joint,
- a more complete synovectomy,
- less postoperative pain,
- decreased postoperative knee stiffness/arthrofibrosis,
- decreased postoperative hemarthrosis,
- shorter hospitalization, lower surgical site morbidity,
- the surgery is performed through arthroscopic portals (thus the division of the quadriceps is avoided),
- better preservation of the menisci,
- revision surgery, if required, is less complicated.
The major arthroscopic disadvantage for Knee Synovectomy is that it may be a more technically challenging operation to perform, and for some diffuse and malignant conditions, it is contraindicated.
The knee joint has the largest and most extensive synovial membrane compared to any other joint. Thus, pathologic conditions involving the synovium of the knee can be symptomatic and debilitating. Benign and malignant processes can involve the synovial membrane.
Knee Synovectomy Indications
- Plica syndrome
- Pigmented villonodular synovitis (PVNS)
- Synovial chondromatosis/osteochondromatosis
- Synovial hemangioma
- Popliteal (Baker’s) cyst
- Seronegative and seropositive arthropathies
Intra-articular malignant conditions (eg, synovial sarcoma), treatment for such conditions is often radical excision with chemotherapy and/or radiation.
Surgeon lack of experience/proficiency: Performing a thorough synovectomy requires excellent technical skills and proficiency in arthroscopy. Inadequate/incomplete performance may lead to local recurrence and/or poor outcomes. Therefore, arthroscopic synovectomy is not recommended if the surgeon does not feel confident in his or her ability to perform a complete and adequate arthroscopic synovectomy. If this is the case, a traditional open approach should be utilized or the patient should be referred to an experienced arthroscopist.
Severe arthritic changes/deformity/contractures: Such conditions may include advanced osteoarthritis, RA, seronegative arthritis, and hemophilia. In such cases, total knee arthroplasty is the definitive treatment of choice.
- Thorough history and physical exam: Document neurovascular status and discuss risk to posterior neurovascular structures when obtaining informed consent .
- Effusion: Aspiration often performed to obtain synovial fluid analysis for diagnostic purposes, and in some cases provide temporary pain relief.
- Reduced ROM and/or pain with passive ROM.
- Tenderness to palpation, often diffuse in cases of inflammatory arthropathy.
- Mechanical symptoms of clicking, catching, or locking.
- Standard knee x-rays to evaluate status of joint (eg, periarticular erosions in RA) and overall alignment/presence of any deformity.
- MRI in evaluation of PVNS, synovial chondromatosis, hemangioma, and inflammatory arthropathies to evaluate synovium, extent of disease, and rule out other intra-articular lesions. MRI in PVNS classically demonstrates low T1 and low T2 signal (due to hemosiderin deposits) and is useful in determining extent of intra- and extra-articular disease.
- CT in cases of synovial chondromatosis is only useful when loose, calcific bodies are present.
- The use of a well-padded thigh tourniquet may be considered as a more complete synovectomy may result in increased bleeding that can make visibility during arthroscopic synovectomy difficult.
- In most cases, a 30-degree arthroscope is used for the majority of the procedure. Nevertheless, for adequate visualization of the posterior compartment, a 70-degree arthroscope is often necessary and should be available for the entire procedure.
- Initially, the inflow pump should be set at a low setting to reduce knee distention and fluid extravasation intraoperatively. It can be adjusted throughout the procedure accordingly.
- Although choice of shaver depends on the anatomy of the patient and the location of the synovectomy, a variety of shaver sizes should also be available.
- A 5.5-mm full-radius knee synovectomy blade is effective in the anterior compartment. A 3.5-mm full-radius synovectomy blade or a 4.5-mm curved synovial resector can be used in smaller knees or hard to reach areas, such as the posterior compartment and under the menisci.
The patient is placed supine on the operative table. It’s preferred that the operative leg be placed into a thigh-holding device 4 finger-breadths above the superior patella such that when the foot of the bed is lowered, the leg is allowed to hang free off the end of the table. This allows for deep flexion and varus/valgus stress of the knee without compromise of portal position. The well leg is placed into a well-leg holder.
Alternatively, the arthroscopic synovectomy procedure can be performed supine with knee flexed over the side of the table against a lateral post with the well leg placed supine on the flattened operative table. The operative extremity is then prepped and draped in the usual sterile technique.
Arthroscopic Synovectomy Portal
Proper portal placement is critical for any arthroscopic procedure. Improper portal placement can lead to iatrogenic injury to the knee as well as inadequate synovectomy due to the difficulty of the procedure. It is often helpful to draw out the anatomy prior to obtaining the portals.
A complete arthroscopic synovectomy of the knee can be performed through the use of a combination of 6 portals: anterolateral, anteromedial, lateral suprapatellar, medial suprapatellar, posterolateral, and posteromedial.
Arthroscopic Synovectomy Procedure
- Supine position, well-padded thigh tourniquet, thigh-holding device 4-finger breadths above the superior patella, well leg placed in well-leg holder
- Operative leg prepped and draped in usual sterile fashion
- Mark out bony landmarks for eventual portal placement
- Inflate tourniquet
- Establish anterolateral and anteromedial portals in routine fashion
- Perform standard diagnostic arthroscopy
- With camera in suprapatellar pouch, establish lateral suprapatellar and medial suprapatellar portals
- Perform synovectomy as indicated, utilizing triangulation to gain access to the gutters, anterior compartment, and intercondylar notch
- Visualize the posterior compartments with the knee flexed 70 to 90 degrees
- Establish posteromedial and posterolateral portals under direct visualization
- Utilize 70-degree arthroscope to perform synovectomies of the posteromedial and posterolateral compartments in systematic fashion.
After the anterolateral and anteromedial portals are established, a standard diagnostic arthroscopy is performed, visualizing and probing the suprapatellar pouch, medial and lateral gutters, trochlear groove, undersurface of the patella, medial and lateral compartments, including the mensci, intercondylar notch, and cruciate ligaments. Any concurrent intra-articular pathology seen during diagnostic arthroscopy, such as meniscal or chondral injury, can be addressed throughout the procedure. In cases in which a pathologic specimen is required, an arthroscopic biter may then be used through the anteromedial portal to obtain a synovial tissue sample from an area of significant pathology. Alternatively, an arthroscopic trap may be placed in the suction tubing of the shaver to obtain significant quantities of resected synovium.
With the camera looking into the suprapatellar pouch, the lateral suprapatellar and medial suprapatellar portals are established under direct visualization approximately 1 cm above and 1 cm lateral (for lateral suprapatellar) or medial (for medial suprapatellar) to the corner of the patella. The 5.5- or 4.5-mm full-radius synovectomy blade can be used through these portals to resect the synovium in the suprapatellar pouch and the upper lateral and medial gutters and to access any portion of a hypertrophic anterior fat pad. Synovial resection is adequate when the shiny capsular layer that lies directly beneath is seen. The lower portions of the lateral and medial gutters can be accessed for resection by alternating the camera through the lateral and medial suprapatellar portals and using the shavers through the anterolateral and anteromedial portals. Next, synovectomy in the anterior compartment and intercondylar notch can be achieved by triangulation of the arthroscope and shaver through the anteromedial and anterolateral portals. The lower lateral and medial gutters can also be visualized and resected through these 2 portals.
There is a 15- to 28-mm safe zone between the posterior cruciate ligament and the popliteal neurovascular bundle for safe arthroscopy of the posterior knee. By holding the knee flexed at 70 to 90 degrees, one can gain better access to the posterior compartment as the intercondylar notch is widened and the neurovascular bundle falls more posteriorly. A 70-degree arthroscope is then used for visualization of the posterior compartment. Furthermore, this allows the posterior neurovascular bundle to fall posteriorly.
A modified Gillquist maneuver is performed with the arthroscope through the anterolateral portal and advanced under the posterior cruciate ligament in order to establish a posteromedial portal under direct visualization. Palpation of the posteromedial knee is performed under visualization to better localize portal placement. At this time, a spinal needle is introduced into the posteromedial corner of the knee joint aiming anteriorly. Dimming of the overhead and room lights and transillumination using the arthroscopy may also aid in introduction of the spinal needle.
The posteromedial portal is the then established, and a blunt cannula is introduced via this portal. The cannula is best introduced over a switching stick to allow for easier and more accurate cannula placement. Caution must be exercised when introducing any instrument into the joint in this location with an emphasis on aiming slightly anteriorly to avoid iatrogenic injury to the posterior neurovascular bundle. The posteromedial portal is typically placed 16 to 35 mm from the saphenous vein.
ArthroscopicSynovectomy of the posteromedial knee is then performed through this portal with a 4.5-mm shaver systematically from the periphery to the center. One must be mindful of the suction during this part of the procedure to avoid drawing the posterior capsule into the shaver, thereby risking accidental iatrogenic injury to vital posterior structures.
Lastly, the lateral portion of the posterior compartment is then accessed similarly by switching the arthroscope to the anteromedial portal. Holding the knee flexed at 90 degrees will allow the common peroneal nerve to fall further posteriorly behind the biceps femoris tendon. A spinal needle is introduced anterior to the biceps femoris tendon, 1 cm above the joint line and 1 cm posterior to the femoral condyle. The posterolateral portal is established and then cannulated like the posteromedial portal. The posterolateral portal is typically placed 40 to 52 mm from the peroneal nerve. Synovectomy of the posterolateral knee is then performed similar to the posteromedial side in a systematic fashion.
Depending on the extent of arthroscopicsynovectomy performed, a drain may be placed and monitored for at least 1 day prior to removal to reduce postoperative hemarthrosis. Nevertheless, this may not be needed if the bleeding is not significant at the conclusion of the case. A compressive dressing is applied to the knee. Patients can be made partial weightbearing with crutches for assistance and are typically discharged the same day or on the first postoperative day.
Cryotherapy with ice packs can aid in postoperative reduction in pain and swelling. Oral pain medication should be prescribed, and physical therapy should start early to ensure rapid restoration of normal gait, ROM, and strength.
Patients should be provided with written home instructions to begin immediate postoperative home therapy with a focus on active ROM and quadriceps strengthening. Although not critical, the use of a continuous passive motion machine to facilitate early motion is reasonable. The majority of patients approach near normal activity level by the fourth postoperative week.
Arthroscopic Synovectomy Complications
Complications resulting from arthroscopic synovectomy are similar to those of any arthroscopic procedure, including anesthesia concerns, infection, bleeding, deep venous thrombosis, arthrofibrosis, and iatrogenic injury to articular cartilage or neurovascular structures.
Caution must be taken during the procedure to maneuver the arthroscope or instruments to avoid excessive pressure on the articular cartilage and to direct instruments away from vulnerable posterior structures when using the posterolateral and posteromedial portals, namely the neurovascular bundle, saphenous vein and nerve, and the common peroneal nerve.
Other complications specific to arthroscopic synovectomy include hemarthrosis resulting in pain and stiffness, postoperative arthrofibrosis requiring a manipulation or arthroscopic lysis of adhesions, reflex sympathetic dystrophy, or incomplete resection resulting in recurrence or persistence of the synovial pathology, thereby requiring additional surgery.
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A study that analyzed patients who underwent Osmic Acid Synovectomy found that approximately 28% patients were in disease remission for their knee joint for over three years duration.How long does it take to recover from arthroscopic synovectomy knee? ›
The recovery period following a synovectomy of the knee joint can vary depending on the extent of the synovitis and the specific surgical technique performed by Dr. Patel. Most patients can expect a full recovery with a return to their normal daily activities in approximately 3 to 4 months.How long is recovery from arthroscopic synovectomy? ›
Generally, full normal stressful activities and sports are resumed after 3-6 weeks. During this time frame, more stressful activities may be engaged as tolerated.What is arthroscopic synovectomy knee? ›
A synovectomy is a surgical procedure for the treatment of synovitis in which part of the synovium of a joint is removed. It may be performed either as an open surgery or with the aid of an arthroscope.What are the disadvantages of synovectomy? ›
Concerns remain that arthroscopic synovectomy may result in subtotal resection of the synovial lining, and more rapid recurrence of joint pain, progression of disease, and likelihood of arthroplasty.Does synovium grow back after synovectomy? ›
The possible complications following synovectomy include: infection, bleeding, nerve and blood vessel damage, damage to bone surface, and no relief of symptoms. Synovium can grow back and may require repeat surgery.Can you walk after synovectomy? ›
Activity: After your knee arthroscopic synovectomy, you may be given crutches. These can be used if you feel you need them, but it is OK to walk without them if you can. You may put full weight on your leg after this surgery.How long until I can walk normally after knee arthroscopy? ›
You will probably need about 6 weeks to recover. If your doctor repaired damaged tissue, recovery will take longer. You may have to limit your activity until your knee strength and movement are back to normal. You may also be in a physical rehabilitation (rehab) program.How much walking should you do after arthroscopic knee surgery? ›
Regular exercise to restore strength and mobility to your knee is important for your full recovery after arthroscopic surgery. Your orthopaedic surgeon or physical therapist may recommend that you exercise for approximately 20 to 30 minutes, 2 or 3 times a day.What are the side effects of arthroscopic synovectomy of the knee? ›
- Bleeding into the joint.
- Blood clots.
- Blood vessel damage.
- Bone surface damage.
- Cartilage damage.
- Ligament damage.
- Nerve damage.
Arthroscopic synovectomy is perfomred to remove the inflamed joint tissue that is causing unacceptable pain or limited function of the knee. Major synovectomy involves surgery on two or more compartments of the knee.What not to do after an arthroscopy? ›
You may shower 48 hours after your surgery and get your incisions wet. Do NOT immerse in a tub or pool for 7 – 10 days to avoid excessive scarring and risk of infection. Keep Ice Packs on at all times exchanging every hour while awake. Icing is very important to decrease swelling and pain and improve mobility.Does synovitis ever go away? ›
Synovitis can go away on its own, but if the symptoms linger, treatment may be necessary. Treatment for synovitis depends on the underlying cause. In most cases, treatments are geared to decrease inflammation, lessen swelling, and manage pain.How long does it take for knee synovitis to heal? ›
Most patients walk normally within 7 days and return to full activity in less than 4 weeks. Others with significant swelling may require a slower rehabilitation.What are the benefits of synovectomy? ›
Synovectomy treats inflammatory arthritis such as RA, psoriatic arthritis, and juvenile idiopathic arthritis. (It's also used to treat joint damage resulting from the blood clotting disorder hemophilia.) You may need this surgery if other treatments don't help your pain and other arthritis symptoms.Is synovectomy part of total knee replacement? ›
During primary total knee arthroplasty (TKA), synovectomy as a part of the procedure has been recommended to relieve pain and inflammation of the synovium, but there is a controversy about it due to increased bleeding.Does synovial fluid grow back? ›
At first the amount of synovial fluid is restored at the expense of its liquid part, percentage of common protein and its fractions increase, and viscosity of synovial fluid decreases. After two days, a gradual restoration of all physiological indices mentioned occurs. By the fourth day they are completely restored.Why is arthroscopy not recommended? ›
Studies have found that knee arthroscopy usually does not relieve pain, and any pain relief a patient does get is short-lived. And while complications from arthroscopy are rare, they can be serious, including blood clots and infections.What helps regenerate synovial fluid? ›
Regular exercise, a healthy diet, nutritional supplements, and joint injections may all help improve or increase synovial fluid and decrease joint pain and inflammation.What are the long term effects of synovitis? ›
Untreated synovitis can lead to permanent joint damage. Over time, this condition may even destroy nearby bone and cartilage in the joint. But that's not all. Synovitis can also damage other structures that support the joint like the tendons—the tissues that connect our muscles to our bones.
One of the great advantages of knee arthroscopy is that you may start walking on the operated knee right away.Do you need a brace after a synovectomy? ›
A knee immobilizer is also required for 4 weeks after surgery. It may be opened and removed for ice application and for therapy and exercises.Can you climb stairs after arthroscopic knee surgery? ›
Answer: Immediately after surgery you will learn to climb stairs safely using crutches. As recovery continues and you work on flexion and extension of the new knee, you will be able to climb without crutches. With the help of physical therapy and building up the quadriceps muscles, stair climbing will be a breeze.What is the best exercise after knee surgery? ›
Walking. Proper walking is the best way to help your knee recover. At first, you will walk with a walker or crutches. Your surgeon or therapist will tell you how much weight to put on your leg.Should I bend my knee after arthroscopy? ›
It is important to keep the knee moving after arthroscopy which means that on a daily basis you should try to bend it as far as comfortably possible, best done in a sitting position. You should also maintain extension by trying to lock it out straight on a regular basis.Will I need a knee brace after arthroscopy? ›
Do I need a knee brace? Knee braces after simple arthroscopic knee surgery are rarely used. However, if your surgery involves more than just removal of torn cartilage or meniscus - for example, if you have a meniscal repair - your knee may be placed in a brace after surgery.Why does my knee still hurt 3 months after arthroscopic surgery? ›
This complication of knee arthroscopy is thought to be the result of microscopic fractures of the bone around the knee joint. These fractures cause inflammation within the bone and significant, persistent pain, typically along the inner (medial) side of the knee.
Sleep on Your Side
You can, but it's wise not to do so until at least a few weeks after surgery, when you can start bending your knee. Make sure you lay on your non-operative side. Sleeping this way makes sure no pressure falls on the knee you had surgery on.
The goal is to not be overly active. If the knee is not tremendously painful, walking can occur without crutches; however, do not overdo it in the first two to three days after surgery since this could result in more swelling than is necessary.How long is physical therapy after arthroscopic knee surgery? ›
It may take 4-5 months for full healing. The patient should be able to bear weight on the knee while standing or walking, immediately after surgery. Crutches will be necessary for 2-7 days after surgery. Rehabilitation to gain full ROM should occur within 1-2 weeks.
Excessive pain in the knee following arthroscopic surgery is usually due to overactivity or spending too much time on your feet before the thigh muscles have been adequately strengthened. Excessive swelling can also cause pain in the knee. It is normal for the knee to be sore and swollen following arthroscopy.What is the risk of blood clot after knee arthroscopy? ›
Clots are most likely to develop in the first week or two after your surgery, but you're at risk for about three months. You won't always notice symptoms, but if you develop a blood clot you might see: New swelling in your lower leg that doesn't go down when you elevate your leg.What are the chances of getting a blood clot after arthroscopic knee surgery? ›
The incidence of deep vein thrombosis (DVT) in orthopedic lower extremities surgery has been reported at 19.3% , but this is a rare condition following arthroscopic surgery, especially arthroscopic meniscal surgery. The risk factors are age greater than 40–60 years ,  and operation time more than 60–120 min.What happens if synovitis goes untreated? ›
"Left untreated, the patient will develop more and more synovitis, which can eventually lead to complete destruction of articular cartilage and the need for joint replacement surgery."Is synovectomy the same as debridement? ›
Elbow debridement surgery is a surgical procedure to remove damaged tissues, bone or foreign materials within the elbow joint. Elbow synovectomy involves the removal of inflamed synovium (the membrane that lines the joints).Is synovectomy done in osteoarthritis? ›
Arthroscopic synovectomy (AS) in knee OA combined with resection of the cartilage lesions is a mild operative procedure and is not associated with postoperative joint stiffness and necessity of continuous rehabilitation.Will I be able to walk after an arthroscopy? ›
You can start with some gentle exercise, such as walking. This may feel a little uncomfortable at first. After a week or two, you may be able to go for longer walks, swim or have a gentle cycle. Don't do any high-impact exercises, such as running, for at least six weeks.What is the most serious complication of arthroscopy? ›
Infection. Thrombophlebitis (clots in a vein) Artery damage. Excessive bleeding (haemorrhage)Can synovitis come back after surgery? ›
The synovium often grows back a few years after surgery. Synovitis is more likely to come back after an arthroscopic procedure than open surgery. If it returns, your doctor will let you know whether you need a repeat procedure.How soon after arthroscopy can I bend my knee? ›
At 6 weeks after surgery, you may gradually resume your previous activities if you have full range-of-motion, full strength and no swelling.
Most people can get back to desk work, school or sedentary activity 3 to 5 days after surgery. If your right knee was operated on, it may be up to 2 weeks before the knee is strong enough to hit the brakes to drive safely. For heavy work, it may take 4 to 6 weeks before the leg is strong enough to allow for working.Why is synovitis so painful? ›
Cartilage loss eventually damages the joint surface and leads to the stiffness and pain characteristic of all types of arthritis. (Osteoarthritis, the more common form of the arthritis, does not involve this type of inflammatory response.)
A synovectomy is a surgical procedure used to treat synovitis and some other conditions that affect the synovium, a thin membrane that lines the inside of certain joints (called "synovial joints"), such as your knee, shoulder or elbow. In a synovectomy procedure, much of the synovium is removed.Why is my knee worse after knee arthroscopy? ›
Excessive pain in the knee following arthroscopic surgery is usually due to overactivity or spending too much time on your feet before the thigh muscles have been adequately strengthened. Excessive swelling can also cause pain in the knee. It is normal for the knee to be sore and swollen following arthroscopy.