The connective tissue - endothelial and underlying loose, lining the articular capsule from the inside - is the synovial membrane forming in the lateral flanks, in the upper inversion and in the anterior part of the fold and villi. When arthroscopy is performed, puffiness, color and vascular pattern, as well as all pathological inclusions in the thickness of the synovia and on the surface, are evaluated, the size, shape, structure of the synovial folds and villi are evaluated. All this is of great importance in the diagnosis of joint diseases. The synovial membrane may be inflamed. Synovitis is the most common manifestation of chronic diseases. Chronic synovitis within the membrane indicates primary inflammation in arthritis and secondary in arthrosis, which deforms the joint.
Synovitis
According to the most modern information, the key link in the development of chronic arthritis is an autoimmune process when an unknown pathogenic factor is recognized by an antigen-presenting cell. Secondary synovitis of deforming arthrosis is associated with the fact that cartilage decay products are accumulated in the joint - fragments of collagen and proteoglycan molecules, chondrocyte membranes, and the like. In the normal state, not a single cell of the immune system contacts these antigens, and therefore they are recognized as completely foreign material. This is what leads to a tough immune response, and therefore is accompanied by such chronic inflammation, from which the synovial membrane suffers. Especially common are such changes in the knee joint. There are a lot of systemic diseases of the synovial membrane, and for them there is a certain classification.
1. Diseases with articular syndrome - a lesion of the connective tissue with rheumatoid arthritis, when mainly small joints are affected. This is a type of erosive-destructive polyarthritis, while the etiology is not very clear, and autoimmune pathogenesis is complex.
2. Infectious arthritis, which is associated with the presence of infections, including hidden ones. For example, the synovial membrane of the joint is affected by infections such as mycoplasma, chlamydia, bacteroids, ureplasm, and many others. This includes septic (bacterial) arthritis.
3. Diseases from metabolic disorders, such as gout, ochronosis (it is a consequence of a congenital disease - alkaptonuria), pyrophosphate arthropathy.
4. The synovial membrane of the joint is susceptible to neoplasms - tumors and tumor-like diseases. This is villonododular synovitis, synovial chondromatosis, synovioma and hemangioma, synovial ganglion.
5. Defeat of the synovial membrane of the joint in a degenerative-dystrophic type and deforming arthrosis are considered to be very common diseases. For example, very many people suffer from degenerative-dystrophic joint damage after forty-five years, and the degree of this lesion may vary.
About the disease
Synovitis is such a common disease that even US military medicine is worried about it, which recently excited Russia with a tender for the collection of RNA and synovial membrane of Russians. This is explained by the fact that in the world there is a persistent search for solutions in the fight against joint diseases. The fact is that the inflammatory process is accompanied by an accumulation of effusion (fluid) in the joint cavity itself, and most often the knee joints suffer, although the defeat can overtake the ankle, and the ulnar, and the wrist, and any other joint. Diseases of the synovial membrane develop, as a rule, only in one of them; rarely enough are several joints affected. Synovitis develops from infection, after an injury, from allergies and certain blood diseases, with metabolic disorders and endocrine diseases. The joint increases in volume, the synovial membrane is thickened, pain appears, a person feels malaise and weakness. If a purulent infection joins, the pain becomes much stronger, general intoxication may occur.
After detecting symptoms, after examinations and studies of synovial fluid, a diagnosis is made. This, for example, inflammation of the synovial membrane of the joint. Treatment is prescribed: puncture, immobilization, if necessary - surgery or drainage. Given the course of the disease, acute synovitis and chronic can be distinguished. Acute is always accompanied by edema, congestion and thickening of the synovial membrane. The joint cavity is filled with effusion - a translucent fluid with fibrin flakes. Chronic synovitis also shows the development of fibrotic changes in the joint capsule. When the villi grow, fibrinous deposits appear, which hang directly into the joint cavity. Soon, the overlays separate and turn into “rice bodies”, floating freely in the fluid of the joint cavity and further injuring the shell. By types of inflammation of the synovial membrane and the nature of the effusion, serous synovitis or hemorrhagic, purulent or serous-fibrinous can be distinguished.
Causes of occurrence
If pathogens enter the joint cavity, infectious synovitis occurs. The causative agent can penetrate the membrane during penetrating wounds of the joint - from the external environment, as well as from the tissues surrounding the sinoid membrane, if purulent wounds or ulcers are located near the joint. Even from distant foci, the infection may well penetrate into the region of the joint cavity, causing inflammation of the synovial membranes of the person, as blood and lymph vessels pass everywhere. Infectious non-specific synovitis is caused by staphylococci, pneumococci, streptococci and the like pathogens. Specific infectious synovitis is caused by pathogens of specific infections: with syphilis - pale treponema, with tuberculosis - tuberculosis bacillus and the like.
With aseptic synovitis, pathogenic microorganisms in the joint cavity are not observed, and inflammation becomes reactive. This happens if mechanical injuries occur - joint bruises, intraarticular fractures, meniscus injuries, when the synovial membrane of the knee joint suffers, ruptures of the ligaments and many more reasons. In the same way, aseptic synovitis occurs when irritated by free articular bodies, as well as structures previously damaged - this is a torn meniscus, damaged cartilage, and the like. Other causes of aseptic synovitis can be endocrine diseases, hemophilia and impaired metabolism. Upon contact of the allergic person with the allergen, allergic synovitis occurs. Treatment of the synovial membrane in this case is supposed after excluding the effects of the allergen on the patient's body.
Symptoms
In non-specific acute serous synovitis, the synovial membrane is thickened, the joint is enlarged. Its contours are smoothed out, even a bursting feeling appears. Pain is not very pronounced or absent. However, the movements of the joint are limited, with palpation there is a slight or moderate pain. The malaise is possible, the local and general temperature rises slightly. Palpation reveals fluctuation. The surgeon must carry out the following tests: covers the opposite parts of the joint with the fingers of both hands and gently presses on either side. If the other hand will feel a push, then the joint contains fluid. The synovial membrane of the knee joint is examined by balloting of the patella. When pressed, it is completely immersed in the bone, then, when the pressure is stopped, it pops up. Unlike purulent acute synovitis, there are no vivid clinical manifestations here.
And acute purulent synovitis is always visible, since the patient's condition worsens sharply, signs of intoxication appear: sharp chills, weakness, fever, even delirium is possible. The pain syndrome is pronounced, the joint with edema in volume is greatly enlarged, with hyperemic skin above it. All movements are extremely painful, in some cases joint contracture develops, and regional lymphadenitis is also possible (nearby lymph nodes increase). Chronic synovitis can be serous, but the form is most often mixed: vilen hemorrhagic, serous fibrinoid and the like. In these cases, the clinical symptoms are scarce, especially in the very early stages: aching pains, the joint quickly gets tired. In chronic and acute aseptic synovitis, the effusion can be infected, after which a much more serious infectious synovitis develops. That is why the study of RNA and synovial membrane is so important.
Complications
Infectious processes can spread far beyond the joint and its membrane, passing to the fibrous membrane, which entails the onset of purulent arthritis. Joint mobility is provided precisely by the state of the synovial membrane and ribonucleic acid, which implements genetic information about a person. The process extends further: phlegmon or periarthritis develops on the surrounding soft tissues. The most serious complication of infectious synovitis is panarthritis, when the purulent process covers all the structures that are involved in the formation of the joint - all bones, ligaments and cartilage. There are cases in which the result of such a purulent process is sepsis. If chronic aseptic synovitis exists in the joint structure for a long time, many unpleasant complications appear.
The joint gradually, but constantly, increases its volume, because the synovial membrane of the hip joint, knee or shoulder does not have time to suck back excess fluid. If treatment for such chronic diseases is absent, dropsy of the joint (hydrarthrosis) may well develop. And if the dropsy is in the joint for a long time, the joint becomes loose, the ligaments cease to fulfill their function, as they weaken. In these cases, not only a subluxation of the joint, but also a complete dislocation.
Diagnostics
After analyzing the clinical signs that are obtained after research and diagnostic puncture, a diagnosis is made. At the same time, not only the presence of synovitis is confirmed, but the reasons for its appearance should be identified, and this is a much more difficult task. To clarify the diagnosis of the underlying disease in chronic and acute synovitis, arthropneumography and arthroscopy are prescribed. A biopsy and cytology may also be required. If there is a suspicion of hemophilia, metabolic disorders or endocrine, appropriate tests are necessary. If the allergic nature of the inflammation of the synovial membrane is suspected, allergic tests should be performed. The most informative is the study of the fluid obtained using diagnostic puncture - punctate. In the acute aseptic form of synovitis acquired as a result of trauma, the study will show a large amount of protein, which is evidence of high vascular permeability.
A decrease in the total amount of hyaluronic acid also reduces the viscosity of the effusion, which characterizes the absence of a normal state of synovial fluid. Chronic inflammatory processes reveal an increased activity of hyaluronidases, chondroproteins, lysozyme and other enzymes, in which case disorganization and accelerated destruction of cartilage begins. If pus is detected in the synovial fluid , this indicates a purulent synovitis process that needs to be investigated by the bacterioscopic or bacteriological method, which will make it possible to establish a specific type of pathogenic microorganism that caused inflammation, and then select the most effective antibiotics. A blood test is required to detect an increase in ESR, as well as an increase in the number of leukocytes and stab neutrophils. If sepsis is suspected, additional blood sterility culture is needed.
Treatment
The patient needs peace, the maximum restriction of the movements of the affected joint, especially during exacerbation. Externally and internally, anti-inflammatory drugs are prescribed - Nimesil, Voltaren, and the like. If synovitis is pronounced, injections are prescribed, then passing into tablet forms of treatment. If there are significant accumulations of fluid in the joint, a puncture is indicated, which, in addition to diagnostic, has therapeutic value. Diagnosis is as follows: purulent arthritis and hemarthrosis (blood in the joint cavity) are differentiated, a cytological examination (especially with crystalline arthritis) of the joint fluid is carried out. During puncture, a rather large amount of yellowish liquid is obtained (especially with inflammation of the synovial membrane of the knee joint - more than one hundred milligrams). After removing the fluid with the same needle, anti-inflammatory drugs are introduced - kenalog or diprospan.
If the cause of the disease is established and the amount of fluid in the joint is insignificant, the patient will have an outpatient treatment. If the inflammation of the synovial membrane has occurred as a result of an injury, the patient is sent to the emergency room. Symptomatic synovitis of the secondary plan should be treated by specialized specialists - endocrinologists, hematologists and so on. If the amount of effusion is large, and the disease proceeds in an acute form, this is an indication for hospitalization. Patients with traumatic synovitis are treated in the department of traumatology, with purulent synovitis - in surgery, and so on - according to the profile of the underlying disease. Aseptic synovitis with a small amount of effusion involves a tight bandage on the joint, an elevated position and immobilization of the entire limb. Patients are referred for UHF, UV radiation, electrophoresis with novocaine. A large amount of fluid in the joint involves medical punctures, electrophoresis with hyaluronidase, potassium iodide and phonophoresis with hydrocortisone.
Therapy and Surgery
Acute purulent synovitis requires mandatory immobilization with an elevated position of the limb. If the course of the disease is not severe, pus is removed from the joint cavity by puncture. If there is a purulent process of moderate severity, continuous and prolonged washing with flow-aspiration with an antibiotic solution of the entire joint cavity is required. If the disease is severe, the joint cavity is opened and drained. Chronic aseptic synovitis is treated by treating the underlying disease, tactically the treatment is established individually, taking into account the severity of the disease, the absence or presence of secondary changes in the synovial membrane and joint, punctures are performed and rest is provided.
Prescriptions include anti-inflammatory drugs, glucocorticoids, salicylates, chymotrypsin and cartilage extract. After three to four days, the patient is sent to paraffin, ozokerite, magnetotherapy, UHF, phonophoresis or other physiotherapy procedures. If there is significant infiltration and frequent relapses, aprotinin is injected into the joint cavity. Chronic synovitis with irreversible changes in the synovial membrane, stubbornly recurring forms of it require surgical intervention - complete or partial excision of the synovial membrane. The postoperative period is devoted to rehabilitation therapy, which includes immobilization, anti-inflammatory drugs, antibiotics and physiotherapy.
Forecast
The prognosis is usually favorable for allergic and aseptic synovitis. If the therapy is carried out adequately, all inflammatory phenomena are eliminated almost completely, the effusion disappears in the joint, and the patient can now move in any volume. If the form of the disease is purulent, complications often develop, contractures form. There may even be a danger to the patient’s life. Chronic aseptic synovitis is often accompanied by stiffness, and in a number of cases relapses occur, contractures develop after synovectomy. It should be noted that synovitis almost always accompanies any chronic diseases in the joints, and therefore relapses are possible.
To reduce the inflammatory process that occurs in the synovial membrane, a course of anti-inflammatory injections is carried out, as well as the introduction of glucocorticosteroids into the damaged joint if there are no congenital joint pathologies (sometimes diagnostic arthroscopy and appropriate treatment are also carried out with pathological changes).So the pain is relieved, and the joint gradually begins to work better. The main thing is to eliminate the main cause of synovitis, and if you then remove the affected part of the synovial membrane, this will necessarily lead to a positive result. The prognosis is not bad for the consequences of surgery.
Effects
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