Chronic synovitis in rheumatology. Evaluation of activity and treatment tactics. proliferative synovitis of the knee proliferative synovitis
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For citation: Olyunin Yu.A. Chronic synovitis in rheumatology. Evaluation of activity and treatment tactics // BC. 2005. No. 8. S. 548
Among the various manifestations of chronic diseases of the joints, synovitis occupies a leading place. The inflammatory process developing in the synovial membrane determines the main features of the clinical picture and is the driving force behind the progression of the disease. It is a reaction of the body to a pathogenic stimulus, which is realized through the transformation of synovia into a kind of organ of immune defense. At the same time, functionally active cells of inflammatory infiltrates are formed not due to 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 the proliferation of stromal elements and synovial blood vessels. Over time, the thin shell of the joint turns into a fairly powerful tissue array. 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 variants 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 an antigen-presenting cell. The cell that recognizes the antigen processes it and presents it to the T-lymphocyte, triggering the synthesis of pro-inflammatory 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 in the joint (fragments of proteoglycan and collagen molecules, chondrocyte membranes, etc.). 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 synovial membrane. The morphological picture of secondary synovitis as a whole does not differ fundamentally from the 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 in itself the result of a destructive process. However, he, in turn, is able to aggravate the destruction of the joint. Therefore, the 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, systemic treatment often does not adequately stop local inflammatory activity, and synovitis proceeds 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 focus of inflammation. At the same time, the tactics of therapeutic measures is 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 inherent in both primary and secondary synovitis. The formation of pain syndrome in inflammatory and degenerative diseases of the joints 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 register the intensity of pain. The simplest of these is the arthralgia score, which usually provides for 5 degrees of symptom severity (0 - no pain, 1 - mild, 2 - moderate, 3 - severe and 4 - very severe pain).
It is somewhat more difficult to assess pain on a visual analog 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 the absence of pain. The extreme 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 the pain syndrome, 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 must be taken into account when determining the tactics of treatment and evaluating 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 (knee, wrist, elbow joints, small joints of the hands and feet). It is quite difficult to detect a 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 assess 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. With short follow-up periods, the dynamics of this indicator can be taken into account when assessing the effectiveness of treatment. However, in cases where the result is evaluated at a fairly long time, 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, a 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 study 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 fix the presence of subluxation, aseptic bone necrosis or ankylosis of the joint.
Ultrasound can be used to visualize the inflamed synovium itself. It allows you to get an image of a section of the joint under study, made in a certain plane. On such a section, it is possible to accurately measure the thickness of the synovial membrane, as well as roughly estimate the amount of synovial fluid in a given section of the joint. Ultrasound provides the possibility of a semi-quantitative assessment of exudative changes. The degree of accumulation of exudate in a certain section of the joint can be expressed in points and then follow the dynamics of this indicator against the background of the treatment. The thickness of the synovial membrane, which can be fixed according to ultrasound, is also one of the signs of synovitis activity. Its value is largely determined by inflammatory edema and significantly decreases when inflammation subsides.
The use of arthroscopy (AS) provides the possibility of direct visual examination of the inflamed synovial membrane of the affected joint. Unlike ultrasound, AU does not accurately measure the thickness of the inflamed synovium and assess the severity of exudative changes in a given joint section. These two methods do not replace, but complement each other. Arthroscopic examination of the joint makes it possible to study the synovial relief throughout its entire length. Depending on the prescription of synovitis and the characteristics of its development in a given joint, changes in the synovial membrane can vary over a very wide range. Normal synovia 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 differential assessment of the nature of joint damage in patients with a similar clinical picture of the disease. To register the observed changes, several methods for their semi-quantitative assessment have been proposed.
Zschabitz A. et al. the morphological changes in the synovial membrane revealed in AS were evaluated using an index, which was calculated according to 4 indicators: vascularization, hyperemia, synovial edema, and villi formation. The severity of each indicator was determined in points from 0 to 3.
This scheme allows you to fix the severity of changes, but do not take into account their prevalence, so it is difficult to characterize the damage to the joint as a whole with its help. Paus A.C. et al. tried to overcome this shortcoming. They divided the joint into 5 regions (posterior, intercondylar, medial, lateral, suprapatellar). In each zone, the severity of the lesion was assessed according to 4 degrees: 1 - no signs of synovitis, 2 - moderate hyperemia without villus formation, 3 - moderate hyperemia with moderate villus formation, 4 - moderate or severe hyperemia with massive villus formation. The overall index was the arithmetic mean of the scores of the 5 indicated areas.
The American College of Rheumatology proposed to assess the severity of hyperemia, thickening and villous proliferation of the synovium on a visual analogue scale and simultaneously record the extent of the lesion as a percentage of the total area of the synovial membrane.
It should be noted that one of the most significant parameters characterizing the features of 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 the drug injected into the joint and the mass of the affected tissue, and on the other hand, worsens the circulation of fluid in the joint and makes it difficult for the drug to enter the inflammation zone.
There are 4 degrees of proliferative changes in the synovial membrane of the knee joint. The first is synovial thickening without significant villous proliferation. The second can be defined as the appearance of focal accumulations of villi against the background of thickened synovium. In the third degree, the villi cover most of the synovium of the lateral sections of the joint, leaving the upper one 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 evaluating the results of treatment of chronic arthritis. Judging by the data of publications that evaluated the effectiveness of intra-articular injections of drugs (in particular, methotrexate and rifampicin), the most dynamic indicator is synovial hyperemia. It clearly decreases with a decrease in clinical signs of inflammation. At the same time, the structure of the synovium 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 maintaining the clinical signs of active inflammation, 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, not accompanied by significant exudative changes, both in chronic inflammatory diseases of the joints and in OA, in addition to systemic drug therapy, drugs are usually prescribed in the form of ointments or gels. In many cases, a beneficial effect can be achieved with the appointment of locally irritating drugs that reduce the severity of pain due to a distracting effect. For this purpose, preparations based on menthol, turpentine, camphor are used.
The use of ointment and gel preparations containing non-steroidal anti-inflammatory drugs (NSAIDs) ensures that these medications pass through the skin directly to the site of inflammation. For this purpose, medicines containing such powerful agents as indomethacin, diclofenac, ibuprofen, piroxicam are widely used. Usually they are used 3-4 times a day, squeezing 4-8 cm from the tube, depending on the size of the affected joint.
Often, the optimal effect can be achieved with the help of combined preparations 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 irritating 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 reduce the period of edema and dysfunction when compared with placebo. Diclofenac and methyl salicylate are among the classic NSAIDs that realize their effect by suppressing the activity of cyclooxygenases, leading to a decrease in the synthesis of prostaglandins, which reduces swelling and infiltration of inflamed tissues. To date, according to experts from the FDA (USA), only preparations containing methyl salicylate, menthol and capsaicin can be considered indisputably effective as analgesics. A-linolenic acid, which is part of linseed oil, binds activated cyclooxygenases in the focus of inflammation.
In the presence of significant exudative manifestations of the inflammatory process, intraarticular administration of HA is the method of choice. It is also practiced for both inflammatory and degenerative joint changes. However, it should be noted that secondary synovitis is generally more resistant to hormones and clinical improvement is often not long enough. For introduction into the joints, microcrystalline suspensions of poorly soluble hormonal preparations are used, which can be deposited in the affected joint for up to 3 weeks. As a result of the gradual dissolution of the hormonal compounds deposited in the joint, a constant supply of a sufficient amount of the drug directly to the inflammation site is ensured. The effect of HA introduced into the joint cavity is mediated by interaction with the corresponding receptors of cells that infiltrate the synovial membrane and participate in the development of synovitis.
The effect of HA on the tissues of the joint 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 the articular cartilage. At the same time, sporadic intra-articular injections of these drugs may have a chondroprotective effect. Therefore, in clinical practice, the introduction 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, also a tangible systemic effect.
The anti-inflammatory effect of HA injected 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 case. The effectiveness of the drug directly depends on the solubility of the microcrystalline suspension. Decreased solubility increases duration of action and improves efficacy. Currently, triamcinolone compounds (hexacetonide and acetonide) have the longest action.
Insufficient effectiveness of intra-articular injections in many cases may be associated with relative resistance to the action of HA due to the production of a large number of pro-inflammatory cytokines in the inflammation site. To avoid the undesirable effects of inflammatory stimulants that accumulate in the joints in chronic synovitis, the exudate is removed before the administration of the drug. However, the proliferative changes and fibrin clots that form in the joint often prevent the full evacuation of the synovial fluid. Therefore, in a number of cases, it is not possible to completely remove it during joint puncture, and pro-inflammatory factors remaining in the joint cavity interfere with the action of the drug.
Almost complete removal of the inflammatory exudate can be achieved by flushing the joint with large amounts of fluid during AS. This method ensures sufficient fluid supply to all parts of the joint and free evacuation of the contents of the articular cavity. In the majority of patients with chronic arthritis, washing the joint in AS already provides a significant reduction in inflammatory changes in itself. However, this effect is usually unstable. Introduction after washing with HA gives significantly more favorable results.
The clinical improvement achieved with intra-articular administration of HA after AS in most patients is longer than with traditional local steroid therapy. We evaluated the effect of pre-washing joints in AS in 55 knee joints of RA patients. In 27 of them, HA was administered in the traditional way after removal of the exudate. 28 before the introduction of HA were washed with AS. At 3 and 6 months after treatment, the reduction 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 with OA. Moreover, unlike chronic arthritis, the introduction of HA into the joint after AS in patients with OA is not required. This phenomenon was noted more than 50 years ago and is apparently due to a decrease in inflammatory changes characteristic of this disease. Washing the knee joints with AS allows you to remove the bulk of cartilage detritus and crystals from them. Elimination of these inflammatory stimulators can lead to a decrease in the activity of synovitis and a decrease in the severity of the pain syndrome. It is also possible that such treatment can reduce the production of enzymes involved in the development of articular cartilage destruction, thereby slowing down the progression of the disease. The clinical effect of AS largely depends on the technical features of its implementation. Thus, the authors who studied the results of AS when using various volumes of liquid for its implementation note that washing the knee joints with 3 liters of liquid gave a more favorable effect than 250 ml. The amount of debris removed during the procedure also correlates with the degree of pain relief.
The beneficial effect observed in patients with OA after washing the joints in AS has led some researchers to use a simplified washing procedure using puncture needles to treat this disease. The results of such treatment are evaluated ambiguously. According to some authors, this procedure is no less effective than washing the joints in AS and provides a longer clinical improvement than intra-articular administration of HA. Others believe that it is not significantly different from placebo. Probably, in patients with OA, as in chronic arthritis, the effect of washing largely depends on its technical features. AS allows to achieve a much more complete removal of cartilage detritus and crystals from the cavity of the affected joint than washing through puncture needles. Therefore, despite the great technical complexity, this procedure seems to be more promising than the simplified version of washing.
Literature
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2. Bradley 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 L.M., Moore M.E. Preferred intraarticular corticosteroids and associated practice: a survey of members of the American College of Rheumatology
4. Choy E.H.S, Panayi G.S. Cytokine pathways and joint inflammation 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 osteoarthritis. 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 R, Ike RW, Seeger LL, Rich E, Skovron ML. Visually-guided irrigation in patients with early knee osteoarthritis: a multicenter randomized, controlled trial. Osteoarthritis Cartilage. 2000 Nov;8(6):412–8.
8. Lindblad S., Hedfors E., Malmborg A.S. Rifamycin SV in local treatment of synovitis – a clinical, arthroscopic and pharmacological evaluation. J. Rheumatol. 1985, 12, 5, 900–903
9. Paus A.C., Pahle J.A. Arthroscopic evaluation of the synovial lining before and after open synovectomy of the knee joint in patients with chronic inflammatory joint disease. Scand J. Rheumatol. 1990, v. 19, p. 193–201.
10. Zschabitz A., Neurath M., Grevenstein J. et al. Correlative histologic and arthroscopic evaluation in rheumatoid knee joints. Surg endosc. 1992, V. 6, p. 277–282.
Exudative synovitis is an inflammatory process in the synovial membrane of the joint, accompanied by the release of a large amount of effusion (exudate). Pathology is quite common and occurs among people of all age groups. The most commonly affected joints are the knee, hip, and ankle. The primary symptoms are pronounced swelling of the joint and pain during exercise.
A large accumulation of fluid in the synovial bag causes discomfort and pain in the joint
Synovitis is an inflammation of the synovial (inner) lining of a joint. The word "exudative" in the name of the disease means the release of a large amount of effusion - fluid, the accumulation of which leads to the formation of severe edema. It is edema that is one of the first symptoms of the disease, having noticed which, it is recommended to immediately consult a doctor.
In the ICD-10 synovitis is coded M65. The exudate that accumulates in the joint can be of a different nature. With purulent inflammation, the disease will be designated as M65.1 - infectious synovitis. With an unspecified nature of the development of pathology, it is coded with the code M65.9.
Reasons for the development of the disease
Inflammation of the synovial membrane develops due to:
- infections;
- allergic reaction;
- joint injuries;
- chronic diseases of the joints;
- systemic diseases;
- obesity.
Infections cause reactive synovitis. It can proceed in an exudative form, which indicates the presence of a large amount of effusion. In fact, exudative can be called any form of the disease, accompanied by the release of exudate, both aseptic and purulent.
Allergic reactions can cause inflammation in the joint. In this case, the inflammatory reaction manifests itself in response to the immunopathological process that occurs in the body of an allergic person.
The most common cause of synovitis is trauma to the joint. The disease in this case develops due to a violation of the movement of the synovial fluid, which accumulates and begins to press from the inside on the shell of the joint. Also, inflammation can be caused by damage to the shell during impact or compression.
Synovitis is often a complication of arthrosis and arthritis. Quite often, such a pathology is observed in psoriatic or gouty arthritis.
Synovitis can develop as a complication of systemic lupus erythematosus or rheumatoid arthritis. The disease is often encountered by patients with diabetes mellitus and people with metabolic disorders, which leads to obesity. In obesity, the development of synovitis is associated with a strong load on the joints. In this case, the knee or hip joint is most often affected.
Purulent exudative synovitis develops against the background of infection of the joint
There are several classifications of the disease - according to localization, the cause of inflammation of the synovial membrane and the type of exudate.
Exudative synovitis happens:
- purulent;
- serous;
- serous-fibrinous;
- hemorrhagic.
Purulent exudative synovitis develops against the background of infection of the joint. Pathology is characterized by the release of pus and the formation of an abscess. As a rule, the cause of inflammation is Staphylococcus aureus.
Serous exudative synovitis is manifested by the accumulation of lymph in the area of inflammation. When puncturing the articular membrane with further examination of the exudate, a significant part of the lymph and interstitial fluid is found in its composition.
Serous-fibrinous synovitis is characterized by the presence of protein (fibrin) in the composition of the effusion. The hemorrhagic form of the disease got its name because of the admixture of blood to the exudate.
One of the rare forms of the disease is exudative-proliferative synovitis. With this type of pathology, the inflammatory process is combined with a change in the structure of the tissues of the synovial membrane. They begin to grow with the formation of villi and nodules. The second name of the disease is pigment-villous synovitis.
Symptoms of the disease
The main symptom of the pathology is pronounced edema. It grows rapidly and can reach impressive sizes. With damage to the knees or elbows, an increase in the size of the joint by several times is noted.
At the same time, not all joints with synovitis swell strongly. With inflammation of the synovial membrane of the hip and ankle joint, swelling can be almost invisible.
With synovitis, pain is noted at times of exertion. At the initial stage of the disease, pain syndrome appears only with prolonged exertion; as the pathology progresses, discomfort becomes noticeable with each flexion and extension of the joint. Typically, synovitis pain resolves with rest. In severe forms of inflammation, the pain increases in the morning and decreases in the evening.
Since inflammation is observed in large joints, a decrease in the amplitude of movements of the affected limb develops. In the initial stages, movement is practically not limited, but as the disease progresses, the motor function of the joint may deteriorate. In severe synovitis of the knee, joint blocks often develop.
With purulent exudative synovitis, the following symptoms are observed:
- hyperemia (redness) of the skin in the affected area;
- increase in body temperature;
- symptoms of intoxication.
The skin around the swollen joint becomes hot to the touch, with acute pain on palpation.
Otherwise, the symptoms of synovitis differ little, regardless of the location of the inflammation and its causes.
Why is the disease dangerous?
If the pathology is not treated, it becomes chronic.
Synovitis proceeds in an acute form. If the pathology is not treated, it acquires a chronic course, characterized by periodic exacerbations. The inflammatory process can spread to the joint capsule (arthritis), tissues around the joint (bursitis). If left untreated, the trophism of the synovial fluid is disturbed and the nutrition of the cartilage tissue worsens, which leads to its degeneration (arthrosis).
Changes in the structure of the synovial membrane lead to the formation of villi and knots that impair movement in the joint. In severe cases, fragments of tissues appear ("articular mouse"), which lead to blockade (immobility) of the joint.
Diagnostics
The disease is easily diagnosed visually due to the characteristic swelling. To clarify the diagnosis, the doctor may refer the patient to an ultrasound. This examination allows you to visualize the condition of the soft tissues around the joint and exclude the presence of growths and salt deposits that can lead to inflammation.
To clarify the nature of synovitis, an articular puncture is performed. With the help of a needle, a small amount of exudate is removed, the study of which allows you to clarify the type of inflammatory process (purulent or aseptic).
Principles of drug treatment
Medicines help relieve pain and swelling of the affected joint
The main method of treatment of the disease is a puncture. The puncture of the synovial membrane of the joint and the removal of some of the exudate leads to an immediate decrease in the severity of symptoms. When the exudate is removed, the pressure on the synovial membrane decreases, as a result of which the pain syndrome subsides.
After the puncture, immobilization of the joint is necessary. With damage to the joints of the legs, orthoses are used; the patient is prescribed movement with the help of a crutch. With synovitis on the hands, bandages and dressings are used. Immobilization reduces the load on the joint, which favorably affects the trophism of the synovial membrane and reduces the inflammatory process.
Further treatment depends on the form of the disease. Until the inflammatory process is stopped, there is a risk of re-enlargement of the joint due to the accumulation of effusion.
The exact treatment regimen depends on the type of exudative synovitis. If the exudate is represented by purulent discharge, antibiotic therapy is necessary. Apply drugs from the group of macrolides, fluoroquinolones, tetracyclines or penicillins. The choice of antibiotic depends on the causative agent of inflammation and the patient's tolerance for a particular drug. As a rule, antibiotic therapy is carried out in a short course, treatment rarely exceeds 7-10 days.
In the aseptic form of exudative synovitis, treatment with non-steroidal anti-inflammatory drugs is practiced - Ibuprofen, Diclofenac, Nimesulide. Their use in conjunction with puncture and immobilization of the joint gives a good result, quickly relieving inflammation.
In severe cases, injections of glucocorticosteroids are indicated. In the treatment of synovitis, Prednisolone, Hydrocortisone, Betamethasone are used. An injection is made directly into the joint cavity. As a rule, one injection is enough for the inflammation to subside.
Rehabilitation Therapy
Physiotherapy helps to restore joints after illness
After stopping the acute inflammatory process, a course of physiotherapy and drugs are prescribed to restore trophism in the joint. With synovitis, therapeutic compresses, magnetotherapy, electrophoresis, and phonophoresis are often used. With the exudative form of inflammation, such methods help to reduce swelling and normalize joint mobility.
To prevent complications of synovitis, chondroprotectors are prescribed. These drugs improve the movement of synovial fluid and provide nutrients to the cartilage. Additionally, the doctor may recommend dietary supplements and vitamins to improve the functioning of the joints.
Surgical treatment
As a rule, exudative synovitis is quite successfully treated with medications. In some cases, surgery may be indicated. The operation is indicated for purulent exudative synovitis. The intervention is aimed at removing purulent exudate to prevent infection of surrounding tissues.
With the growth of the synovial membrane, its excision is necessary. This is done through arthroscopy.
Forecast
The success of synovitis treatment depends on timely diagnosis.
With timely detection of the initial symptoms of the disease and complex treatment, the prognosis is usually favorable. Treatment of acute synovitis takes several weeks, of which at least two are allocated for rehabilitation and physiotherapy.
In advanced cases, the disease becomes chronic. If changes have begun in the tissue of the synovial membrane, surgery is indispensable. In some cases, irreversible changes in the joint are noted, so the patient is prescribed arthroplasty.
The success of treatment depends on timely diagnosis of the disease. If edema or swelling appears in the joint area, it is recommended not to delay a visit to a specialist.
The knee joint belongs to the group of the largest joints. It has a complex structure and takes on a large load. Injuries, infections, allergies, and other causes can cause knee inflammation. One of the most common diseases is synovitis of the knee joint.
Synovitis of the knee joint - inflammation of the synovial membrane of the articular capsule of the knee joint with the formation of exudate or effusion. Synovial fluid is always present in the knee joint, but when synovitis occurs, its amount increases significantly. In case of infection, the effusion turns into purulent contents.
Symptoms
The first manifestations of synovitis occur after a few hours, but more often on the second day.
And they have three main manifestations:
- an increase in size and deformation of the joint due to the accumulation of fluid in the joint cavity;
- limitation of motor function of the joint;
- the pain syndrome has a long and aching character.
Sometimes there may be an increase in temperature in the area of the joint in the absence of hyperemia of the periarticular tissues. In most cases, this disease develops without clear symptoms and requires additional diagnosis.
Types and causes of the disease
Most often, synovitis of the knee joint occurs after an injury, due to a fall or bruise. In addition, synovitis can be caused by pathological changes in the joint. For example, in violation of metabolic processes in the body, a malfunction of the immune system, or as a result of a complication of another disease.
Causes of synovitis of the knee joint:
- injury;
- systemic or autoimmune disorders;
- secondary manifestation of another disease.
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Synovitis can occur in acute and chronic form, subdivided into:
Infectious
Occurs when pathological microorganisms penetrate into the synovial fluid. The joint fluid becomes cloudy and purulent, containing a large number of bacteria and leukocytes. Pathogenic bacteria can enter the joint with an open injury or be introduced with the help of blood (hematogenous route) or lymph (lymphogenic route) from internal foci of infection. In turn, infectious synovitis is divided into:
- nonspecific synovitis, with the determination of pathogenic microorganisms in the synovial fluid: pneumococci, streptococci, staphylococci, etc.;
- specific synovitis containing pathogenic microorganisms: causative agents of syphilis, tuberculosis mycobacteria.
Aseptic
With this type of synovitis, the joint effusion is more transparent with the characteristic presence of a large number of lymphocytes. It develops against the background of an injury or an allergic reaction of the body.
Reactive
It is manifested by an allergic reaction of the body to a mechanical or toxic effect on the knee joint. Causes can be: autoimmune or systemic diseases, excessive exercise, bad habits, reactions to medications, certain foods or other allergens.
The doctor's task is to identify the cause that caused such a secondary manifestation of the disease as synovitis of the knee joint. After the diagnosis is made, treatment is carried out aimed at eliminating the root cause of the synovitis.
exudative-proliferative
Most often occurs due to trauma. It is characterized by a large amount of turbid exudate rich in protein, hematogenous and histogenic cells.
post-traumatic
The most common manifestation of the disease. It is the body's response to intra-articular damage and destruction of joint tissues.
Chronic
It has its own symptoms. Swelling of the joint and local temperature increase are not pronounced. The stiffness of the joint increases gradually. Allocate: serous, serous-fibrinous and villous forms of chronic synovitis.
Serous
Occurs rarely. At the beginning of the disease, the clinical manifestations are mild. Most often, patients reveal complaints:
- general fatigue;
- fatigue when walking;
- slight limitation of movement in the joint;
- aching pain in the knee.
In the process of diagnosis, the content of the effusion in the diseased joint is revealed, which develops into hydrarthrosis (dropsy of the joint). This causes sprains and loosening of the joint, leading to a risk of dislocation.
Serous fibrinous synovitis
Causes excessive production of joint fluid by the synovial membrane, which bursts the joint. At the same time, the synovial membrane becomes thinner, and fibrous deposits begin to form on it. Fibrous deposits reduce the elasticity of the synovial membrane and prevent the outflow of joint fluid. This thickens the fibrous membrane of the articular cavity, leading to fibrosis. This type of synovitis requires urgent treatment, as it certainly leads to joint deformity and limitation of motor function.
Villous synovitis
It is characterized by a high content of fibrin in the exudate in the form of threads and clots, which tend to thicken, forming intra-articular bodies. It proceeds with the formation of hypertrophied and sclerotic villi, which are able to lace up, forming rice bodies and chondromic bodies.
Diagnostics
To clarify the diagnosis, a number of studies of the knee joint are carried out.
MRI, radiography and ultrasound. These types of diagnostics are absolutely painless, informative, carried out superficially and without additional incisions and tissue punctures. Unlike puncture and arthroscopy, MRI, radiography and ultrasound do not have a therapeutic load.
Complete blood count and additional examinations. They are carried out with synovitis of a secondary nature. The success of the treatment of synovitis depends on the establishment of a true diagnosis and the correct therapy.
Treatment
First of all, the diagnosis of the knee joint and the whole body is carried out to determine the cause of the synovitis. The choice of the direction of the course in treatment depends on the diagnosis and the root cause of the onset of the disease.
Stages of treatment:
Puncture or arthroscopy are considered as the first step in the treatment of synovitis. Performing diagnostics with these methods, the knee joint is washed, excess fluid is removed from it and medications are administered.
The most common is the puncture of the knee joint. The procedure is painful, but it also carries a therapeutic load. The resulting liquid is sent to the laboratory for analysis and determination of the nature of the inflammation.
Step-by-step instructions for performing a puncture of the knee joint:
Step 1. All fluid is removed from the joint bag with a syringe.
Step 2 Flushing the joint with saline to cleanse it of a possible infection.
Step 3 The introduction of the drug.
After removing excess fluid, the patient immediately feels relief.
Arthroscopy is an informative low-traumatic method. Allows you to determine the intra-articular pathology, the causes of pain and carry out treatment.
Stages of arthroscopy:
Step 1. Through a small incision, the doctor inserts a miniature instrument called an arthroscope.
Step 2 The image of the joint is displayed.
Step 3 The surgeon gets the opportunity to detect damage and carry out the necessary treatment.
The reliability of this procedure is 95-100%. For the patient, arthroscopy is almost painless and the patient can leave the clinic within 1-2 days after the diagnosis.
Immobilization. To ensure rest, a tight bandage is applied to the joint. With synovitis aggravated by infection, it is recommended to apply a rigid splint or plaster.
Medical treatment. To relieve the inflammatory process, suppuration and to fight infection, the following are prescribed:
- non-steroidal anti-inflammatory drugs - suppress the inflammatory process and reduce pain (indomethacin, ibuprofen, voltaren, diclofenac);
- antibiotics - are introduced into the joint cavity immediately after the puncture to prevent the attachment of a secondary infection or suppress the bacterial nature of inflammation;
- corticosteroids - are prescribed for intra-articular administration in the malignant course of the disease (dexamethasone, kenalog-40);
- inhibitors of proteolytic enzymes - indicated in the treatment of chronic synovitis with a large formation of effusion and joint infiltration (trasilol, Gordox);
- microcirculation regulators (ATP, nicotinic acid, trental, troxevasin);
- Dietary supplements to restore the structure of cartilage and maintain organisms after a disease.
Physiotherapy procedures. After removing the inflammatory process for restorative and supportive purposes, it is recommended to conduct a course of magnetotherapy, electrophoresis, UHF or phonophoresis.
Complex of physiotherapy exercises. A special set of exercises will help restore the motor function of the joint.
Forecast
In many ways, the prognosis for the treatment of synovitis depends on the nature of the pathogen, the general condition of the patient and the chosen treatment tactics. Under favorable conditions, the treatment is able to restore the motor function of the joint in full, but as a consequence, stiffness of the joint may remain.
When purulent synovitis is detected, the patient's life is threatened due to blood poisoning. In the acute course of the disease, hospitalization is indicated. If you suspect synovitis of the knee joint, you should consult a doctor for a diagnosis and adequate treatment.
Proliferative synovitis is a joint disease characterized by inflammation of the synovium. It can occur in any joint, but proliferative synovitis of the knee is the most common. This is due to the most common knee injury. Inflammation in several places most often occurs with polyarthritis and other extensive diseases.
Due to the appearance and accumulation of exudative fluid in the articular cavity, pressure increases, disrupting motor functions. In this case, the synovial tissue grows, which can gradually become a thick massive formation.
The disease is rarely diagnosed in the acute stage, imperceptibly passes into the chronic form and causes destructive changes in the affected organ.
Proliferative synovitis goes through 4 stages in its development:
- The growth of the synovial membrane without proliferation of the villi, or it is insignificant.
- Foci of villous accumulations begin to form on the thickened tissue.
- Filling with villi of the lateral parts of the joints, which is more than half of the entire synovial membrane. The top is not affected.
- The proliferation of the villi spreads to all departments, becoming diffuse.
Symptoms
Pain is the main symptom of the disease. The nature and intensity depend on the severity of the process and the pressure on the nerve endings. Pain causes limitation of movement and forced position. There is a special method for determining the intensity of pain in points, where 0 is no pain, 1 is weak, 2 is moderate, 3 is strong and 4 is very strong pain.
The diseased joint usually swells due to the presence of an abnormal accumulation of fluid in it and deforms.
Of the common symptoms, one can note an increase in temperature, most often to subfibrile, weakness and rapid onset of fatigue.
With a long course of the disease, atrophy of the surrounding muscles gradually occurs due to the lack of active movements.
Causes
There may be a lot of them. First of all, synovitis is divided into infectious and non-infectious. In the first case, any pathogenic microorganism that causes inflammation can become the cause of the development of the disease.
Other causes include endocrine disorders, allergens, trauma, and neurogenic factors.
Diagnostics
In addition to external examination and palpation of the diseased organ, the doctor may prescribe an x-ray to assess the consequences of synovitis. Ultrasound is used to measure the synovium and the volume of fluid in the cavity.
Arthroscopy allows you to visually examine the affected shell of the diseased joint. It perfectly complements ultrasound, so both studies are often used to most accurately assess the condition of the inflamed organ.
Treatment
Usually, complex therapy is carried out, including many methods. Before talking about surgery, you should make sure that conservative treatment is ineffective. It goes in several directions:
- Elimination of the root cause of the disease. Appointment of antibacterial therapy in infectious nature, antiallergic drugs, treatment of endocrine disorders, etc.
- Elimination of symptoms of synovitis.
- General strengthening of the body.
- Therapy of impaired motor functions.
- Physiotherapy procedures and exercise therapy for the final rehabilitation of the joint.
Depending on the severity and stage of the disease, topical anti-inflammatory drugs such as gels and ointments are prescribed. Currently, preference is given to drugs containing methyl salicylate, capsaicin, diclofenac and menthol. The presence of these components effectively reduces inflammation and its symptoms, reducing pain and swelling. Such means include Dicloran plus, which combines all of these substances.
With the accumulation of exudative fluid in the cavity, the introduction of hormonal corticosteroids directly into the joint after puncture is used.
At first, it is necessary to immobilize the affected joint with a splint or pressure bandage. Prolonged immobility is contraindicated, as it causes degeneration of the muscle layer and stiffness of the joint itself.
Everyone who has developed an inflammatory process in the synovial membrane should know about the treatment of synovitis. Often, patients with a similar diagnosis are prescribed surgery. Most often, the pathology develops in the knee, ankle, elbow and wrist joints, with changes affecting one or more joints. Synovitis can affect the tendons of the long head of the biceps and temporomandibular joint, as well as the wrists.
Synovitis is an inflammatory process in the synovium that limits the normal functionality of the musculoskeletal system.
Basic information about the disease
The essence of the pathology is that under the influence of certain factors (damages and injuries, infectious processes, allergies), the synovial membrane becomes inflamed and an effusion forms. This phenomenon is accompanied by general intoxication of the body, loss of strength, weakness, pain and enlargement of the joint, synovitis often develops in rheumatoid arthritis.
What types are there?
Depending on the side of the lesion, there is left-sided and right-sided synovitis. According to the nature of the course of the disease, it is divided into chronic and acute. In the acute form, redness, swelling of the membrane is observed, outwardly the effusion resembles an almost transparent liquid, in special cases fibrin particles are found. The second form is characterized by the progression of fibrous processes in the capsule, deposits appear that hang from the articular cavity. Depending on the cause of development, the classification provides for the following types:
- Exudative-proliferative synovitis. One of the most frequently diagnosed forms, it develops as a result of serious injuries.
- Villous-nodular synovitis. The formation of special villonodular structures is characteristic. Many patients are faced with the problem of cystic formation.
- Purulent and serous. To confirm the diagnosis, it is necessary to carry out. Occurs subsequently bruises and injuries that affect the tissue, bursa and tendons.
- Pigmented-villous. Severe pigmentary synovitis is more common in young patients under 30 years of age.
- Recurrent. Synovial hypertrophy occurs.
- infectious synovitis. Among the pathogens are streptococci, staphylococci and other microorganisms. They enter the articular surface after damage through the blood or lymph.
Causes of the problem
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According to experts, a number of the following factors are predisposing to the development of pathology:
- Damage and injury. The risk group includes athletes who daily injure the joint capsule.
- infectious processes. After damage, the capsule ceases to function as a barrier, thereby opening the way for infection.
- Complications after the disease. The cause can be both pathologies of the joints (bursitis, rheumatoid arthritis), and sexually transmitted diseases, for example, gonorrhea.
- Allergy.
- Torn posterior horn of the medial meniscus.
- Increased weight.
What are the symptoms of character?
The disease has its own special features. Common symptoms of synovitis, characteristic of both forms, are as follows:
- Limited mobility of the limbs. Synovitis with arthritis of the rheumatoid type is characterized by an increase in the intensity of pain, it is difficult for the patient to walk.
- Unsharp tissue edema develops.
- The shape of the articular surface changes.
- Prostration.
- The skin around the injured area is hot.
Chronic synovitis is characterized by an increase in the membrane. As a result, the joint becomes loose, and the patient runs the risk of getting a dislocation. In the acute form, inflammation of the joint of the foot often occurs, the main blow falls on the area of \u200b\u200bthe big toe. While walking, patients note pain and redness of the skin in the area of the phalanx, the quality of life deteriorates.
If you ignore the symptoms and do not treat synovitis, there is a risk of developing complications that affect the health and life of a person.
Why is synovitis dangerous?
Synovitis can become a source of dangerous suppuration, the formation of cysts.
Symptoms of the disease do not appear immediately, but after a few days, and in the future, the following pathological processes may develop against the background of the underlying disease:
- purulent form of arthritis;
- thickened synovial membrane;
- damage to hyaline cartilage;
- a state of sepsis;
- cyst formation;
- panarthritis;
- phlegmon of soft tissue;
- increase in body temperature.
Diagnostic methods
The diagnosis of "acute synovitis" is made only after a comprehensive study of all indicators. The process begins with an examination, when the specialist has the opportunity to examine a small area of the lesion, note the temperature of the skin, color, and also determine the mobility of the limb. After that, blood tests are checked in the laboratory, in which eosinophils, high iron levels, and other uncharacteristic changes are found. A mandatory part of the check is a hardware study, including X-ray, MRI and ultrasound. On x-rays and other tests, you can visualize the problem, understand the extent of the consequences.
Treatment for synovitis
It is pointless to count on a short period of procedures. The problem is not treated with the use of one "magic" pill. The course of therapy for synovitis in adults lasts up to 3 weeks, and it is worth talking about the complete restoration of joint activity only after 2-3 months. It is recommended during this period to protect your health as much as possible, to prevent infectious diseases, to exclude dangerous physical activity, to fully comply with the recommendations.
Pharmacy preparations
The therapeutic program includes several options for dealing with pathology. The most commonly used method is to stop the onset of the inflammatory process and eliminate pain using medications. Drugs are prescribed in the treatment of synovitis of the mandibular joint and other areas directly by the doctor, it is forbidden to prescribe drugs on your own.
With synovitis, the doctor will definitely prescribe anti-inflammatory drugs.
An acute type of synovitis in adults can be cured with antibiotics and intramuscular injections, gradually switching to a tablet form. In therapy, glucocorticoids and non-steroidal anti-inflammatory drugs are used, the dosage of which must be monitored by a specialist. In the event of adverse reactions and complications, it is necessary to change the tactics of treatment.
The most dangerous complication is the loss of the main joint function. As a large amount of fluid accumulates, the ligaments weaken. Due to the looseness of the joint, the risk of subluxation or even dislocation increases.
What is immobilization?
To treat bilateral synovitis of the knee joint, it would be wise to use the option of immobilizing the limb, since in some cases the joint becomes loose, which increases the risk of dislocations and other injuries. There are several ways to immobilize a joint. The first option is to use a plaster splint for up to 2 weeks. Such a measure of treatment is relevant for a pronounced inflammatory process. The second option is used in case of reducing the intensity of synovitis with the use of a special medical device - an orthosis.