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PERFECT BUT PAINFUL TKR
THE ROLE OF SYNOVECTOMY IN TOTAL KNEE
ARTHROPLASTY : A PROSPECTIVE
NON-RANDOMISED ANALYSIS OF 50 CASES
AUTHOR-Dr ABDUL RAHMAN
Assistant Professor
CO-AUTHOR-DR MOHAMED ASHRAF
PROFESSOR & HOD
Dept Of Orthopaedics
Travancore Medical College
KOLLAM,KERALA,INDIA
PAIN RELIEVER TURNS PAIN GENERATOR
TKR IS AN OPERATION FOR PAIN
“ Chitranjan Singh Ranawat
”
• 10 - 34 % of all TKR are not happy
• 20 % of TKR patients experience more
pain post-operatively
• Knee pain Top five reasons for knee
replacement revisions
RANKIN K S ET AL, PILOT FEASIBILITY STUDY,
HISTORICAL PERSPECTIVE & STATISTICS OF TKR
• 1968 : FIRST EVER SUCCESSFUL TKR
• 250 MILLION IN WORLD AFFECTED WITH OA KNEE
• More than 2.5 lakh undergo TKR in India every year, which is
2.5 times the number of such procedures conducted
annually about five years ago
Dr Rajesh Malhotra, Head of Orthopaedics division, AIIMS
TOI Sept 2022
DIFFERENT TYPES OF TOTAL KNEE IMPLANTS
 Cruciate - Preserving
 Cruciate - Substituting
 Total Condylar - 3 System
 Navigation - Guided
Surgery
 Enhanced Kinematics
 Wear - Resistant bearing
surfaces
Pubmed; 11(4):218-26, Chithranjan S Ranawat
SOCIO - ECONOMIC BURDEN
• PERSONAL
• MEDICAL
• SOCIO-ECONOMIC
HUNTRT D J ET AL
LANCET 2019
PAINFUL “ FAILED ” TKR : OBVIOUS REASONS
• Arthrofibrosis
• Aseptic Loosening
• Component
Mal-positioning
• Infection
• Instability
• Polyethylene wear
• Psychological factor
• Patello femoral causes
PAINFUL SEEMINGLY PERFECT TKR :
OBSCURE REASONS
• Persistent synovial pathology
• Synovial impingement
• Synovial hypertrophy
• Neurogenic pain
• Metal poly debri release
SYNOVIUM AS A SOURCE OF PAIN IN TKR
• Synovium richly supplied
with free nerve endings
• Synovectomy :
Provides prompt relief
Ossy ssek b et al
J ortho research 2011
SYNOVITIS IN OSTEOARTHRITIS
• Synovium often inflamed &
hypertrophied in OA
• Hence synovectomy often reduces
this post-op complications
Perry t a et al,
osteoarthritis cartilage,2020
SYNOVECTOMY IS THE TREATMENT OF
CHOICE IN :
 RA SYNOVITIS
 TB SYNOVITIS
 PVNS
 SYNOVIAL CHONDROMATOSIS
 LIPOMA ARBORESCENCE
THEN WHY NOT IN TKR …???
RETAINING SYNOVIUM IN TKR
• Lining cells may induce inflammation
• Sub-synovial cells may induce bone and
cartilage destruction
These may lead to aseptic loosening
• Synovial impingement may lead to
post-op pain
METAL-POLY DEBRIS INDUCED SYNOVITIS
Phagocytic
cascade
response
Synovitis
leads to pain
Treatment :
Synovectomy
RECURRENT BLEEDING AFTER TKR
•TREATMENT :
SYNOVECTOMY
RAVI B, HOSACK L ET AL
J AM ACAD ORTH SURG,2019
SYNOVECTOMY IN TKR IS CONTROVERSIAL
DUE TO “ BLEEDING ”
Anzo porez et al zur j of ortho 2018
Zhaoning et al bjj 2013
PRE-OP SYNOVITIS SCORE MORE - USG OR MRI
• Synovectomy :
Must be done in TKR,
Otherwise persistent
post-op pain
Peterson k k et al clinj
of pain, 2021
REDUCTION OF POST-OP PAIN IS
THE KEY TO SUCCESS IN TKR
Auyoung d b et al , j of arthroplasty,
2015
SURGEON &
SYNOVECTOMY
• Decided by the Surgeon
pre-op & intra-op assessment
• But Surgeon can’t be a
Pathologist on table…!!!
Tanavalee a, JBJS br 2011
SYNOVECTOMY
• Reduces
Pain & Inflammation
• Improves
ROM
Su x ,arthroscopy,2018
Liu w x ,peer journal,2018
OUR STUDY DETAILS
•50 patients with OA knee
joint treated with total knee
arthroplasty with near-total
synovectomy and its functional outcome
OUR ANALYSIS AND SCORING
• Age group 55 - 70 years
MALE
FEMALE
63%
4th Qtr
2%
SEX RATIO
0
5
10
15
20
25
30
35
40
VARUS
KNEE
VALGUS
KNEE
Category 4
KNEE DEFORMITY
The overall efficacy of the procedures were assessed
postoperatively for :
• Postoperative pain
• Knee joint effusion
• Patellar clunk
• Range of movement
• Stability of prosthesis
All cases were followed up at 1 month, 3 months, 6 months & yearly
once thereafter for a minimum of 3 years
LYSHOLM KNEE SCORING
SYSTEM
 36 knees scored : Excellent
 13 knees scored : Good
 1 knee scored : Fair
EXCELLENT
72%
GOOD
26%
FAIR
2%
EXCELLENT GOOD FAIR
OUR PER-OP EXPERIENCE & HPR DATA
Pathology No Of Cases Percentage
Non Specific
Synovitis
41 82 %
Rheumatoid
Synovitis
4 8 %
Tuberculous
Synovitis
3 6 %
PVNS 1 2 %
Synovial
Chondromatosis
1 2 %
Others 0 0
PRE/POST OP X-RAYS
PATIENT WITH SATISFACTORY ROM POST
TKR/SYNOVECTOMY
7 DAYS POST OP
ONE YEAR POST OP
CONCLUSION
 SYNOVIUM WILL BE OR MAY BE
PATHOLOGICAL IN ALMOST ALL TKR
 RETAINING PATHOLOGICAL SYNOVIUM ITSELF
MAY BE THE PAIN SOURCE
 SYNOVECTOMY IS CURATIVE IN MANY SITUATIONS
 MINOR ISSUES FAR OUTWEIGH LONG TERM BENEFITS
PERFORMING SYNOVECTOMY IN TKA
WILL GIVE A COMPLETE
 PATHOLOGICAL DIAGNOSIS
 AVOID PERSISTENCE OF SYNOVIAL PATHOLOGY ALONG WITH
LONG-TERM BENEFITS OF SYNOVECTOMY IN THE FORM OF
MINIMAL TO NO JOINT EFFUSION
 LESS PAIN
 ABSENCE OF SYNOVIAL HYPERTROPHY & PATELLAR CLUNK
 GOOD RANGE OF MOVEMENT OF KNEE
ACKNOWLEDGEMENT
• Prof Dr Mohammed Ashraf M
• Prof Dr Ayyapan Nair
• Prof Dr Jiju George
• Prof Dr Arun Kumar A S
• All Staff Members,
Department of Orthopaedics,
Travancore Medicity Hospital
Thank You for
your support…
UNIT I UNIT II UNIT III
Dr MOHAMMED ASHRAF (HOD) Dr JIJU GEORGE Dr AYYAPPAN NAIR
DR SURESH S PILLAI Dr VINOD V S Dr NAIJU AJUMUDHEEN
Dr GOKUL DEV Dr ARUN KUMAR A S Dr SHANKAR
Dr HASEEB MUKTHAR Dr ABDUL RAHMAN Dr RAMU
Dr SHAMMAS Dr JOBIN JACOB JOB Dr BHASKAR SUBIN SUGATH
Department of Orthopaedics
Travancore Medical College

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PERFECT BUT PAINFUL TKR -ROLE OF SYNOVECTOMY.pptx

  • 1. PERFECT BUT PAINFUL TKR THE ROLE OF SYNOVECTOMY IN TOTAL KNEE ARTHROPLASTY : A PROSPECTIVE NON-RANDOMISED ANALYSIS OF 50 CASES AUTHOR-Dr ABDUL RAHMAN Assistant Professor CO-AUTHOR-DR MOHAMED ASHRAF PROFESSOR & HOD Dept Of Orthopaedics Travancore Medical College KOLLAM,KERALA,INDIA
  • 2. PAIN RELIEVER TURNS PAIN GENERATOR TKR IS AN OPERATION FOR PAIN “ Chitranjan Singh Ranawat ” • 10 - 34 % of all TKR are not happy • 20 % of TKR patients experience more pain post-operatively • Knee pain Top five reasons for knee replacement revisions RANKIN K S ET AL, PILOT FEASIBILITY STUDY,
  • 3. HISTORICAL PERSPECTIVE & STATISTICS OF TKR • 1968 : FIRST EVER SUCCESSFUL TKR • 250 MILLION IN WORLD AFFECTED WITH OA KNEE • More than 2.5 lakh undergo TKR in India every year, which is 2.5 times the number of such procedures conducted annually about five years ago Dr Rajesh Malhotra, Head of Orthopaedics division, AIIMS TOI Sept 2022
  • 4. DIFFERENT TYPES OF TOTAL KNEE IMPLANTS  Cruciate - Preserving  Cruciate - Substituting  Total Condylar - 3 System  Navigation - Guided Surgery  Enhanced Kinematics  Wear - Resistant bearing surfaces Pubmed; 11(4):218-26, Chithranjan S Ranawat
  • 5. SOCIO - ECONOMIC BURDEN • PERSONAL • MEDICAL • SOCIO-ECONOMIC HUNTRT D J ET AL LANCET 2019
  • 6. PAINFUL “ FAILED ” TKR : OBVIOUS REASONS • Arthrofibrosis • Aseptic Loosening • Component Mal-positioning • Infection • Instability • Polyethylene wear • Psychological factor • Patello femoral causes
  • 7. PAINFUL SEEMINGLY PERFECT TKR : OBSCURE REASONS • Persistent synovial pathology • Synovial impingement • Synovial hypertrophy • Neurogenic pain • Metal poly debri release
  • 8. SYNOVIUM AS A SOURCE OF PAIN IN TKR • Synovium richly supplied with free nerve endings • Synovectomy : Provides prompt relief Ossy ssek b et al J ortho research 2011
  • 9. SYNOVITIS IN OSTEOARTHRITIS • Synovium often inflamed & hypertrophied in OA • Hence synovectomy often reduces this post-op complications Perry t a et al, osteoarthritis cartilage,2020
  • 10. SYNOVECTOMY IS THE TREATMENT OF CHOICE IN :  RA SYNOVITIS  TB SYNOVITIS  PVNS  SYNOVIAL CHONDROMATOSIS  LIPOMA ARBORESCENCE THEN WHY NOT IN TKR …???
  • 11. RETAINING SYNOVIUM IN TKR • Lining cells may induce inflammation • Sub-synovial cells may induce bone and cartilage destruction These may lead to aseptic loosening • Synovial impingement may lead to post-op pain
  • 12. METAL-POLY DEBRIS INDUCED SYNOVITIS Phagocytic cascade response Synovitis leads to pain Treatment : Synovectomy
  • 13. RECURRENT BLEEDING AFTER TKR •TREATMENT : SYNOVECTOMY RAVI B, HOSACK L ET AL J AM ACAD ORTH SURG,2019
  • 14. SYNOVECTOMY IN TKR IS CONTROVERSIAL DUE TO “ BLEEDING ” Anzo porez et al zur j of ortho 2018 Zhaoning et al bjj 2013
  • 15. PRE-OP SYNOVITIS SCORE MORE - USG OR MRI • Synovectomy : Must be done in TKR, Otherwise persistent post-op pain Peterson k k et al clinj of pain, 2021
  • 16. REDUCTION OF POST-OP PAIN IS THE KEY TO SUCCESS IN TKR Auyoung d b et al , j of arthroplasty, 2015
  • 17. SURGEON & SYNOVECTOMY • Decided by the Surgeon pre-op & intra-op assessment • But Surgeon can’t be a Pathologist on table…!!! Tanavalee a, JBJS br 2011
  • 18. SYNOVECTOMY • Reduces Pain & Inflammation • Improves ROM Su x ,arthroscopy,2018 Liu w x ,peer journal,2018
  • 19. OUR STUDY DETAILS •50 patients with OA knee joint treated with total knee arthroplasty with near-total synovectomy and its functional outcome
  • 20. OUR ANALYSIS AND SCORING • Age group 55 - 70 years MALE FEMALE 63% 4th Qtr 2% SEX RATIO 0 5 10 15 20 25 30 35 40 VARUS KNEE VALGUS KNEE Category 4 KNEE DEFORMITY
  • 21. The overall efficacy of the procedures were assessed postoperatively for : • Postoperative pain • Knee joint effusion • Patellar clunk • Range of movement • Stability of prosthesis All cases were followed up at 1 month, 3 months, 6 months & yearly once thereafter for a minimum of 3 years
  • 22. LYSHOLM KNEE SCORING SYSTEM  36 knees scored : Excellent  13 knees scored : Good  1 knee scored : Fair EXCELLENT 72% GOOD 26% FAIR 2% EXCELLENT GOOD FAIR
  • 23. OUR PER-OP EXPERIENCE & HPR DATA Pathology No Of Cases Percentage Non Specific Synovitis 41 82 % Rheumatoid Synovitis 4 8 % Tuberculous Synovitis 3 6 % PVNS 1 2 % Synovial Chondromatosis 1 2 % Others 0 0
  • 25.
  • 26. PATIENT WITH SATISFACTORY ROM POST TKR/SYNOVECTOMY 7 DAYS POST OP
  • 28. CONCLUSION  SYNOVIUM WILL BE OR MAY BE PATHOLOGICAL IN ALMOST ALL TKR  RETAINING PATHOLOGICAL SYNOVIUM ITSELF MAY BE THE PAIN SOURCE  SYNOVECTOMY IS CURATIVE IN MANY SITUATIONS  MINOR ISSUES FAR OUTWEIGH LONG TERM BENEFITS
  • 29. PERFORMING SYNOVECTOMY IN TKA WILL GIVE A COMPLETE  PATHOLOGICAL DIAGNOSIS  AVOID PERSISTENCE OF SYNOVIAL PATHOLOGY ALONG WITH LONG-TERM BENEFITS OF SYNOVECTOMY IN THE FORM OF MINIMAL TO NO JOINT EFFUSION  LESS PAIN  ABSENCE OF SYNOVIAL HYPERTROPHY & PATELLAR CLUNK  GOOD RANGE OF MOVEMENT OF KNEE
  • 30. ACKNOWLEDGEMENT • Prof Dr Mohammed Ashraf M • Prof Dr Ayyapan Nair • Prof Dr Jiju George • Prof Dr Arun Kumar A S • All Staff Members, Department of Orthopaedics, Travancore Medicity Hospital Thank You for your support…
  • 31. UNIT I UNIT II UNIT III Dr MOHAMMED ASHRAF (HOD) Dr JIJU GEORGE Dr AYYAPPAN NAIR DR SURESH S PILLAI Dr VINOD V S Dr NAIJU AJUMUDHEEN Dr GOKUL DEV Dr ARUN KUMAR A S Dr SHANKAR Dr HASEEB MUKTHAR Dr ABDUL RAHMAN Dr RAMU Dr SHAMMAS Dr JOBIN JACOB JOB Dr BHASKAR SUBIN SUGATH Department of Orthopaedics Travancore Medical College