TOTAL KNEE ARTHROPLASTY IS ONE OF THE MOST COMMONLY PERFORMED SURGICAL PROCEDURE PERFORMED FOR ADVANCED OSTEOARTHRITIS KNEE.IT IS PAIN RELIEVING AND A DISABILITY MODIFYING PROCEDURE. BUT A MINORITY OF PATIENTS ARE STILL EXPERIENCING PAIN EVEN AFTER THE PROCEDURE. AUTHORS ANALYSE VARIOUS FACTORS LEADING TO THE REASON FOR THE PAIN. THEY ARE EXAMINING THE ROLE OF THE SYNOVIUM AS THE REASON FOR PAIN AND SYSTEMATICALLY ANALYSE ITS ROLE. DR ABDUL RAHMAN IS WORKING AS ASSISTANT PROFESSOR AND IS AN ARTHROPLASTY SURGEON WITH VAST EXPERIENCE. DR MOHAMED ASHRAF IS THE HEAD OF THE DEPARTMENT AND IS EXPERIENCED IN KNEE.HIP, SHOULDER AND ELBOW ARTHROPLASTY. DR MOHAMED ASHRAF WAS THE FORMER HOD ORTHOPAEDICS GOVT TD MEDICAL COLLEGE ALLEPPEY KERALA INDIA PRESENTATION IS FROM TRAVANCORE MEDICAL COLLEGE AND MEDICITY HOSPITALS KOLLAM KERALA INDIA

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

24. PRE/POST OP X-RAYS

26. PATIENT WITH SATISFACTORY ROM POST
TKR/SYNOVECTOMY
7 DAYS POST OP

27. ONE YEAR 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