Help! First time synovectomy

[LucyC]

Hi I'm due to have an arthroscopic synovectomy on my knee within the next few weeks and I'd appreciate any feedback from anyone who's had this procedure. What sort of things should I expect? I have been told it will be very painful and bruised for a few weeks so what would be the likely recovery time?

I have seronegative monoarthropathy in my left knee (inflammatory arthritis) which was supposedly caused by a virus never leaving my system as a child. This built up loads of inflammation in my body which then hit a weak spot - my knee, after it twisted badly riding, after my horse jumped awkwardly over a large fence. It then swelled very minimally every now and then (this was 4 years ago), it was ignored as it wasn't a problem or noticeable and I didn't fancy an aspiration!!

However 2 years ago a swelling the size of an orange appeared above my knee cap over night resulting in immense pain and not being able to walk. I was admitted to hospital (at this point, they thought the riding incident had broken a bit of cartilage off which was causing the occasional swelling) where the orthopaedic consultant was amazed at the size of it. Four days, a painful aspiration, blood and aspirated fluid tests, an MRI scan and finally an arthroscopy left the doctors bewildered. A few weeks later my now rheumatology consultant diagnosed the inflammatory arthritis and I was put on sulphasalosine/salazopyrine to control it. This took a few months to work, in the meantime the HUGE swellings continued but each time I had it aspirated with no problems.

June 2002 found the knee swelling much more painful and larger than ever (grapefruit, small football size) and more concentrated above the knee cap, despite the continuous medication. Aspirations produced nothing at all on 5 or 6 occasions even when the needle was put directly into the swelling (not an experience I'd like to repeat). steroid injections, increased sulphasalosine and prednisalone also have done nothing. So now it is decided that I should have a synovectomy along with another wash out as it is thought the synovium has become so thick that no medication can penetrate it to deal with the swelling. Why it is so thick, they don't know...any ideas?

Since June it has been swelling continously every 6 days and then will stay swollen for another 6 days before returning to its "normal"state and starting the cycle again. At each swelling I can hardly walk, have immense shooting pains and have to take loads of high dose pain killers. I have had to put my life on hold, I can no longer ride, I find it difficult to stay standing or walk for long periods and its really getting me down. I've had to wait so long for the operation due to the NHS system in England...but thats another story..its just so frustrating. This site has been wonderful to find as I know I'm not the only one who is having problems with their knees.

I just hope that this operation works and I am able to continue my life.

If anyone has had a similar problem or knows of ways to help deal with this I would love to hear from you.

[Rosa]

Hi Lucy, I have experienced some similar(ish) symptoms to you. About 3.5 years ago both my knees swelled after a long hike (I was also a keen runner at the time). After rest, the left knee went down, but the right has remained constantly swollen ever since - with periods of increased swelling. GP prescribed anti-inflams with no effect. Eventually (yes! on the NHS! a year later) saw an orthapedic surgeon - had x-rays (showed minimal damage to patellar cartilage) and MRI - only showed inflammation. Another long wait (year and half) had 1st arthroscopy and patellar shaved. After this, symptoms of swelling worsened, and full ROM was lost (about 5 deg extension deformity, and couldnt flex the leg fully due to pressure of fluid). Another 6 months and saw rheumy who diagnosed seronegative monoarthopathy (RA tests were negative). Anti-inflams didnt work, neither did steriod infection. After 3 years and at the end of my tether (given up all exercise, horse-riding, running, hiking) decided to fork out and go private (twice! the first guy was too dismissive). Pain by the way was shooting pain around knee cap and just above - swelling everywhere, made worse particularly by just standing around!
Anway, second private appt was more positive and I had another arthoscopy in Sept 2002 where the surgeon found 'exuberant' synovitis, adhesions everywhere, some more damage to patellar cartilage, and an almost complete supra-patellar septum (plica) with adhesions. There was tissue growing in all sorts of places, and blocking extension. All this sort of stuff cant always be seen on MRI. The patellar was also found to be laterally tracking. I had a LR, shaving, lysis of adhesions and partial synovectomy. Biopsies showed characteristics of RA (but I'm sero-neg). I am still recovering, pain is minimal (virtually negligable for normal activity) but the swelling is still very evident and I lack full ROM, still cant kneel or squat and my quad is still very weak - I think the strengthening exercises are inhibited by the swelling.
Now back with the rheumy who took more blood tests, and I am awating the results. I think I may also end up having to have a complete synovectomy.
Have you had an arthroscopy already - if not I think they should investigate other things which may be causing the problem, such as plica or maltracking before taking the synovium out completely which seems drastic in the first instance. I think rheumatologists and orthapedic surgeons need to work together in cases such as this. If I were you, I would be tempted to have an initial private appt with one of the specialists indicated on the Knee Guru pages. OK its not always cheap (but may not be as expensive as you think), - you can always have any surgery on the NHS, and you can get any X-rays or MRI scans you have had done sent the the private doc.
Just out of interest, the virus which you were told caused your swelling - any ideas what it was? I'm looking for any info on what my swelling could be (it still shows the same pattern as pre-op).
Good luck with whatever treatment you decide on.
Ros

[LucyC]

Hi Ros
Thanks for your input, its good to know there's at least one other person out there with similar knees!
I did have an arthroscopy two years ago when it first swelled really big but that found nothing (along with an x-ray and an mri scan). Since my problems in June 2002 I have had another x-ray but that again showed nothing more than profuse swelling, no cartilage damage or any other abnormalities. All signs point to the synovium.

I am finally on a cancellation list for the NHS after much pestering (and it pays to do this), although I have resorted at times to see both the surgeon and rheumatologist privately. Fingers crossed I will have the operation any day.

I got a call yesterday saying I could have the operation today but as the knee is in its swollen stage, the surgeon has said to wait. Hopefully the next time they call my knee won't be as big.

Has anyone mentioned to you that persistent swelling could damage the cartilage?? whenever I ask they
say that as long as it's sorted soon it won't be a problem but from what I keep reading on the internet, damage could set in.

I don't think it was an exact virus that caused the seronegative monoarthropathy, more that a virus just never left the system even though all physiological symtoms had gone. This then built up all the inflammation within my body which then targeted the knee.

Are you on any medication for your seronegative monoarthropathy?As I said I am on Sulphasalosine to reduce the inflammation and so have to have regular blood tests which always show characteristics of RA but have sero-neg value for RA. I also had a course of oral steroids (Prednisalone) after the steroid injection failed, have you tried this for your swelling? In my case it only worked for about a week but in most cases this is all thats needed to settle things down.

I too get those shooting pains, I have been told it is where the patellar is floating on all the swelling and just gets knocked against other structures due to the immense amount of fluid.

Good luck with your blood tests and I hope they are able to sort you out soon, swollen knees are such a pain.

Lucy

[Rosa]

Hi Lucy,
Thanks for the reply.
Is your op going to be done arthroscopically?
Have you managed to talk to anyone who has had a synovectomy? I was wondering what the recovery was like, and how close to normal function can be gained afterwards - and whether a sporty life can be resumed!
I have tried a few drugs to bring down the swelling including indomethicin, voltarol and Naprosyn. None of these worked for me. The rheumatologist was reluctant to try anything else becasue of possible side effects outweighing any benefits. No mention has been made of oral steriods, so I'll bring that one up when I see him again next month.
I too am worried about the effects of swelling on the cartilage. In fact the first arthroscopy I had apparently showed a small amount of damage to the patellar cartilage which was shaved. Just over a year later I had a second arthroscopy where a large area of damage was removed. I cant see how it could increase so much over one year if it was just a mechanical problem...
(I have also been told that steriod injections can have a detrimental effect on cartilage...)
Good luck with getting a date for the op soon - please keep me posted. Hope it all goes well,
Ros

[LucyC]

Hi Ros
Yeah the synovectomy will be done arthroscopically at the same time as they have a wash out and discover any other surprises in there!

As yet I haven't found anyone who's had a synovectomy apart from your partial synovectomy as I too would to know the likely recovery period as I am desperate to get back in the saddle. I've only been able to manage a few horse rides in the last few months but as I only have a small period of time when the knee isn't swollen each week, its usually at these times when I'm too busy or other things are happening. I have managed a couple of rides when the knee is swollen on a 13.2hh pony!! as mounting and dismounting is a lot easier but have had to do work without stirrups as I can't bear any weight through my left heel without my knee hurting.

I will be able to know the full amount of damage that the constant swelling has or hasn't caused after the arthroscopy, it does seem a bit worrying that you had a lot of damage removed just a year later from a seemingly mechanical problem. Hopefully my results will be able to shed a bit more light on this, as I have had near enough constant severe swelling for over 6 months, with intermittent periods of swelling in the year prior to that.

I was also told that after that being put on the sulphaslosine for about a year or so would clear things up completely and the sereonegative monoarthropathy would disappear forever, however a year later and I now have this new problem.

What have you been told about sereonegative monoarthropathy? Is it a condition for life? Is it likely to turn into full blown RA? articles seem so hazy on this subject.
Anyway I'll keep you posted, good luck with your blood tests.
Lucy

[Jennifer]

Rosa and Lucy~~~~

I have had a partial synovectomy. It was incidental to other procedures that were done for a maltracking patella. It would be hard for me to tell what the recovery period would be as I also had chondroplasty, some plica removal, thermal shrinkage and the partial synovectomy. For the whole mess I was partial weight bearing for 6 weeks and then back to rehab for another 6 weeks.

Good luck.

Jennifer

[Rosa]

Hi Lucy & Jennifer,
I havent been able to find much about seronegative arth either. Any articles tend to mention it in passing, or as an afterthought! but dont go into any detail. My rheumatologist is also suitably vague on the subject. I've been told it can just disappear with time, but I havent heard that it can develop into RA - apparently RA, ankylosing spondylitis, and other types of named conditions (inlcuding arthritis related to IBS or Crohns disease) have been ruled out for me. Its just that the synovium is showing characteristics (& pathology) of RA. I think if the swelling continues, he may suggest a complete synovectomy.
I had the partial synovectomy (plus LR, shaving etc) last Sept. I was weight bearing the next day, and didnt need crutches. I started PT about a week later. I only needed pain meds for a couple of days after the op. If you havent got any other damage in there, perhaps the recovery from a total synovectomy wont be too bad? Although I had damage to the patellar, all other cartilage was intact, so the fluid didnt appear to have had an effect on other areas.
Although I had the op over 4 months ago, there is still constant swelling, which is showing the same patterns of increasing at certain times. My quads are really weak, despite all the PT I am doing (plus ex bike). The problem is that I need to build up the muscles, but any exercise/PT increases the swelling which inhibits muscle build up - catch 22 situation! Time to try some different anti-inflams maybe..
Like you, I want to get this sorted out to prevent any further damage & get back to my normal way of life!
Good luck
Ros

[Meags]

Hi Lucy

Reading your post was really interesting - I had a arthroscopic synovectomy just before Xmas (eight weeks ago), and it was a last ditch resort for me, but your story sounds quite similar to me!

I have been ill since March 2004, and I only was diagnosed with Psoriatic Arthritis (I gather similar to yours) in June 2005. I also suffer from slight psoriasis on the skin - which apparently gives you a 30% of chance of getting arthritis. Its apparently a condition for life - but if it remains controlled, it should be managable to live with (I am 31). Problem is it is unpredictable, but keeping up exercise and maintaining healthy levels sure helps to combat it.

I had multiple blood tests from February 2004, which showed a high level of white cells, meaning I had an infection, but no one could figure out exactly 'what' type of infection. They then started to point the finger at Lupus as my ANA levels in my blood returned positive, so I started to see a Rheumatologist here in Sydney who's a top expert in Lupus, but he was very sceptical that it was Lupus and continued the monthly blood tests and watching my ongoing health. I had symptoms of extreme fatigue, aching muscles, skin rashes to a small degree (psoriases), but nothing eventuated. I had every X-ray I could think of, blood tests, MRI's, nuclear testing and nothing showed! It is sooooooo frustrating.

I then twisted my left knee in May 2005. It firstly blew up for three to four days, then subsided again. I then twisted it again (yes I am accident prone!) and it stayed swollen, and like you, I could barely walk. I couldn't bend it at all and it made my life quite miserable. I was on holidays at the time, so cut that short to go back to Sydney and was recommended to my Rheumatologist. He was busy so I was seen by another Rheumatologist who immediately aspirated the knee (which I HATE!), but she was certain it was arthritis from my symptoms. This process went on for another three to four months. My physio and aerobics instructor (I took up aqua aerobics just to get some movement - and don't regret it for a second!) was sure that there was mechanical damage as well as inflammation, but my specialist refused to listen. She wanted me to go on Methadrixane only and no word of scans or even surgery. Therefore I had another four aspirations and cortisone shots. I kept at her about getting scans done, but she refused to do it and tried to bully me onto taking the Methadrixane. She basically said 'she' was the expert, and my physio etc knew nothing. I eventually got so frustrated with her that I took a friends advice and saw another Rheumatologist. He immediately ordered X-rays and MRI scans of the knee and discovered that indeed I did have arthritis, but the synovial lining was that inflamed, and it was showing slight damage around the knee. He was quite sure I would be up for surgery but first put me onto salazopyrine and decided to watch the knee for a month or so. He also diagnosed reactive arthritis in my left foot, which has since affected four of the five toes. I didn't improve, so I was referred to an Orthopaedic Surgeon in late November. He basically took one look at the knee and the MRIs/X Rays and booked me in for surgery on the 20th December.

My knee reacted really well to surgery - I stayed overnight in hospital as they put a drain into the knee, but my surgeon was really impressed with its recovery. I could also tell from post op that the feeling in the knee was different - it had lost the grinding restrictive pain of the arthritis. I spent a week lying around on the couch (perfect for Xmas) and constantly kept ice packs on it morning and night - a definite must!!! I started going to an orthopaedic physio one week after surgery and started hydrotherapy once the wounds had healed. The surgeon showed me photos later and it was amazing how inflamed the synovial lining was - it was like a volcanic eruption! He also scraped back damage that the arthritis had done (basically eating the lining near the cartilage) and he also washed the knee out. I was on two crutches for approx 4 weeks. Back at work after seven weeks, but still have one crutch to get around on sometimes when my knee is just a bit too sore (usually after I have kept it bent for more than 1/2 hr sitting etc).

The strength of my knee has improved and I can now bend the knee to 115 degrees (started at 65 one week after op), but I have got massive problems as to straightening the knee. It just won't do it. I was at the physio this morning and he is certain that I have got muscle damage and joint damage - mainly from limping since May last year, so when I see my surgeon next week for my follow-up, he is recommending that I may have to go under again to have the knee straightened. Not sure what is involved in this - but it sounds quite scary! This probably wouldn't have happened had my first specialist done the scans of the knee and I not limped around for nearly seven months, but its a lesson learned. I am still on salazopyrine and take nurofen plus (pain killers), but it is definitely so much better than not having the surgery.

I am so glad that I changed specialists and seeked further advice. My weakness in the knee not straightening is a setback, but I am sure its only a temporary one. I see my physio once a week and do hydro in the local pool three times a week - water work is a def must - it is sooooo good for the knee.

Wishing you all the best!!!

[oceanluver]

Lucy,
Hey in case you have not already found it on the post op page there are several posts from people with synovectomy, you can find some good info in there, I did. I had synovial plica removed June 22nd, left knee, and the day I found this site was a blessing because I got more helpful info here than from OS or PTist involved in my surgery and recovery. Hope that helps you. Take care. Be blessed daily. Oceanluver
ps. also found some good info from a person on here at the Steadman-Hawking site

http://www.steadman-hawkins.com/aboutUs.asp

[Lvc595]

HI,

I know it's been a few years since your synovectomy.
Please let me know how long it took you before you were able to be weight bearing and w/out crutches.

It sounds like you went ot see Dr. Dye in SF.. I am going to have a Synovectomy in April.

Thanks for your reply,
Lori

[MoLu]

Hi Lori-

I've had several synovectomies. Both arthroscopy and open procedures. After arthroscopy it was an easy recovery in terms of weight bearing. I'd say 2-4 weeks to get off the crutches but PT lasts a couple of months. Now an open procedure was much harder. One dr had me with a leg immobolizer and the other one didn't. Same operation but different opinions on rehab. I could weight bear immediately though even with the immobolizer. I'd say 6-8 weeks on the open procedure. Do you know if you will be having arthrosopy? It was a breeze compared to a TKR that I had 5 months ago. It really isn't too bad of a procedure so don't get to scared. Remember they are removing an already inflammed membrane and they are not cutting bone or tendons which is much worse to heal from. Do plan on lots of rehab though. Write if you have any more questions and I'll try to help. Good luck to you.
Martha

[DMB14]

Hello! I had a synovectomy this past Friday, so am still in the early stages. I will post later with how it's going, but am wondering how quickly if at all people returned to running short distances? Also I hve been using a cryo cuff since the surgery and it is amazing- I highly recommend to reduce pain and swelling post surgery!