Synovectomy (knee / rheumatoid wrist)

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• recurrence of synovitis, as the disease itself is not cured
• some loss of joint movement
• bleeding into the joint (haemarthrosis) and wound swelling
• infection of the joint
• damage to articular cartilage or menisci by instruments
• nerve or vessel injury, especially at the back of the knee
• wrist: extensor tendon rupture, instability, need for splint for some weeks
• conversion from arthroscopic to open synovectomy

Pre-operative details for this operation

1. Joint and sidemark the joint
2. DiagnosisRheumatoid arthritisChronic nonspecific synovitisHaemophilic synovitisOther (state)how it was established: serology, fluid for crystals and cytology, MRI
3. Duration of medical treatment and responsedrugs and months; synovectomy is for synovitis not controlled after about 6 months
4. X-ray grade of joint damagejoint space, erosions; late synovectomy in advanced arthritis fails often
5. Antirheumatic drugsDMARDs such as methotrexate usually continued; biologic agents stopped with surgery timed at the end of the dosing cycle; record date of last dose
6. Steroid coverif on long-term steroids: stress dose of hydrocortisone given (drug, dose, time)
7. Cervical spine flexion-extension X-ray (rheumatoid)atlantoaxial instability matters for intubation
8. Haemophilia (if applicable)factor level, factor given, haematologist's plan

Anaesthesia and position

1. AnaesthesiaGeneralSpinalBrachial plexus block (wrist)Local with sedation
2. Tourniquetsite, pressure, inflation and deflation times; knee: keep under 90 minutes for routine cases
3. PositionSupine, lateral post / leg holder (knee)Supine, arm on hand table (wrist)
4. Arthroscopy set-up (knee)30 and 70 degree scopes, shaver with full-radius resector, pump or gravity inflow, fluid used

Operative findings

1. Joint fluidvolume, colour, rice bodies
2. Synoviumtype (villous, hypertrophic, pigmented, fibrinous), extent by compartment
3. Articular cartilagegrade and site of damage in each compartment
4. Menisci and cruciates (knee)intact / torn / eroded
5. Wrist: tendons, carpal and DRUJtendon fraying or rupture, periarticular erosions, bone spurs on ulna, TFCC
6. Photographs or video recordedYesNo

Procedure (steps)

1. Examination under anaesthesiarange of motion, effusion
2. Skin preparation, draping and tourniquetantiseptic, pressure, time
3. Knee portalsAnterolateralAnteromedialSuperolateral / superomedialPosteromedialPosterolateralfour or five portals, including the posterior ones, are usual for a full synovectomy
4. Systematic diagnostic arthroscopysuprapatellar pouch, gutters, compartments, notch, posterior pouches
5. Synovium sampled for HPE and culturebefore shaving
6. Synovectomy by compartmentshaver to the plane between synovium and capsule; posterior compartments with 70 degree scope through the notch and resector through posterior portal; synovium under menisci and around cruciates; menisci preserved
7. Open knee synovectomy (if done instead)approach and extent; only a small part of posterior synovium can be removed through an anterior approach
8. Wrist: exposurestraight dorsal longitudinal incision; retinaculum opened (fourth compartment in Z fashion); EPL identified and protected; dorsal tenosynovectomy
9. Wrist: posterior interosseous nerveResected (partial denervation)Preserved
10. Wrist: capsule and synovectomytransverse or U-shaped distally based capsular flap; traction; synovium removed from radiocarpal and intercarpal joints with small rongeur; erosions curetted
11. Wrist: DRUJlongitudinal capsular incision; synovectomy with forearm rotation; ulnar spurs removed; distal ulna excision if done (length)
12. Tendon work (wrist)frayed tendons repaired or sutured to neighbour; ECU relocated; retinaculum passed deep to tendons
13. Final check and haemostasisremaining synovium, cartilage, tourniquet release time

Closure, drains and dressing

1. DrainIntra-articular suction drainSubcutaneous drain (wrist)None
2. Portals or capsuleknee portals: suture; wrist capsule: interrupted nonabsorbable, forearm in supination for DRUJ
3. Intra-articular local anaestheticdrug, strength, volume
4. Skinsuture and technique
5. Dressing / splintModified Jones compression dressing (knee)Bulky dressing with sugar-tong splint, wrist neutral, forearm supinated (wrist)
6. Distal circulation and sensation at end

Specimens and implants

1. Synovium for HPESent in formalinNot sent (reason)
2. Joint fluid or tissue for culture, crystals, cytologytests asked
3. ImplantsNoneSuture anchor or other (make, size, lot)

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Neurovascular observation of the limbfrequency, and when to call the doctor
2. Drainrecord output; knee drain out before discharge, wrist drain out at 24 hours
3. Mobilisation (knee)weight bearing as tolerated with crutches; range-of-motion and quadriceps exercises from day 1
4. Splint and movement (wrist)sugar-tong splint with forearm supinated for about 3 weeks, then wrist and forearm exercises
5. Analgesiadrug, dose, frequency
6. Antirheumatic drugscontinue DMARDs; restart biologic agents not before 14 days and only if the wound has healed with no infection
7. Steroidsminor procedures: stress dose on the day of surgery only; larger procedures: taper to the usual dose over 1 to 2 days
8. Thromboprophylaxisearly mobilisation; drug and dose if prescribed
9. HPE and culture reportsreview at follow-up

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery