We will briefly review
synovial anatomy
histopathologic changes of synovial disorders
classification of synovial disorders
MRI findings of synovial disorders related to histopathological changes
BackgroundSynovial membrane
lines the inner surface of joint capsule, all other intra articular structures with the exception of articular cartilage
small gap between insertion synovial membrane/capsule 「BARE」 area
composed of:
intimal layer
supportive (subintimal) layer
Mechanism of synovial disorders
Fig. 1: Mechanism of synovial disorders
References: MANISA CELAL BAYAR UNI. - Istanbul/TR
Synovial disorders
Synovial inflammation
synovial chondromatosis
pigmented villonodular synovitis (PVNS)
lipoma arborescens
synovial hemangioma
synovial sarcoma
nonspesific chronic synovitis
Rheumatoid artrithis and other sero negative arthritis
septic arthritis
other arthritis( iatrogenic, congenital, exc.)
inflammatory synovial disorders
tumors and tumor like lesions
miscellaneous
hyperplasia or hypertrophy of synovial cells
varying degrees inflammation
MRI is the gold standart in imaging
same signal intensity with effusion on T1-W images
lower signal intensity (SI) than effusion on T2-W images
Fig. 2: Knee MRI showing low T1w signal and high T2w signal of hypertrophied synovium
References: Ege University Department of Radiology
Rheumatoid arthritis(RA)
Rheumatoid arthritis is the most common chronic inflammatory joint disease, with a prevalence of 0.5–1.0%
2-3 times more common in women
The presence of synovitis is considered a strong predictor of future erosive changes
x-ray demonstrate late changes and deformities
Fig. 3: Advanced changes and deformities of the hand typical of rheumatoid arthritis
References: Ege University Department of Radiology
Key imaging findings in early RA
Synovitis
Bone marrow edema
Bone erosions
Fig. 4: Typical MRI findings of RA in the hand
References: MANISA CELAL BAYAR UNI. - Istanbul/TR
Synovitis &RA
Bone erosions & RA
Bone erosions are defined as a partial or complete loss of the low signal intensity that characterizes the cortical bone in both T1- and fluid-sensitive sequences.
The erosion can be further characterized as active when there is significant postcontrast enhancement of adjacent bone.
Fig. 6: Bone erosions of the carpal bones and 4th metacarpal head (arrows)
References: MANISA CELAL BAYAR UNI. - Istanbul/TR
Bone marrow edema &RA
Bone marrow edema, not visualized on X-R, is a pre-erosive sign of arthritic bone damage and may have prognostic value in early RA
Low SI on T1-W,
High SI on T2-W fluid sensitive sequences
HighSI T1-W +C fs
Fig. 7: Bone marrow edema of carpal bones and 2nd metacarpal base on PD fs coronal view
References: Ege University Department of Radiology
Usually arthritic symptoms first develop in the hands and wrists in a characteristic symmetric, proximal distribution.
Feet and large joints like hip, knee and shoulder may also be involved.
Fig. 8: Synovial effusion, hypertropy, erosions of humeral head and tuberculum majus, and subchondral bone marrow edema
References: Ege University Department of Radiology
Fig. 9: RA involvement of shoulder: synovial thickening, pannus formation, erosion and/or resorption articular cartilage irregularity
References: Ege University Department of Radiology
Soft tissue swelling -fusiform and periarticular. It represents a combination of joint edema and tenosynovitis
Fig. 10: Wrist joint effusion and flexor tenosynovitis
References: MANISA CELAL BAYAR UNI. - Istanbul/TR
Atlantoaxial joint may also be involved in RA.
Fig. 11: Involvement of atlantoaxial joint with RA demonstrating chronic changes and ankylosis
References: Ege University Department of Radiology
detection of diasease activity
detection of therapy response
Fig. 12: Synovial effusion, hypertrophy, enhancement, bone erosion, edemaQuantitative measurement from synovial enhancement rate following Gadalinium administration with color maps and time-intensity curves
References: MANISA CELAL BAYAR UNI. - Istanbul/TR
Juvenile idiopathic arthritis: juvenile rheumatoid arthritis (JRA): Still's disease: is the most common chronic arthritic disease of childhood, and has multiple subtypes.
MRI shows synovial hypertrophy, joint effusions as well as osseous and cartilaginous erosions
Fig. 13: 12y/o female with knee involvement, synovial effusion, hypertrophy and small marginal erosions (arrows)
References: MANISA CELAL BAYAR UNI. - Istanbul/TR
Oligoarticular or polyarticular arthritis of a duration of six weeks or longer must be present to diagnose JIA
Fig. 14: Asymmetrical left sacroileitis and left hip joint effusion
References: Ege University Department of Radiology
Septic arthritis
a destructive arthropathy caused by intra-articular infection.
clinical history
localization
laboratory tests
duration of the disease
destruction of subchondral bone on both sides of a joint
juxta-articular osteoporosis
MRI sensitive for early cartilaginous damage
aspiration of joint fluid
Fig. 15: Synovial effusion similar with RA however with more extensive bone marrow edema, soft tissue inflammation and osteomyelitis
References: Ege University Department of Radiology
Fig. 16: Post-contrast images of the same case
References: Ege University Department of Radiology
Brucellosis is rare case of septic arthritis
Fig. 17: 30y/o male with knee involvement Synovial effusion with higt T1w signal, hypertrophy and marginal erosions (arrows)
References: MANISA CELAL BAYAR UNI. - Istanbul/TR
Familial Hypertrophic Synovitis (Jakobs syndrome)
A rare chromosomal genetic syndrome where the male person has an extra Y male chromosome, becoming XYY instead of normal XY or XX
Fig. 18: Bilateral hip involvement with synovial effusion
References: Ege University Department of Radiology
Reactive (foreign body) Synovitis
The detection of foreign body is especially important because it may serve as an unrecognized nidus for infection.
The retained foreign matter may result in cellulitis, abscess, or fistula formation.
It may result in synovitis if the joint and osteomyelitis if bone are violated.
Fig. 19: foreign body causing synovitis in knee joint of a child
References: Ege University Department of Radiology
Noninflammatory synovial disorders
Pigmented villonodular synovitis(PVNS)
proliferation of synovium with deposit of lipid and hemosiderin
diffuse form : knee, hip, elbow, wrist
Fig. 20: diffuse form of PVNS of the knee
References: Ege University Department of Radiology
Fig. 21: Secondary degenerative changes due to PVNS
References: Ege University Department of Radiology
Fig. 22: Giant cell tumor of the tendon sheat located at the flexor tendon of the 4th finger of the foot with low T2w signal components.
References: MANISA CELAL BAYAR UNI. - Istanbul/TR
Hemophilia
Haemophilia A accounts for around 80% of cases and results from a deficiency of coagulation Factor VIII.
incidence: 1 in 5000 male births. Approximately a third of affected individuals have no family history.
Haemophilia B (Christmas disease) accounts for the remaining 20% of cases and results from a deficiency of coagulation Factor IX.
Incidence : 1 in 25,000 male births.
Around 70% of patients have the severe form of the disease characterized by spontaneous haemorrhage or haemorrhage following minor trauma.
The hallmark of the disease is haemorrhage, particularly into joints and/or soft-tissue
hemophilic arthropaty - in almost all individuals
hemophilic pseudotumor - in ~2%
soft tissue haematoma, may lead to contractures
serious life-threatening haemorrhage (intracranial, thoracic, abdominal)
Fig. 23: Low signal in the ankle joint representing chronic blood products with destructive changes of the joint
References: MANISA CELAL BAYAR UNI. - Istanbul/TR
Early degenerative joint desease with widening of the intercondylar notch, bulbous medial femoral condyle, juxtaarticular osteoperosis and joint space narrowing is secondary to recurrent intraarticular bleeding.
Fig. 24: Early degenerative joint desease of the right knee
References: Ege University Department of Radiology
Synovial chondromatosis
chondroid changes of synovium
primary : no underlying disease : chondroid metaplasia of synovium : multiple intraarticular chondral bodies
secondary : Degenerative joint disease : small incorporated cartilage fragments situmulate metaplasia of the synovium
Fig. 25: Intraarticular bodies may show signal similar to the cartilage, cortical (yellow arrows) or trabecular (red arrows) bone depending to its internal composition
References: MANISA CELAL BAYAR UNI. - Istanbul/TR
Fig. 26: Calcified intraarticular lesion with low signal on all sequences like cortical bone
References: Ege University Department of Radiology
Fig. 27: Multiple small free intraarticular bodies, synovial thickening and enhancement
References: MANISA CELAL BAYAR UNI. - Istanbul/TR
Fig. 28: Calcified intraarticular bodies (arrows) are easily demonstrated with x-ray and computed tomography
References: MANISA CELAL BAYAR UNI. - Istanbul/TR
Lipoma arborescens
Fig. 29: Villous proliferation and fatty replacement of the synovium of the right knee
References: MANISA CELAL BAYAR UNI. - Istanbul/TR
Fig. 30: Lipoma arborescens with calcified intraarticular calcified bodies
References: MANISA CELAL BAYAR UNI. - Istanbul/TR
Synovial Hemangioma
Synovial haemangioma is a rare benign vascular malformation that occurs in relation to the joint.
It is sometimes considered a sub type of soft tissue heamangioma
The lesions typically present in children and young adults.
Fig. 31: Hemangioma in the knee joint with vascular channels
References: Ege University Department of Radiology
Intraarticular synovial sarcoma
While these tumour arise near joints, it is rare form them to arise from the joint itself and despite their name, they do not arise from synovial structures, e.g. joints, tendon sheaths and bursae.
Fig. 32: Enhanching intraarticular mass lesion
References: Ege University Department of Radiology
Synovial sarcoma
Synovial sarcomas typically present in adolescents and young adults (15-40 years of age).
There may be a mild (M:F 1.2:1) male predilection.
The most common location for these tumours is within the soft tissues adjacent to large joints, e.g the knee and popliteal fossa
MRI is the modality of choice to locally stage the tumour.
The mass is usually large and variably well-defined
Fluid-fluid levels are seen in up to 10-25% of cases
Calcifications seen in 30% of cases are non-specific and not usually osteoid or chondroid in appearance
Fig. 33: Synovial sarcoma involving the soft tissues of the knee and destructiive changes of the tibia
References: Ege University Department of Radiology
Fig. 34: Synovial sarcoma of the plantar soft tissues of the foot
References: Ege University Department of Radiology
MRI is gold standart in evaluating synovial disorders
MRI findings are related to histopathologic changes
Better evaluation both intraarticular and paraarticular structures
Early detection of cartilage and subchondral bone changes
Quantitative measurement of therapeutic efficasy and follow up patients
Better grading than plain radiography for inflammatory synovial diseases
For the differential diagnosis of tumors and tumor like lesions plain radiography shuld be obtained
References1. Gabriel SE. The epidemiology of rheumatoid arthritis. Rheum. Dis. Clin. North Am. 2001;27 (2): 269-81.
2. Sommer OJ, Kladosek A, Weiler V et-al. Rheumatoid arthritis: a practical guide to state-of-the-art imaging, image interpretation, and clinical implications. Radiographics. 25 (2): 381-98. doi:10.1148/rg.252045111
3. SugimotoH, Takeda A, Hyodo K. Early-stage rheumatoid arthritis: prospective study of the effectiveness of MR imaging for diagnosis. Radiology2000; 216: 569–575.
Orguc S,Tıkız C, Aslanalp Z, Erbay PD. Comparison of OMERACT-RAMRIS Scores and Computer Aided Dynamic Magnetic Resonance Imaging Findings of Hand and Wrist as a Measure of Activity in Rheumatoid Arthritis . Rhematology International (Rheumatol Int. 2013 Jul;33(7):1837-44
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