Arthroscopic synovectomy of the rheumatoid wrist. A 3.8 year follow-up

Advances in wrist arthroscopic surgery in Indonesia

Since the 1990s, new insights in wrist arthroscopy have led to the introduction of numerous treatment methods. Consequently, therapeutic procedures are no longer limited to resection as more specialized repair and functional reconstruction methods, involving tissue replacement and essential structural augmentation, have been shown to be beneficial. This article discusses the most prevalent reasons and uses for wrist arthroscopy, with an emphasis on Indonesia’s most recent and major advances in reconstructive arthroscopic surgery. Joint debridement, synovectomy, ganglionectomy, capsular release, and osteotomies are frequent resection operations. Ligament repair and arthroscopy-aided reduction and fixation for fractures and nonunion are all examples of reconstructive surgery.

Arthroscopic Synovectomy of the Wrist in Patients With Rheumatoid Arthritis: A Systematic Review of the Current Literature

BACKGROUND

Rheumatoid arthritis (RA) of the wrist can lead to loss of wrist function and progressive joint destruction if inadequately treated. Arthroscopic synovectomy of the wrist may prove a valuable treatment for local inflammation.

OBJECTIVE

The aim of this study was to perform a systematic review evaluating functional outcomes and pain following arthroscopic synovectomy of the wrist in RA patients.

METHODS

A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines. MEDLINE, EMBASE, The Cochrane Library, Web of Science, and Google Scholar were searched for studies describing pain or functional outcomes following arthroscopic synovectomy of the wrist in RA patients (CRD42021270846). Risk of bias was assessed using the Methodological Index for Non-Randomized Studies. Data collection included patient characteristics, pain scores, wrist function questionnaires, secondary surgery, and complications.

RESULTS

Six noncomparative cohort studies were included, with a total of 153 arthroscopic synovectomies. Disease duration of RA ranged from 32 to 89 months, and radiographic progression was mild to moderate. The Methodological Index for Non-Randomized Studies scores ranged from 8 to 10 out of 16. Mean follow-up ranged from 21 to 95 months. Improvements were seen in pooled mean visual analog scale pain score (from 7.7 to 2.2, p < 0.05), pooled mean Modified Mayo Wrist Score (from 43.3 to 70.4, p < 0.05), and the Disability of the Arm, Shoulder, and Hand (from 67.5 to 36.5, p < 0.05). Two complications occurred, and 5 patients required secondary surgery.

CONCLUSIONS

There is limited evidence suggesting that arthroscopic synovectomy of the wrist improves wrist function and pain in patients with RA, with few complications. In centers with arthroscopic expertise, it can be considered as a treatment option.

Wrist Arthroscopy in Juvenile Idiopathic Arthritis: A Review of Current Literature and Future Implications

Introduction  Juvenile Idiopathic Arthritis (JIA) is the most common rheumatological condition in children and frequently affects the wrist. The roles for wrist arthroscopy and arthroscopic synovectomy (AS) in JIA are unclear. Our aim was to find the current evidence supporting its use. Methods  Systematic literature review of relevant publications from 1990 to present in the Cochrane Library, Clinical Knowledge Summaries, DynaMed, PEMSoft, NICE Guidance, MEDLINE, EMBASE, and PubMed. Results  We found no publications detailing the use of arthroscopy or AS specifically in patients with JIA involving the wrist. There is evidence that AS reduces pain, improves function, and induces remission in patients with rheumatoid arthritis resistant to medical management. Discussion and Conclusion  Although there is paucity in evidence for the use of AS in the wrists of patients with JIA, studies suggest it to be safe and effective, and could be applied to patients with refractive JIA. It is possible that early identification of patients suffering from JIA with extensive joint destruction and little symptoms could benefit from AS, delaying joint destruction and preserving function.

Arthroscopic Synovectomy of Wrist in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systemic inflammatory disorder affecting multiple joints. Wrist involvement is common. Patients with persistent symptoms despite medical management are candidates for surgery. Synovectomy can provide pain relief and functional improvement for rheumatoid wrist. Arthroscopic synovectomy is a safe and reliable method, with minimal postoperative morbidity. This article reviews the role, technique, and results of arthroscopic synovectomy in the rheumatoid wrist.

Update on the surgical treatment for rheumatoid arthritis of the wrist and hand

Surgical procedures for the treatment of rheumatoid arthritis are aimed at restoring function and decreasing pain. Over the past four decades multiple procedures have been described in the management of early and late disease. This article will review the most common forms of surgery used in the treatment of rheumatoid arthritis.

Long-term results of arthroscopic wrist synovectomy in rheumatoid arthritis

PURPOSE

To investigate the effects of arthroscopic wrist synovectomy on the clinical course of rheumatoid arthritis in a large series with long-term follow-up.

METHODS

We performed arthroscopic synovectomy on 56 wrists in 49 patients with rheumatoid arthritis. At a mean follow-up of 7.9 years (range, 5-12 y), we evaluated pain and patient satisfaction using a visual analog scale and assessed overall function using the Mayo wrist score. Radiographic stage was graded according to Larsen stage. We determined clinical outcomes on the recurrence of wrist synovitis, which we evaluated by symptoms of pain and swelling and physical examination. Preoperative variables were statistically analyzed to find factors that could influence the results.

RESULTS

The mean visual analog scale score for wrist pain decreased from 6.3 to 1.7, and the mean Mayo wrist score (evaluated in 39 wrists) improved from 48 (range, 5-70) to 76 (range, 55-100). The mean visual analog scale score for patient satisfaction was 7.9. At final follow-up, synovitis was controlled in 42 wrists (75%) and recurred in the others. The mean Larsen stage progressed from 2.2 to 3.3. Analysis of preoperative variables revealed no factors that significantly affected clinical outcomes in terms of sex, age, duration of wrist symptom, preoperative serologic inflammatory markers, or Larsen stage.

CONCLUSIONS

Arthroscopic synovectomy of the wrist can provide pain relief and functional improvement with control of synovitis in 75% of rheumatoid wrists that have not responded to medication.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Arthroscopic synovectomy for rheumatoid wrists and elbows

PURPOSE

To evaluate the treatment outcome of wrist and elbow arthroscopic synovectomy for patients with rheumatoid arthritis.

METHODS

3 men and 18 women aged 27 to 71 (mean, 54) years underwent arthroscopic synovectomy for rheumatoid arthritis of the wrist (n=12) and elbow (n=13). All patients had received multiple medications including non-steroidal anti-inflammatory drugs, disease-modifying anti-rheumatic drugs, and steroids, as well as physiotherapy and splintage for 6 months, but the joint pain and disability persisted. The median duration of rheumatoid arthritis was 89 (range, 24-156) and 108 (range, 36-360) months for the wrist and elbow joints, respectively. According to the Larsen grading, the radiographic stages of the wrists and elbows were classified as grade 1 (n=4+4), grade 2 (n=4+5), and grade 3 (n=4+4). Visual analogue scale for pain, the wrist and elbow flexion-extension arcs, grip strength, key pinch strength, inflammatory markers, disability and symptoms were compared pre- and post-operatively.

RESULTS

The median follow-up period was 30 (range, 18-78) and 34 (range, 18-78) months for wrists and elbows, respectively. There was significant improvement in pain, joint motion, inflammatory markers, and disability score. All patients were satisfied with the surgery. There was no neurovascular or wound complication. No patient was taking longterm pain-control drugs. One patient underwent a second arthroscopic synovectomy after 15 months owing to exacerbation of arthritis.

CONCLUSION

Arthroscopic synovectomy is recommended for patients with rheumatoid arthritis who fail conservative treatment.

Reconstruction of the rheumatoid hand

Previous studies have shown large variation in the rate of common surgical procedures performed for the rheumatoid hand. This article provides a comprehensive overview of each surgical treatment option for rheumatoid hand reconstruction.

Arthroscopic synovectomy of the wrist

Arthroscopic synovectomy is safe and reliable, with mild postoperative morbidity. The rationale of a surgical synovectomy is to excise inflamed synovium and thereby, remove as much effusion and inflammatory substrate as possible. In most cases, arthroscopic synovectomy is performed as an outpatient procedure. The technique has also been used for other diagnoses causing wrist arthritis, but very few results have been reported and the indications remain to be defined. In rheumatoid arthritis (RA), juvenile chronic arthritis (JCA), systemic lupus erythematosus (SLE), and postinfectious monoarthritis, a long period of increased comfort and improved function can be anticipated.

Rheumatoid synovectomy: does the surgical approach matter?

BACKGROUND

Surgical synovectomy relieves pain in patients with rheumatoid arthritis (RA). The comparative effect of arthroscopic versus open synovectomy on pain reduction, recurrence of synovitis, radiographic progression, and need for subsequent total joint arthroplasty (TJA) is unclear. Whether synovectomy relieves pain in patients with advanced degenerative joint changes is also controversial.

QUESTIONS/PURPOSES

We therefore asked whether arthroscopic synovectomy resulted in equal pain relief, recurrence rates, rates of radiographic progression, likelihood of arthroplasty, and whether surgical synovectomy relieved pain and halted progression in the presence of advanced RA.

METHODS

We searched PubMed, Cochrane Database of Systematic Reviews, and BMJ Clinical Evidence. After appropriate selection criteria, 58 studies were identified, including 36 on open synovectomy and 22 on arthroscopic synovectomy, with a total of 2589 patients and a mean followup of 6.1 years. Meta-analysis was performed for knees and elbows, comparing open versus arthroscopic synovectomy. Variables included the percentage of patients with pain reduction, recurrence of synovitis, radiographic progression, and need for subsequent TJA or arthrodesis.

RESULTS

Patients undergoing arthroscopic synovectomy had similar pain reduction, but more frequent recurrences of synovitis and radiographic progression than patients with open synovectomy. Patients undergoing arthroscopic synovectomy had similar and decreased risks of subsequent elbow and knee arthroplasties, respectively. Advanced preoperative radiographic RA did not correlate with worse pain scores nor increased need for subsequent arthroplasty when compared with minimal degenerative joint changes.

CONCLUSIONS

Arthroscopic synovectomy, while providing similar pain relief, may place patients at higher risk for recurrence and radiographic progression of RA. Advanced preoperative degenerative joint disease should not be an absolute contraindication to synovectomy.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Current concepts and treatment for the rheumatoid wrist

Wrist involvement in rheumatoid arthritis (RA) is common. Within 2 years of diagnosis, more than half of patients will have wrist pain, and more than 90% will have wrist disease by 10 years. Although wrist involvement is generally thought to be less disabling than RA of the fingers and hand, it can be a significant cause of pain and disability. Severe disease with bony destruction and synovitis in the wrist can also result in soft-tissue problems including tendon ruptures. In addition to musculoskeletal involvement, systemic manifestations of RA can occur. Felty syndrome can result in a low white blood count and splenomegaly in association with RA. New generation, disease-modifying pharmacologic agents offer promise in controlling the disease progression. Surgical treatments for the diseased wrist are aimed at relieving pain and restoring function. Common procedures include: synovectomy and tenosynovectomy, tendon reconstruction, distal ulnar resection and/or distal radioulnar joint reconstruction, partial and full wrist arthrodesis, and total wrist arthroplasty.

[Possibilities of wrist arthroscopy. Even for patients with arthritis?]

The wrist is the most commonly involved joint in rheumatoid arthritis (RA). Because it becomes involved early in the disease course and because this involvement rapidly progresses, early and adequate treatment is necessary to prevent disease progression. Arthroscopic synovectomy is recommended for pain relief and functional recovery in early-stage RA and is also helpful in advanced RA. The technique is complicated, and the learning curve is steep, but its efficiency is high. Arthroscopic synovectomy of the wrist reduces pain and improves function in most cases. It also improves motion, which is an advantage to the open procedure, and patient acceptance of this procedure is high. Nevertheless, arthroscopic synovectomy may delay the need for complex surgery, such as wrist arthrodesis or total wrist arthroplasty in selected cases.

Treatment of the wrist in rheumatoid arthritis

Wrist involvement is common in rheumatoid arthritis and affects up to 50% of patients within the first 2 years after the onset of the disease, including bilateral involvement. It is a progressive disease that destroys the articular cartilage and surrounding soft tissues, thus leading to severe deformities. Radiological changes are characteristic and include narrowing of the joint line, cysts, and periarticular osteoporosis. Clinical changes are characterized by different scoring systems, indicating different therapeutic options. Surgical orthopedic treatment options include joint-preserving techniques to prevent further damage (radiosynoviorthesis, synovectomy, or axial correction with tendon transfers in earlier stages) and joint replacing techniques to restore function (arthrodesis, resection arthroplasty or total joint arthroplasty in later stages). This article reviews pathologic changes in the rheumatoid hand and their surgical treatment alternatives.

Arthroscopic synovectomy in rheumatoid arthritis of wrist

The wrist is the most commonly involved region of the upper extremity in rheumatoid arthritis (RA). Because the wrist joint becomes involved early during the disease course and its involvement rapidly progresses, and because the disabilities associated with progressive RA are significant, early and adequate treatment must be introduced to prevent disease progression. Various treatment methods can be employed to treat RA wrists based on radiological and clinical findings. Arthroscopic synovectomy is recommended for pain relief and functional recovery in early stage RA, and is also helpful in advanced staged RA with Larsen stage III. However, arthroscopic synovectomy is not recommended as an effective method of treatment for all patients with advanced radiographic changes. Nevertheless, arthroscopic synovectomy may delay the need for complex surgery, such as wrist arthrodesis or total wrist arthroplasty in selective cases. Although arthroscopic synovectomy of the wrist cannot improve grip strength or range of motion, it can reduce wrist pain and improve function, and thus facilitate return to work.

Arthroscopic synovectomy in wrists with advanced rheumatoid arthritis

We evaluated the effects of arthroscopic wrist synovectomy for patients with advanced rheumatoid arthritis. We retrospectively reviewed data for 11 patients with moderately advanced arthritis and joint space narrowing of 25% to 50% (Group A) treated from May 1993 to March 2000. We compared effects of these patients with effects of six patients with earlier disease and joint space narrowing of 0% to 25% (Group B). For Group A, the total modified Mayo wrist scores increased from an average of 26.36 points preoperatively to an average of 56.36 points postoperatively. Postoperative scores for pain and return to work status, and two components of the modified Mayo wrist score also showed differences compared with the respective preoperative scores. There was an increase in final followup scores in return to work status and total modified Mayo wrist scores. Group A showed larger differences than Group B. Our data suggest that arthroscopic synovectomy is a useful treatment for modest and moderate stages of rheumatoid arthritis. It is especially effective for decreasing pain and improving function, allowing patients to return to work.

LEVEL OF EVIDENCE

Therapeutic study, Level III. See the Guidelines for Authors for a complete description of levels of evidence.

Le poignet rhumatoïde

Wrist involvement in Rheumatoid Arthritis (RA) is frequent, variable in its presentation, heterogeneous in its evolution and has an important impact on the function of the affected hand. Surgery must be indicated within the framework of a structured medical and surgical approach that considers the whole patient. Surgical treatment at the wrist level is indicated in cases of resistant chronic pain, persistent articular synovitis, or chronic tenosynovitis and also in cases of painful limitation of supination, risk of complications due to wrist deformity and tendinous or neurological complications. The surgical goal in RA is to restore correct function but not neccessarily normal anatomy, with the goal of achieving a painless, stable wrist, correctly positioned. Motion depends on the status of the different joints and on the bone stock. Knowledge of the natural progression of the disease helps in the surgical decision making process. The pathogenesis and patterns of deformity, the clinical and X-ray appearances and the various techniques applied to the surgery of the rheumatoid wrist are studied and discussed including palmar wrist and dorsal wrist procedures, conservative and non-conservative options.

Arthroscopic synovectomy in wrist arthritis

Arthroscopic synovectomy is a safe outpatient procedure with minimal postoperative morbidity. In patients who have rheumatoid arthritis and possibly also in patients who have JRA, SLE, and postinfectious arthritis, a long period of increased comfort and improved function can be anticipated. The procedure may be considered in post-traumatic cases with joint contracture and as an adjunct to other measures for certain osteoarthritic disorders. In patients who have septic arthritis with insufficient clinical improvement after systemic antibiotics and lavage, arthroscopic synovectomy seems advantageous.

Hand surgery in rheumatoid arthritis: state of the art and suggestions for research

OBJECTIVE

The role of surgery in the clinical management of patients with rheumatoid arthritis (RA)-associated hand dysfunction is still a subject of controversy. The efficacy of surgery in RA-associated hand dysfunction is assessed through an exhaustive review of published studies.

METHODS

A high-sensitivity search strategy was used to identify in MedLine and CENTRAL original studies related to hand and wrist surgery in RA patients. We selected articles including at least two adult RA patients which evaluated clinical outcomes through an observational or experimental design. Eligible studies were evaluated by standardized criteria. Two investigators independently used a pre-defined form to extract data about patient population, intervention, follow-up and clinical outcomes. Disagreements were discussed and resolved.

RESULTS

One hundred and ninety-six papers met inclusion criteria. Only five were randomized trials, while most studies followed an observational design, often of poor quality. As such, we could not pool data for statistical analysis; however, we were still able to provide a best evidence synthesis. A positive trend suggesting the efficacy of total carpal arthrodesis and metacarpophalangeal arthroplasty in reducing pain and improving function seemed to emerge from the published studies.

CONCLUSIONS

Despite recent advances in medical treatment, surgery still plays a role in the clinical management of RA-associated hand dysfunction. However, the majority of the available studies showed methodological flaws that prevented a clear definition of both surgical indications and criteria for choosing any specific procedure. Suggestions for further investigations are also provided.

[Wrist arthroscopy. Current indications and results]

Arthroscopy of the wrist is a recent technique but already validated for many indications. It rarely gives rise to complications but requires a learning curve just like any other endoscopic procedure. It allows complete visualization of the osseous, articular, synovial and ligamentous structures of the different joints comprising the wrist. There are two main indications for wrist arthroscopy: i) Diagnostic; when other investigations have proved inconclusive (assessment of carpal instabilities, osteochondral fractures and certain synovial pathologies...); ii) therapeutic; these have recently widened in terms of carpal pathology. Lesions of the triangular fibrocartilage complex (traumatic or degenerative) are best diagnosed and treated arthroscopically. Arthroscopic treatment is the least invasive, most effective and safest means of performing procedures such as debridement, TFCC reattachment, and ulna shortening. Other conditions can benefit greatly from wrist arthroscopy such as certain wrist ganglions, rheumatoid synovitis, radiocarpal fractures and some scaphoid fractures. Degenerative pathology of the wrist also presents opportunities for articular debridement ("shaving"), synovectomy or even various "ectomies".

Complications of wrist arthroscopy

PURPOSE

To determine the incidence and nature of complications after arthroscopy of the wrist joint.

METHODS

The outpatient records and surgical reports of 211 patients who had wrist joint arthroscopy were reviewed to determine type of procedure, type of anesthetic, portals used, and incidence and nature of postsurgical complications.

RESULTS

We identified a total of 11 complications in our patient group (5.2%). Of these, 2 patients (0.9%) developed major complications and 9 patients (4.3%) developed minor complications. Five complications 45% were identified in the immediate postsurgical period and 6 (55%) were delayed complications. All of the minor complications resolved at latest follow-up evaluation with conservative care.

CONCLUSIONS

Wrist arthroscopy is a safe procedure with a low rate of major and minor complications. In spite of its limitations wrist arthroscopy remains an invaluable tool in the diagnosis and treatment of wrist joint disorders.

Office-based arthroscopic synovectomy of the wrist in rheumatoid arthritis

We present an office-based technique for performing arthroscopic synovectomy of the wrist in patients with rheumatoid arthritis. Intra-articular anesthesia as well as subcutaneous portal anesthesia are used. Standard portals are used in the radial carpal and midcarpal joints. Standard instrumentation is used and the synovectomy is accomplished using a motorized shaver. We performed 30 procedures in 21 patients: 15 complete synovectomies, 3 radioulnar carpal synovectomies because of only limited disease, and 12 limited synovectomies because these patients were participants in a clinical trial and required only limited synovectomy for investigational purposes. There were no complications. Office-based arthroscopic synovectomy of the wrist in patients with refractory rheumatoid arthritis can be performed safety and effectively. This technique is useful in both a clinical as well as a research setting.

Wrist arthroscopy: principles and clinical applications

With the development of better and smaller equipment, arthroscopy of the wrist offers the same benefits achievable with arthroscopy of the knee, shoulder, or elbow - not only diagnostic information but also a therapeutic option. Standardized techniques of performing wrist arthroscopy have been developed to evaluate the treat various wrist disorders, such as lesions of the triangular fibrocartilage complex, intra-articular distal radius fractures, and scaphoid fractures. Arthroscopy is now performed in the treatment of dorsal-wrist ganglion cysts and interosseous ligament disruptions, as well as for bone incisions, such as radial styloidectomy, distal ulnar excision (wafer procedure), and proximal-row carpectomy. Compared with other techniques, arthroscopic procedures, such as repair of the triangular fibrocartilage complex, demonstrate better results and improved localization of the injury with a low complication rate. In addition, arthroscopic procedures involve lesssurgical dissection, less postoperative pain, a shorter recovery time, and an earlier return to work for the patient.