SLR - February 2013 - Rogers
Reference: Choi, Woo Jin, Choi, Gi Won, Lee, Jin Woo. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 19 June 2012. pp 1-8.
Scientific Literature Review
Reviewed by: Ryan J. Rogers, DPM
Residency Program: St. Hospital and Medical Center, Detroit, MI
Podiatric Relevance:
Open joint synovectomy has been shown to improve pain and delay articular cartilage destruction in patients with rheumatoid arthritis; however, concern for prolonged rehabilitation and postoperative joint stiffness exist with open joint synovectomy. Arthroscopic synovectomy has been associated with less postoperative complications in the knee and hip joints. The authors hypothesize that arthroscopic synovectomy of the ankle joint would yield lasting pain relief and improved function when performed in early stage rheumatoid arthritis patients.
Methods:
Inclusion criteria for the study include synovitis in the ankle joint resulting in pain and dysfunction, which was unresponsive to systemic treatment for 6 months and radiographic findings of grade 3 or less (Larsen grade 3 characterized by marked osseous erosions). Exclusion criteria were history of trauma, prior surgery, severe radiographic destruction and gross deformity. Eighteen patients who underwent unilateral arthroscopic ankle synovectomy met inclusion criteria. All received anti-inflammatory medications, disease-modifying antirheumatic drugs, and prednisolone during the study.
Surgical Technique:
Ankle arthroscopy was performed with a tourniquet and noninvasive distraction with a foot strap in place. Standard anterolateral, anteromedial, and posterolateral portals were utilized. An oscillating shaver and cautery device was utilized to debride hypertrophic synovial tissue, rough articular cartilage, and loose debris, with attempt to perform complete synovectomy of all pathologic-appearing tissue. Hemostasis was achieved before completion of the surgery. Weightbearing as tolerated was permitted with cane, crutch, or walker assist immediately following surgery. Physical therapy, ROM and muscle-strengthening exercises were initiated as soon as possible.
Results:
The mean duration of RA and symptoms prior to surgery was 6.5 years and 13 months, respectively. The mean postoperative follow-up was 5 years (range 2-8.6 years). No postoperative complications were encountered. The mean VAS score for pain improved from 5.6 points preoperatively to 2.2 postoperatively. The mean AOFAS score improved from 65.2 +/- 4.4 points preoperatively to 85.7 +/- 6.7 at final follow-up. VAS and AOFAS scores were significantly improved at 1 year follow-up; however, additional significant improvements beyond 1 year were not noted.
Conclusions:
Arthroscopic ankle joint synovectomy is a safe and effective procedure for patients with rheumatoid arthritis, with the best results yielded when the procedure is performed early in the disease process without presence of articular cartilage degeneration.