Open synovectomy

Just like every joint, the knee joint is covered with a joint lining (synovial membrane) from the inside. This joint lining could be inflamed (synovitis), which may be caused by mechanical problems within the joint, cartilage detachment, loose bodies, the unevenness of the cartilage surface, and mechanical problems induced by joint wear.

Synovitis is painful, especially during joint movements, because the amount of fluid increases during movement, and it tightens the joint lining. Usually, the joint gets swollen due to the increased amount of joint fluid. Additionally, the joint may become warmer, and the general signs of inflammation may develop.

In one part of the cases, synovitis could be caused by foci i.e., a hidden inflammation that is present somewhere else in the body (e.g., dental, urological, gynecological, or laryngeal foci).
Synovitis may also develop as a consequence of rheumatological pathologies, mainly because of rheumatoid arthritis, lupus, and gout.

What treatment options are available?

Non surgical treatment

Treatment must be started with an investigation in all cases. The cause of synovitis must be revealed. Sometimes this takes a longer period of time: the search for inflammatory foci, laboratory tests, and a rheumatological investigation, if necessary. If the cause is revealed during these examinations, then the treatment must be continued at the affected area – dentistry, urology, gynecology, laryngology, rheumatology. The inflammatory symptoms resolve usually within a few weeks, or months, if the cause is eliminated. In a few cases, the symptoms and the inflammation persist. These could be managed further, and alleviated with anti-inflammatory drugs, and physical therapy treatments. The same treatment methods are considered if no inflammatory foci, rheumatological, or other causes are confirmed. Surgery is performed if joint pain, swelling still persist despite of the above treatments.

Surgical treatment

The surgical treatment of synovitis is a minimal invasive procedure in mild cases, and it is performed with an arthroscopic method, through small incisions. The advantage of an arthroscopic intervention is that it is less demanding than an open surgery, so the pain after the intervention is less intense, and the duration of recovery is shorter too.

The aim of the arthroscopic intervention is to remove the inflamed parts of the joint lining from as large an area as possible. This is performed with a special shaver, which was designed for this purpose.

Only two to three small cuts will be visible on the knee after the arthroscopic surgery. During surgery, the joint lining which has proper blood flow will be injured on a larger area, which could be the origin of smaller bleedings after the surgery, so in the majority of the cases, a drain is left in the knee joint to manage this blood; this is removed on the first day after surgery. It is recommended to regularly perform the practiced physiotherapy exercises at home, and unload the operated limb, if necessary.

Usually, a resting period of one month is recommended after the intervention. In non problematic cases, the patient is discharged home on the first day after surgery. It may become necessary to apply thrombosis prophylaxis for a defined period of time after surgery; this could be administered by the patient too. It could happen that smaller cartilage injuries, or uneven cartilage surfaces are found during the surgery. These will also be treated, if necessary.

What happens during the surgery?

During the surgery, two to three incisions of 1 cm are made on both sides of the knee, so that the arthroscopic optics and devices could be inserted into the knee joint. Special manual devices and a motor shaver are used during the intervention to remove the tissue fragments from the inflamed areas of the joint lining. The area is rinsed, so that the inflammatory fluid and the debris are removed. If macroscopic image of the inflamed tissue makes it necessary, then it will be sent for a histopathological analysis.

In case of extensive inflammation, the joint is explored, so that the inflamed joint lining could be safely removed from all parts of the knee joint. This is mostly necessary to achieve that the recurrence of the disease would occur with a smaller probability. In cases like this, the recovery is more prolonged, especially in the first few days after the surgery, and it requires more patience from the patient. Thorough surgical hemostasis is performed as much as possible during surgery, but usually it is necessary to insert a suction drain into the joint, which drains the blood, and plasma that accumulates after surgery.

Elastic bandage is applied on the patient’s knee after the surgery.

What happens if the justified surgical treatment is not performed?

The inflammatory process remains present causing additional pain, or potential difficulty in movements. In case of a chronic, long-term inflammation, the cartilage surface may get damaged too, which may lead to joint wear (arthrosis) in the long term. This process is irreversible and may cause a very painful joint with limited range of motion that could only be treatment with a greater surgical intervention.

Certain histological variants of chronic, long-term synovial inflammations are sometimes prone to malignant degeneration.