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GUEST EDITORIAL
Year : 1978  |  Volume : 24  |  Issue : 2  |  Page : 63-67

Synovianalysis


Department of Medicine, Seth G. S. Medical College and K.E.M. Hospital, Parel, Bombay-400 012., India

Correspondence Address:
K S Godkhindi
Department of Medicine, Seth G. S. Medical College and K.E.M. Hospital, Parel, Bombay-400 012.
India
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Source of Support: None, Conflict of Interest: None


PMID: 722607

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How to cite this article:
Godkhindi K S, Tilve G H, Nair K G. Synovianalysis. J Postgrad Med 1978;24:63-7

How to cite this URL:
Godkhindi K S, Tilve G H, Nair K G. Synovianalysis. J Postgrad Med [serial online] 1978 [cited 2019 Aug 20];24:63-7. Available from: http://www.jpgmonline.com/text.asp?1978/24/2/63/42670


Synovial fluid reflects the pathology of joint diseases. The presence of synovial fluid, was known from the 16th century. Examination of joint fluid did not attract attention, until 1953 when Ropes and Bauer, published their monograph on the subject, in which the diagnostic value of synovial fluid examination was stress­ed. [7],[12] Examination of synovial fluid can be the only way in diagnosing conditions like septic arthritis, villonodular synovitis and crystal synovitis, and in other arth­ritides adds to the accuracy of diagnosis. With advances in immunological and bio­chemical techniques synovial fluid has be­come a ground for research in under­standing the pathogenesis of various joint diseases.

Synovial fluid is dialysed from plasma and enriched in hyaluronate by the syno­vial membrane. Hyaluronate, a high molecular weight polymer, by the virtue of its long coiled structure, imparts the unique quality of viscosity, to the joint fluid. [3],[4] Highly viscous synovial fluid film, subserves the function of lubrication of joints and nourishes the joint struc­tures. During the inflammation, there is depolymerisation of hyaluronate and viscosity is reduced, exposing the joint surfaces to more friction and damage. The polymerisation can be increased by salicylate and indomethacin therapy. [5] The normal protein content of synovial fluid is one third that of plasma, with 60­70%0 as albumin, and 6-7% as alpha 2 , globulin. This distribution prevails as long as synovial fluid is normal. During inflam­mation gamma globulins are raised and fibrinogen enters the fluid making it coagulable.

Pathogenetic mechanisms of joint disease

Inflammatory response to a disease may be an attempt to eliminate or destroy the causative agent which may be an organ­ism, antigen antibody complex, or deposited crystal. Extension of such a response may damage the delicate struc­ture of joints causing disability. Immune mechanisms causing damage to the joint are considered in two ways, one in which the antibodies are directed to the specific component of the body tissues and the other in which the antigen antibody com­plexes are trapped at the synovial mem­brane, initiating the inflammatory reac­tion. The former concept, that of auto­immunity, is based on the description of systemic lupus erythymatosus (SLE) phenomenon. It is known, that a factor in serum of patients with SLE reacts with the nucleoprotein (DNA) of the damaged leukocyte. The resulting complexes undergo phagocytosis resulting in L.E cells. Various antinuclear factors arc seen by immunofluorescent techniques it SLE, scleroderma and rheumatoid arthri­tis. [2] It was shown, that the tissue specific antibodies were found in the organ affected as well as in circulation. Cross react­ing antibodies are found in rheumatic fever. Hepten induced sensitivity was described with an example of Sidormid purpura, where a drug altered the plate­lets, to induce anti-platelet antibodies causing purpura. Similar cause may b: present in hydralazine or procainamid induced SLE like picture, though these drugs may just be uncovering pre-existing SLE

Second mechanism in which a wide spread tissue damage occurs, is antigen antibody complex as a causative agent This is evidenced by such complexes seer at the site of damage as in glomerulone­phritis and SLE. Rheumatoid factor: (RF) are found in high titres in sera of patients suffering from rheumatoid arthritis with severe vascular involve­ment and in neuropathy. The leukocyte inclusions, the low complement activity in synovial fluid and the rheumatic nodule which begins as vasculitis, suggest the combination of rheumatoid factor with immunoglobulin complexes as pathogenic. Such a combination is shown to generate inflammatory mediator kinins.

When antigen engages antibody, reac­tion with complement occurs, followed by sequential addition of other components resulting in potentiation of antibody activity. Polymorphs are attracted tc the site under the influence of chemotac­tic factors. This process leads to a release of proteolytic enzymes from lysosomes which are present in synovial cells, causing additional damage. Cartilagen­ous cells and macrophages contain lyso­somal enzymes which disrupt the mast cell granules to aggravate the inflamma­tion. [15] Kinins liberated during the process are potent vasodilators, leucotactic, and cause increased permeability; these are released when kallekrein enzymes act on kniniogen. [6]

Collection of the synovial fluid

The synovial fluid can be aspirated easily from the knee joint in presence of an effusion. Aspiration from other joints is usually difficult, and more so from nor­mal joints. When carried out under strict aseptic precautions, the aspiration of the joints is safe. The knee joint aspiration is done as follows:

A small area of the skin between lateral condyle and patella is infiltrated with Xylocaine. Using wide bore needle, the anaesthetised skin is punctured and the needle is directed inwards under the patella gently into the cavity. Extreme care is taken to avoid the scoring of the joint surfaces. The fluid aspirated, is col­lected in three different test tubes. The first sample is collected in EDTA, second sample is used as such for microscopy, third one is used for bacteriological cul­ture.

Examination of synovial fluid

1. Appearance of synovial fluid: Colour and clarity of the fluid are noted.

2. Fibrin clot test: Plain synovial fluid is observed for formation of clot, and the clotting may be graded 1 to 4 plus depend­ing on the firmness.

3. Rope's test: The synovial fluid is centrifuged and supernatant (1 ml) is ad­ded to 4 ml. of distilled water, and 0.13 nil of 7 N acetic acid. A precipitate is for­med at the junction of the acid and the fluid.

The clot floats normally. Firmness and thickness of clot are recorded.

4. Viscosity: Fluid from the syringe can be allowed to drip in the form of a string. Longer the string formed more is the viscosity. Viscosimeter is used for more accurate readings.

5. Microscopy: A drop of fluid mixed with EDTA, is put on a slide and a cover slip is laid on it. Doubly refractile crystals may be seen under light microscope, but polarised light microscopy will enhance the identification of crystals. When there is a difficulty in distinguishing crystals of urate and calcium pyrophosphate the pH of the fluid may be raised to 9 or the fluid may be incubated in uricase to dissolve the urate crystals leaving the calcium pyrophosphate crystals unaffected.

6. Cytology: Cellular structures are counted using white blood cell counting areas on a haemocytometer. The fluid is diluted to 1: 20, by using 0.85 per cent saline and 0.1 per cent methylene blue in distilled water. The differential count is done on a smear prepared of the sediment from synovial fluid. A relative percentage of polymorphonuclear cells to mononu­clear cells is noted as an indication of synovial reaction.

Immunological, biochemical and other studies may be carried out on the same fluid in advanced laboratories.

Pathological changes in synovial fluid

An easy aspiration from a joint in­dicates some synovial reaction in that joint. A decrease in the contents of hya­luronate and albumin together can be noted on a poor flocculation formed on ad­dition of acetic acid whereas normally a thick ropy clot is formed. The glucose levels are decreased in synovial fluid dur­ing inflammation in proportion to the number of leucocytes. Many enzymes like beta glucoronidase, pepsin, trypsin, amy­lase, lipase, peroxidase, transaminases, al­kaline and acid phosphatases are found in the fluid. The levels of enzymes are in proportion to the number of white cells in the fluid [12]

Complement activity is decreased and kinins are increased in rheumatoid syno­vial fluid. Rheumatoid factors may be found in synovial fluid in the absence of the same in serum. The leucocytes, macro­phages, and synovial cells are seen in the fluid during inflammation. Relative per­centage of polymorphs to mononuclear cells is a reliable index of the type of synovial reaction. Doubly refractile crys­tals of sodium urate in gout and of sodium pyrophosphate in chondrocalcino­sis are diagnostic. [8],[9] Cholesterol crystal plates with notched corners are found in rheumatoid arthritis. [11] In degenerative joint diseases desquamated cartilagenous fragments are seen. Rheumatoid arthri­tis cell, which is a leukocyte with intra­cytoplasmic inclusions carrying gamma globulin determinants, is found in rheu­matoid synovial fluids. [14]

Depending on the analysis of synovial fluid the joint diseases are grouped into non-inflammatory, inflammatory, septic and haemorrhagic types. [13] [Table 1].

A clear straw coloured, viscous fluid with a good clot on addition of acetic acid, and minimal increase in cell count upto 2000, indicates mild synovial reaction. Such a type of fluid is found in traumatic arthritis, osteoarthritis, rheumatic fever, and systemic lupus erythematosus.

A turbid, yellow coloured fluid with low viscosity, showing fibrin clot but poor clot on addition of acetic acid, and having a high cell count with predominent poly­morphonuclear cells, indicates definite in­flammation of the joints, as found in cases of rheumatoid arthritis, gout and pseudogout.

In septic arthritis, the synovial fluid is inflammatory with a very high cell count, most of the cells being polymorphs and the culture of such a fluid is usually posi­tive.

The last group, where the synovial fluid is haemorrhagic, is found in cases of trauma, haemorrhagic diathesis, pigment­ed villonodular synovitis and neoplasms.

However the groups are overlapping e.g. an inflammatory type of fluid may be found in osteoarthritis where one has to consider the possibility of erosive forms of osteo-arthritis which produces inflam­mation, or the presence of pre-existing rheumatoid arthritis. [1],[10] An increase in cell count may follow an intra-articular administration of drugs which may mimic sepsis or rheumatoid process. The bac­teriological studies in such cases are man­datory, which may yield a growth of streptococci, staphylococci, pneumococci, or coliform bacteria.

Synovial fluid aspiration is a simple and safe procedure. Synovianalysis aids in diagnosis and prognosis as well. With the advanced laboratory techniques, synovial fluid examination has been a great help in understanding the complex pathogene­sis of joint disorders.

 
 :: References Top

1.Crain, D. C.: Interphalangeal osteoarthri­tis, J. Amer. Med. Assoc., 175: 1049-1053, 1961.  Back to cited text no. 1    
2.Elling, P.,: Antinuclear factors in rheuma­toid arthritis. Ann. Rheum. Dis., 27: 406­411, 1968.  Back to cited text no. 2    
3.Gardner, E.: Structure and functions of joints. In. "Arthritis and allied conditions". Eds. Hollander, J. L., McCarthy, D. J. Jr.,8th Edition, Philadelphia, 1972, pp. 67-81.  Back to cited text no. 3    
4.Hammermann, D. and Schubert, M.: Diar­throdial joints, an essay. Amer. J. Med., 3­555-590, 1962.  Back to cited text no. 4    
5.Holt, P. J., How, M. J., Long, V. J. W. and Hawkins, C. F.; Mucopolysachcarides in synovial fluid. Ann. Rheum. Dis., 27: 264-269, 1968.  Back to cited text no. 5    
6.Kaplan, A. P. and Austen, K. F.: A pre­albumen activator of prekallekrein. J. Exp. Med., 133: 696-712, 1971.  Back to cited text no. 6    
7.King, D. J.: "Syncvial membrane and synovial fluid." Les Angeles Medical Press. 1938.  Back to cited text no. 7    
8.McCarthy, D. J. Jr.: Diagnosis of gouty arthritis. Postgrad. Med., 33: 142148, 1963.  Back to cited text no. 8    
9.McCarthy, D. J. Jr., Kohn, N. N. and Faires, J. S.,: Significance of calcium phos­phate crystals in synovial fluid of arthritic patients. "The pseudo-gout syndrome" I Clinical Aspects. Ann. Int. Med., 56: 711­737, 1962.  Back to cited text no. 9    
10.10. Moskowitz, R. W.: Quoted In, "Arthritis and allied conditions". Eds. Hollander,J. L., McCarthy, D. J. Jr. 8th Edition, Philadelphia. 1972, pp. 1032 1053.  Back to cited text no. 10    
11.Ralph, A. J.: Study of synovial fluids. In, "Arthritis and allied conditions". Eds, Hollander, J. L., McCarthy, D. J. Jr. 8th Edition Philadelphia, 1972, p: 67-81.  Back to cited text no. 11    
12.Ropes, M. W. and Bauer, N.: "Synovial fluid changes in joint diseases." Mass Har­vard University Press, Cambridge, 1953.  Back to cited text no. 12    
13.Schmid, F. R. and Ogata, R. I.: Synovial fluid in joint disease. Med. Clin. North. Amer., 49: 165-179, 1965.  Back to cited text no. 13    
14.Vaughan, J. H., Barnett, E. V., Michael, V. S. and Jacox, R. F,: Intracytoplasmic inclusions of immunoglobulins in rheuma­toid arthritis and other diseases. Arthr. and Rheum., 11: 125-134, 1968.  Back to cited text no. 14    
15.Weissmann, G., Becher, B., Wiedmann, G. and Bernheimer, A. W.: Studies on lysosomes. Amer. J. Path., 46: 129-147, 1965.  Back to cited text no. 15    



 
 
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