Inflammatory Synovitis Rheumatoid Arthritis

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Rheumatoid arthritis is the most common inflammatory arthritis, affecting 1-2% of the population. Onset of the disease is typically in the fourth and fifth decades of life. With current medical management, overall prognosis has improved, but unfortunately after 10-12 years with the disease, more than 80% of patients have evidence of some joint deformity. Juvenile rheumatoid arthritis (JRA), although not as common, involves the hip in approximately one third of children and adolescents, leading to pain, deformity, and lifetime disability.47 The hallmark of the disease in juvenile and adult patients is persistent immune system-mediated inflammatory synovitis of varying degrees. The resulting synovitis, when uncontrolled, can result in articular cartilage destruction, bony erosions, and subsequent deformities. In JRA, the growing proximal femur may become malformed secondary to the increased synovial blood flow associated with inflammation and synovitis, changing the mechanics of the joint and further increasing the likelihood of its early degeneration.46

The current mainstay of long-term treatment in rheumatoid arthritis is the use of anti-inflammatory medications, disease-modifying agents, and immunosuppresive medications. When acute symptomatic flares of synovitis occur, intra-articular corticosteroids may be used, and have shown some bene-fit.46,47 If medical management is unable to curtail synovitis in the hip, progression to advanced degeneration is likely secondary to weightbearing during ambulation. Historically, or thopedic surgeons have become involved with management of rheumatoid hip problems after the degenerative process and joint deterioration have begun, rather than early in the course of synovitis and symptomatic management of the disease. Arthrotomy and synovectomy have been reported in select patient populations, but the procedure definitely has not become a routine part of the accepted treatment strategy. The painful, end-stage degenerative rheumatic hip has been effectively treated with arthroplasty, but in young patients this treatment has not been without the long-term consequences of loosening and the need for multiple revision procedures.46-51

Although somewhat controversial in the treatment of rheumatoid arthritis, synovectomy has been used to treat intra-articular inflammation since the early 1900s. The inferences supporting synovectomy stem from the theory that removal of the diseased synovial tissue removes the source of inflammation responsible for the degenerative process, and that healthy tissue regeneration will occur. Although clinical symptomatic improvement has been documented following the procedure, the "new" synovium has been shown to share pathologic characteristics with the original tissue.52,53,54 The clinical improvement seen may in fact be related to the volume of synovial tissue regeneration, and the hiatus from active synovial inflammation and that which occurs during healing and reformation. Pain relief and symptomatic improvement following synovectomy in a variety of joints have been demonstrated by large, controlled multicenter studies, but unfortunately improved functional range of motion or decreased progression of joint deterioration has not been seen.46,48-49,55 These large studies do not address the hip specifically, and include all synovial joints. When the results are separated to isolate the major weightbearing joints, the results of synovectomy have been better. This has been noted by Granberry and Brewer, who highlight the points that syn-ovectomy is most effective early in the disease process before periostitis and erosions are evident, in monoarticular or pauciarticular forms, and when the sedimentation rate is not elevated.50

Another factor confounding the results of synovectomy in rheumatoid arthritis is the timing of the procedure in relationship to the amount of radiographic joint degeneration that has occurred. Most authors have refuted the utility of "late" synovectomy after radiographic evidence of joint degeneration is present,54,56 and Heimkes et al have reported accelerated progression of the degenerative process in this situa-tion.56 In the case of "early" synovectomy, or treatment before radiographic change has occurred, the results in specific situations have been favorable.9,47,54,57,58 It is in this early phase of the disease, when medical management has been ineffective, that synovectomy may contribute to the overall symptomatic treatment strategy, in concordance with medical management, rather than being perceived as interference.58 Synovectomy may offer short-term symptomatic relief and delay the need for a more extensive total joint arthroplasty, a delay that may be very important in a young patient with the disease. The systemic nature of rheumatoid arthritis must always be kept in mind, and any surgical procedure short of arthroplasty is symptomatic treatment aimed at safely providing pain relief and maintaining mobility, not at curing the disease. There is no evidence to suggest that synovectomy retards the bony destruction or the disease process.52,55,59,60

The majority of published work concerning arthroscopic synovectomy in rheumatoid arthritis involves the more peripheral and superficial joints. In the lower extremity, the knee has been the focus of most studies.5,61,62 In the knee, arthro-scopic synovectomy has been shown to be comparable to syn-ovectomy by arthrotomy in short-term reduction of pain and swelling with reduced morbidity, hospital stay, and postoperative rehabilitation. In the absence of advanced grade 3 to 4 chondral damage, improved joint function during daily activities was demonstrated.61 Cleland et al, in a small prospective study, demonstrated symptomatic improvement in pain with ambulation and reduced knee swelling maintained at 24 months, and patients universally regarded the procedure as worthwhile.62

The hip joint, because of its anatomic location and in accessibility, has not commonly been treated with synovectomy, and very little published information exists to support or refute the arthroscopic procedure in this location. The few reports that exist include only small numbers of patients, and focus on the JRA population. Open synovectomy of the hip in rheumatoid arthritis has been reported, usually as part of a larger series including multiple joints, and the results have been difficult to interpret. Albright et al, in a series of nine hips (five patients with JRA) treated with subtotal and complete synovectomy, showed symptomatic improvement and preserved joint motion in four of five patients. They concluded that synovectomy of the hip may be useful for progressive hip involvement in younger patients whose skeletal immaturity contraindicates major reconstructive procedures.63 Hol-gersson et al, also in a pediatric population with JRA, showed that arthroscopic intervention may be of benefit early in the disease process when evidence of joint destruction is minimal. In this series, arthroscopy provided better information about the cartilage than did roentgenograms, allowed de-bulking of the synovial membrane, and provided useful information that assisted in guiding future treatment.9

Arthroscopic synovectomy of the hip joint is definitely not being promoted as curative in the rheumatoid patient with active or chronic synovitis, but more as an adjunct in the management of selected patients with early affliction in the hip.

Synovectomy may be useful in the minimally erosive stages of the disease when the active synovitis is not suppressed by conservative modalities.47 The diagnostic and theraputic role of hip arthroscopy, if utilized, should come early in the disease process, prior to radiographic change. In the acutely symptomatic hip, the disparity between arthroscopic and radiographic degeneration has been shown in the rheumatic by

Die Spirale
Figure 14.8. Thick and redundant synovium impinging at the articular-synovial junction.

Holgersson, and in the early osteoarthritic by Santori and Vil-lar.9,64 Symptoms in the hip out of proportion to radiographic findings can be due to varying degrees of florid synovitis and advanced articular surface damage, despite evidence of joint space preservation.64 In this disease process, the extent of articular destruction forecasts the success for intervention, as manifested by the poor results with "late" synovectomy. In an acutely symptomatic patient with minimal radiographic degeneration of the hip joint, advanced chondral change and degeneration may still be encountered arthrocopically during the "early" synovectomy. In this situation the arthroscopic de-bridment and synovectomy may provide symptomatic relief, but more importantly it provides visual assessment of the articular surfaces and an accurate diagnosis. Not only can the intractable symptoms be explained, but future treatment may properly be influenced and planned. Hip arthroscopy has few reported complications, does not complicate future reconstructive efforts, and may effect, in a timely manner, the decision to provide definitive treatment via total joint arthro-plasty. In the rheumatoid patient, appropriate timing for a reconstructive hip procedure may decrease the stress and prolong the function of other lower extremity joints that are secondarily affected by a proximal contracture and compensatory gait.

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