SYNOVECTOMY [lat. (membrana) of synovialis a synovial membrane + Greek ektome excision, removal] — the full or partial excision of a synovial membrane of the joint capsule which is carried out usually on large joints — knee, coxofemoral, elbow, etc.
For the first time total excision synovial membrane (see) R. Folkmann (1877) made at tubercular you drive. The subsequent attempts of carrying out S. for treatment of tubercular damage of joints (is preferential at children) made by F. Kenig, K. G are re, etc., often led to emergence in the postoperative period of rigidity of a joint, and sometimes and to an anchylosis, several best results were noted at hron. nonspecific synovites. Due to adverse functional outcomes as method of treatment of a synovitis of any etiology soon refused S. Emergence of antibiotics and their effective use at various inflammatory diseases of joints were the cause for review of a role of S. in complex treatment of synovites. For this period in the certain countries considerable experience of S., however lack of the publications generalizing the long-term results of this operation is accumulated, does not allow to give a final assessment to its efficiency in the anatomic and functional relation.
The page can be the independent operation undertaken at primary disease of a synovial membrane, i.e. true synovitis (see), and at secondary defeat of a synovial membrane can be a part of other operation (e.g., necretomies at tuberculosis of the ends of bones, the next to a joint). According to most of surgeons, the age of patients has no essential value during the definition of indications to S. though there are also opponents of carrying out this operation at children's age. Operation C. is made under an endotracheal anesthesia (see. Inhalation anesthesia ) .
Technology of operation it is various depending on localization of process. As an example it the practiced S. can serve a thicket of others at hron. synovites knee joint (see) tubercular or rhematoid origin. At the same time the plait on an extremity is usually not imposed. The Parapatellyarny section is begun 4 — 5 cm above a patella, conducted on the outer edge of a sinew the four-head of a muscle of a hip, bending around polukruzhno a patella, and continue further parallel to a ligament of a patella to tuberosity of a tibial bone. According to a skin section cut a fascia and a fibrous membrane of the joint capsule. Delete a synovial membrane since its upper torsion, to-ry later opening under control of an eye it is entirely excised. In the absence of intra joint commissures the synovial membrane of anteriointernal and anteroexternal departments of a joint quite easily is removed. In the presence of cicatricial unions in a nadnadkolennikovy bag big care in their separation and allocation of a ligament of patella is required. For approach to perednetsentralny department of a joint delete alate folds of a synovial membrane and the fatty lump concluded between them in the beginning. Then the patella is dislocated a joint surface in a wound, the extremity is as much as possible bent in a knee joint, delete a synovial membrane perednetsentralny and side departments of a joint and process crucial ligaments. The last moment of operation presents the greatest difficulties since quite often sheaves are shrouded cicatricial granulyatsionnoy in fabric, from their cut it is necessary to allocate carefully. Also process tibial and fibular collateral sheaves. Meniscuses (see. Meniscuses joint ) or exempt from the fabric which expanded around them cicatricial granulyatsionnoy, or (depending on their state) entirely delete. Synovial obolochku'zadny departments of a joint scrape out an acute spoon. Cover cartilages exempt from the granulyatsionny fabric crawling over them, their uzurirovanny sites delete. Enter antibiotics into a wound and layer-by-layer sew up it with leaving of two drainages for the prevention of possible accumulations of blood and carrying out instillations of solutions of antibiotics in the cavity formed on site the bag excised on a bottom d-kolennikovoy and in actually cavity of a joint. The extremity is stacked on the functional tire and fixed in the provision of bending in a knee joint at an angle 70 — 80 °. Drainages delete in the 48th hour.
Receiving good functional outcomes at S. considerably depends on the correct maintaining patients in the postoperative period. The extremely important role in it belongs to LFK, to-ruyu begin in the first days after operation when the extremity is in the functional tire. In the first 10 —-12 days make passive, and further (on the Balkan frame) the passive and active movements. In 3 — 4 weeks appoint resorptional and soothing physiotherapeutic procedures, massage of muscles of the lower extremity, especially muscles of front group of a hip.
It is allowed to lift up the patient (without any fixing of a joint, but on crutches) not earlier than 1 — 1,5 month later after operation. Massage (see) and LFK (see. Physiotherapy exercises ) it is necessary to continue not less than a year after an extract of the patient from to lay down. institutions. In the subsequent at limited mobility in a joint and lack of the general contraindications it is recommended mud cure (see).
In the postoperative period the treatment of a basic disease which was carried out before operation continues (see. Tuberculosis extra pulmonary, tuberculosis of bones and joints ; Pseudorheumatism ).
Early complications of S. are connected directly with a local operational injury (an intra joint exudate, a hemarthrosis, etc.). In different terms after operation a recurrence of basic process with increase of commissural changes and rigidities of a joint is possible that demands repeated operative measures. Excision of a synovial membrane sharply breaks an angioarchitecture of a joint, reducing degree of its vascularization that quite often leads to development of degenerative and dystrophic processes with the subsequent formation of deforming arthroses (see).
According to V. A. Zvantseva, G. Balchev, etc., subtotal S. gives more than at a half of adult patients good functional outcomes.
Bibliography: Zvantseva V. A. The long-term results of a subtotal synovectomy of a knee joint at a tubercular synovitis at adults, Probl. tube., No. 8, page 46, 1975; Kornev P. G. Surgery of bone and joint tuberculosis, p. 2, page 90, L., 1971; Pavlov V. P., etc. The long-term results of an early synovectomy of a knee joint at a pseudorheumatism, Vopr. revm., No. 4, page 18, 1979; M and l I in with to and St. The synovectomy at a sinovialnat a form on a tuberkulozniya drives, Surgery (Sofia), t. 15, No. 2-3, page 158, 1962; N e lima n n H. W. u. T a n t s with h e w P. Ergebnisse der Synovektomie am Kniege-lenk bei Rheumatoidarthritis, Beitr. Or-thop. Traum., Bd 27, S. 338, 1980.
D. K. Khokhlov.