Chronic synovitis in rheumatology. Assessment of activity and treatment tactics

The lower limbs are subjected to high loads, performing shock-absorbing, supporting and motor functions. Diseases of the leg joints lead to decreased performance and a deterioration in the patient’s quality of life.

MRI image of the knee joint

Timely diagnosis of inflammatory processes contributes to effective treatment and helps prevent the development of serious complications. MRI shows synovitis of the knee joint in the initial stages, visualizing changes in the joint capsule.

Magnetic resonance imaging is a safe, non-invasive type of hardware research. Scanning is carried out using an induction field that affects the arrangement of hydrogen atoms in water dipoles. The reaction of tissues directly depends on the saturation of cells with fluid. The obtained data is sent to the computer monitor in the form of layer-by-layer images of the area of ​​interest.

Types of disease

Synovitis is divided into two large groups - non-infectious and infectious. Among the non-infectious ones we can highlight:

• traumatic: caused by excessive physical exertion and injuries during sports;
• allergic: caused by taking medications, exotic fruits or any other contact with an allergen (plant pollen, animal dander);
• neurogenic: occurs due to severe stress or neurological diseases;
• endocrine – provoked by endocrinological pathologies (diabetes mellitus).

Infectious synovitis can be caused by pathogenic microorganisms that provoke inflammation in the synovial membrane with spread to soft tissue. It can also result from a complication of a purulent-inflammatory process already present in the body.

Depending on the nature of the course, there is an acute form, which develops rapidly, and a chronic form, with gradually increasing symptoms.

In acute synovitis, a change in the shape of the joint can be observed; it increases in volume in just a few hours or days, swelling and thickening of the synovial membrane appear. Acute synovitis is characterized by:

• moderate increase in body temperature;
• pain on palpation;
• the appearance of clear or translucent fluid in the joint cavity.

A person feels aching and bursting pain, weakness and malaise. Movement in the joint is limited.

With chronic synovitis, clinical symptoms are mild. The patient may complain of fatigue, fatigue while walking, aching pain that is constant, and minor discomfort when moving. In this case, all metabolic processes and blood circulation are disrupted.

The diffuse type of giant cell tumor (pigmented villous nodular synovitis) and giant cell tumor of the tendon sheath (benign synovioma, tenonodular synovitis) are usually monoarticular proliferative processes localized in the synovial membranes of the joints and tendon sheaths. Three forms of synovitis have been identified: isolated tendon sheath injury (giant cell tumor of the tendon sheath), solitary intra-articular nodule (localized nodular synovitis), and diffuse involvement of synovial tissue, often with villi formation and pigment deposition (diffuse giant cell tumor type). These three forms of synovitis have significant similarities in their histological appearance and biological behavior. The diseases are rarely polyarticular, do not metastasize, and can cause bone erosion. They occur mainly in the third and fourth decades of life, with equal frequency in men and women. The knee joint, fingers, and toes are most often damaged; rarely - hip, elbow, shoulder, wrist joints. Cytogenetic studies that have shown the presence of aneuploidy and chromosomal aberrations in patients with pigmented villous nodular synovitis most likely indicate the neoplastic nature of the pathological process.

Clinical picture. Pain, swelling of the affected area, limitation of movements.

X-ray - the bone is usually not changed, there are foci of destruction when they grow into the bone (up to 10% of cases); changes characteristic of osteoarthritis.

Pathomorphology.

Macroscopically, in the diffuse form - compaction of the synovial membrane, in the nodular form - single or multiple nodes (up to 3-4 cm in diameter), usually encapsulated; when cut, the fabric is grayish-ocher to brownish-brown (iron deposits); the growth of the formation is not into the cavity of the joint or tendon sheath, but outward from them.

Microscopy. Two types of cells predominate - histiocyte-like cells and collagen-producing synovial fibroblasts (these cells proliferate under the synovial membrane); the presence of giant multinucleated cells is characteristic; hemosiderin grains are often visible in the cytoplasm of histiocyte-like cells; lymphocytes, xanthoma cells, etc. are also found; fibrosis (sometimes hyalinosis) of the stroma, formation of pseudosynovial clefts.

Differential diagnosis. Chronic synovitis in rheumatoid or traumatic arthritis, fibroma, uric acid gout, synovial sarcoma, hemangioma, hemangiopericytoma.

Treatment. The main treatment method is surgery.

The outcome is favorable; after surgical treatment, relapses develop with giant cell tumor of the tendon sheath in up to 30% of cases, with pi

Main symptoms

With synovitis, most often only one joint is affected, but sometimes the disease is multiple.

The main symptoms of synovitis can be considered:

• increase in volume and smoothing of the contours of the joint;
• pain during exercise;
• pronounced swelling of soft tissues;
• difficulty moving;
• skin hyperemia;
• chills and general malaise.

If we talk about infectious synovitis, it almost always begins acutely: the patient feels severe throbbing pain, and the body temperature rises sharply. After some time, the knee joint swells, signs of general intoxication of the body appear: weakness, drowsiness, headache, nausea and even vomiting.

The non-infectious form develops quite slowly. First, the synovial membrane, which lines the joint capsule from the inside, becomes inflamed and also produces synovial fluid (synovium). The first sign is a feeling of discomfort in the area of ​​the affected knee joint, as well as pain during exercise. Swelling gradually appears, and painful sensations increase.

If you find yourself with such symptoms, then do not self-medicate, but immediately make an appointment with a doctor.

Causes of synovitis

Synovitis is divided into two groups - aseptic and infectious. Aseptic factors include traumatic, neurogenic, allergic factors and endocrine disorders. Infectious synovitis can be caused by pathogenic microorganisms that cause specific (pathogens - tuberculous mycobacteria) and nonspecific (pathogens - staphylococci, streptococci, pneumococci) inflammatory processes in the area of ​​the synovial membrane. Pathogens can enter it from the environment through the wound surface by contact, as well as by lymphogenous or hematogenous routes from the source of infection inside the body.

Diagnostic methods

To identify the cause of the pathology and make an accurate diagnosis, it is necessary to conduct a comprehensive diagnosis. After collecting anamnesis and systematizing the data obtained about the patient’s complaints and previous diseases, a visual examination is carried out. In this case, the injured knee is palpated, the gait and the patient’s ability to straighten the joint are analyzed. The patient is asked to do:

• Puncture.
  In this case, the surgeon numbs the pain, and then pierces the joint cavity with a thin needle, collecting the synovium. In laboratory analysis, attention is paid to the color, transparency and viscosity of the liquid. Next, it is subjected to microscopic and cytological examination to determine the cause of inflammation. The results obtained make it possible to choose the right treatment tactics.
• MRI.
  Using this method, you can see the structure of the synovial membrane. If there is liquid, the device allows you to estimate its quantity. Thanks to MRI, the specialist will receive a detailed description of the functionality of the joint, as well as information about the condition of the surrounding tissues, blood vessels, and nerve fibers.
• Ultrasound.
  Used to visualize changes in the thickness of the inflamed synovium. This is one of the signs of synovitis activity. At the same time, it is possible to examine in detail the structure of soft tissues and detect the pathological process at an early stage.
• Arthroscopy.
  This therapeutic and diagnostic procedure makes it possible to examine the affected joint, differentiate the nature of the lesion, and also study the relief of the synovial membrane along its entire length.

Based on these data, the specialist determines the diagnosis, clarifies the form and degree of development of the disease, and prescribes treatment.

Causes

Damage to the synovial membrane by the inflammatory process is a problem that not all people face during their lives. Doctors identify a number of factors that contribute to the development of the disease.

1. Injuries

Among the main reasons for the development of the disease are traumatization. Most often, synovitis is caused by sprains and ruptures of ligaments, and fractures in the ankle joint.

1. Birth defects

Often in the practice of an orthopedic traumatologist there are congenital defects that contribute to the development of the disease. This could be, for example, hallux valgus or flat feet. In this case, the load is distributed incorrectly, which leads to inflammation.

1. Diseases

Osteochondropathy of the talus. As a result, the articular surfaces are deformed, and a free osteochondral articular fragment may form. The above factors cause synovitis.

1. Shoes

Incorrectly chosen shoes can contribute to the development of symptoms of synovitis. For this reason, the disease affects women who are forced to wear high-heeled shoes, due to which the load on the ankle joint is very high.

1. High physical activity

Another important factor is intense physical activity. The joint does not have an infinite reserve of strength, and sooner or later its functionality begins to decline, which leads to the appearance of unpleasant symptoms.

Statistics

PVUS accounts for about 1% of all joint diseases, and is somewhat more common in women. The predominant age for detection of pathology is 2-3 decades, less often - children and old age. The disease is monoarticular. Any joint can be affected, but the predominant localization is the knee (80% of all cases).

Etiology and pathogenesis.

In the first report about PVUS, owned by Ch. M.E. Chassaignac (cited from P. Byers et al., 1968), who in 1852 described damage to the tendon sheaths of two fingers, suggested the sarcomatous nature of the process. In subsequent years, the disease was described under various names, but always with the addition of the suffix “oma”. A number of authors [Chistova P. M., 1971, 1973; Jaffe H. et al., 1941; WyllieJ., 1969] obtained data confirming, in their opinion, the inflammatory nature of the disease.

At present, the tumor nature of the process and the possibility of its malignancy are completely excluded. Features of the ultrastructure of xanthoma “foamy” cells, which, along with fibroblastic ones, are the most numerous elements, allow us to suggest that the basis of the pathology is a local disorder of lipid metabolism [Rodionova S. S., 1981; Mikhailova L.N. et al., 1983]. In this case, the phenomena of inflammation develop secondarily, since an admixture of segmented and plasma cells is not always present. In addition, data have been obtained [Rodionova S.S., 1981] on the development of a delayed-type hypersensitivity reaction in PVUS, and therefore the participation of altered immunological reactivity in the pathogenesis of the process cannot be ruled out.

The spread of pathological tissue into the bone occurs along the nutrient canals. The primary cause of the spread is an increase in intra-articular pressure due to excessive growth of pathological tissue. More frequent bone damage when PVUS is localized in the hip and ankle joints is due to a well-developed capsular-ligamentous apparatus, which prevents capsule stretching.

The accumulation of tissue at different depths in the bone leads, due to pressure, to microfractures of the adjacent bone beams and the formation of cavities of different sizes filled with altered synovial tissue. A certain role in the spread of the process into the bone and the formation of cavities is played by lytic enzymes secreted by macrophages, the activity of which is increased not only in the joint effusion, but also in the affected synovial tissue [Rodionova S. S., 1981].

Treatment

Treatment of synovitis can be different, depending on the causes of the disease and the severity of its course. For simple inflammation of the synovial membrane, conservative treatment is carried out at home or in the hospital:

• The affected leg is tightly bandaged with elastic bandages or a plaster cast is applied, ensuring rest for the joint. It is recommended to use crutches or a cane when walking.
• Physiotherapy is prescribed, for example, UHF therapy.
• Anti-inflammatory therapy is prescribed.
• If a lot of fluid accumulates in the joint, then a puncture is performed - a puncture with a needle - during which the pathological contents are removed and medications are injected into the joint
• The cause of synovitis identified during arthroscopy is eliminated (therapeutic athroscopy is performed).

The high efficiency of patient treatment in the multidisciplinary CELT clinic is ensured by a combination of modern equipment, progressive treatment regimens and experienced, highly qualified personnel.

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Recovery

1. One of the most important tasks of the postoperative period is to restore the full range of motion in the joint. For this purpose, already from the 2nd day after surgery, patients begin isotonic training of the muscles of the limb, and from the 5th day - to active movements in the joint.
2. If the knee joint is affected, development is carried out using a Beler splint or a CITO splint. The number of movements is increased gradually, and at the same time the amplitude of movement is increased. The development is carried out during the day for 15 minutes every hour, in addition, laying is prescribed in the position of the maximum achieved flexion or extension.
3. Physical therapy is carried out under the guidance of a methodologist, but in order to achieve complete restoration of movement, the patient’s psychological disposition to constantly work independently throughout the day is necessary. The absence of this attitude in children often leads to poor functional results. In this regard, treatment of the diffuse form of PVUS in children is recommended over the age of 14 years.
4. To prevent the formation of scars, during the 1st week the area of ​​the surgical wound is punctured and the hematoma is removed, pyrogenal is prescribed according to the generally accepted scheme, and after the sutures are removed, exercises are carried out in the pool.
5. Regardless of the location of the PVUS, static unloading of the joint is carried out for 1.5-2 months after surgery, patients move only with the help of crutches, then gradually switch to walking with a cane. Static unloading creates favorable conditions for capsule restoration and prevention of aseptic necrosis.
6. The use of radiation therapy in the postoperative period is based on the idea of ​​radiosensitivity of actively proliferating tissue. The goal of radiation therapy is to affect the synovial tissue of transition zones (the area of ​​​​the articulating surfaces of bones where altered synovial cells remain), as well as pathological tissue that may remain in the lumen of the nutrient canals, at different depths in the bone tissue.
7. Radiation therapy is carried out in radiology departments 3 weeks after surgery. The boundaries of the radiation fields should correspond to the preoperative stretching of the joint capsule or slightly exceed it. Single dose 1.5-2 Gy, total - 18-19 Gy. In those rare cases when pathological tissue extends beyond the fibrous membrane (possibly due to long-term existence of the disease), the total focal dose is increased to 21-23 Gy.

With PVUS of the hip joint, due to anatomical features (danger of impotence) and the extensiveness of marginal resections of the bones forming the joint (increases the risk of post-radiation necrosis), radiation therapy should be used extremely carefully. During the irradiation period, static unloading continues, and patients must intensively engage in exercise therapy. The course of pyrogenal started after the operation also continues. The use of combined treatment eliminates the recurrence of the process.

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Diagnostics

Synovitis of the ankle joint does not begin to be treated until the diagnosis is confirmed. The following diagnostic methods are used in combination, which allows you to make an accurate diagnosis and eliminate errors:

1. Visual assessment

Inspection of the joint is a mandatory stage of the diagnostic search. Moreover, it is assessed not only at rest, but also in motion. For example, when walking or performing any simple actions.

1. Instrumental techniques

Sometimes the swelling of the surrounding tissues is so severe that it becomes difficult to evaluate the joint. In this case, ultrasound, MRI, and radiography are used as auxiliary measures.

MRI of the ankle

1. Performing a puncture

The method of obtaining intra-articular fluid is not only diagnostic, but also therapeutic. On the one hand, the doctor can evaluate the bacterial composition of the synovial fluid and identify the infectious agent, if any. On the other hand, excess fluid that interferes with normal functioning is removed from the joint cavity, which alleviates the symptoms of the disease.

Only after the doctor is confident in the diagnosis will he begin to choose the optimal treatment.

Conservative therapy

In the treatment of synovitis of the ankle joint, it is first necessary to try to stop the pathological condition using conservative techniques. For this:

• the patient is taught to properly fix the affected joint to reduce the load;
• carry out physiotherapeutic measures that will help relieve inflammation and improve regeneration processes;
• select medications that can relieve pain and eliminate swelling of the affected area;
• after the onset of stable remission, courses of physical therapy are recommended to improve joint mobility and prevent relapses of the disease.

Puncture of joint fluid can also be part of conservative therapy. By removing excess fluid, the functionality of the joint can be improved. However, puncture is a measure that gives only temporary results. Treatment in any case should be aimed at eliminating the causes of the pathology. For example, it may be necessary to clear up an infection with antibiotics or fight an autoimmune process.