Knee Osteotomy Decreases Joint Inflammation Based on Synovial Histology and Synovial Fluid Analysis.

PURPOSE: To examine the biological changes in the joints of patients with knee osteoarthritis (OA) before and after around-knee osteotomy (AKO), focusing on synovial fluid (SF) and synovial pathological changes. METHODS: Patients who underwent AKO for medial compartment knee OA between 2019 and 2021 were examined. SF and synovium were obtained at the time of AKO and plate removal after bone union (mean, 16.8 months [range: 11-38 months] postoperatively). SF volume and interleukin (IL)-6 concentrations in SF were assayed using enzyme-linked immunosorbent assay. Synovitis was assessed histologically using a semiquantitative scoring system. Macrophage infiltration was assessed by immunohistochemistry using a semiquantitative score for F4/80 expression. The M1/M2 ratio was calculated using percentage of cells positive for CD80 and CD163. The expression of proinflammatory cytokines was assessed by the percentage of IL-1ß- and IL-6-positive cells. The number of vascular endothelial growth factor-positive luminal structures was counted to assess angiogenesis. The change in each parameter was compared before and after AKO using the Wilcoxon matched-pairs signed-rank test. RESULTS: Twenty-four knees of 21 patients were included. SF volume and IL-6 concentration significantly decreased postoperatively (12.6 ± 2.1 mL vs 4.2 ± 0.6 mL; P < .0001 and 50.5 ± 8.6 pg/mL vs 20.7 ± 3.8 pg/mL; P = .0001, respectively). A significant reduction in synovitis score (P = .0001), macrophage infiltration (P < .0003), M1/M2 ratio (P < .0007), angiogenesis (P < .0001), and the percentage of IL-1ß- and IL-6-positive cells in the intima (P < .008 and P < .002, respectively) was found after AKO. CONCLUSIONS: SF volume and IL-6 concentrations in the SF decreased and inflammatory synovium pathology improved after AKO. In addition to biomechanical changes, the biological environment of the joint can be improved after AKO. LEVEL OF EVIDENCE: Level IV, retrospective therapeutic case series.

Arthroscopic debridement of the ankle in synovitis.

Inflammation and hypertrophy of the ankle joint's synovial lining can occur due to various causes. Chronic pain and degenerative changes may be due to synovitis causing clinical manifestations through traction on the joint capsule. The failure of conservative treatment for at least six months indicates arthroscopic debridement, which can provide significant pain relief without the morbidity of extensive surgical exposures. This study was therefore conducted to establish the functional results of arthroscopic debridement of the ankle joint in synovitis. Fifteen patients with chronic ankle pain who had not responded to conservative treatment for approximately six months were included in the study. Arthroscopic debridement was performed using a shaver blade, followed by a postoperative ankle physiotherapy regimen. Patients were assessed preoperatively and postoperatively using the AOFAS, FADI, and VAS scores, with a mean follow-up period of 26 months. There was a significant improvement in the final clinical outcomes of the patients. The post-operative VAS score improved to 2.20±0.56 (2-4) (p-value=0.001), the AOFAS score was 86±8.25 (65-98) (p-value-0.001), and the FADI Score was 86.93±7.35(70-96) (p-value=0.001). Thirteen patients (86.67%) achieved outstanding or good results, while two had fair results, according to Meislin's criterion. One patient reported a superficial wound infection, which subsided with antibiotic therapy. The study findings indicate that arthroscopic ankle debridement is an efficient method to treat persistent ankle discomfort induced by synovitis, and it has a low postsurgical complications rate, quicker recovery, and less joint stiffness.

Better post-operative outcomes at 1-year follow-up are associated with lower levels of pre-operative synovitis and higher levels of IL-6 and VEGFA in unicompartmental knee arthroplasty patients.

PURPOSE: Osteoarthritis (OA) is associated with inflammation, and residual inflammation may influence outcomes following knee arthroplasty. This may be more relevant for patients undergoing unicompartmental knee arthroplasty (UKA) due to larger remaining areas of native tissue. This study aimed to: (1) characterise inflammatory profiles for medial UKA patients and (2) investigate whether inflammation markers are associated with post-operative outcomes. METHODS: This prospective, observational study has national ethics approval. Bloods, synovial fluid, tibial plateaus and synovium were collected from medial UKA patients in between 1 January 2021 and 31 December 2021. Cytokine and chemokine concentrations in serum and synovial fluid (SF) were measured with multiplexed assays. Disease severity of cartilage and synovium was assessed using validated histological scores. Post-operative outcomes were measured with Oxford Knee Score (OKS), Forgotten Joint Score (FJS-12) and pain scores. RESULTS: The study included 35 patients. SF VEGFA was negatively correlated with pre-operative pain at rest (r - 0.5, p = 0.007), and FJS-12 at six-week (r 0.44, p = 0.02), six-month (r 0.61, p < 0.01) and one-year follow-up (r 0.63, p = 0.03). Serum and SF IL-6 were positively correlated with OKS at early follow-up (serum 6 weeks, r 0.39, p = 0.03; 6 months, r 0.48, p < 0.01; SF 6 weeks, r 0.35, p = 0.04). At six weeks, increased synovitis was negatively correlated with improvements in pain at rest (r - 0.41, p = 0.03) and with mobilisation (r - 0.37, p = 0.047). CONCLUSION: Lower levels of synovitis and higher levels of IL-6 and VEGFA were associated with better post-operative outcomes after UKA, which could be helpful for identifying UKA patients in clinical practice. LEVEL OF EVIDENCE: Level IV case series.

Blau syndrome with persistent fetal vasculature: a case report.

BACKGROUND: Blau Syndrome (BS) is a rare autosomal dominant noncaseous granulomatous disease caused by mutations in the NOD2 gene. The disease is characterized by granulomatous dermatitis, symmetrical arthritis, and uveitis, which, if left untreated, can progress to blindness. The diagnosis of BS can be challenging because of its rarity and overlap with other rheumatologic disorders. Early detection of ocular involvement is critical to prevent vision loss and improve the prognosis of patients with BS. CASE PRESENTATION: In this report, we present a case of a five-year-old Chinese girl diagnosed with BS one year ago after presenting with a systemic rash and urinary calculi. Genetic testing was recommended by a physician, and a heterozygous mutation of the NOD2 gene c.1538T > C (p.M513T) was identified. Eight months ago, due to bilateral corneal punctate opacity, we had examined and diagnosed bilateral uveitis, bilateral corneal zonal degeneration, persistent fetal vasculature (PFV) in the right eye, and perivascular granuloma in the right eye. As a result, Vitrectomy was performed on the right eye, resulting in a significant improvement in visual acuity from 1/50 on the first day after surgery to 3/10 after 1 week. After 6 months, the visual acuity of the right eye was maintained at 3/20, but opacification of the lens posterior capsule was observed. Follow-up appointments are ongoing to monitor the condition of the affected eyes. Our report underscores the importance of prompt detection and management of ocular involvement in BS accompany with PFV to prevent vision loss and improve patient outcomes. CONCLUSIONS: This report details the case of a child diagnosed with BS who accompanied a periretinal granuloma and PFV in the right eye. Regrettably, the left eye was observed to have no light perception (NLP) with the fundus not being visible. The occurrence of ocular complications in patients with BS, must be closely monitored to prevent vision loss and enhance treatment outcomes. This case underscores the importance of prompt diagnosis and management of ocular complications in patients with BS to prevent further damage and optimize patient outcomes.

Age and synovitis affect the results of the treatment of knee osteoarthritis with Microfragmented Autologous Fat Tissue.

PURPOSE: This study aims to assess the effectiveness of Microfragmented Autologous Fat Tissue (MFAT) treatment for knee osteoarthritis and to investigate whether patients' pre-treatment clinical condition, such as synovitis, correlates with clinical outcomes, to identify potential predicting factors for the success or failure of the treatment. METHODS: In this prospective Cohort Study Level II multicentric trial, consecutive patients with a diagnosis of early/mild osteoarthritis and failure of previous conservative measures were enrolled to undergo diagnostic arthroscopy and a single MFAT injection. Patients were assessed with repeated scoring systems at baseline, 6 months, and 12 months after surgery. The demographic features, the arthroscopic findings, the immunophenotype of injected tissue and the histologic examination of synovia of failed patients were analyzed. RESULTS: Data from 91 patients showed a significant improvement in Lysholm, WOMAC scores at 1-year follow-up (p < 0.001). A significant decrease in VAS score was observed, while a significant improvement of measured flexion angle was registered at 1 year (p < 0.001). No major complications were reported. Age and synovitis were identified as significant factors influencing the clinical outcome (p < 0.05). Body mass index, previous or concomitant procedures, and specific cartilage defects had no influence. The mean number of injected adipose tissue-derived mesenchymal stem cells seem not to correlate with the clinical outcome. CONCLUSION: MFAT is effective in reducing pain when used with a single dose injection in early/mild OA of the knee, without major complications. Age over 60 and synovitis may be predictive for persistent pain at one year and should be considered before indications.

Is histopathological synovitis score a predictor of postoperative requirement for additional or alternative drug treatment in the patients with rheumatoid arthritis?

OBJECTIVES: Histopathological synovitis scoring is useful for assessing activity in patients with rheumatoid arthritis (RA) at sampling, but it is unclear whether it can be a predictor of future drug treatment. The purpose of this study was to examine whether histopathological synovitis score is a predictor of postoperative requirement for additional or alternative drug treatment after total knee arthroplasty (TKA). METHODS: Thirty patients with RA in whom synovial samples were obtained during TKA were included. Patients were divided into the drug treatment enhanced group (EG), which included patients who needed additional or alternative drug treatment within 1 year after TKA, and the drug treatment maintenance group (MG). The Rooney synovitis score (RSS) was compared between groups. Logistic regression analysis was performed to clarify prognostic factors for postoperative drug treatment change. RESULTS: The total RSS was significantly higher in the EG than in the MG (29.3 vs 15.1; P < .001). Multivariate analysis showed that total RSS and swollen joint counts were independent variable associated with postoperative requirement for additional or alternative drug treatment (P < .05). CONCLUSIONS: Histopathological synovitis scoring may predict requirement for additional or alternative drug treatment in patients with RA after TKA.

Knee Alignment Correction by High Tibial Osteotomy Reduces Symptoms and Synovial Inflammation in Knee Osteoarthritis Accompanied by Macrophage Phenotypic Change From M1 to M2.

OBJECTIVE: This study aimed to determine whether alignment correction by high tibial osteotomy (HTO) can change the biologic intraarticular microenvironment of osteoarthritic (OA) knees. METHODS: Synovial tissue (ST) and fluid (SF) were collected from the affected knees of 31 OA patients during initial HTO and plate removal surgeries. Changes in gene expression in ST were investigated by microarray and real-time polymerase chain reaction (PCR). ST specimens were also evaluated histologically using synovitis scores and immunofluorescence staining to determine macrophage polarity. Cytokines and chemokines in SF were analyzed by enzyme-linked immunosorbent assays. The mechanism of macrophage polarization was investigated in human peripheral blood mononuclear cell-derived macrophages and fibroblast-like synoviocytes (FLS) stimulated with cartilage fragments. We also evaluated Spearman correlations between Knee Injury and Osteoarthritis Outcome scores (KOOS) and macrophage-related gene expression. RESULTS: The microarray results indicated down-regulated inflammatory genes and pathways. Real-time PCR determined that genes expressing proinflammatory IL1B and IL6 were down-regulated and M2 macrophage-related IL1RA, IL10, CCL18, and CD206 were up-regulated. Histologic findings revealed attenuated synovitis scores and a shift from M1 to M2 macrophages. Interleukin-1ß (IL-1ß) concentrations in SF decreased after HTO. Cartilage fragments were responsible for M1 macrophage polarization and proinflammatory gene and protein expression in macrophages, whereas cartilage fragments up-regulated only IL-6 protein in FLS. Postoperative KOOS positively correlated with the expression of the M2-related genes CCL18 and CD206. CONCLUSION: Correction of lower limb alignment with HTO attenuated synovial inflammation and changed macrophage polarization from M1 to M2, suggesting an improved intraarticular environment in knee OA.

Metal Artifact Reduction MRI in the Diagnosis of Periprosthetic Hip Joint Infection.

A 54-year-old woman presented with progressive right hip pain after hip arthroplasty 9 years earlier. The emerging role of metal artifact reduction MRI in the noninvasive diagnosis of infectious synovitis as the surrogate marker for periprosthetic hip joint infection and differentiation from other synovitis types is discussed.

Cut and cure: surgical therapy of synovitis.

Surgical management for synovitis has undergone radical change in the last few years with the evolution of DMARDs and advanced Interventional Radiology techniques. Here we present areas where surgical therapy may still be the most effective option, either alone or in conjunction with non-surgical measures.

Chronic postoperative pain after total knee arthroplasty: The potential contributions of synovitis, pain sensitization and pain catastrophizing-An explorative study.

BACKGROUND: A subset of osteoarthritis patients will experience chronic postoperative pain after total knee arthroplasty (TKA), but the source of pain is unclear. The aim of this exploratory study was to assess patients with and without postoperative pain after TKA using magnetic resonance imaging (MRI), quantitative sensory testing (QST), clinical assessment of pain and assessments of catastrophizing thoughts. METHODS: Forty-six patients completed the 6-month postoperative assessment. MRI findings were scored according to the MRI Osteoarthritis Knee Score recommendation for Hoffa synovitis, effusion size and bone marrow lesions. QST included assessment of pressure pain thresholds (PPTs), temporal summation of pain (TSP) and conditioned pain modulation (CPM). Pain catastrophizing was assessed using the Pain Catastrophizing Scale (PCS). Clinical pain assessment was conducted using a visual analogue scale (VAS, 0-10 cm), and groups of moderate-to-severe (VAS > 3) and none-to-mild postoperative pain (VAS ≤ 3) were identified. RESULTS: Patients with moderate-to-severe postoperative pain (N = 15) demonstrated higher grades of Hoffa synovitis (p < 0.001) and effusion size (p < 0.001), lower PPTs (p = 0.039), higher TSP (p = 0.001) and lower CPM (p = 0.014) when compared with patients with none-to-mild postoperative pain (N = 31). No significant difference was found in PCS scores between the two groups. Multiple linear regression models found synovitis (p = 0.036), effusion size (p = 0.003), TSP (p = 0.013) and PCS (p < 0.001) as independent parameters contributing to the postoperative pain intensity. CONCLUSION: These exploratory findings could indicate that chronic postoperative pain after TKA is a combination of joint-related synovitis and effusion, sensitization of central pain mechanisms and potentially pain catastrophizing thoughts, but larger studies are needed to confirm this. SIGNIFICANCE: The end-stage treatment of knee osteoarthritis is total knee arthroplasty. Some patients experience chronic postoperative pain after total knee arthroplasty, but the mechanism for chronic postoperative pain is widely unknown. The current study indicates that higher levels postoperative of synovitis and effusion, higher temporal summation of pain and higher pain catastrophizing scores could be associated with higher chronic postoperative pain.

Clinical course in patients with chronic undifferentiated arthritis of the elbow after arthroscopic synovectomy.

BACKGROUND: Surgical treatment can be considered for patients with undifferentiated arthritis (UA) limited to the elbow joint. The purpose of this study was to analyze the clinical outcomes of arthroscopic synovectomy. METHODS: Nineteen patients who underwent arthroscopic synovectomy for chronic UA of the elbow between 2006 and 2019 were enrolled in this study. One patient was excluded because of evidence of tuberculosis in the biopsy. Chronic UA of the elbow was defined as (1) localized synovitis diagnosed by magnetic resonance imaging, (2) no specific cause, and (3) no response to conservative treatment for >3 months. We compared baseline characteristics and clinical outcomes between the remission and disease progression groups. RESULTS: Postoperatively, synovitis was controlled in 13 patients. In 5 patients, the symptoms disappeared after surgery without any medical treatment. Four patients discontinued disease-modifying antirheumatic drugs. Nine patients were classified as in remission. The disease progression group had a longer symptom duration, elevated rheumatoid markers, and higher Larsen grading. However, the difference was not statistically significant. CONCLUSIONS: Arthroscopic synovectomy achieved remission in approximately 47% of patients with chronic UA of the elbow. Although arthroscopic synovectomy did not prevent RA, it can be considered for rapid resolution of synovitis and diagnostic purposes.

A Case of Rice Body Synovitis of the Knee Joint.

BACKGROUND: Rice body synovitis (RBS) is a rare disease. It is prone to be developed due to rheumatoid disorder or tuberculosis infection. Additional infectious arthritis (non-tuberculous mycobacterial infection and fungal infection), juvenile arthritis, the onset of adult Still's disease, systemic lupus erythematosus (SLE), seronegative arthritis, and non-specific arthritis. The clinical imaging, histopathological features, and surgical treatment process of a patient were documented combined with literature. Furthermore, differentiation was performed with additional synovitis diseases so that the cognition of synovitis could be enhanced for clinical reference. CASE PRESENTATION: The present study reported a 50-year-old female patient who suffered from intermittent left knee pain with limited movement for 9 years. The conditions were aggravated after long-term standing or walking and remitted after taking a rest, accompanied by noose and jamming. The specialist range of motion (ROM) examinations of the left knee revealed: 30° - 0° - 110° and left McMurray sign (+). Plain MRI scanning revealed that in the left knee cavity and the popliteal fossa area, a large number of low signals on free rice-like bodies were visible inside and the lower femur and the upper tibia exhibited abnormally high signals of patchy lipography. Surgical exploration revealed numerous rice-like free bodies in the suprapatellar bursa, the intercondylar fossa, and the posterior articular capsule. The patient presently has resolution of symptoms after surgical treatment. CONCLUSIONS: The RBS of the knee joint is very rare in the clinic. As MRI examination can provide valuable information, clinicians should actively perform MRI examination. Once the disease is diagnosed by examination, surgery is the optimal treatment.

Correlation of arthroscopic findings with clinical-radiological signs and symptoms of temporomandibular joint dysfunction: retrospective study of 829 joints.

Temporomandibular joint (TMJ) arthroscopic findings are difficult to predict based on clinical criteria. Few studies have attempted to correlate signs, symptoms, and characteristics of patients with the final arthroscopic findings. The aim of this study was to assess the correlation between clinical-radiological signs and symptoms and arthroscopic findings in patients with TMJ dysfunction undergoing arthroscopy. A retrospective study was performed involving 487 patients (829 joints) with TMJ dysfunction who underwent TMJ arthroscopy between 2000 and 2019. The clinical-radiological variables recorded were pain, maximum mouth opening, joint noises, Wilkes classification, and disc displacement. The arthroscopic findings evaluated were synovitis, chondromalacia, adhesions, disc perforation, disc displacement, and roofing. Pain symptoms were significantly associated with the intensity of synovitis (P = 0.005) and disc displacement evaluated arthroscopically (P < 0.001). A statistically significant relationship was observed between Wilkes stage and the level of synovitis (P < 0.001) and chondromalacia (P < 0.001). Mouth opening was negatively correlated with adhesions (P < 0.001). Based on this study, pain symptomatology was associated with the intensity of synovitis and disc displacement evaluated arthroscopically, the Wilkes stage was a good predictor of the severity of synovitis and chondromalacia, and mouth opening was negatively correlated with adhesions.

[Radiosynoviorthesis of the thumb's carpometacarpal joint]. / Radiosynoviorthese des Daumensattelgelenks.

Radiosynoviorthesis (RSO) is an established therapeutic method for the local treatment of pain in aseptic joint inflammation (e.g. arthritis, activated osteoarthritis, synovitis). RSO can be used for the treatment of synovial membrane inflammation of the finger joints such as the thumb's carpometacarpal joint. The beta emitter Erbium-169 (Er-169) is injected into the joint space, which irradiates the inflamed synovialis, thereby leading to fibrosis and obliteration of the pain receptors of the synovial membrane. The chances of success in the treatment of the thumb's carpometacarpal joint by RSO are estimated to be 54-100% within 2-6 weeks after therapy.

Macroscopic aspects of glenohumeral synovitis are related to rotator cuff tear severity.

BACKGROUND: The microscopic pattern of inflammatory mediators associated with rotator cuff pathology is well documented; however, little is known regarding the contemporary presence of macroscopic inflammatory joint involvement. Our aim was to investigate shoulder synovitis in a large group of patients with different sized rotator cuff tears (RCTs) and to correlate the degree of macroscopic inflammatory changes of the glenohumeral joint with RCT severity. MATERIALS AND METHODS: A total of 296 consecutive patients (169 F, 127 M; mean age ± standard deviation: 60.75 ± 7.91) submitted to arthroscopic RCT repair were enrolled. RCT was classified intraoperatively. Glenohumeral synovitis was investigated according to 4 parameters (Davis classification 2017: capsule color, villous projections, capillaries, and axillary recess). A total score was calculated, and a 3-grade severity scale was introduced. Statistics was performed. RESULTS: Intraclass correlation coefficient (ICC) results show good to excellent reliability: capsule color (ICC: 0.95; 95% confidence interval [CI]: 0.89-0.99), villous projections (ICC: 0.90; 95% CI: 0.85-0.95), capillaries (ICC: 0.91; 95% CI: 0.86-0.95), and axillary recess (ICC: 0.55; 95% CI: 0.80-0.89).The synovitis total score was found to be 1.47 ± 1.16, 2.86 ± 1.84, and 3.99 ± 1.64 in patients with type I, II, and III RCTs, respectively. A significant difference was found between groups (P < .001). The prevalence of all the examined parameters was found to be significantly different between the different sized RCT groups (capsule color: P < .001; villous projections: P < .001; capillaries: P < .001; and axillary recess: P < .001). According to a 3-grade severity scale, the prevalence of absent, mild, and severe glenohumeral synovitis significantly differed between the RCT severity groups (P < .001). CONCLUSIONS: The present study demonstrated that synovitis is a constant finding of rotator cuff pathology; it is present in 75% of patients with RCTs and correlates with tear severity. Whether synovitis is the cause or effect of RCT is still questionable. Further studies are also needed to better understand its role as a pain generator, as documented in other diseases.

The use of the ligament augmentation and reconstruction system for posterior cruciate ligament reconstruction in isolated and multiligament knee injuries: A systematic review.

PURPOSE: To evaluate the efficacy and safety of the Ligament Augmentation and Reconstruction System (LARS) in posterior cruciate ligament (PCL) reconstruction in isolated PCL injuries and multiligament knee injuries, analysing clinical, radiographic, and patient reported outcome measures (PROMs). METHODS: A systematic review according to PRISMA guidelines was performed through Embase via Ovid, PubMed, and the Cochrane Library to identify studies reviewing LARS use for PCL reconstruction. The methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: From 225 results screened, 13 studies were included published between 2004 and 2020, analysing LARS use for PCL reconstruction. Mean follow-up was 21 months to 11.9 years, however only four studies had follow-up of over five years. Results in isolated PCL reconstruction utilising LARS demonstrated scores that were consistent with good function and minimal limitation in daily or sporting activities, in addition to a significant improvement in knee laxity and low complication rates. Symptomatic rupture and synovitis rates were both 1.7% in this group. LARS use in complex multiligament injuries demonstrated satisfactory PROMs, although there was concern regarding residual laxity on stress radiography. CONCLUSIONS: LARS demonstrates good outcomes in PCL injury reconstruction in the short to mid-term, particularly in isolated PCL injuries, achieving equivocal or improved results compared to autograft reconstruction using hamstring tendon in the three comparative studies included. LARS has a quicker recovery time and no donor-site morbidity, however long-term data is lacking. Utilising LARS for reconstruction of the PCL in multiligament injuries revealed more variable results.

Correlation between Severity of Synovitis and Clinical Features in Rotator Cuff Tears.

BACKGROUND: Rotator cuff tears can be asymptomatic in some cases; however, even when the tear size is small, clinical symptoms can be very severe. This suggests that symptoms of rotator cuff tears are related to factors other than the size. Although synovitis has been cited as one of the factors, there is no grading system for synovitis in rotator cuff tears. Moreover, there are few studies that evaluated the relationship between synovitis and clinical features in patients with rotator cuff tears. METHODS: Patients with medium-sized rotator cuff tears, who were scheduled for arthroscopic repair, were recruited for this study. The glenohumeral joint was divided into 4 quarters. Then, vascularity and hypertrophy of the joint were graded in each quarter using a modified scoring system. Clinical assessment was performed preoperatively and at 3 months and 6 months after surgery. Finally, correlation between the severity of synovitis and clinical features was analyzed. RESULTS: The intraobserver correlation coefficient was 0.815 to 0.918 and the interobserver correlation coefficient was 0.779 to 0.992 for the single measurement. Vascularity was significantly correlated with the range of motion, strength, and constant score within 6 months after surgery. Hypertrophy was correlated with the range of motion within 6 months after surgery. CONCLUSIONS: Synovitis in the shoulder with rotator cuff tears can be graded by using our modified scoring system. The severity of synovitis was closely related to the clinical features after surgery. Therefore, when treating patients with rotator cuff tears, treatment of synovitis should also be considered.

Synovitis and synovectomy in haemophilia.

Joint bleeds cause major morbidity in haemophilia patients. The synovial tissue is responsible for removal of blood remnants from the joint cavity. But blood components, especially iron, lead to a series of changes in the synovial tissue: inflammation, proliferation and neovascularization. These changes make the synovium vulnerable to subsequent bleeding and as such a vicious cycle of bleeding-synovitis-bleeding may develop leading to chronic synovitis. The initial step in the treatment is adequate clotting factor supplementation and immediate physiotherapeutic involvement. If these measures fail, synovectomy may be indicated. Non-surgical options are chemical and radioactive synovectomy. This is a relatively non-invasive procedure to do synovectomy, leading to a reduction in pain and joint bleeds. Radioactive synovectomy seems more effective than chemical synovectomy in larger joints. Surgical options are open and arthroscopic synovectomy. Open synovectomy has been found to decrease the incidence of breakthrough bleeds but at the cost of loss of joint motion. Use of arthroscopic synovectomy has been advocated to reduce bleeding episodes with less morbidity to extra-articular tissue and preservation of joint motion. Use of a continuous passive motion (CPM) machine and early mobilization can decrease the postoperative stiffness and promote early recovery. This review addresses the current understanding of synovitis and its treatment options with specific emphasis on chemical and radioactive synovectomy and surgical options.

90Y Radiosynovectomy in Persistent Synovitis Caused by Knee Replacement: Long-Term Outcome.

INTRODUCTION: After knee replacement, therapy resistant, persistent synovitis is a common issue, which causes effusion and pain, and leads to loosing. It has been hypothesized that radiosynovectomy (RSO) is useful in these patients. MATERIALS AND METHODS: A cohort of 55 patients with 57 knee replacements and persistent synovitis underwent RSO using 4.9 ± 0.24 mCi (182 ± 9 MBq) of Y-citrate. The number of RSOs ranged from 1 to 4. Bone scans before and 3 months after every RSO were performed. Long-term follow-up ranged from 0.8 to 7.6 years with a mean of 23.2 months. For qualitative analysis, an established 4 steps scoring was used. For quantification, the uptake was determined within the Tc-MDP scintigraphy blood pool phase before and after therapy. RESULTS: Long-term response was in 27% with excellent, 24% good, 30% weak, and 20% no response. The duration of response was 12.0 ± 12.0 months (maximum, 54 months). In patients with repeated treatment, the effect after the first therapy was lesser than in patients who received a single treatment in total. However, 3 months after the last RSO, patients with repeated treatment showed a similar effectiveness than single treated patients. At the end of long-term follow-up, patients with repeated RSOs had a higher effectiveness at similar duration response. In bone scan, 65% of patients showed a reduction of uptake. When comparing subjective and objective response, 78% of patients showed a concordance in both symptoms and scintigraphy. Pilot histological analysis revealed that the synovitis is triggered by small plastic particles. CONCLUSIONS: We concluded that RSO is an effective therapy in patients with knee replacement and persistent synovitis with high long-term response. Repeated treatment leads to a stronger long-time response.