Arthroscopic Guided Synovectomy, Synovial Biopsies, and Pathotype Identification in Refractory Rheumatoid Arthritis

Summary

This study presents a comprehensive procedure of synovectomy and synovial biopsies via arthroscopy in the shoulder for an RA patient, as well as the pathological classifications and treatments.

Abstract

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by synovial hyperplasia and joint destruction. Synovectomy and synovial biopsies are valuable procedures for diagnostic and research purposes. Synovectomy may also provide symptomatic relief in selected cases when medical therapy is insufficient. Arthroscopic-guided techniques offer a minimally invasive approach with enhanced accuracy in tissue sampling. This technique provides the distinct advantage of direct visualization, allowing for targeted biopsy of specific areas within the joint and the collection of tissue, including the crucial lining layer. Significant insights into the pathobiology of RA have been gained through the study of synovium obtained via this method. Moreover, emerging evidence has suggested that synovial tissue retrieved through arthroscopy may facilitate the identification of pathotypes, enabling a more precise, personalized approach to treatment selection for individual patients. Therefore, this paper presents a detailed description of the arthroscopic guided synovectomy in the shoulder and synovial biopsies and identification of pathotypes in a RA patient, drawing on the extensive experience at Renji Hospital.

Introduction

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by persistent synovial inflammation, leading to joint destruction and significant disability¹. While advances in disease-modifying antirheumatic drugs (DMARDs) have improved outcomes, up to 30-40% of RA patients failed to respond to individual agents¹. Given the heterogeneity in treatment response, there is an increasing need for synovectomy and synovial biopsies in clinical practice to facilitate early diagnosis, guide personalized therapeutic strategies, and improve patient outcomes².

Synovectomy....

Protocol

All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee, as well as with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For the inclusion and exclusion criteria, refer to Supplementary File 1.

1. Preparation of the patient

1. Evaluate the patient to confirm readiness for the arthroscopic-guided synovectomy and synovial biopsy procedure.
2. Obtain informed consent and brief the patient on the procedure, including potential risks and expect....

Results

Arthroscopic synovial biopsy was performed in a patient with active shoulder synovitis and systemic inflammatory arthritis. On clinical examination, the shoulder exhibited a limited range of motion and localized tenderness, particularly in the anterior region. Inflammatory markers were elevated (CRP: 24.23 mg/L; ESR: 59 mm/h), while RA-related autoantibodies were negative. The DAS28 score for this patient was 5.81, indicating a high level of disease activity in RA.

Preoperative MRI demonstrate.......

Discussion

This paper described a detailed procedure of synovectomy and synovial biopsy in the management of RA, particularly when performed in large joints like the shoulder. Synovectomy may offer symptomatic relief by removing inflamed synovial tissue, particularly in cases of joint-specific, treatment-refractory synovitis. It is typically considered an adjunct to pharmacologic therapy, rather than a primary intervention. Synovectomy is an important procedure for RA patients, particularly in cases where inflammation persists desp.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
0.9% Sodium Chloride Injection (1000ml)	Baxter	A-WN-014-1
10% formalin	Various	Not applicable
560 surgical imaging system	Smith-Nephew	93300001
Αdhesive sterile gauze	Various	Not applicable
Arthroscope (1.9 mm, 30°)	Smith-Nephew	4184
Arthroscope (2.7 mm, 30°)	Smith-Nephew	7205682
Arthroscope (4 mm, 30°)	Smith-Nephew	7220287
Biopsy forceps	Various	Not applicable
Limb position (Spider 2)	Smith-Nephew	72203299
Mosquito forceps	Various	Not applicable
Pneumatic toruniquet	Zimmer-Biomet	60-2200-301-01
Povidone-iodine	Various	Not applicable
Radiofrequecncy ablation probe	Smith-Nephew	ASC4250-01
Radiofrequecncy ablation probe(2.3 mm)	Smith-Nephew	AC2823-01
Radiofrequecncy ablation system	Smith-Nephew	H4500-00
Scalpel No 11	Various	Not applicable
Scissors straight 11 cm	Various	Not applicable
Shaver blade (2.0 mm)	Smith-Nephew	72201507
Shaver blade (2.9 mm)	Smith-Nephew	72201509
Shaver blade (3.5 mm)	Smith-Nephew	7205306
Shaver blade (3.5 mm)	Smith-Nephew	7205345
Shaver handpiece	Smith-Nephew	72201500
Shaver system	Smith-Nephew	72200873
Sterile surgical gloves	Various	Not applicable
Suture 4.0 Vicryl	Johnsons	W4993
Waterproof drape	Various	Not applicable