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Arthroscopy in arthritis
Pathophysiology
Inflammatory arthritis is the most common situation where a synovectomy or biopsy may be indicated. Some causes of osteoarthritis may, however, also benefit from a synovectomy. A radiographic association between calcium pyrophosphate dihydrate crystal deposition disease (CPPD) and chronic scapholunate (SL) dissociation and scaphotrapezial (ST) osteoarthritis has been noted ( Fig. 15.1 ) but the question of cause and effect has not been completely settled. A recent report has linked gout and SL and lunotriquetral (LT) ligament pathology as well. Wilczynski et al. recently reported the arthroscopic findings in seven patients with the diagnosis of gout and nontraumatic wrist pathology. All seven wrists had diffuse synovitis, with crystalline deposits throughout the radiocarpal joint (positive histology for urate crystals in four patients) and focal crystalline precipitates on the SL and LT ligaments but not on the triangular fibrocartilage complex 
(TFCC). SL ( ) (six cases) or LT ligament (five cases) disruption was noted in addition to an early SL advanced collapse pattern of arthritis in six of the seven patients.
Synovial biopsy
Synovial biopsy indications
An arthroscopic synovial biopsy is indicated in inflammatory conditions when a tissue sample is required to aid in the diagnosis, such as with inflammatory arthritis, gout, sarcoidosis, or granulomatous infection. Synovial biopsy is also useful when a quantitative analysis of the inflammatory response in a rheumatoid patient is indicated for prognostic reasons.
Contradindications
A bleeding disorder is a relative contraindication to a biopsy.
Outcomes
Kraan et al. demonstrated that the inflammation in one joint is generally representative of that in other inflamed joints, and that it is possible to use serial samples from the same joint, selecting either large or small joints, for the evaluation of antirheumatic therapies. They examined nine patients with rheumatoid arthritis and performed an arthroscopic synovial biopsy of both an inflamed knee joint and an inflamed wrist or metacarpophalangeal joint. Multiple biopsy specimens were collected and stained for macrophages, T cells, plasma cells, fibroblast-like synoviocytes, and interleukin-6 (IL-6) by immunohistochemistry. They found no significant differences in mean cell numbers for all markers investigated in samples from the knee joint compared with samples from the small joints, but they did find a statistically significant correlation for the numbers of sublining macrophages, T cells, and plasma cells, and for IL-6 expression. It is most efficient to take a sample directly using arthroscopic forceps although a full radius resector and arthroscopic scalpel may also be used.
Synovectomy
Indications for arthroscopic synovectomy
An arthroscopic synovectomy is indicated in patients with rheumatoid arthritis ( Fig. 15.2 A–F) who have not responded to 3 to 6 months of appropriate medical management, and who have a stable wrist joint with well-preserved articular surfaces. The procedure is also beneficial in patients with juvenile rheumatoid arthritis, systemic lupus, or postinfectious arthritis. AP and lateral x-ray views are performed to screen for avascular necrosis (AVN), though MRI is more accurate.
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