Arthroscopic synovectomy for rheumatoid wrists and elbows

Transcription

1 Journal of Orthopaedic Surgery 2012;20(2): Arthroscopic synovectomy for rheumatoid wrists and elbows Chor-yat Stephen Chung, 1 Chi-Hung Yen, 1 Man-Lung Ronald Yip, 2 Siu-Cheong Jeffrey Justin Koo, 1 Weng-Nga Virginia Lao 2 1 Department of Orthopaedics and Traumatology, Kwong Wah Hospital, Hong Kong 2 Department of Medicine and Rheumatology, Kwong Wah Hospital, Hong Kong ABSTRACT 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, ) and 108 (range, ) 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. Key words: arthritis, rheumatoid; arthroscopy; elbow; wrist INTRODUCTION Up to 50% and 75% of patients with rheumatoid arthritis (RA) present with elbow and wrist symptoms, respectively. 1,2 The usual symptoms include pain, Address correspondence and reprint requests to: Dr Chor-yat Stephen Chung, Department of Orthopaedics and Traumatology, Kwong Wah Hospital, 25 Waterloo Road, Hong Kong. E- mail: chungstephen@gmail.com

2 220 CYS Chung et al. Journal of Orthopaedic Surgery swelling, and stiffness that cause difficulties in activities of daily living. Initial treatment involves anti-inflammatory drugs, anti-rheumatic agents, immunosuppressive drugs, steroids, and biologics. In cases of failed conservative treatment or progressive joint destruction with breakthrough pain, surgical procedures such as synovectomy, arthrodesis, and joint arthroplasty are necessary to relieve pain and improve function. 3 8 Open synovectomy is indicated in patients with mild-to-moderate rheumatoid arthritis, but postoperative wound pain and stiffness may delay rehabilitation and return to normal activities of daily living Arthroscopic synovectomy is less traumatic and achieves comparable results in patients with early stage of RA. 3,4,8,13,I4 In patients with advanced RA with substantial joint destruction, arthrodesis or arthroplasty is more reliable in the long term. 7 We evaluated the treatment outcome of wrist and elbow arthroscopic synovectomy for patients with RA. MATERIALS AND METHODS Between October 2003 and October 2008, 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). Patients with uncontrolled medical conditions, drug allergy to local anaesthesia, or a history of trauma or previous surgery to the joints were excluded. All patients had received multiple medications including nonsteroidal anti-inflammatory drugs (NSAIDs), diseasemodifying anti-rheumatic drugs, and steroids, as well as physiotherapy and splintage for 6 months, but the joint pain and disability had persisted. The median duration of rheumatoid arthritis was 89 (range, ) and 108 (range, ) months for the wrist and elbow joints, respectively. According to the Larsen grading, 15 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). 21 of the 25 affected joints involved the dominant hand. joint spaces and bone destruction. Under portal site local anaesthesia (PSLA), a 2.7-mm diameter, 30º arthroscope was introduced through a 3/4 portal, whereas a 6U portal served as a working portal in the radiocarpal joint. Mid-carpal radial, mid-carpal ulnar, and scaphotrapeziotrapezoid portals served as working arthroscope portals. Synovectomy was performed using a motorised shaver, without thermal coagulation. The median operation time was 32 (range, 15 54) minutes. Blood loss was minimal. For arthroscopic synovectomy of the elbow, patients were lying in a lateral decubitus position with elbow support. The forearm was operated on through full supination and pronation to improve visibility on the radial head (Fig. 1b). A pneumatic tourniquet was not used, as it may cause discomfort and pain to attain haemostasis. Under PSLA, a 2.7-mm diameter, 30º arthroscope was introduced through anteromedial and anterolateral portals for the anterior compartment, whereas for the posterior compartment, mid-posterior and posterolaetral portals were used. Synovectomy was performed using a motorised shaver, taking special care to avoid inadvertent injury to neighbouring neurovascular (a) (b) Surgical techniques For arthroscopic synovectomy of the wrist, patients were placed supine with the shoulder abducted at 90º on an arm board. A pneumatic tourniquet was not used. Irrigation fluid (normal saline) was elevated as high as practicable to ensure adequate hydrostatic pressure for haemostasis. The index, middle, and ring fingers were placed in fingers traps for 12 pounds of traction (Fig. 1a). Joint laxity in RA patients facilitates distraction despite narrowed Figure 1 (a) Three-finger traction by a traction tower for arthroscopic synovectomy of the wrist joint, and (b) a lateral decubitus position for arthroscopic synovectomy of the elbow joint.

3 Vol. 20 No. 2, August 2012 Arthroscopic synovectomy for rheumatoid wrists and elbows 221 structures. The median operation time was 82 (range, 73 95) minutes. Blood loss was minimal. Postoperatively, a light dressing was applied without a suction bottle. Patients were discharged home on the same day. They were referred to an out-patient physiotherapist for immediate active and passive joint mobilisation and strengthening exercises. Assessment The visual analogue scale (VAS) for pain was assessed preoperatively, one week postoperatively, and at the final follow-up. The wrist and elbow flexionextension arcs were measured using a goniometer positioned in line with the lateral aspect of the radius and 3rd metacarpal bone, and the lateral aspect of the arm and forearm, respectively. Range of pronation and suspination was not measured because of high intra-observer and inter-observer errors. Grip strength (kg) was measured by a Jamar dynamometer with the elbow flexed to 90º and unsupported in a standardised sitting posture (Fig. 2a), as different elbow positions affect the maximal grip strength. 16 Key pinch strength (kg) was measured by a pinch gauge (Fig. 2b). A mean of 3 trials was recorded and compared with the contralateral side at the final follow-up. Inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured. Disability and symptoms of the upper extremity were assessed using a validated Chinese version of the disabilities of the arm, shoulder and hand (DASH) questionnaire, 17 which consists of 30 items, with a total score of 0 (no disability) to 100. Pre- and post-operative VAS score for pain, range of movement of wrist and elbow joints, and the DASH score were compared using the Wilcoxon signed rank test. Outcomes between wrist and elbow arthroscopic synovectomies were compared using the Mann-Whitney U test. A p value of <0.05 was considered statistically significant. RESULTS The median follow-up period was 30 (range, 18 78) and 34 (range, 18 78) months for wrists and elbows, respectively. Preoperatively, both groups had comparable pain (p=0.478) and limitation in range of motion (p=0.477), but elbow joint symptoms were more disabling in terms of the DASH score (p=0.046). In patients having wrist synovectomy, the median VAS score for pain decreased significantly from 8 (range, 5 10) preoperatively to 3 (range, 1 5) at week one and to 0 (range, 0 5) at the final followup (p<0.005 and p=0.004, Table). The median wrist flexion-extension arc improved significantly (65º [range, 30º 120º] vs. 95º [range, 50º 150º], p=0.014), as did the median DASH score (67.5 [range, 30 90] vs [range, 15 48], p=0.004). In patients having elbow synovectomy, the median VAS pain score decreased significantly from 9 (range, 5 10) preoperatively to 4 (range, 2 6) at week one and to 1 (range, 0 7) at the final followup (p<0.005 and p=0.004, Table). The median elbow flexion-extension arc improved significantly (75º [range, 30º 110º] vs. 105º [range, 60º 140º], p=0.004), as did the median DASH score (82 [range, 44 95] vs. 45 [range, 18 69], p=0.004). In both groups of patients, the median grip strength and key pinch strength improved to 92% and 88% of the contralateral side, respectively. The inflammatory markers also improved significantly: median ESR (102 [range, ] vs. 44 [range, 14 82], p<0.05) and median CRP (47 [range, ] vs [range, ], p<0.001). No patient was taking long-term NSAIDs for pain control, thus avoiding potential side effects. There was no change in the dosage and types of disease-modifying anti-rheumatic drugs being used. One patient underwent a second arthroscopic synovectomy after 15 months owing to exacerbation of arthritis. All patients were satisfied with the surgery and had returned to their normal daily activities. There was no complication such as neurovascular injury and wound infection. (a) (b) Figure 2 Measurement of (a) grip strength and (b) key pinch strength DISCUSSION In patients with rheumatoid arthritis of the wrist and elbow joints, arthroscopic synovectomy improves pain, joint motion, and upper-limb function. 3,4,8,14,18 It can be safely performed under PSLA in an ambulatory setting, so as to reduce length of hospital stay and costs. It achieves satisfactory results even for Larsen grade-3 or advanced degenerative joint disease. 6,19

4 222 CYS Chung et al. Journal of Orthopaedic Surgery Sex/age (years) Joint operated Ipsilateral joint involved Contralateral joint involved Table Patient characteristics and outcomes Visual analogue scale score for pain Range of motion (degrees) Erythrocyte sedimentation rate C-reactive protein Disabilities of the arm, shoulder and hand questionnaire score Preop Week 1 Final Preop Final Preop Final Preop Final Preop Final F/63 Elbow Shoulder Elbow, wrist, M/58 Elbow - Shoulder, elbow, knee M/58 Elbow Shoulder, knee F/52 Elbow Wrist F/66 Elbow Knee Elbow F/66 Elbow Knee Elbow F/65 Elbow - Wrist, hip F/56 Elbow F/58 Elbow Wrist F/45 Elbow - Elbow M/70 Elbow Shoulder Shoulder F/27 Elbow Wrist F/52 Elbow Wrist, hand Median (range) 9 (5 10) 4 (2 6) 1 (0 7) (60 94 (64 44 ( ( ( (44 110) 140) 120) 82) 103) 24.5) 95) F/39 Wrist Knee F/52 Wrist Elbow F/65 Wrist Knee Elbow F/40 Wrist F/71 Wrist Shoulder, Shoulder ankle F/42 Wrist F/48 Wrist F/54 Wrist F/44 Wrist Shoulder Shoulder, elbow, wrist, foot F/52 Wrist Knee F/62 Wrist Elbow M/45 Wrist Knee Elbow Median (range) 8 (5 10) 3 (1 5) 0 (0 5) ) 95 (50 150) 111 (38 120) 45.5 (14 58) 38.3 ( ) 12.2 ( ) ) 45 (18 69) 36.5 (15 48) Arthroscopic lavage and synovectomy reduced the amount of inflammatory mediators (prostaglandins and interleukins) within acutely inflamed joints and provided a normal joint environment for immediate pain relief. The haematological response was fast and long lasting, as inflammatory parameters (ESR and CRP) remained low at the final followup. 20,21 Continuation of anti-rheumatic medications after surgery is important in controlling disease progression. 22 The range of motion improved because of reduction in pain and swelling. Arthroscopic synovectomy is minimally invasive, has less surgical morbidity, and enables immediate rehabilitation exercises to prevent joint stiffness. Arthroscopic capsulotomy can alleviate joint contracture; caution should be paid to avoid inadvertent injury to the radial nerve, 19 particularly in cases with previous trauma or surgery in the affected joint, as altered anatomy may increase the risk of neurovascular injury, especially around the elbow joint Recurrent synovitis is a major concern 21 ; its rate can be as high as 24%. 8 In our study, patients achieved long-term (a mean of 32 months) improvement

5 Vol. 20 No. 2, August 2012 Arthroscopic synovectomy for rheumatoid wrists and elbows 223 in pain, joint motion, inflammatory markers (ESR and CRP), and DASH score. Complete removal of all inflamed synovial tissue may not be necessary; repeat arthroscopic synovectomy can be performed for exacerbation of pain. ACKNOWELDGEMENTS We thank Ms Kian Chong for providing secretarial support and Dr Clara Poon for providing statistical support. REFERENCES 1. Ilan DI, Rettig ME. Rheumatoid arthritis of the wrist. Bull Hosp Jt Dis 2003;61: Lehtinen JT, Kaarela K, Ikavalko M, Kauppi MJ, Belt EA, Kuusela PP, et al. Incidence of elbow involvement in rheumatoid arthritis. A 15 year endpoint study. J Rheumatol 2001;28: Kim SJ, Jung KA, Kim JM, Kwun JD, Kang HJ. Arthroscopic synovectomy in wrists with advanced rheumatoid arthritis. Clin Orthop Relat Res 2006;449: Adolfsson L. Arthroscopic synovectomy in wrist arthritis. Hand Clin 2005;21: Adams BD. Surgical management of the arthritic wrist. Instr Course Lect 2004;53: Park MJ, Ahn JH, Kang JS. Arthroscopic synovectomy of the wrist in rheumatoid arthritis. J Bone Joint Surg Br 2003;85: Gallo RA, Payatakes A, Sotereanos DG. Surgical options for the arthritic elbow. J Hand Surg Am 2008;33: Horiuchi K, Momohara S, Tomatsu T, Inoue K, Toyama Y. Arthroscopic synovectomy of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 2002;84: Eichenblat M, Hass A, Kessler I. Synovectomy of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 1982;64: Brumfield RH Jr, Resnick CT. Synovectomy of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 1985;67: Tulp NJ, Winia WP. Synovectomy of the elbow in rheumatoid arthritis. Long-term results. J Bone Joint Surg Br 1989;71: Vahvanen V, Eskola A, Peltonen J. Results of elbow synovectomy in rheumatoid arthritis. Arch Orthop Trauma Surg 1991;110: Adolfsson L, Frisen M. Arthroscopic synovectomy of the rheumatoid wrist. A 3.8 year follow-up. J Hand Surg Br 1997;22: Tanaka N, Sakahashi H, Hirose K, Ishima T, Ishii S. Arthroscopic and open synovectomy of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 2006;88: Larsen A, Dale K, Eek M. Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol Diagn (Stockh) 1977;18: Li K, Hewson DJ, Hogrel JY. Influence of elbow position and handle size on maximal grip strength. J Hand Surg Eur Vol 2009;34: Lee EW, Chung MM, Li AP, Lo SK. Construct validity of the Chinese version of the disabilities of the arm, shoulder and hand questionnaire (DASH-HKPWH). J Hand Surg Br 2005;30: Wei N, Delauter SK, Beard S, Erlichman MS, Henry D. Office-based arthroscopic synovectomy of the wrist in rheumatoid arthritis. Arthroscopy 2001;17: Kang HJ, Park MJ, Ahn JH, Lee SH. Arthroscopic synovectomy for the rheumatoid elbow. Arthroscopy 2010;26: Kanbe K, Inoue K. Efficacy of arthroscopic synovectomy for the effect attenuation cases of infliximab in rheumatoid arthritis. Clin Rheumatol 2006;25: Nakamura H, Nagashima M, Ishigami S, Wauke K, Yoshino S. The anti-rheumatic effect of multiple synovectomy in patients with refractory rheumatoid arthritis. Int Orthop 2000;24: Kim SJ, Jung KA. Arthroscopic synovectomy in rheumatoid arthritis of wrist. Clin Med Res 2007;5: Lee BP, Morrey BF. Arthroscopic synovectomy of the elbow for rheumatoid arthritis. A prospective study. J Bone Joint Surg Br 1997;79: Kelly EW, Morrey BF, O Driscoll SW. Complications of elbow arthroscopy. J Bone Joint Surg Am 2001;83: Haapaniemi T, Berggren M, Adolfsson L. Complete transection of the median and radial nerves during arthroscopic release of post-traumatic elbow contracture. Arthroscopy 1999;15: Ruch DS, Poehling GG. Anterior interosseus nerve injury following elbow arthroscopy. Arthroscopy 1997;13:756 8.