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Arthroscopic Synovectomy in Wrists with Advanced Rheumatoid Arthritis

Kim, Sung-Jae; Jung, Kwang-Am; Kim, Jong-Min; Kwun, Jun-Dae; Kang, Ho-Jung

Clinical Orthopaedics and Related Research: August 2006 - Volume 449 - Issue - p 262-266
doi: 10.1097/01.blo.0000218732.44591.c9
SECTION II: ORIGINAL ARTICLES: Hand
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We evaluated the effects of arthroscopic wrist synovectomy for patients with advanced rheumatoid arthritis. We retrospectively reviewed data for 11 patients with moderately advanced arthritis and joint space narrowing of 25% to 50% (Group A) treated from May 1993 to March 2000. We compared effects of these patients with effects of six patients with earlier disease and joint space narrowing of 0% to 25% (Group B). For Group A, the total modified Mayo wrist scores increased from an average of 26.36 points preoperatively to an average of 56.36 points postoperatively. Postoperative scores for pain and return to work status, and two components of the modified Mayo wrist score also showed differences compared with the respective preoperative scores. There was an increase in final followup scores in return to work status and total modified Mayo wrist scores. Group A showed larger differences than Group B. Our data suggest that arthroscopic synovectomy is a useful treatment for modest and moderate stages of rheumatoid arthritis. It is especially effective for decreasing pain and improving function, allowing patients to return to work.

Level of Evidence: Therapeutic study, Level III. See the Guidelines for Authors for a complete description of levels of evidence.

From the Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea.

Received: August 25, 2004

Revised: February 7, 2005; September 4, 2005; November 18, 2005

Accepted: February 21, 2006

Each author certifies that he has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his institution has approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research and that consent was obtained.

Correspondence to: Sung-Jae Kim, MD, Department of Orthopaedic Surgery, Yonsei University College of Medicine, CPO Box 8044, 134, Shin-chon-Dong, Seodaemun-Ku, 120-752, Seoul, Korea. Phone: 822-361-5640; Fax: 822-363-1139; E-mail: sungjaekim@yumc.yonsei.ac.kr.

Rheumatoid arthritis (RA) of the wrist can be treated nonoperatively, or surgically with a synovectomy, wrist arthrodesis, or an arthroplasty.2,4,9,11,13 The goal of synovectomy is to prevent progression of chronic synovial inflammation. Some authors suggest this prevents additional damage and offers better functional capacity.6,10 Open synovectomy has been the conventional method when nonoperative treatment fails.7,17 Arthroscopic synovectomy is a relatively atraumatic procedure and requires a short hospital stay.4,5,16,18 Some authors suggest arthroscopic synovectomy yields better results than open synovectomy.4,14,18 However, arthroscopic synovectomy was performed mainly for patients with minimal radiographic and cartilage damage.4,14 Wrist arthrodesis or arthroplasty usually are recommended for patients with advanced radiographic changes.

We questioned whether pain would be reduced and functional status of the wrist would be improved after arthroscopic synovectomy in patients with advanced radiographic changes. We hypothesized that the degree of improvement in pain and functional status would be similar to that in early-stage RA.

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MATERIALS AND METHODS

We retrospectively reviewed data of 25 patients treated from May 1993 to March 2000 to evaluate the effectiveness of arthroscopic synovectomy of the wrist (radiocarpal joint and midcarpal joints) for treatment of patients with RA in various stages. Eighteen patients with complete followup documentation were included for analysis. Two patients had died and three were unable to attend because of geographic reasons. Two additional patients were lost to followup within 3 months after surgery. Patients were classified by the stages described by Larsen et al (Tables 1,2).12 Selection of the original 25 patients was limited to patients with RA of Larsen Stage III or less who did not respond to nonoperative treatments such as systemic medication, local steroid injection, and physical therapy for more than 6 months. Patients were excluded if they had extensor synovitis, severe destruction of finger or distal radioulnar joints, previous surgery on the involved wrist, and had Larsen Stage IV disease as evaluated on routine radiographs. The 18 patients included in the analysis had RA for an average of 49.3 months preoperatively (range, 6-180 months). The average age of patients was 40.7 years (range, 16-66 years). Three patients were males and 15 patients were females. Six patients had an associated RA in other regions including the elbow, ankle, and knee. Eighteen patients (19 wrists) were examined clinically and radiographically after an average followup of 69.5 months (range, 33-118 months). One patient had bilateral involvement. Fourteen wrists were the patients' dominant wrists and five were nondominant wrists.

TABLE 1

TABLE 1

TABLE 2

TABLE 2

All operations were performed by one surgeon (SJK). Standard wrist arthroscopy techniques were used.1,19 Patients were placed in the supine position with the shoulder abducted 90° on an arm board. A pneumatic tourniquet was applied on the upper arm. The forearm was suspended in a wrist traction device. The second and third fingers were placed under 7 to 10 pounds traction. A 1.9-mm diameter, 30°-arthroscope (Dyonics, Andover, MA) initially was placed into the 3-4 portal and then into the 6-U portal for diagnostic wrist arthroscopy. After locating the radio-carpal and ulnocarpal joints, synovectomy for all visible inflamed synovial tissues was performed using a 1.9-mm full-radius motorized suction shaving device (Dyonics). Débridement of the articular surface then was performed. To examine the midcarpal joint, another accessory portal was established including the midcarpal radial portal and midcarpal ulnar portal. Débridement of the inflammatory synovial joints then was performed.

The preoperative and final followup visual analog scale (VAS) and modified Mayo wrist scores were evaluated (Table 3).8 The subjective assessment of pain was evaluated by VAS (0-10 points; 10 points for worst possible pain and 0 points for no pain) and assessed by physicians (SJK, HJK). The modified Mayo wrist assessment was given to 17 patients. The assessment could not be used for the patient with bilateral involvement. The four components of the modified Mayo wrist score include pain, return to work status (functional status), range of motion (ROM), and grip strength.8 Pain was rated as mild if it occurred at the extremes of movement and did not interfere with daily activities. Pain was rated moderate if it was sufficient to cause alteration in work or leisure activities. Pain was rated severe if it occurred during activities of daily living or at rest. The return to work status was scored according to the patient's ability to return to work. Range of motion was measured with a goniometer. Total ROM was measured as a sum of the angle of flexion and angle of extension. A maximum score of 25 points was given if the total ROM was greater than 120°. Grip strength was measured using a dynamometer (Smith & Nephew, Memphis, TN). If 90% of strength was acquired in the involved wrist compared with the uninvolved wrist, the patient was given a maximum score of 25 points. These clinical ratings were assessed preoperatively by the surgeon (SJK) who performed the procedure, and postoperative ratings were assessed by another surgeon (HJK) who was blinded to the treatment group.

TABLE 3

TABLE 3

Three surgeons (KAJ, JMK, JDK) assessed anteroposterior (AP) radiographs of each wrist and were blinded to the treatment group. They were not aware of the clinical conditions of patients according to the rating system of Larsen et al12 (Table 1) or the modified version of their system as described by Rau and Heborn.15 The radiographs were measured individually by each rater. Rating of the Larsen stage was determined by mutual agreement among raters when necessary. The lower, more non-operative score always was used. The percentage of joint space narrowing in the affected wrist as compared with the contralateral wrist was measured in 17 patients. This was not determined for the one patient with bilateral involvement. The midcarpal and radiocarpal joints were selected for recording percentages of joint space narrowing. The percentage of joint space narrowing was measured once by each rater and was categorized as: 0-25%, 25-50%, 50-75%, and greater than 75%. Preoperatively, six of 19 wrists were Stage I, two wrists were Stage II, and 11 wrists were Stage III (Table 2). Preoperatively, 11 wrists with Larsen Stage III (Group A) RA had joint space narrowing of 25-50% or less compared with the contralateral wrists (Fig 1). Six wrists with Larsen Stages I and II (Group B) RA showed joint space narrowing of 0-25%.

Fig 1

Fig 1

The reliability of the Larsen stage and joint space narrowing among raters was quantified by kappa index. The breakdown of an acceptable level of interrater reliability was set to 0.4. A kappa level greater than 0.75 indicated high reliability. An acceptability of 0.4 was reached with a kappa index of 0.742 in joint space narrowing and 0.752 in Larsen stage rating. Wilcoxon's signed rank test was used to evaluate differences between preoperative and postoperative data including VAS and modified Mayo wrist scores. A Mann-Whitney U test was used to measure differences in preoperative and postoperative data among patients with Larsen Stage III (Group A) RA and patients with Larsen Stages I and II (Group B) RA. Probability values less than 0.05 were considered significant. All analyses were performed using SPSS 12.0 (SPSS Inc., Chicago, IL).

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RESULTS

For Group A, VAS decreased (p < 0.01) from 8.4 preoperatively to 5.1 postoperatively. The modified Mayo wrist score for pain increased (p = 0.01) from 3.63 preoperatively to 18.18 at final followup, and return to work status increased (p = 0.02) from 6.81 preoperatively to 16.36 at final followup. There were no differences in ROM and grip strength scores. Total modified Mayo wrist scores increased (p = 0.002) from an average of 26.36 points preoperatively to an average of 56.36 points at final followup.

For Group B, VAS decreased (p < 0.01) from 8 preoperatively to 4.5 at final followup. In assessment of each component of modified Mayo wrist scores, the score for pain increased (p = 0.01) from 6.25 preoperatively to 20 at final followup. However, there were no differences in ROM, grip strength, and return to work status. The total modified Mayo wrist scores increased (p = 0.02) from an average of 67.5 points preoperatively to an average of83.75 points at final followup (Table 4).

TABLE 4

TABLE 4

In comparison between Groups A and B, Group A had a lower score in each preoperative component of the modified Mayo wrist scores than Group B, except for the pain score (Table 5). There were increases from preoperative to final followup scores in the return to work status (p =0.001) and total modified Mayo wrist score (p = 0.005). Group A showed larger differences compared with Group B (Table 5). One patient had immediate numbness of the superficial radial nerve postoperatively, but it disappeared 1 month postoperatively. There were no wrist arthrodeses or wrist arthroplasties.

TABLE 5

TABLE 5

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DISCUSSION

Some authors4,5,14 have suggested that arthroscopic synovectomy of the wrist in the early stages of RA can provide pain relief with preserved or improved mobility. For patients with advanced radiographic changes, wrist arthrodesis or arthroplasty usually are recommended. Some authors recommend arthroscopic wrist synovectomy in patients with advanced radiographic changes, but their studies mainly focus on the outcome of arthroscopic synovectomy for patients with early-stage RA.4,14 Our study included seven patients with an early stage of RA (Larsen Stages I, II) and 11 patients with Larsen Stage III RA with medium destructive cartilage. The patients with Larsen Stage III RA and joint space narrowing of 25% to 50% and patients with early-stage RA experienced improvements after arthroscopic synovectomies. Patients with Larsen Stage III RA had improvements in pain score and return to work status at final followup. The improvement in pain scores using VAS was similar to the results of Park et al14 who reported a decrease from 8.2 preoperatively to 4.8 postoperatively. We found a decrease from 8.4 preoperatively to 5.1 postoperatively in the 11 patients with Larsen Stage III RA. The preoperative pain rating using a modified Mayo wrist score8 was higher than moderate in all patients, but showed improvement at final followup. Preoperatively, 13 patients had limitations of daily activities and needed assistance from others. All showed improvement at final followup. Five patients with early stages of RA (Larsen Stages I, II) were independent preoperatively. Although the patients showed no improvements in grip strength and ROM at the final followup, they all had improvements in hand functional status (combing their hair, using a spoon, lifting, and opening a door).

Our study has several limitations. First is the small number of patients and the use of simple grading using the Larsen staging system12 instead of other scoring methods.14 We had a substantial loss of patients to followup, which could bias the results. In addition, our study included three nondominant wrists with Larsen Stage III RA. The grip strength may have been lower compared with strength in a study with all dominant wrists. This also may have affected grip strength score and total modified Mayo wrist score of wrists with Larsen Stage III RA when compared with wrists with Larsen Stage I or II RA.

There were no preoperative differences in pain scores between Groups A and B. Both groups showed the same level of improvement from preoperative to final followup. The return to work status for Group A was lower than for Group B preoperatively, but Group A showed a larger increase than Group B postoperatively. We think an arthroscopic synovectomy is helpful for patients with Larsen Stage III RA, especially regarding improving pain and return to work status.

Joint-space narrowing results from degeneration of the articular cartilages as pannus spreads across the joint surfaces. However, some disparity between the degree of erosion and narrowing of the joint space may occur, especially in the erosive phase of arthritis.12 In our study, all 11 patients with Larsen Stage III RA had joint-space narrowing of 25% to 50% compared with the contralateral wrists preoperatively. Synovectomy is not recommended for weightbearing joints such as the knee or ankle for patients with radiographically advanced joint-space narrowing; open procedures such as arthrodesis or arthroplasty are recommended.16 In our study, patients with advanced radiographic changes and joint-space narrowing had satisfactory surgical and clinical results after synovectomies. However, this does not mean it will prevent radiographic worsening. In our study, nine patients had progression of their RA to a higher radiographic grade even though clinical symptoms improved. Postoperatively, three of six patients with Larsen Stage I RA progressed to having Larsen Stage II RA. One of two patients with Larsen Stage II RA progressed to having Larsen Stage IV RA. Five of 11 patients with Larsen Stage III RA progressed to having Larsen Stage IV RA. A synovectomy has not been shown to change the natural progression of the disease.3,4

Given the limitations of this study, we cannot suggest arthroscopic synovectomy is an effective method of treatment for all patients with advanced radiographic changes. However, arthroscopic synovectomy can be considered before performing an arthrodesis or arthroplasty. Although arthroscopic synovectomy of the wrist cannot improve grip strength and ROM, it can reduce wrist pain and improve function, allowing for a faster return to work.

Acknowledgment

We thank Dr. S. J. Song for revision of the manuscript in English.

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