Synovitis of the knee joint

The knee joint is the largest in the human body, and, in addition, during the process of walking it is affected by the entire mass of our body, and therefore injuries and diseases of the knee occupy one of the first places in traumatology.

Not every traumatic impact ends in a dislocation or fracture; often the bone structures and ligaments remain intact, and the only consequence is synovitis of the knee joint.

The main feature of the disease is the formation of serous exudate in the joint cavity, which, unlike hemarthrosis, does not contain blood. Fluid (synovium) is present in the joint cavity normally, but with inflammation of the synovium, its amount increases significantly.

Causes of the disease

Synovitis can be infectious or non-infectious in nature. Usually it develops secondary to sinusitis, otitis media or another focus of pathogenic microflora. But the disease can also be caused by:

• allergic reaction;
• other pathologies (arthritis, gout, psoriasis, diabetes mellitus);
• joint injuries with damage to the bursa.

Inflammation of the synovial membrane occurs in 5–6% of the population. Adults are more susceptible to it, while the prevalence of the disease in children does not exceed 2–3%. People at risk include people who do heavy work, sports, or lack good physical fitness. In both cases there is a high risk of injury.

Types of synovitis

The disease is classified according to the composition of the fluid secreted into the bag, the location of the lesion and the reasons that caused the inflammatory process. The inflamed membrane releases exudate into the bursa. Depending on its composition, the following types of synovitis are distinguished:

• serous (clear liquid containing proteins and leukocytes);
• purulent (pus);
• hemorrhagic (blood);
• fibrinous (fibrin is a protein that clots blood).

Based on localization, synovitis is distinguished between elbow, knee, hip, wrist and other types. If it was caused by other diseases, then it is called secondary (rheumatoid, psoriatic, diabetic). If the disease was not preceded by another pathology, it is considered primary.

Treatment of synovitis of the knee joint

The same procedure is the first stage of treatment for the disease synovitis of the knee joint. A thin needle is used to suck out part of the liquid and then inject it into the joint cavity.

After the puncture, the knee joint should be provided with maximum rest. For this purpose, they resort to immobilization using a tight pressure bandage, a knee brace or special knee orthoses. The goal is not to completely eliminate mobility in the joint; you just need to reduce the load as much as possible. As for complete immobilization, it is rather harmful in this case and can contribute to the development of contractures. To prevent contractures, it is also recommended to limit the period of partial fixation to one week.

How does the disease manifest itself?

Synovitis occurs similarly to bursitis - inflammation of the joint capsule. But these diseases need to be distinguished. In the first case, the inflammatory process covers only the bursa membrane, in the second - all its tissues.

Symptoms of synovitis include:

• redness of the skin at the site of the affected joint;
• pain and stiffness of movement;
• swelling, smoothing the relief of the joint;
• increase in body temperature (locally or systemically).

If left untreated, the disease becomes chronic. It is manifested by a decrease in symptoms. It becomes easier to move, the pain goes away, the swelling subsides. But the disease is prone to frequent relapses.

Treatment methods for synovitis

The diagnosis and treatment of synovitis is carried out by an orthopedic traumatologist. When a patient comes to him, he first conducts a survey, examines the diseased joint and palpates it. Then he prescribes a blood test and hardware examination of the affected area (ultrasound, radiography, MRI). If inflammation of the synovial membrane is detected, he performs a puncture. During it, the doctor takes a sample of the fluid to study its composition and identify the causative agent of the infection.

After making a diagnosis and establishing the causes of the development of the pathology, the patient may be prescribed:

• Extraction of excess exudate. The procedure is carried out using a long and sharp needle, through which the liquid accumulated in the bag is sucked out. As a result, swelling and pain are reduced.
• Rinsing the joint capsule with an antiseptic. It is carried out similarly to the first procedure. The solution is injected through a needle and then sucked out through it along with the pathological contents.
• Introduction into the bursa of glucocorticosteroids, which have a powerful anti-inflammatory effect.

Depending on the causes of the disease, the patient may also be prescribed antibacterial or antiallergic drugs. If body temperature rises, antipyretic drugs may be prescribed. Treatment also includes compresses to relieve pain.

Early action guarantees a favorable outcome of the disease. To prevent the development of complications, contact a doctor at the first symptoms of the disease. Our surgeons will conduct a thorough diagnosis and prescribe effective treatment, after which you will again be able to experience the joy of free and painless movements.

Chronic synovitis in rheumatology. Assessment of activity and treatment tactics

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Regular issues of "RMZh" No. 8 dated April 29, 2005 p. 548

Category: General articles

Author: Olyunin Yu.A. 1 1 FGBNU NIIR im. V.A. Nasonova, Moscow, Russia

For quotation:

Olyunin Yu.A. Chronic synovitis in rheumatology. Assessment of activity and treatment tactics. RMJ. 2005;8:548.

Among the various manifestations of chronic joint diseases, synovitis occupies a leading place. The inflammatory process developing in the synovium determines the main features of the clinical picture and is the driving force behind the progression of the disease. It is the body’s response to a pathogenic stimulus, which is realized through the transformation of the synovium into a kind of immune defense organ. In this case, functionally active cells of inflammatory infiltrates are formed not due to the local proliferation of the initially present cellular elements, but as a result of the migration of the corresponding cells from the circulation.

This process leads to the formation of highly specialized cellular aggregates, the components of which actively interact with each other and produce aggressive products that cause tissue damage. The formation of inflammatory cell infiltrates is accompanied by proliferation of stromal elements and blood vessels of the synovium. Over time, the thin shell of the joint turns into a fairly powerful tissue mass. The structure and functional activity of such tissue varies in different diseases, in different patients suffering from the same disease, in different joints of the same patient, and even within the same joint. The most common types of chronic synovitis are primary inflammation of the synovium in chronic arthritis and secondary synovitis in patients with osteoarthritis (OA). According to modern concepts, the key link in the development of chronic arthritis is the recognition of an unknown pathogenic factor by the antigen-presenting cell [4]. The cell that recognizes the antigen processes it and presents it to the T lymphocyte, triggering the synthesis of proinflammatory cytokines that induce the migration of inflammatory cells into the joint and the proliferation of synovial vessels. The development of secondary synovitis in OA is associated with the accumulation of cartilage degradation products (fragments of proteoglycan and collagen molecules, chondrocyte membranes, etc.) in the joint [6]. Normally, cells of the immune system do not come into contact with these antigens and therefore recognize them as foreign material. This leads to the development of an immune response, accompanied by chronic inflammation of the synovium. The morphological picture of secondary synovitis as a whole is not fundamentally different from those changes that are observed in chronic arthritis. Active synovitis in patients with chronic arthritis is accompanied by the production of proteolytic enzymes that mediate joint destruction. Chronic synovitis in OA is itself the result of a destructive process. However, it, in turn, can aggravate joint destruction [1]. Therefore, suppression of the chronic inflammatory process, apparently, can slow down the progression of the disease not only in chronic inflammatory joint diseases, but also in OA. The basis for the treatment of inflammatory changes in the joints is systemic drug therapy. However, often systemic treatment does not adequately suppress local inflammatory activity and synovitis occurs as a relatively autonomous process, which is supported mainly by local mechanisms. In such cases, a favorable result can be achieved with the help of therapeutic measures aimed directly at the source of inflammation. At the same time, the tactics of therapeutic measures are largely determined by the activity of the inflammatory process. The main clinical signs of the activity of chronic inflammation of the synovial membrane are arthralgia and swelling of the affected joint. These symptoms are equally characteristic of both primary and secondary synovitis. The formation of pain syndrome in inflammatory and degenerative joint diseases can be associated with various mechanisms. But the main role among them is probably played by irritation of the nerve endings located in the joint under the influence of inflammatory mediators produced here. Joint pain is the leading symptom of the disease, and the functional limitations that develop in the patient are primarily associated with it. Currently, there are two main ways to record the intensity of pain. The simpler of them is the assessment of arthralgia in points, which usually provides 5 degrees of severity of the symptom (0 - no pain, 1 - mild, 2 - moderate, 3 - severe and 4 - very severe pain). It is somewhat more difficult to assess pain using a visual analogue scale (VAS), but this method provides more accurate results. VAS is a straight line 100 mm long. The zero point of the scale located on its left edge means no pain. The far right point corresponds to unbearable pain. Between these extreme positions, the patient must indicate the level corresponding to his pain sensations. It should be borne in mind that pain is a dynamic indicator, the severity of which varies depending on the time of day and the physical activity of the patient. Therefore, it is not the intensity of pain at the time of examination that should be recorded, but its maximum level over the past week. The exudative component of inflammation is not as noticeable for the patient as pain, but is of exceptional importance as an objective indicator of the activity of synovitis. The presence of exudate in the cavity of the affected joint is necessarily taken into account when determining treatment tactics and assessing the effectiveness of the therapy. When examining a patient, as a rule, one can quite reliably judge the presence or absence of exudate in those joints that are sufficiently accessible for visual and palpation examination (knees, wrist elbow joints, small joints of the hands and feet). It is quite difficult to detect moderate accumulation of exudate in the ankle and shoulder joints. It is not possible to detect fluid in the hip joints without the help of instrumental research methods. In order to reliably estimate the amount of exudate, it must be evacuated from the joint cavity. You can roughly assess the severity of the exudative component of arthritis by measuring the circumference of the inflamed joint. For short periods of observation, the dynamics of this indicator can be taken into account when assessing the effectiveness of treatment. However, in cases where the result is assessed at a sufficiently long term, a decrease in the circumference of the joint can occur due to atrophy of the muscles located in this area. Therefore, when examining a patient, qualitative registration of the presence or absence of exudate provides more reliable data than an attempt to quantify it. Additional information about the nature of changes in the affected joint can be obtained using instrumental research methods. The most common of these is radiography. However, a standard x-ray examination allows us to evaluate not the features of the development of synovitis, but its consequences. It makes it possible to determine, first of all, the degree of destruction of the joints, to record the presence of subluxation, aseptic necrosis of the bone or ankylosis of the joint. Ultrasound can be used to visualize the inflamed synovium itself. It allows you to obtain an image of a section of the joint under study, made in a certain plane. Using such a section, you can accurately measure the thickness of the synovial membrane, as well as approximately estimate the amount of synovial fluid in a given part of the joint. Ultrasound provides the ability to semiquantitatively assess exudative changes. The degree of accumulation of exudate in a certain part of the joint can be expressed in points and then the dynamics of this indicator can be monitored against the background of the treatment. The thickness of the synovial membrane, which can be recorded by ultrasound, is also one of the signs of synovitis activity. Its value is largely determined by inflammatory edema and decreases significantly as inflammation subsides. The use of arthroscopy (AS) allows direct visual examination of the inflamed synovium of the affected joint. Unlike ultrasound, AS does not allow one to accurately measure the thickness of the inflamed synovium and assess the severity of exudative changes in a given part of the joint. These two methods do not replace, but complement each other. Arthroscopic examination of the joint makes it possible to study the relief of the synovium along its entire length. Depending on the duration of synovitis and the characteristics of its development in a given joint, changes in the synovial membrane can vary within a very wide range. Normal synovium in the form of a thin transparent film covers the joint capsule. The development of the inflammatory process is accompanied by its thickening, the appearance of hyperemia, proliferation of villi, and the formation of fibrin clots on its surface. AS allows for a differentiated assessment of the nature of joint damage in patients with a similar clinical picture of the disease. To record observed changes, several methods for their semi-quantitative assessment have been proposed. Zschabitz A. et al. assessed the morphological changes in the synovium identified in AS using an index, which was calculated according to 4 indicators: vascularization, hyperemia, swelling of the synovium and villi formation [10]. The severity of each indicator was determined in points from 0 to 3. This scheme allows you to record the severity of changes, but does not take into account their prevalence, so it is difficult to characterize the damage to the joint as a whole. Paus AC et al. tried to overcome this drawback [9]. They divided the joint into 5 regions (posterior, intercondylar, medial, lateral, suprapatellar). In each zone, the severity of the lesion was assessed in 4 degrees: 1 - no signs of synovitis, 2 - moderate hyperemia without villi formation, 3 - moderate hyperemia with moderate villi formation, 4 - moderate or severe hyperemia with massive villi formation. The overall index was the arithmetic average of the scores of the 5 specified areas. The American College of Rheumatology has proposed assessing the severity of hyperemia, thickening, and villous proliferation of the synovium using a visual analogue scale and simultaneously recording the extent of the lesion as a percentage of the total area of ​​the synovium. It should be noted that one of the most significant parameters characterizing the development of chronic synovitis may be the degree of increase in the volume of the affected synovium, an indicator of which is the severity of its villous proliferation. As it progresses, the size of the inflammatory focus increases, which, on the one hand, leads to a change in the ratio between the amount of drug injected into the joint and the mass of the affected tissue, and on the other hand, it impairs the circulation of fluid in the joint and makes it difficult for the drug to enter the inflammatory zone. There are 4 degrees of proliferative changes in the synovial membrane of the knee joint. The first is thickening of the synovium without significant villous proliferation. The second can be defined as the appearance of focal accumulations of villi against the background of a thickened synovium. In the third degree, the villi cover most of the synovium of the lateral parts of the joint, leaving the upper part free. The fourth degree is characterized by diffuse villous proliferation, which covers all parts of the joint. Arthroscopic control could be of some interest for assessing the results of treatment of chronic arthritis. Judging by the data from publications that assessed the effectiveness of intra-articular injections of drugs (in particular, methotrexate and rifampicin), the most dynamic indicator is synovial hyperemia [8]. It clearly decreases with a decrease in clinical signs of inflammation. At the same time, the structure of the synovia is generally quite stable. When examining patients before and after radiosynovectomy, we also observed the disappearance of hyperemia with favorable clinical results. In addition, in some cases, areas of synovial sclerosis and fatty degeneration of synovial villi appeared. While clinical signs of active inflammation persisted, hyperemia of the synovial membrane persisted in all cases. The tactics of local treatment of chronic synovitis is determined by the activity of the local pathological process and the effectiveness of previous therapy. In the presence of pain syndrome that is not accompanied by significant exudative changes, both in chronic inflammatory diseases of the joints and in OA, in addition to systemic drug therapy, medications in the form of ointments or gels are usually prescribed. In many cases, a beneficial effect can be achieved by prescribing locally irritating drugs that reduce the severity of pain due to a distracting effect. For this purpose, preparations based on menthol, turpentine, and camphor are used. The use of ointment and gel products containing nonsteroidal anti-inflammatory drugs (NSAIDs) ensures that these medications are delivered through the skin directly to the site of inflammation. For this purpose, medications containing such powerful agents as indomethacin, diclofenac, ibuprofen, and piroxicam are widely used. They are usually used 3-4 times a day, squeezing 4-8 cm out of the tube, depending on the size of the affected joint. Often, the optimal effect can be achieved using combination drugs containing ingredients with different mechanisms of action. One such successful combination is Dicloran Plus. It contains three anti-inflammatory components (diclofenac, methyl salicylate, linseed oil) and menthol, which has a local irritant effect. Menthol has a so-called “cooling” effect - due to irritation of cold receptors. A number of drug studies have shown that “cooling” gels containing menthol have significant analgesic activity and help to shorten the period of swelling and dysfunction when compared with placebo. Diclofenac and methyl salicylate are among the classic NSAIDs that achieve their effect by inhibiting the activity of cyclooxygenases, leading to a decrease in the synthesis of prostaglandins, which reduces swelling and infiltration of inflamed tissues. At the moment, according to FDA (USA) experts, only drugs containing methyl salicylate, menthol and capsaicin can be considered undeniably effective as analgesics. A-linolenic acid, which is part of flaxseed oil, binds activated cyclooxygenases at the site of inflammation. In the presence of significant exudative manifestations of the inflammatory process, the method of choice is intra-articular injection of GC. It is also practiced for both inflammatory and degenerative joint changes. It should be noted, however, that secondary synovitis is generally more resistant to the action of hormones and clinical improvement is often not long-lasting. For injection into joints, microcrystalline suspensions of poorly soluble hormonal drugs are used, which can be deposited in the affected joint for up to 3 weeks. As a result of the gradual dissolution of hormonal compounds deposited in the joint, a constant supply of a sufficient amount of medicine directly to the site of inflammation is ensured. The effect of GCs introduced into the joint cavity is mediated by interaction with the corresponding receptors of cells infiltrating the synovium and participating in the development of synovitis. The effect of HA on joint tissue largely depends on the dose and frequency of administration. Frequent injections of high doses of hormones in the experiment contributed to the development of degenerative changes in articular cartilage. At the same time, sporadic intra-articular injections of these drugs may have a chondroprotective effect. Therefore, in clinical practice, the injection of HA into the same joint is allowed no more than 3–4 times a year. The number of injections into different joints is not particularly regulated. However, they should not be performed too often and regularly. Otherwise, local therapy will actually become an analogue of systemic hormonal treatment, since the drug is constantly absorbed from the joint cavity into the bloodstream and provides, in addition to local, a noticeable systemic effect. The anti-inflammatory effect of GCs introduced into the joint is usually quite pronounced. The duration of the improvement achieved can vary within very wide limits. It depends both on the properties of the drug and on the characteristics of the course of inflammation in each specific case. The effectiveness of the drug directly depends on the solubility of the microcrystalline suspension. Reduced solubility increases duration of action and increases effectiveness. Currently, triamcinolone compounds (hexacetonide and acetonide) have the most long-lasting effects [3]. The lack of effectiveness of intra-articular injections in many cases may be associated with relative resistance to the action of GCs due to the production of a large number of pro-inflammatory cytokines at the site of inflammation. To avoid the unwanted effects of inflammatory stimulants that accumulate in the joints during chronic synovitis, the exudate is removed before administering the drug. However, proliferative changes forming in the joint and fibrin clots often prevent the full evacuation of the synovial fluid. Therefore, in a number of cases, it is not possible to completely remove it with a joint puncture and the pro -inflammatory factors remaining in the joint cavity impede the effect of the drug. The almost complete removal of inflammatory exudate can be achieved when the joint washes with a large amount of fluid during the AC. This method provides sufficient fluid intake into all parts of the joint and free evacuation of the contents of the joint cavity. In most patients with chronic arthritis, the joint washing with AS already in itself ensures a significant decrease in inflammatory changes. However, this effect is usually unstable. Introduction after washing the Civil Code gives significantly more favorable results. The clinical improvement achieved with intra -articular administration of the Civil Code after the AC is longer in most patients than with traditional local steroid therapy. We evaluated the effect of pre -washing the joints with AC on 55 knee joints of patients with RA. In 27 of them, the Civil Code was introduced in the traditional way after removing the exudate. 28 Before the introduction of the Civil Code were washed at the AC. 3 and 6 months after treatment, the decrease in arthralgia in these patients was significantly more significant than in the control group. A significant decrease in pain in the knee joints is observed after AS and in patients of OA [5]. Moreover, in contrast to chronic arthritis, the introduction into the joint of the Civil Code after AS in patients of the OA is not required. This phenomenon was noted even more than 50 years ago and is due, apparently, by a decrease in inflammatory changes characteristic of this disease. Rinsing the knee joints with AS allows you to remove the bulk of cartilage detritus and crystals from them. The elimination of these stimulants of inflammation can lead to a decrease in synovitis activity and a decrease in the severity of pain. It is also possible that such treatment can reduce the production of enzymes involved in the development of joint cartilage destruction, thereby slowing down the progression of the disease. The clinical effect of the AC largely depends on the technical features of its implementation. Thus, the authors who studied the results of the AC when using various volumes of fluid for its conduct, note that washing the knee joints with 3 liters of liquid gave a more favorable effect than 250 ml. The amount of detrit, removed during the procedure, also correlates with the degree of reduction in the severity of pain syndrome [7]. The favorable effect observed in patients with the joints after washing the joints at the AC prompted some researchers to use a simplified rinse procedure using puncture needles for the treatment of this disease. The results of such treatment are evaluated ambiguously. According to some authors, this procedure is no less effective than washing the joints with AS and gives a longer clinical improvement than the intra -articular introduction of the Civil Code. Others believe that it does not differ significantly from placebo [2]. Probably, in patients of the OA, as in chronic arthritis, the effect of washing largely depends on its technical characteristics. AS allows you to achieve significantly more complete removal of cartilaginous detritus and crystals from the cavity of the affected joint than washing through puncture needles. Therefore, despite the greater technical complexity, this procedure seems more promising than a simplified washing option. Literature 1. Panasyuk E.Yu., Tsvetkova E.S., Olyunin Yu.A., Smirnov A.V. Arthroscopy in the diagnosis of gonarthrosis. Scientific and practical rheumatology 2000, No. 2, p. 12–17. 2. Bradyy JD, Heilman DK, Katz BP, GSELL P, WALLICK JE, Brandt KD. Tidal Irrigation As Treatment for Knee Osteoarthritis: A Sham - Controlled, Randomized, Double - Blinded Evaluation. Arthritis Rheum. 2002 Jan; 46 (1): 100–8. 3. Centeno LM, Moore Me Preferred Intraarticolar Corticosteroids and Associated Practice: A Survey of Members of the American College of Rheumatology 4. Choyi Ehs, Panayi Gs Cytokin E PathWays and Joint InflamMatio in Rheumatoid Arthritis. New England Journal of Medicine, 2001, 344, 12, 907–916 5. Edelson R, Burks RT, BloEbaum RD, Short - Term Effects of Knee Washout for OsteartHritis. Am J Sports Med 1995, 23 (3), 345–9 6. Ghosh P, Smith M. Osteoarthritis, Genetic and Molecular Mechanisms. Biogerontology, 2002, 3, 85–88 7. Kalunian KC, Moreland LW, Klashman DJ, Brion PH, Concoff Al, Myers S, Singh Rw, Seeger LL, Rich E, Skovron Ml. Visually - Guuided Irrigation in Patience with Early Knee Osteoarthritis: A Multicenter Randomized, Controlled Trial. Osteoarthritis Cartilage. 2000 nov; 8 (6): 412–8. 8. Lindblad S., Hedfors E., Malmborg As Rifamycin SV in Local Treatment of Synovitis - A Clinical, Arthroscopic and Pharmacolagical Evaluation. J. RHEUMATOL. 1985, 12, 5, 900–903 9. Paus Ac, Pahle Ja Arthroscopic EvalUration of the Synovial Lining Before and Inter Open Synovence of the Knee Joint In Patys with Chronic INFLAMATORY JOIN T Disease. Scand J. Rheumatol. 1990, V. 19, p. 193–201. 10. Zscchabitz A., Neurath M., Grevenstein J. et al. Correlative Histologic and Arthroscopic Evalving in Rheumatoid Knee Joints. SURG ENDOSC. 1992, V. 6, p. 277–282.

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