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The authors present a case of particulate synovitis due to a silicone hemi-implant. Other names for this condition are silastic detritic synovitis and silastic foreign body synovitis. Small, free pieces of silastic cause inflammation of the synovial tissues. A literature review also is presented.
Prosthetic arthroplasties are performed frequently in arthritic patients. The usual causes of prosthetic failures are loosening, infection, subluxation, or fracture. A 65-year-old man with total knee arthroplasty illustrates the complication of prosthetic synovitis developing 5 years after metal-polyethylene arthroplasty. Double contrast arthrography revealed nodular synovial filling defects. Arthrotomy and hematoxylin-and-eosin-stained histological sections of the synovium showed nonpigmented villonodular synovitis (VS). Giant cells and polyethylene particles were observed by polarized light within the synovium.
OBJECTIVE: Tenascin is an extracellular matrix glycoprotein with effects on cell adhesion, cell migration, and lymphocyte activation. We proposed to identify the expression of human tenascin messenger RNA (mRNA) and protein in inflammatory synovitis and in normal synovium, and to identify potential regulatory cytokines. METHODS: Immunohistochemistry and in situ hybridization were used to identify the expression of tenascin in synovium. Northern blot analysis of RNA and both immunoblot analysis and enzyme-linked immunosorbent assay of proteins were used to identify tenascin in synovial cell cultures. RESULTS: Tenascin was found along the synovial lining layer and in perivascular areas of normal synovium. In inflammatory synovitis, tenascin protein and mRNA expression were shown to be increased in the synovial lining layer, in perivascular areas, in lymphoid aggregates, and in areas of fibrosis. Interleukin-1, a major mediator of tissue injury in inflammatory synovitis, induced tenascin expression and deposition in primary synovial fibroblast cultures. CONCLUSION: Tenascin mRNA and protein are increased in inflammatory synovitis, and interleukin-1 is an inducer of tenascin in synovial fibroblasts. This identifies a new pathway by which interleukin-1 alters the extracellular matrix composition in synovitis. Since tenascin has effects on lymphocyte activation and cell adhesion, the induction of tenascin in inflammatory synovitis may play a role in the pathophysiology of arthritis.
Specific - pathogen - free chickens were inoculated in the right tibiometatarsal joint with a synovitis-derived Mycoplasma synoviae strain before or during dexamethasone treatment. Development of synovitis in chickens inoculated during the drug treatment was apparently delayed in comparison with development of synovitis in non-treated chickens. Severity of clinical synovitis in chickens inoculated before the drug was given was apparently less than that in chickens not treated or in chickens treated with dexamethasone. Histopathologic changes in the early stage of the infection (1 to 2 weeks) were not modified by dexamethasone treatment, although those changes in the succeeding stage (6 to 7 weeks) were greatly lessened. A relationship was observed between the dosage of dexamethasone and the severity of synovitis, as well as the kinds of cells that infiltrated into the joint lesions. Although serum antibody titers in chickens treated with an excessive dose of dexamethasone were markedly lower, clinical, bacteriologic, and histopathologic observations in chickens treated with dexamethasone were similar to those previously found in surgically thymectomized chickens. These results may support the theory that multiple synovitis of chickens caused by M synoviae infection develops mainly because of an immune response, especially by thymus-dependent functions.
A number of laboratory variables, including Hb., ESR and several phase proteins, fluctuated in concord with the clinical signs of synovitis activity in patients with rheumatoid arthritis during a controlled study of 3 disease-modifying anti-rheumatic drugs (DMARD). The correlation between laboratory variables and clinical synovitis was significant in a large patient population but the correlation coefficients were not of such magnitude that any of the laboratory variables reflected clinical synovitis activity in a reliable manner in the individual patients. In patients treated with azathioprine, the response of the Hb, (and consequently of the ESR), was reduced compared to patients given other DMARD. This phenomenon was caused by the bone marrow suppressing effect of azathioprine. However, the effect of azathioprine on the clinical synovitis activity did not differ from that of the 2 other drugs. Similar results were found by reviewing the literature about controlled trials of DMARD. In the present trial the clinical evaluation was performed under optimal conditions. In daily clinical practice the evaluations of the joints may be less than optimal since they may be performed by different rheumatologists with varying experience. Consequently, it may be difficult to do without the unreliable laboratory variables mentioned in the routine assessments of disease activity, unless the quality of routine evaluations of synovitis activity is improved considerably.
It has been suggested that incorporation of shards of fibrillated cartilage into the synovium is a cause of synovitis in osteoarthritis (OA). We examined the prevalence with which fragments of cartilage are seen in synovium, and their association with synovitis, in patients with endstage OA and early OA of the knee. Samples of synovium were obtained from 12 patients with endstage OA who were undergoing knee joint replacement and 30 with only mild/moderate radiographic changes of OA who exhibited articular cartilage changes of OA at arthroscopy. The presence of cartilage shards was sought in synovium from the medial and lateral tibiofemoral compartments and the suprapatellar pouch of each patient. Comparable volumes of the synovial lining from patients with endstage and early OA were examined, and tissue mononuclear cell infiltration was graded as an indicator of synovitis. Cartilage shards were seen in synovium from 7 of 12 patients with endstage OA, all of whom had synovitis. No topographic relationship was found between shards and mononuclear cell infiltration. In contrast, cartilage fragments were not seen in synovium from any of the 30 patients with early OA, although 9 of them had full thickness cartilage ulcers and 17 had evidence of synovitis.
A correlation between pain scores by questionnaire and synovitis index via arthroscopic inspection was made in 28 patients with internal derangement of the temporomandibular joint (TMJ) with closed lock. A statistically significant but weak correlation was found between the visual analog scale of pain and the index of distribution of synovitis. However, in the questionnaire, pain on chewing had a positive correlation with both the intensity and distribution of synovitis in the TMJ. This study indicates that synovitis is one cause of TMJ pain in patients with closed lock.
It is not always easy to diagnose certain types of monoarthritis of the knee joints. In such cases, it is essential to evaluate the condition of the synovitis both macroscopically and microscopically, as the synovial appearance (synovitis) closely reflects the pathological condition (arthritis) of the knee joints. Arthroscopy is an excellent tool for visualizing and evaluating the condition of the synovium macroscopically. On arthroscopic examination, precise evaluation of the villi often provides clues, enabling accurate diagnosis. In addition, histological sections obtained from biopsy specimens in various cases of synovitis give significant information. In this article, arthroscopic observation and histological sections of various cases of synovitis are compared, and the diagnostic value and limitations of arthroscopic examination are discussed.
STUDY OBJECTIVE: To determine the diagnostic value of screening laboratory and initial body temperature data in differentiating septic arthritis of the hip from transient synovitis of the hip in children who present to the emergency department with a complaint of hip pain. DESIGN: Retrospective review of cases of septic arthritis of the hip and transient synovitis of the hip in a 1:2.5 ratio. SETTING: An urban regional children's hospital with 20,000 annual ED visits. RESULTS: Ninety-four children with transient synovitis of the hip and 38 children with septic arthritis of the hip were identified. The children with septic arthritis of the hip had a significantly higher initial temperature (38.1 C versus 37.2 C, P = .000014), mean erythrocyte sedimentation rate (44 mm/hr versus 19 mm/hr, P = .000001), and mean WBC count (13,200/mm3 versus 11,200/mm3, P = .02). However, the degree of overlap in these variables was large. The combination of an erythrocyte sedimentation rate of more than 20 mm/hr and/or a temperature of more than 37.5 C identified 97% of all cases of septic arthritis of the hip. CONCLUSION: There is clinically significant overlap in the erythrocyte sedimentation rate, temperature, and WBC count in children with septic arthritis of the hip versus transient synovitis of the hip. All children with an irritable hip without a clearly identified source who have an erythrocyte sedimentation rate of more than 20 mm/hr or a temperature of more than 37.5 C should be considered for diagnostic hip aspiration.
This study details the immune response to cartilage proteoglycan in experimental chronic IgG-induced immune synovitis. Antibodies reactive with purified rabbit proteoglycan monomer were observed in nine of nine rabbits with immune synovitis. IgG-immunized but nonsynovitic control animals with no pathology showed no antibody response. A panel of murine monoclonal antibodies with defined specificity towards rabbit proteoglycan were utilized to characterize the epitope specificity of the immune synovitis polyclonal anti-proteoglycan response. One murine monoclonal antibody, 6C11, inhibited the binding of the polyclonal antisera to proteoglycan in all nine animals with significant (greater than 40%) inhibition in six of nine rabbits. Further inhibition studies utilizing DEAE-cellulose-resolved proteoglycan tryptic peptides revealed that peptides poor in chondroitin sulfate were strong inhibitors of binding of the polyclonal antibodies to the proteoglycan substrate. In particular, keratan sulfate-containing tryptic peptides were most inhibitory on a per weight basis. These results indicate that, in chronic IgG-induced immune synovitis, anti-proteoglycan antibodies elicited are heterogeneous with regard to specificity, but a relatively large proportion predominantly recognized a portion of the proteoglycan molecule containing core protein and associated keratan sulfate.
Data have been analysed from a retrospective review of 151 patients with monarthritis of more than 3 months' duration, usually involving the knee joint. The largest group, 49 patients (32%), had synovitis of unknown cause, 44 (29%) had synovitis probably associated with osteoarthrosis and 13 (9%) were diagnosable at presentation as having rheumatoid arthritis according to American Rheumatism Association (1959) criteria, which include serological and histological findings. There was only one case of tuberculous synovitis. Twelve of the thirteen patients diagnosed as rheumatoid arthritis developed involvement in other joints. In most other conditions, however, including synovitis of uknown cause, the prognosis was favourable, with either improvement or complete remission.
We used ultrasonography to examine 36 children suffering from transient synovitis and 12 children with early Perthes' disease. Widening of the joint space was revealed by ultrasonography in all affected hips with either disease. In the patients with transient synovitis, capsular distension was attributed to synovial effusion, while in the patients with Perthes' disease it was produced by thickening of the synovial membrane. Neither capsular distension nor thickening of the joint cartilage was seen in the contralateral normal hip in the patients with transient synovitis, but they were common in early Perthes' disease. Ultrasonography may provide significant diagnostic clues to differentiate early Perthes' from transient synovitis.
Four patients are described with documented coccicioidal synovitis of the knee joint. In two of them, no previous diagnosis of coccidioidomycosis had been made prior to diagnosis of coccidioidal synovitis. The other two had active disease after courses of amphotericin B administered both parenterally and intra-articularly for disseminated coccidioidomycosis and coccidioidal synovitis. After synovectomy and limited parenteral amphotericin B therapy, none of the four patients whos evidence of active synovial infection two to seven years later. Synovectomy appears to be an important aspect of the optimal therapy of coccidioidal synovitis of the knee, and when performed, the parenteral dosage of amphotericin B can be limited. Intra-articularly administered amphotericin B is also advocated when possible.
Twenty-five patients who had had a diagnosis of pigmented villonodular synovitis of the knee were followed for an average of four and one-half years (range, two to ten years) after arthroscopic treatment. Five patients had had localized lesions and had been managed with local resection; all five had improvement, with no apparent recurrence. The remaining twenty patients had had diffuse disease. Of these twenty, eleven had had a complete arthroscopic synovectomy. All eleven had definite improvement in pain and function, and almost all had a decrease in synovitis and an increase in the range of motion of the knee; the disease recurred in only one. The other nine patients had had a partial arthroscopic synovectomy. Although most had some improvement in function and range of motion and a decrease in pain and synovitis, the disease recurred in five of the nine. Thus, in the patients who had had diffuse pigmented villonodular synovitis, the rate of recurrence was lower in those who had had a complete arthroscopic synovectomy than in those who had had a partial arthroscopic synovectomy (p = 0.01).
Little is known about transient synovitis of the hip in the community. Using data from the Dutch national survey of morbidity and interventions in general practice, a study was undertaken to look at the incidence and management of transient synovitis of the hip in children under 15 years of age. Transient synovitis of the hip was diagnosed in 19 children, 17 of whom were new cases. The mean age of the children was six years six months with a sex ratio of 2.8:1.0 boys to girls. An incidence rate of 1.1 per 1000 person years was calculated. General practitioners prescribed drug treatment for six children and bed rest was advised for six children. Two children were referred for an x-ray examination. Clear follow-up arrangements were made for 16 of the 19 children. It appears that general practitioners preferred to adopt a wait-and-see approach to transient synovitis of the hip rather than referring children for diagnostic ultrasound or x-ray examination.
A case is described of post-traumatic subacute synovitis of a finger exhibiting pseudo-tumoral appearance and radiographic bony changes. Arteriography showed non-malignant hypervascularisation suggesting a benign synovial tumour. Biopsy established a diagnosis of simple subacute synovitis. The swelling regressed spontaneously over the subsequent months. In the case of simple post-traumatic subacute synovitis differential diagnosis should take into account the possibility of villonodular synovitis which involves histiocyte proliferation.
Pigmented villonodular synovitis is a benign disease of the synovial membrane of joints, tendon sheaths, or bursae, which nevertheless can cause marked local destruction. Its diagnosis is often delayed because complaints and symptoms are nonspecific. Familiarity with the disease may ensure an earlier diagnosis and consequently early onset of therapy, which may prevent serious damage. This paper describes 18 patients suffering from localized or diffuse pigmented villonodular synovitis. Findings possibly suggestive of pigmented villonodular synovitis include hemarthrosis, soft tissue swelling, radiological evidence of cyst formation at a distance from the weight-bearing area of a joint, an increased triglyceride concentration, and a positive bone scan. A normal appearance on arthroscopy does not rule out the disease. Therapeutic results are better in the localized than in the diffuse form of the disease.
In a nonhemophilic 72-year-old man, a persistent degenerative hemarthrosis of the shoulder joint was associated with a complete tear of the rotator cuff. Extensive, rusty synovial pigmentation and hyperplasia (hemosiderotic synovitis) mimicking pigmented villonodular synovitis (PVS) were noted at surgery. Spontaneous hemarthrosis of the shoulder includes rapid onset of severe pain, limitation of movement, subsequent appearance of a bruise on the affected shoulder and arm, and radiological evidence of joint degeneration. Hemosiderotic synovitis results from chronic intraarticular bleeding. With the breakdown of trapped hemoglobin, iron-containing hemosiderin is stored in synovial tissue producing rusty discoloration and proliferative reaction. The classic cytoarchitecture of PVS has additional subsynovial nodular proliferation of mononuclear cells. Hemarthrosis may produce significant structural alteration of joints. Its prompt recognition and the awareness of underlying causes should lead to earlier diagnosis, appropriate therapy, less joint destruction, and better outcomes.