Technique for Percutaneous Biopsy of the Synovium of the Hip Joint

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A decision is made after a complete radiological evaluation of joint disease. The degree and location of synovial proliferation are systematically evaluated prior to PBS by means of magnetic resonance imaging (MRI) with intravenous administration of gadolinium or arthrography combined with computed tomography (CT). Gadolinium-enhancement MRI is especially

FIGURE 1 Simulation of needle approach to the hip joint on a transverse image. Computed tomography R: right; H: horizontal line; A: point where the needle tip first reaches the bone; A-B: simulation of needle approach.

valuable in localizing synovial hypertrophy and in determining the biopsy site. The patient's hemostasis must be checked in the days preceding the procedure. A sedative drug (e.g., 100 mg hydroxyzine dichlorhydrate) is administered orally one hour prior to the examination, and a perfusion of antalgic drugs (e.g., Propacetamol Chlorhydrate) is given during the procedure.

PBS is performed under local anesthesia on an outpatient basis. However, because the patient received sedative drugs before the procedure, the patient has to be escorted back home. PBS is achieved under single plane fluoroscopy guidance. An SNCN allows for multiple sampling in the inferior and medial joint recess, which is a frequent site of synovial proliferation and the preferred site for tissue sampling (Fig. 1). The patient is placed supine on the X-ray table with the leg stabilized in internal rotation by sandbags. The hip joint is approached through an anterolateral route (Figs. 1 and 2). The point of skin puncture is determined with the aid of palpation and fluoroscopy. It is located 3 to 4 cm medial to the anterior aspect of the greater trochanter (Fig. 3A). The appropriate level of puncture is determined under fluoroscopic control by placing a metallic ruler over the patient's hip in order to simulate the approaching needle on the fluoroscopic screen. The ruler is appropriately tilted so that it projects over the junction of the femoral head and neck as simulated in Figure 2. After skin preparation, the joint is draped and superficial and deeper planes are anesthetized with 1% lidocaine. The joint is first approached with a 20-gauge needle. If present, synovial fluid is aspirated for bacteriologic and cytologic examination. If no fluid is aspirated, sterile saline solution is injected and then reaspirated to be sent for bacteriological analysis. Distension of the joint with contrast media,

FIGURE 3 Needle approach for percutaneous biopsy of the synovium of the hip. The introducer is first advanced to the lateral aspect of the junction of the femoral head and neck (A). The lateral notch-cutting needle is then introduced into the joint through the trephine (small arrow) (B). Gentle alteration in trephine inclination (large arrow) facilitates advancement of the lateral notch-cutting needle.

FIGURE 3 Needle approach for percutaneous biopsy of the synovium of the hip. The introducer is first advanced to the lateral aspect of the junction of the femoral head and neck (A). The lateral notch-cutting needle is then introduced into the joint through the trephine (small arrow) (B). Gentle alteration in trephine inclination (large arrow) facilitates advancement of the lateral notch-cutting needle.

1% lidocaine, and saline solution makes easier the penetration of the biopsy instruments into the joint space (7). Because repeated filling of the joint cavity during the procedure also facilitates the biopsy of multiple samplings, a lockable three-way stopcock is placed over the 20-gauge needle. The introductor and then the SNCN are inserted by means of a skin stab and advanced toward the lateral aspect of the junction of the femoral head and neck. The needle is simultaneously directed downward at an angle of 20° to 30° to the horizontal plane (Fig. 3A). When the needle contacts the bone at the correct point, it is withdrawn 2 cm and advanced again 2 cm in a direction more horizontal toward the anterior aspect of the joint (Fig. 3B). A gentle alteration in the position and inclination of the needle is usually needed to allow the SNCN to slide along the anterior aspect of the bone. Once a correct placement of the SNCN has been achieved (the cutting window must be tangential to the surface of the joint), the biopsy is performed. The SNCN is removed with each specimen while the introductor remains in place. Return of fluid through the lumen of the SNCN or through the introductor confirms a correct biopsy site. The same process is repeated in adjacent areas of the joint space using slight alterations in inclination and position of the biopsy needle. Repeated fillings of the joint with contrast media or saline solution helps in obtaining multiple specimens. Radiographs are performed during the procedure to document the exact site of tissue sampling (Figs. 4 and 5). After the

FIGURE 4 Percutaneous biopsy of the synovium in hip infection due to Escherichia coli.

procedure, patients are advised to rest for 24 hours. The need for rapid consultation in case of fever, abnormal increase in pain, swelling, or any signs and symptoms that may indicate complications is carefully explained.

Specimen biopsy must be carefully examined during the procedure. Synovial tissue has a pale pink color that can be distinguished from muscle and from yellow-white fibrinous exudate or necrotic material (8). To minimize the sampling error, many specimens are taken from various parts of joint lining (8). Several specimens are fixed in neutral formalin. When gout, calcium pyrophosphate dehydrate, or apatite crystal-related arthropathies are suspected, absolute alcohol is also used (9). Some other specimens and synovial fluid are taken for bacteriologic examination.

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