Jebmh.com Original Research Article

Effectiveness of in TKA- A Comparative Study between Complete and Partial Synovectomy

Mohan Babu Lebaku1, Suresh Babu Gangireddi2

1Assistant Professor, Department of Orthopaedics, Balaji Institute of Research and Rehabilitation for Disabled, Tirupati, Andhra Pradesh. 2Consultant, Department of Orthopaedics, M. S. Multi-Speciality Hospital, Pithapuram, Andhra Pradesh.


BACKGROUND Surgical management of late stage Osteoarthritis is Total Knee . Corresponding Author: During this surgery, hypertrophied is noticed. In some Dr. Lebaku Mohan Babu, Plot No. 101, Tirupathi Towers, patients, total synovectomy was performed. In some patients, partial synovectomy Tirupathi, Andhra Pradesh. was performed. The main objective is to consider the amount of blood loss, assess E-mail: [email protected] recruitment rates and protocol adherence in these patients. DOI: 10.18410/jebmh/2019/625

METHODS Financial or Other Competing Interests: We performed a single-centre pilot RCT. Patients with inflamed synovium were None. randomised to receive synovectomy versus a control group that did not undergo How to Cite This Article: synovectomy. By measuring patient enrolment, completeness of follow-up, and Lebaku MB, Gangireddi SB. Effectiveness safety via haemoglobin decrease and documentation of adverse events, feasibility of synovectomy in TKA- a comparative was determined. study between complete and partial synovectomy. J. Evid. Based Med. Healthc. 2019; 6(47), 2999-3002. DOI: 10.18410/jebmh/2019/625 RESULTS

We screened 187 patients’ eligible patients, who progressed through to Submission 04-11-2019, randomization. All made it to the 12-month follow-up, indicating good protocol Peer Review 08-11-2019, adherence. There were no major differences in adverse events or haemoglobin Acceptance 16-11-2019, decrease demonstrating acceptable safety. Outcomes relating to satisfaction were Published 25-11-2019. reliably obtained.

CONCLUSIONS Patients with inflamed synovium of the knee who are due to undergo TKA can be reliably recruited to a randomised trial and synovectomy can be performed safely. To assess whether routine synovectomy would improve outcomes in these patients, large number is needed to be screened to identify eligible participants, and therefore, a multi-centre trial would be required.


Osteoarthritis, Knee, OA Knee, Advanced OA Knee, Synovectomy, Effectiveness of


J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 47/Nov. 25, 2019 Page 2999

Jebmh.com Original Research Article

BACKGROUND for 24 hours postoperatively. If a patient’s blood pressure

fell and remained low (<90 mmHg) with symptoms In the middle- to old-age population, osteoarthritis (OA) is consistent with hypovolaemia, which did not respond to the most common disease affecting synovial .1 Massive crystalloid volume expansion, then blood transfusion was health economic burden related to physical disability is OA administered. Low molecular- weight heparin (strength 100 knee.2 Severe pain not controlled with regular analgesic mg/ml, 40 mg/ 24 hours) was injected subcutaneously after medication accompanied by radiographic evidence of a delay of 24 hours as routine thromboprophylaxis. After space narrowing, osteophyte formation and subchondral three days the heparin was replaced by rivaroxaban (10 sclerosis is defined as Late-stage osteoarthritis of the knee. mg/24 hours), which was continued for four weeks. At 24 Common intraoperative finding in patients with osteoarthritis hours after the operation, the patients were permitted to (OA) or (RA) of the knee3 is synovial stand without walking and all patients subsequently proliferation. Following Synovectomy combined with other underwent the same rehabilitation protocol. Briefly, knee specific surgical procedures have reported favorable results flexion and extension exercises were started one day after in most of the studies.4 Surgery in the form of total knee the operation. These exercises were continued with the arthroplasty (TKA) remains the most effective method of addition of graduated assisted walking from the second day. managing late-stage cases due to a complete lack of The blood loss of all patients at 24 hours Recorded and blood disease-modifying osteoarthritis agents.5 It is the surgeon’s investigations were repeated. Concealed haemorrhage was decision to do synovectomy while doing total knee calculated by the Gross equation and according to Sehat, replacement.6 Minimal amount of synovium as possible Evans and Newman and Nadler, Hildalgo and Bloch. should be removed as recommended by Krackow et al.6 of the patella was performed as a crude Because of improving knee implant designs and a lowering estimate whether residual synovial membrane was of thresholds for surgeons to offer surgery, there are an associated with an effusion. In order to perform this test, increasing number of patients receiving TKA.4 the patient lies supine and the examiner places their proximal hand over the suprapatellar pouch and the distal hand (mainly the thumb and index finger of the distal hand)

METHODS over the patella. The examiner compresses the suprapatellar pouch with the proximal hand and then compresses the

patella into the femur. A positive result would be downwards This study was undertaken at BIRRD hospital, Tirupati movement of the patella then rebounding once the pressure between September 2010 and September 2011, a total of on the patella is removed; hence the appearance of a 187 patients with primary OA undergoing TKR were included floating or ballotable patella. in the study. The patients were divided into two groups according to a random number table generated by a

computer (Microsoft Office Excel 2003; (Microsoft Corp., RESULTS

Seattle, Washington). All patients and the clinicians who assessed them before and after the surgery were blinded to the randomisation. Group 1 (synovectomy plus TKR) There was a decrease in mean haemoglobin levels observed comprised 96 patients (66 women and 30 men) with a mean in both groups from pre-operatively to day one post- age of 65.4 years (53 to 83). Group 2 (TKR alone) comprised operatively. No patient received a blood transfusion. There 91 patients (73 women and 18 men) with a mean age of were 5 adverse events reported during the study. One was 64.9 years (50 to 88). Exclusion criteria were bilateral TKR, serious adverse events due to hospitalisation of the patients with a history of oral antiplatelet medication, fasting participants, in the synovectomy group. In this case, the blood glucose > 10 mmol/l, and revision TKR. Routine blood participant had developed a superficial wound infection. This tests and coagulation screening were completed before the was treated with antibiotics only and did not require surgical operation. Stature, body weight were evaluated pre- intervention. In synovectomy procedure, these serious operatively for all patients. The KSS comprises two sub adverse events were not classified. All the randomized scores, one assessing the knee joint itself and the second patients completed follow-up to the 1-year end point. From assessing function. All operations were performed by a 6 weeks, there was a significant improvement in knee range different surgeon (SK) using an anterior midline incision and of motion medial parapatellar approach with a tourniquet (pressure of Post-operatively to 1 year post-operatively for both 260 mmHg for all patients). All operations were performed groups there was a significant improvement in mean under Spinal anaesthesia. WOMAC scores for the no synovectomy and the In group 1 the synovial membrane was excised. Apart synovectomy group. There was no significant difference from this, the operations in both groups were the same. The between groups in mean WOMAC scores for pain (p= cemented PS TKR implants of various company were used, 0.448), function (p= 0.131) and stiffness (p= 0.531) at 1 and no patellae were replaced. A drain was implanted and year post-operatively. There was no difference between then removed at 24 hours with the volume of drainage groups in terms of patient satisfaction reported for pain recorded. The tourniquet was not deflated until a pressure relief, return to activities of daily living (ADL), return to bandage had been applied. Continuous monitoring was used recreational activities and overall satisfaction from at 1 year

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 47/Nov. 25, 2019 Page 3000

Jebmh.com Original Research Article

post-operatively. We found no marked differences in the CONCLUSIONS

immediate post-operative period, except that in the synovectomy group there was a statistically significant In our study, we randomised the participants intra- increase in both visible (mean drainage) and invisible blood operatively after confirmation of the macroscopically loss (concealed loss) inflamed synovium and performed a meticulous

synovectomy technique retaining the vascular layer. Large

multi-centre surgical studies are warranted to assess the DISCUSSION

potential benefits in larger patient cohorts, regarding synovectomy during . Objective measures The evidence of an inflammatory component of knee OA at of inflammation both in the joint tissues and systemically the early to late stages of disease is increasing and can even should be included in future trial design. A combined be tracked systemically.7 At the knee joint, apart from the approach using arthroscopic synovectomy and medical synovium, there are studies indicating that other tissues therapies may avoid the requirement for such as the fat pad can be a source of inflammation.8 Further in patients with severe pain likely related to synovitis but studies of various joint tissue types from patients with knee with minimal changes on the plain radiograph. Close OA have implicated epigenetic effects that result in the up collaboration between orthopaedic surgeons and regulation of pro-inflammatory cytokines9 and the link from rheumatologists is required to define these treatment inflammation to the stimulation of pain pathways in knee OA strategies. is well established.10 TKA remains the treatment of choice for late-stage disease but the significant proportion of

dissatisfied patients continues to be a challenge. Accurate REFERENCES

identification of those patients who are at risk of residual pain due to persistent inflammation in the soft tissues [1] Glyn-Jones S, Palmer AJ, Agricola R, et al. following TKA is the aim of future therapy for knee OA., Osteoarthritis. Lancet 2015;386(9991):376-387. involving assessing clinical, radiological and possibly [2] Agaliotis M, Mackey MG, Jan S, et al. Burden of reduced systemic parameters to define the level of inflammation in work productivity among people with chronic knee pain: the joint prior to embarking on therapy. There have been a systematic review. Occup Environ Med three randomised controlled trials that have sought to assess 2014;71(9):651-659. 11-12 the effect of synovectomy during TKA. [3] Krasnokutsky S, Belitskaya-Levy I, Bencardino J, et al. We found that synovectomy did not improve clinical Quantitative magnetic resonance imaging evidence of outcomes after TKR. This strongly supports the contention synovial proliferation is associated with radiographic that long-term post-operative recovery was not affected by severity of knee osteoarthritis. Arthritis Rheum retention or excision of the synovial membrane of the knee 2011;63(10):2983-2991. joint. In our series TKR was followed by variable and at times [4] Malkoc M, Korkmaz O. Results of arthroscopic considerable blood loss and associated transfusion. In a synovectomy for treatment of synovial lipomatosis prospective study of 4642 unilateral primary TKRs Bierbaum (lipoma arborescens) of the knee. J Knee Surg 13 et al observed a blood transfusion rate of 36%, which was 2018;31(6):536-540. not dissimilar to our own findings. We accept that we had [5] Fibel KH, Hillstrom HJ, Halpern BC. State-of-the-art no specific thresholds for transfusion other than the clinical management of knee osteoarthritis. World J Clin Cases indications described earlier. There are many factors that 2015;3(2):89-101. 14 influence the amount of blood lost at surgery, and there is [6] Zhaoning X, Xu Y, Shaoqi T, et al. The effect of both visible bleeding and concealed haemorrhage. The main synovectomy on bleeding and clinical outcomes for total reason for concealed bleeding is haemocytolysis and blood knee replacement. Joint J 2013;95-B(9):1197- 15 infiltrating into soft tissue. This study showed that 1200. statistically significant differences existed not only in the [7] Attur M, Statnikov A, Samuels J, et al. Plasma levels of drainage volume between the two groups but also in the interleukin-1 receptor antagonist (IL1Ra) predict hidden blood loss. Perhaps it is not surprising that radiographic progression of symptomatic knee synovectomy adds to blood loss and our findings are also osteoarthritis. Osteoarthritis borne out by those of Kilicarslan et al. It should be noted 2015;23(11):1915-1924. that the surgical technique for synovectomy is important, [8] Ioan-Facsinay A, Kloppenburg M. An emerging player in because an accurate synovectomy technique that removes knee osteoarthritis: the infrapatellar fat pad. Arthritis the subintimal and intimal layers but leaves the vascular Res Ther 2013;15(6):225. layer intact will result in minimal haemorrhage if the precise [9] Rogers EL, Reynard LN, Loughlin J. The role of tissue planes are identified and respected. inflammation-related genes in osteoarthritis. Osteoarthritis Cartilage 2015;23(11):1933-1938. [10] Neogi T, Guermazi A, Roemer F, et al. Association of joint inflammation with pain sensitization in knee

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 47/Nov. 25, 2019 Page 3001

Jebmh.com Original Research Article

osteoarthritis: the multicenter osteoarthritis study. [13] Bierbaum BE, Callaghan JJ, Galante JO, et al. An Arthritis Rheumatol 2016;68(3):654-661. analysis of blood management in patients having a total [11] Kilicarslan K, Yalcin N, Cicek H, et al. The effect of total hip or knee arthroplasty. J Bone Joint Surg Am synovectomy in total knee arthroplasty: a prospective 1999;81(1):2-10. randomized controlled study. Knee Surg Sports [14] Bullock DP, Sporer SM, Shirreffs TG. Comparison of Traumatol Arthrosc 2011;19(6):932-935. simultaneous bilateral with unilateral total knee [12] Tanavalee A, Honsawek S, Rojpornpradit T, et al. arthroplasty in terms of perioperative complications. J Inflammation related to synovectomy during total knee Bone Joint Surg Am 2003;85(10):1981-1986. replacement in patients with primary osteoarthritis: a [15] Pattison E, Protheroe K, Pringle RM, et al. Reduction in prospective, randomised study. J Bone Joint Surg Br haemoglobin after knee joint surgery. Ann Rheum Dis 2011;93(8):1065-1070. 1973;32(6):582-584.

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 47/Nov. 25, 2019 Page 3002