Sir,

This procedure may be considered in early rheumatoid arthritis with DMARD failure.failure. Now a days it is nearly obsolete in this part with introduction of newer Biologics.Arthroscopic synovectomy as a temporary reliever of pain is no longer a viable option.

Yes, I agree the newer biologics seem to be very effective today, but not in 100% of the cases, and on the other hand they are very expensive. I still believe that early synovectomy could be applied in refractory to medications cases in an attempt to avoid rapid destruction of the joints. In stubborn monoarthritis or oligoarthritis it could be not only pain reliever but also curative by elimination of the terrain of rheumatoid process.

I am agree with your opinion, but radiation synoviectomy is also an alternative treatment in providing long term relief of pain and deformity of inflamed joints.

Hi there! We should consider that clinically and biologically there are patients that will not respond fully to the best treatment. Therefore, treatments like synovectomy could not be forgotten. However, as the new treatments and clinical schedules has change and continuously updated, the role and a clear indication of synovectomy need to be assessed again.

Dr. Boecht, I agree with you entirely. In the 60's and 70's there were a lot of reports that pointed out good long-term results following synovectomy. It is strange that the possibilities of this kind of treatment for RA have been forgotten ?

The possiblity of non-invasive anti-TNF therapies are pushing in European Union and USA this method in obscurity for RA, however it should be still great for local inflamations such as pigmented villonodular synovitis (PVNS). Saying that, in older patients with weak immune system and in a resource poor health systems, such as the Bulgarian, synovectomy seems like a good choice.

Dear Dr.Stoyanov, 

We are discussing the application of early synovectomy (arthroscopic, open or radiational) as an option in cases with refractory to DMARD's rheumatoid arthritis. Not as first line treatment. To my best knowledge also THF-blockers (also in combination with other drugs) do not control the rheumatoid process in more than 70 % of the cases and they also are not applied as first line therapy.

So I believe early synovectomy should not be forgotten, independently on the health care resources available.

Meanwhile, the classic textbook on surgical treatment of RA is written by the Swiss surgeon Norbert Gschwend "Die operative Behandlung der chronischen Polyarthritis". In my opinion this book has not lost its importance also today. You may have a look at it. 

Dear Panayot

 A combined therapy with biologics and arthroscopic synovectomy leads to improvement of composite measures such as DAS28. Arthroscopic synovectomy can be a powerful tool for the tight control in RA treatments. 

Dear Nelson, 

I share your opinion entirely.

Dear Panayot

Thank you

Best regards

As I understand it there has never been good documentation of the long term benefit of synovectomy in RA. It is certainly useful for PVNS. My own experience over the years was that synovectomy in the long term was a waste of time and quite often produced significant unwanted effects like loss of range of motion. I do not think it should be used in RA without better validation and I doubt we will ever want to get that. I do not think there is any theoretical reason to use it because the disease is systemic and synovial tissue regenerates following removal. The same applies to radiation synovectomy which I think should not be used since it produces chromosome breakages. Almost all patients can now be controlled on biological therapy if DMARDs are inadequate - with four different classes of biologic now available. Prosthetic surgery remains a jewel in the crown of arthritis management but I think synovectomy should be consigned to history.

No doubt, the contemporary medications for rheumatoid polyarthritis are more effective today. Synovectomy has a more limited application today. Nevertheless, I still believe there are stubborn cases of monoarthitis and oligoarthritis that may be subjected to synovectomy after failure of drugs to control the disease. The fact that many patients are indicated for prosthetic surgery shows that their  RA has not been well controlled by medications.

dear dr Tanchev

as a small member, I agree with you synovectomy have limited role in RA such as prolonged and severe disease that resistant to medical drugs such as DMARDs, Corticosteroids and also the patient symptopms are not control, we could use this option.

but do you have special time range that you decide to do synovectomy for your patients?

sincerely yours

Dr. Seyed, the classic rule  is to treat a RA patient conservatively 6 months and if he/she remains refractory to drugs, then synovectomy should be performed in an attempt to prevent damage to the articular cartilage.

Regards  

I agree with Dr. Edwards. In longstanding RA cases, when appropriate DMARD therapy is not started early enough, then there may be such a thing as persistent monoarticular knee synovitis, for example, and in such cases, a synovectomy can be useful. However, generally speaking, the treatment of RA in this day and age is by systemic oral or biologic therapy,    

In patients with persistent synovitis without joint space narrowing, synoviectomy may control symptoms in a specific joint. Surgical synoviectomy can be performed either by open or by arthroscopic techniques. Radiation synoviectomy has been used in multiple joints to control synovial proliferation. 

Rcent technological progress have made it possible to indentify cellular subtyped, cell surface markers and cell products important in imunopathogenesis of Rh A. 

I used infrequently for patients with monoarticular disease and many treatment failures. I agree with Dr Edwards statements.

This is a link to my doctor thesis (1980). It is in German. I must say the results of the early synovectomy at that time were not so bad. On the contrary, with a FU more than 4 years the results were very good and the complications were infrequent. This  was at a time when the medicamentous treatment was not so developed and was not so effective.  Obviously, the medications used today have modified the treatment approach. 

s.google.com/share?url=http%3A%2F%2Fwww.researchgate.net%2Fpublication%2F258837606_Surgical_synovectomy_of_the_knee_joint_in_rheumatoid_arthritis_%28Thesis_Abstract%29

Over the years, I have a seen a fair number of patients first evaluated by an orthopedic surgeon, who based upon a diagnosis of recurrent "multifocal ganglion cysts" underwent repeated surgical synovial resections from multiple hand joints. In the end, these surgeries did not make any difference. The diagnosis in these patients from the beginning was of course RA. The treatment of RA is not multiple "ganglion cyst" removal, but rather early and appropiate DMARD therapy, either oral or biologic,

My approach is different for surgery in knee. I am trying to develop herbal formulations for synovial fluid as well as cartilage. My herbal formulation for management of synovial fluid has good success. Many patients are happy with the results. Cartilage management formulation is not yet very well accepted. One doctor, whose own cartilage as damaged, has commented that his pain is reduced considerably. But still I feel it needs modifications.

In fact I want to try in patients, where knee replacement is recommended, but not possible various reasons like age, uncontrolled diabetic, etc.

I welcome comments on my experiments. 

Generally I agree with Dr Edwards - there is no long term studies showing efficacy. However, there are cases where there is a single swollen joint that does not seem to respond to treatment, and recurs after an intra-articular steroid injection. If all the other joints are OK, then I would discuss the possibility of a surgical synovectomy with the patient. One major reason for its use is that many patients are reluctant to keep increasing DMARDs for a single swollen joint.

Pain relief can also be achieved by radiosynovectomy in case of single inflamed joint that does not respond to systemic treatment and intraarticullar steroid injection.

Mr. Ulhas ,

how we can get your formulation for trial.