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Role of needle synovial biopsy in joint diseases.

INTRODUCTION: Symptoms complex of pain swelling and stiffness of joints labeled as arthritis is a common entity in clinical practice affecting all age groups. Blood test and radiology of involved joint is usually normal in the early stages of many arthritis. Delay in proper diagnosis leads to inability to control the disease process at an early stage usually leading to an irreversible damage to the joints. With detailed clinical examination supported by conventional investigations, diagnosis is often possible. But, a typical clinical presentation with negative routine investigations makes diagnosis of early arthritis difficult. It is in these cases that simple procedures such as synovial fluid examination and biopsy of the synovial tissue can provide an important clue to a possible diagnosis early in the course of the disease and to evaluate response to treatment if analysis is done at frequent intervals during the course of treatment. [1,2,3] Even though, arthroscopic and open synovial biopsy through open arthrotomy yields adequate tissue for histopathology, it has some disadvantages like hospitalization, anesthesia and fear of infection preventing its routine application. [4] These could be obviated by closed needle biopsy which can be done under local anesthesia as an outpatient procedure.

MATERIALS AND METHODS: Fifty patients with various joint afflictions presenting in our orthopedic OPD formed materials of the present study. Each patient was thoroughly examined with regard to history and symptomatology. Apart from the routine blood and urine examinations, a special note was made of the ESR, RA factor and serum uric acid level as per the clinical diagnosis in a particular case. After necessary laboratory investigations, radiographs of the affected joints where taken. X-ray of the chest was done in all cases of suspected tuberculosis. The synovial fluid and synovial tissue so obtained were subjected to analysis under the following headings:

1. Physical characteristics: Volume, color and clarity were observed in a clear glass tube. Viscosity was tested by length of string formation of the synovial aspirate when expressed from a syringe. Mucin clot test was performed with 5% acetic acid. Fibrin clot test was performed by allowing the fluid to stand and graded as 1 to 4 plus.

2. Microscopic examination: Wet mount prepared by placing a drop of synovial fluid previously mixed with EDTA on a glass slide and TLC, DLC and wet smear examination was done.

3. Biochemical analysis: Synovial fluid sugar and proteins were estimated by methods similar to those used for blood estimation.

4. Bacteriological analysis: The synovial fluid was sent for gram stain, AFB stain and culture.

TECHNIQUE OF ARTHROCENTESIS USING PARKER PEARSON NEEDLE: The knee joint was the commonest site biopsied. The knee joint was kept in extension and synovial fluid was displaced from the supra patellar pouch to the medial and lateral aspect of the patella by squeezing downwards from the supra patella pouch. After local anesthetic infiltration of the joint capsule, the needles 'A' and 'B' as shown in Fig. 1 was introduced through a point on the lateral aspect 2 cm above and 2 cm lateral to the midpoint of upper border of patella into the joint cavity. The synovial fluid so aspirated was collected into the empty test tubes and sterile bottles for further analysis.

The needle 'A' was taken out leaving the cannula 'B' in position. Now the notched needle 'C' which had been fitted with a 20 ml syringe was inserted through the lumen of the cannula so that its blunt end with the saw tooth entered the synovial space. Strong suction was then applied to the barrel of the syringe and the toothed needle was slightly withdrawn after aspiration of a few millilitres of synovial fluid. When the notched orifice became occluded by the synovial tissue, further aspiration became impossible. The suction was maintained to hold synovial tissue within the notch.

The syringe and inner needle were then held motionless in the right hand while the left hand slowly advanced the outer trocar using a slight twisting and rotation motion for about 1 cm to ensure that the specimen has been severed and held in the notch. The outer trocar was then left in place and the inner needle with the attached syringe was removed. The piece of synovial tissue was removed from the notched with a needle point and the entire process was repeated several times in different direction and regions of the joint. The specimen so obtained were collected in a vial containing 10% formalin solution and sent for histopathological examination. Figure. 2(a) and 2(b) shows the synovial fluid and synovial biopsy of knee joint respectively.

After the procedure was completed a compression bandage was applied. As a precaution patients were advised to rest for about 12 hours with limb elevation. Compression bandage was removed after 72 hours of biopsy and further treatment was advised in accordance with the result of biopsy reports. The same technique was used for other joints as per their landmarks.

OBSERVATIONS AND RESULTS: There were 34 males and 16 females with an age distribution from 13 years to 63 years. 44 cases were monoarticular and 6 cases were polyarticular. Knee joint was involved more commonly in both monoarticular as well as polyarticular forms of the disease and shown in Fig. 3. The physical properties, the biochemical analysis (Protein and blood synovial fluid sugar difference) and the cytological studies that were carried out in this study are documented in Table 1. It can be further observed from Table 1 that the physical, biochemical and cytological studies show a pattern more or less specific to a particular group of disease. Based on this pattern, joint diseases can be divided under 3 groups as shown in Table 2.

With Parker Pearson needle and their technique adequate representative synovial tissue for histopathology could be obtained in 41(82%) out of 50 joints. In the rest 9 cases open synovial biopsies were done to reach a definitive diagnosis. Table 3 shows the final histopathological diagnosis (41 closed+9 open) in this study.

DISCUSSION: Affection of the joints, monoarticular or polyarticular by various diseases is a common orthopedic problem. On the basis of clinical examination with conventional radiological and laboratory aids, the diagnosis often can be reasonably made. These findings are sometimes equivocal and therefore necessity of tissue diagnosis arises. Closed needle biopsy is a simple outpatient procedure without complications that aids in establishing the diagnosis after clinical and radiological correlation. Careful review of literature would reveal that the importance of this simple procedure as an aid to diagnosis of joint diseases has been stressed by various authors from time to time. [1,2,5,6,7,8,9,10,11,12]

Involvement of the knee joint has been found to be the commonest form of joint disease both in the present study and by previous workers also. [1,10,12,13] On the basis of synovial fluid examination (i.e. physical, biochemical and cytological examination) various arthritis could be grouped into 3 groups as per the nature and severity of inflammation.

Even though literature states very minimal amount of fluid requirement for the studies, it was generally observed that at least 5ml of fluid was required to perform the basic important tests comfortably. In spite of this, in certain percentage of cases clinical, radiological and synovial fluid finding are equivocal or inconclusive. In these cases it is only the synovial biopsy that has usually solved the diagnostic dispute. Closed needle biopsies have been performed using several different types of needles including the Polley Bickel biopsy needle, [7] Franklin-Silverman liver biopsy needle, [8] Copes needle, [11] and the Parker Pearson needle. [1,2,14,15]

Parker Pearson needle has been the needle of the choice for many workers as it had yielded reasonably good amount of synovial tissue for histological interpretation. By using Parker Pearson technique adequate tissue for HPE could be obtained in 41 out of 50 patients (82%) in this study. The main causes of failure were:

a) Involvement of deep-seated joint like hip.

b) Contracture of the joint.

c) Biopsy not from a representative site.

d) Apprehensive patient with poor tolerance under local anaesthesia.

Table 4 and Table 5 show the comparison of synovial fluid analysis and synovial biopsy between this study and other workers respectively. The present series shows a higher incidence of non-specific lesions (32%) compared to other authors like Verma et al and Sakhuja et al. [12,11,13] It can be observed that the total number of cases for the study were also less in three of the workers. [2,11,13] Two of the authors had considered only monoarthritis cases. [2,13] In this series, out of the 16 cases (32%) diagnosed by biopsy as nonspecific lesions, 6(12%) cases could not be grouped into any definite pathology clinically also. Two (4%) of these patients had a definite history of trauma but histopathologically did not reveal any extravasated RBC's, fibrin thrombi or haemosiderin laden macrophages. This can be due to sampling error and hence they had to be labelled in the non-specific group. The rest 10(20%) cases were suspected clinically to be either tubercular or rheumatoid arthritis. Five (10%) of these patients were in the younger age group (12-31 yrs) and had a short febrile illness preceding the onset of joint symptoms.

Fever subsided dramatically without any therapeutic intervention there by strongly suggesting that these cases were probably forms of viral arthritis following viral infections. This leaves a proportion of 9 cases (18%) of non-specific synovitis those could not be sub grouped into one of the etiological groups referred in table 3. This is because a fair number amongst these are probably due to conditions like Psoriasis, Behcet's disease, Reiter's arthritis, Enteropathic arthritis or Ankylosing spondylitis that have histological picture indistinguishable from chronic non-specific synovitis in early presentation of the disease. In the present study we encountered normal appearance of synovium in 6 cases out of 50. The clinical diagnosis was non-specific in 3 cases and one each of rheumatoid, tubercular and traumatic arthritis.

Thus it is evident that even after needle biopsy it is difficult to make definitive diagnosis in small group of patients. The limitations of the needle biopsies must be taken into account when interpreting the histological samples. Since the joint surfaces are not seen as in an open or arthroscopic biopsy the findings of direct inspection of the joint are not available and hence the selection of the biopsy site is more of chance. It can also be that the disease process was too early that histopathological changes were yet to occur. Pitkealthly et al [13] reported normal studies in 16% of their cases even after open biopsies. Long-term follow up and repeat interval biopsy would be required in these cases to detect any change to a particular pathology.

Since needle biopsies yield very minimal amount of representative tissue compared to open biopsies it requires the trained eyes of an experienced pathologist to obtain better results. It is ideal for the specimens to be reviewed by a single pathologist who is a part of the team.

No complications like infection, intra articular hemorrhage or needle fragmentation [16] were encountered in the present study. From the present study and comparing with the study of other workers it is quite evident that closed needle synovial biopsy is an important useful investigative adjunct to correlate and confirm the diagnosis made after clinico-radiological and synovial fluid evaluation. At times synovial biopsy alone gives the conclusive diagnosis.

CONCLUSION: To summarize needle synovial biopsy in a simple and easy to perform outpatient procedure which can be reliably done by junior doctors also. It is very cost effective as it does not require hospitalization, anesthesia or costly equipments. Unlike open or arthroscopic biopsies repeated interval biopsies are feasible on the same patient to assess progress of the disease and response to treatment. An attempt at tissue diagnosis by this simple procedure may give conclusive diagnosis where clinical diagnosis and laboratory parameters are equivocal.

DOI: 10.14260/jemds/2015/1107

ACKNOWLEDGEMENTS: We would like to acknowledge the contributions of Dr. Anoop Sreevalsan, Professor Obstetrics and Gynaecology, Chettinad Hospital and Research Institute, Kelambakkam, Chennai 603103 for his guidance in preparing the manuscript.

REFERENCES:

[1.] H. Ralph Schumacher, Jr. and Peter Kulka. Needle biopsy of the synovial membrane-Experience with the Parker Pearson technique. The New England Journal of medicine 1972; 286(8): 416-419.

[2.] Rajendra Verma, Gupta SP and Katju Vinod. Place of synovial fluid examination and needle biopsy of synovial membrane in diagnosis of monoarticular joint diseases. Ind J Ortho 1983; 17(1): 08-12.

[3.] Barry Bresnihan. Are synovial biopsies of diagnostic value? Arthritis Res Ther 2003, 5: 271-278.

[4.] Singhal O, Kaur V, Kalhan S, Singhal MK, Gupta A and Machave YV. Arthroscopic synovial biopsy in definitive diagnosis of joint diseases: An evaluation of efficacy and precision. Int J App Basic Med Res 2012; 2: 102-6.

[5.] Curtiss PH, Jr. Changes produced in synovial membrane and synovial fluid by disease J Bone Joint Surg 1964; 46A: 873-888.

[6.] Sheldon P Blau. The synovial fluid. Orthopaedic clinics of North America 1979; 10(1): 21-35.

[7.] Polley HF, and Bickel WH, Punch biopsy of synovial membrane. Ann Rheum Dis 1972; 10: 227-287.

[8.] Moon MS, Kim JM, Lee HS and Ahn YP. Synovial biopsy by Franklin--Silverman needle. Clin Orthop 1980; 150: 224-8.

[9.] Leon Sokoloff. Biospy in rheumatic diseases. Med Clinics North America 1961; 45: 1171-1180.

[10.] Bhatia A, Kapoor S, Vishwakarma GK, Sagreiya K and Geeta Ashokraj. Cytology as a diagnostic aid in arthritis. Indian J Med Res 1981; 73: 761-767.

[11.] Shakhuja AC et al. Synovial fluid analysis and synovial biopsy in various types of arthritides. Ind J Ortho 1981; 15(2): 157-161.

[12.] Vikas Gupta, Vinod Kumar Sharma, Rao KS and Rajesh Chandra. Joint fluid analysis in arthritis--Clinico pathological study. Ind J Ortho 1998; 2(2): 88-90.

[13.] Pitkeathly DA, Griffiths HE and Catto M. Monarthritis: A study of forty-five cases. J Bone Joint Surg 1962; 46B (4): 685-96.

[14.] Parker RH and Pearson CM. A simplified synovial biopsy needle. Arthritis Rheum 1963; 6: 172-176.

[15.] Sterling G. West. Synovial Biopsies. In: Rheumatology secrets, 3rd edition, Philadelphia: Elsevier Health Sciences; 2014. p. 76-77.

[16.] Bocanegra TS, McClelland JJ, Germain BF and Espinoza LR. Intraarticular fragmentation of a new Parker-Pearson synovial biopsy needle. The Journal of Rheumatology 1980; 7(2): 248-250.

M. Venkataraman [1], Sathyadharan. P [2]

AUTHORS:

[1.] M. Venkataraman

[2.] Sathyadharan P.

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor, Department of Orthopaedics, Chettinad Hospital & Research Institute, Kelambakkam.

[2.] Assistant Professor, Department of Orthopaedics, Chettinad Hospital & Research Institute, Kelambakkam.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. M. Venkataraman, Door No.11, Plot No. 6, Kulothungan Street, Chitlapakkam, Chennai-600064.

E-mail: orthovenkat@yahoo.com

Date of Submission: 22/04/2015. Date of Peer Review: 23/04/2015. Date of Acceptance: 20/05/2015. Date of Publishing: 30/05/2015.

Table 1: Physical, biochemical and cytological properties
of synovial fluid

Sl.     Diagnosis      No. of   Physical
No.                    cases

                                 Appearance     Viscosity    Mucin
                                   colour/                  clot test
                                   clarity

1         Normal         6       Straw/clear      High        Good
         Synovial
          fluid
2     Osteoarthritis     4      Pale yellow/      High        Good
                                    clear
3       Traumatic        4      Haemorrhagic/     High        Good
        arthritis               xanthochromic
4      Neuropathic       1       Straw/clear      High        Good
5      Villonodular      1       Straw/clear      High        Good
        synovitis
6       Rheumatoid       6      Yellowish to       Low       Fair to
        arthritis                 Greenish/                   poor
                                   cloudy
7      Tuberculous       8      Yellow/turbid      Low        Poor
        arthritis
8        Chronic         16     Yellow/clear      high       Fair to
       nonspecific                                            good
        synovitis
9         Gouty          1         Yellow/         Low        Good
        arthritis                  cloudy
10        Septic         2         Yellow,         Low        Very
        arthritis                grey/turbid                  poor
11     AVN femoral       1          Blood          Low        QIS *
           head                    stained

Sl.     Diagnosis      Biochemical
No.

                        Proteins       Blood
                          (gm%)       synovial
                                       fluid
                                     difference
                                       (mg%)

1         Normal          1.5-3         < 10
         Synovial
          fluid
2     Osteoarthritis      1.2-3         < 15
3       Traumatic         2.5-5        10-20
        arthritis
4      Neuropathic         2.9           59
5      Villonodular         2            12
        synovitis
6       Rheumatoid       3.5-6.4       20-30
        arthritis
7      Tuberculous       3.2-6.8       24-50
        arthritis
8        Chronic         2.5-5.5       25-60
       nonspecific
        synovitis
9         Gouty             2            12
        arthritis
10        Septic           6-8         50-60
        arthritis
11     AVN femoral        QIS *        QIS *
           head

Sl.     Diagnosis      Cytological
No.

                       Total cell     Predominant
                        countper       cells seen
                       [mm.sup.3]

1         Normal         50-200       Poly, lympho
         Synovial                     & mono with
          fluid                       poly < 25 %
2     Osteoarthritis     200-500       Variable/
                                       polymorphs
3       Traumatic       680-4000        Variable
        arthritis                      with RBCs
4      Neuropathic        9200        Lymphocytes
                                          40 %
5      Villonodular        900        Lymphocytes
        synovitis
6       Rheumatoid      7600-8500      Polymorphs
        arthritis
7      Tuberculous     6000-12000     Lymphocytes
        arthritis
8        Chronic        500-12000       Variable
       nonspecific                     from poly
        synovitis                    to lymphocytes
9         Gouty            900        Lymphocytes
        arthritis
10        Septic          26000      Polymorphs 90%
        arthritis
11     AVN femoral        QIS *          QIS *
           head

* QIS--Quantity Insufficient

Table 2: Table showing the three groups based on synovial
fluid analysis

                          Groups                 Number of cases

Group I     Non-Inflammatory group
            a. Traumatic Arthritis                     04
            b. Osteo Arthritis                         04
            c. Villonodular Synovitis                  01
            d. Neuropathic joint                       01
Group II    Mild to Moderate Inflammatory Group
            a. Rheumatoid Arthritis                    06
            b. Tuberculous arthritis                   08
            c. Chronic non-specific synovitis          16
            d. Gouty Arthritis                         01
Group III   Septic or Severe Inflammatory Group
            a. Septic Arthritis                        02
            Total                                 43(excluding
                                                 AVN and normal
                                                    studies)

Table 3: Final histo pathological diagnosis (41 closed + 9 open)

Sl.             Diagnosis              Monoarticular   Polyarticular
No.                                    No. of cases    No. of cases

1          Rheumatoid Arthritis              3               3
2         Tuberculous Arthritis              8              --
3     Chronic nonspecific synovitis         15               1
4             Osteoarthritis                 4              --
5         Villonodular synovitis             1              --
6            Gouty arthritis                 1              --
7            Septic arthritis                2              --
8          Traumatic arthritis               4              --
9            Normal synovium                 4               2
10          Neuropathic joint                1              --
11           AVN femoral head                1              --
                  Total                     44               6

Sl.             Diagnosis              Total   Percentage
No.                                               (%)

1          Rheumatoid Arthritis          6         12
2         Tuberculous Arthritis          8         16
3     Chronic nonspecific synovitis     16         32
4             Osteoarthritis             4         8
5         Villonodular synovitis         1         2
6            Gouty arthritis             1         2
7            Septic arthritis            2         4
8          Traumatic arthritis           4         8
9            Normal synovium             6         12
10          Neuropathic joint            1         2
11           AVN femoral head            1         2
                  Total                 50        100

Table 4: Comparison of synovial fluid analysis

Groups         Present Study         Verma et al [2]

               No. of   Percentage   No. of   Percentage
               cases                 cases

Group-I          10       23.25        5          20
Group-II         31       72.09        19         76
Group-III        02        4.65        01         4
Haemorrhagic     --         --         --         --
Total          43 **       100         25        100

Groups         Shakhuja et al [11]   Vikas Gupta et al [12]

               No. of   Percentage   No. of   Percentage
               cases                 cases

Group-I          3         8.57        13         25
Group-II         25       71.43        32       61.54
Group-III        07         20         02        3.84
Haemorrhagic     --         --         5         9.62
Total            35        100         52        100

** (Excluding normal synovial biopsy and AVN)

Table 5: Comparison of synovial biopsy results

Sl.            Diagnosis           Present       Verma       Shakhuja
No.                                 Study      et al [2]    et al [11]

                                    Cases/       Cases/       Cases/
                                  Percentage   Percentage   Percentage

1        Rheumatoid Arthritis       06/12        02/08        07/20
2        Tuberculous Arthritis      08/16        11/44       15/42.86
3         Chronic nonspecific       16/32        06/24       01/2.86
               synovitis
4           Osteoarthritis          04/08        02/08       02/5.71
5       Villo-nodular synovitis     01/02          --           --
6           Gouty arthritis         01/02          --           --
7          Septic arthritis         02/04        01/04        07/20
8         Traumatic arthritis       04/08        03/12       03/8.57
9           Normal synovium         06/12          --           --
10         Neuropathic joint        01/02          --           --
11         AVN femoral head         01/02          --           --
Total                               50/100       25/100       35/100

Fig. 3: Chart showing distribution of anatomical sites of
biopsies (no. of cases, percentage %)

Knee       22,44%
Ankle      16,32%
Wrist      6,12%
Shoulder   1,2%
Elbow      2,4%
Hip        3,6%

Note: Table made from pie chart.
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Title Annotation:ORIGINAL ARTICLE
Author:Venkataraman, M.; Sathyadharan, P.
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Jun 1, 2015
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