Handbook of Joint Disorders Arthroscopy & Pathology S Radha, Tameem Afroz, JVS Vidyasagar
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IntroductionCHAPTER 1

2
 
ARTHROSCOPY
Arthroscopy is now possible for majority of joints, serves as a diagnostic and therapeutic tool (Figs 1.1 to 1.3) It enables visualization of intra-articular structures simultaneously offers an opportunity to repair any damage visualized to such structures. It is a low-cost, low-risk procedure with a minimal post-procedural morbidity. These advantages have made arthroscopy a popular tool in the hands of rheumatologists and orthopedic surgeons.
 
Historical Background
In 1913, Birchner performed endoscopic examination of cadaveric knee joints in Switzerland to diagnose meniscal injuries.1
Takagi2 developed an arthroscope in 1920 to diagnose knee tuberculosis but this instrument was not user friendly. Watanabe, student of Takagi, refined arthroscopic techniques and published “The Atlas of Arthroscopy” in 19573 and also performed the first arthroscopic meniscectomy in 1962.
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Fig. 1.1: Arthroscope with sheath and obturator
3
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Fig. 1.2: Punches of various sizes and angles used for synovial biopsy
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Fig. 1.3: Arthroscopic procedure
4
 
Advantages of Arthroscopy
  • Joint visualization: Arthroscopy has distinct advantages in visualization of joint anatomy in comparison to radiologic techniques. Articular cartilage and synovial lesions are difficult to assess by Computed Tomography (CT) techniques.4 Raunest et al5 noted that magnetic resonance for MRI had a diagnostic accuracy of 72% for meniscal tears when compared to arthroscopy in a double blind trial in patients with a clinical suspicion of meniscal injury. No studies are reported in literature comparing MRI and arthroscopy in assessing soft tissue injuries associated with osteoarthritis.
  • Tissue sampling: Arthroscopy allows sampling of synovial tissue for histopathological assessment as well as providing tissue for performing ancillary studies like tissue polymerase chain reaction (PCR) for tuberculosis. In comparison with closed needle biopsies, arthroscopic biopsies allow selective sampling of tissue under visual guidance, this offers distinct advantage as synovial involvement is not equally distributed.
 
Diagnostic Indications for Arthroscopy
  • Osteoarthritis with atypical features and mechanical symptoms.
  • Chronic septic arthritis.4
  • Culture negative synovial fluid in septic arthritis.
  • Inflammatory arthritis not responding to regular line of treatment.
  • Monoarticular synovitis.
  • 5Assessment of joint damage in osteoarthritis and rheumatoid arthritis for planning further management.
 
Therapeutic Indications for Arthroscopy
  • Removal of loose bodies in osteoarthritis, as these have the potential to cause damage to the intact articular cartilage as well as cause frequent mechanical problems.
  • Repair of coexisting meniscal tears in osteoarthritis.
  • Irrigation and removal of debris in osteoarthritic joint which affords transient improvement in clinical symptoms.
  • Repair of ligamentous and meniscal injuries secondary to trauma.
  • Removal of blood from the joint cavity become blood is an irritant to the joint structures namely the synovium and the cartilage, thus preventing early onset joint damage.
 
Complications of Arthroscopy
Minor complications:
  • Portal site tenderness
  • Post-arthroscopic effusion.
Rare complications:
  • Infection
  • Hemarthrosis—seen in synovectomy procedures6
  • Joint rupture
  • Deep vein thrombosis—due to post-arthroscopic immobilization and failure to mobilize the limb early.
6
 
SYNOVIAL BIOPSY
 
Introduction
Over 200 different types of arthropathies have been described.7 Majority of these arthropathies present with synovitis. In arthropathies with atypical clinical presentations and arthropathies with typical immunological findings, synovial fluid examination and synovial biopsies can provide valuable information which can help in clinching the diagnosis and as well as help in monitoring the response to treatment and progression of the disease.
 
Historical Overview
In 1932, a technique for obtaining non-surgical synovial tissue for diagnostic purposes using a dental nerve extractor that is introduced into the joint through a large-caliber needle was proposed.8 In 1963, Parker and Pearson described a simplified 14 gauge needle that did not require a skin incision.9 The production of high-definition, small bore arthroscopes (1-2.7 mm),10 and sophisticated local regional blocks have enabled day-care arthroscopy as a routine and regular procedure.
 
Synovial Biopsy and its Clinical Applications
  • Acute infections: Synovial tissue examination can play an important role in the diagnosis of joint infections. In acute arthritis, routine Gram stain of the synovial fluid and tissue can provide clues regarding the type of bacteria implicated. In rare cases, when synovial fluid cultures are negative, cultures of the fibrin on the surface of the synovium and the synovium as such can help in clinching a diagnosis.
  • 7 Chronic infections: In infections like tuberculosis and fungal lesions, synovial involvement can be patchy. Multiple site biopsies under visualization during arthroscopy can provide tissue for routine studies as well as for ancillary techniques like Polymerase Chain Reaction (PCR).
  • Chronic granulomatous diseases: The diagnosis of sarcoidosis is established after synovial biopsy.11 The histological feature is a noncaseating granuloma. Central area is composed of CD4 lymphocytes surrounded by mononuclear cells and rimmed by a mixture of CD4, CD8 lymphocytes, mast cells and fibroblasts.
  • Crystal disorders: Both in gout and pseudogout, tophus-like deposits can be demonstrated in synovial tissue.12 Deposits are soluble in routine fixation and processing techniques, therefore special procedures are adapted to demonstrate these deposits.
  • Amyloid can be demonstrated by using amyloid stains on the synovial tissue.
  • Arthropathy associated with ochronosis and hemachromatosis demonstrate characteristic histological features.13
  • Synovial biopsies play an important role in diagnosis of tumors and tumor like lesions of the synovium and provide tissue for performing immunohistochemical stains for definite diagnosis. (Ref. Chapter on Tumors and Tumors like Lesions)
  • Rheumatoid arthritis: Synovial biopsies, though not routinely required for a diagnosis of rheumatoid arthritis, play an important role in monitoring the progression of the disease and monitoring the response to disease modifying antirheumatic drugs (DMARDs). 8In early arthritis, before the evolution of the set criteria for diagnosis of rheumatoid arthritis, synovial biopsies can help in recognizing potentially erosive arthritis.
REFERENCES
  1. Strobel M, Eichhorn J, Schiebler W. Basic principles of knee arthroscopy. Nnormal and pathologic findings, tips and tricks. Springer-Verlag  Berlin:  1992. p.2.
  1. Takagi K. Practical experiences using Takagi's arthroscope. J Jpn Orthop Assoc 1933; 8: 132–4.
  1. Watanabe M, Takeda S, Ikeuchi H. Atlas of arthroscopy. In: Igaku-shoin,  Tokyo/  2nd edn. 1969.
  1. O’ Rourke KS, Ike RW. Diagnostic arthroscopy in the arthritis patient. Rheum Dis Clin North Am 1994; 20: 321–42.
  1. Raunest J, Oberle K, Lehnert J, et al. The clinical value of magnetic resonance imaging in evaluation of meniscal disorders. J Bone Joint Surg 1991; 73A: 11–6.
  1. Arnold WJ. Office based arthroscopy. Bull Rheum Dis 1992; 4: 3–6.
  1. Huskisson EC, Hart FD. Joint diseases. All the arthropathies. 3rd edn. John Wright  Bristol:  1978. p.158.
  1. Forestier J. Instrumentation pour biopsie medicale. CR Seances Soc Biol Filiales 1932; 110: 388–402.
  1. Parker HR, Pearson CM. A simplified synovial biopsy needle. Arthritis Rheum 1963; 6: 172–6.
  1. Wallace DA, Carr AJ, Loach AB, et al. Day case arthroscopy under local anaesthesia. Ann R Coll Surg Engl 1994; 76: 330–1.
  1. Newman L, Rose C, Maier L. Sarcoidosis. N Engl J Med 1997; 336: 1224–34.
  1. Schumacher HR. Synovial fluid analysis and biopsy. In: Kelley WN, Harris ED, Ruddy S, Sledge CB (Eds). Textbook of Rheumatology. WB Saunders Company  Philadelphia:  1993. pp.562–78.
  1. Barry Bresnihan. Are synovial biopsies of diagnostic value? Arthritis Res Ther 2003; 5: 271–8.