Arthroscopic Pathological Findings For Early Diagnosis And Treatment Of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systemic auto-immune disease characterized by chronic inflammation of synovial membranes, with which result in deformity and dysfunction of joints. With higher mobidity and mortility the RA is severely jeopardize the heath of the humanbeing. The exact pathological and physiological process of the RA is still unclear, the joint destruction is the main cause for the RA mutilation. It is accepted that the synovial membrane pathological changes plays an important role in the onset of the joint injury in RA. The synovial member is the first tissue which is injured and localized in the synovial membrane of the joint at the beginning. The secondary development after that causes the joint deformity and dysfunction. The clinical appearance of the RA is a complex syndrome, and the diagnosis is based on the clinical appearance, x-ray film and blood RF detection. The classification riteria made by ARA in 1987 is still used in practice for diagnosis of the RA. The standards is not good for early diagnosis of the RA due to it's limitations which can not satisfy the clinical request for early diagnosis of the RA, and can not provide a clear evaluation for the prognosis.There are none specific medicine in treatment of the RA, and the present treatment can only delay or block the damage before the joint injury, and it can not reverse the damaged joint. Therefore, the aim of the present treatment is to prevent the damage to the joint, preserve the joint function, and to improve the patient's quality of life. Early diagnosis and treatment is a key element for controlling the development of the RA, reducing the damage of joint and mutilation. It is an important project for clinics to increase the early diagnosis and treatment levels.With the development of the arthroscopic techniques, arthroscope has been widely used in practice. The pathological changes in the joint cavity, synovial membrane, joint cartilage, and ligament can be directly observed with arthroscope. Selective biopsy of the synovial membrane and cartilage, resection and repairing of the diseased tissue in the joint can be performed with minimal invasion, less pain, and early recovery.Based on the idea above, we investigated 29 cases with RA (confirmed diagnosis and doubtful diagnosis) for the clinical appearance, serum index tests, arthroscopic examination, synovial membrane biopsy, and analysis of the fluid in joint. Research Contents and Results29 cases with 31 knees were divided into two groups: 20 cases with 24 knees fit in all items of the Standards of ARA in 1987 goes into the Clinical Confirmed RA group; 9 cases with 11 knees only fit in 2 to 3 items of the Standards of ARA in 1987 goes into Doubtful RA group. From the arthroscopic and pathologic study, we found that in the Clinical Confirmed RA group, 19 cases with 23 knees are with RA, 1 case with 1 knee is with pigmented villonodular synovitis. The results shown the limitations of the present Standards made by ARA in 1987.The arthroscope procedures were performed to observe the form of the synovial membrane, diseased position, pannus formation, fibrous tissue proliferation, cartilage damage, and meniscus injury. The arthroscopic findings in finally confirmed RA in the two groups show that the joint damage, cartilage and meniscus injury is more severe in the Clinical Confirmed RA group than that in the Clinical Doubtful RA group. It shows the arthroscope examination is helpful for the early diagnosis of RA and let the patients have an early opportunity for early treatment.The biopsy was taken from all synovial membrane for HE staining for pathological confirmation. Only 10 cases in clinical confirmed RA group show positive in RA pathology, and 3 cases in clinical doubtful RA group show positive in RA pathology. The results show that it is very difficult to get a confirmed RA diagnosis just on the base of the biopsy of the synovial membrane for the reason of non-characteristic pathological manifestation of RA, and the clinical features, especially, the arthroscopic examination should be included.The immnohistological staining for nerve fibers in synovial membrane of RA shows massive nerve fiber proliferation, and the fiber proliferation might be responsible for the joint pain in RA.Follow-up study after arthroscopic surgery in 2-6 months shows that 70% in clinical confirmed RA group, 88% in clinical doubtful RA group are excellent and good. The effective arthroscopic results suggest that arthroscopic procedure should be applied in early phase for blocking the RA development.For all 26 cases of finally confirmed RA, the relationship between the symptoms and the arthroscopic findings were investigated, it shows that the up-stair pain in the knee related with cartilage destruction in the middle part of the patella; the down-stair pain in the knee related with cartilage destruction in the lower part of the patella; standing-up from sitting position pain related with cartilage destruction in the upper part of the patella; hyper-extension pain related with proliferation of the sup-patella synovial membrane; hyper-flexion pain related with the proliferation of the posterior synovial membrane in knee joint; McMurray sign related with the proliferation over or below the body of the meniscus; long distance walk pain related with extensive light to midrange proliferation of the synovial membrane, fading of the cartilage and meniscal surface gloss. The investigation between the clinical symptoms and the arthroscopic findings in synovial membrane proliferation, cartilage destruction will help us in general treatment and selection of the time for arthroscopic surgery.For all 26 cases of finally confirmed RA, the relationship between the symptoms and the arthroscopic findings were investigated, it shows that the up-stair pain in the knee related with cartilage destruction in the middle part of the patella; the down-stair pain in the knee related with cartilage destruction in the lower part of the patella; standing-up from sitting position pain related with cartilage destruction in the upper part of the patella (90o area); hyper-extension pain related with proliferation of the sup-patella synovial membrane; hyper-flexion pain related with the proliferation of the posterior synovial membrane in knee joint; McMurray sign related with the proliferation over or below the body of the meniscus; long distance walk pain related with extensive light to midrange proliferation of the synovial membrane, fading of the cartilage and meniscal surface gloss. The investigation between the clinical symptoms and the arthroscopic findings in synovial membrane proliferation, cartilage destruction will help us in general treatment and selection of the time for arthroscopic surgery.Conclusion: It is validated that the pathological changes in the joint cavity, synovial membrane, joint cartilage and ligament can be directly observed with arthroscope; The tissue at different phases and position can be obtained for biopsy study; Resection and repairing of the diseased tissue in the joint can be performed with minimal invasion at the same time. It is helpful to make early diagnosis, take differential diagnosis, estimate range and degree of lesion in the cavity and early repair. Improvement of technique can direct and cooperate with medication, promote the prognosis in the RA. The sufficient analysis to their biopsy in the different phases and position is helpful to illuminate pathogenesis and pathology. We have made a foundation and system for the next step in the RA research.