Needle versus Forceps Technique in
Ultrasound-Guided Synovial Biopsy of
the Knee Joint
Thomas Hügle1, Piotr Urbaniak1, Magdalena Müller-Gerbl2, Christian Marx3,
1Department of Rheumatology, University Hospital Basel, Switzerland
2Institute of Anatomy, University Basel, Switzerland
3Ultrasound Center Rheumatology, Basel, Switzerland
Prof. Thomas Hügle, Department of Rheumatology, University Hospital Basel, Switzerland;E-mail:
December 29, 2016; Accepted: April 4, 2017; Published: April 17, 2017
Citation: Thomas Hügle, Piotr Urbaniak, et.al. (2017) Needle versus Forceps Technique in Ultrasound-Guided Synovial Biopsy of the Knee Joint. J Rheumatol Arthritic Dis 2(2):1-3.
Objectives: Ultrasound-guided synovial biopsy is increasingly
applied in rheumatology. Usually forceps- or needle-based techniques
are used. So far there has been no direct comparison of different
devices regarding their suitability in high resolution musculoskeletal
ultrasound (hrMSUS)-guided synovial biopsy.
Methods: A core needle biopsy (Quickcore, Cook Medical,
Bloomington, IN, USA), an anterograde arthroscopy forceps (Karl Storz
GmbH, Tuttlingen, Germany), a retrograde forceps (Retroforce, Karl-
Storz GmbH Tuttlingen, Germany) and an convexly shaped integrated
core needle system (Synovex, Hipp Medical, Kolbingen, Germany)
were tested for ultrasound-guided synovial biopsy of the suprapatellar
recess in cadaver knee joints. Four senior rheumatologists scored
each intervention from 0-5 regarding the following characteristics:
visualization, handiness, accuracy, synovial tissue yield, invasiveness
and overall suitability. Each intervention was recorded as static
images and video clips.
Results: In all devices, enough representative synovial tissue was
obtained and the instruments were all well visualized by hrMSUS. Core
needle biopsy and the integrated needle system were best visualized
due to their horizontally shaped closing mechanism. The core needle
obtained a high yield of superficial synovial tissue and was the least
invasive procedure. Despite handiness and accuracy were higher
in the forceps instruments, overall suitability for hrMSUS -guided
synovial biopsy was rated highest for the core biopsy needle.
Conclusion: Technically, all of the tested devices can be used
for hrMSUS-guided synovial biopsy. Core needle biopsy seems to be
most suitable for this intervention due to a low invasiveness, good
visualisation and optimal yield of superficial synovial tissue.
Keywords: Synovial Biopsy; Ultrasound; Ultrasound-Guided;
Forceps; Needle; HrMSUS; Core Biopsy; Retrograde Biopsy; Synoviti;
Synovial biopsies can be required for the diagnosis of
various rheumatic or metabolic disorders such as inflammatory
arthritis, sarcoidosis, amyloidosis, chondromatosis or
hemochromatosis which can be undetectable by serology,
arthrocentesis or magnetic resonance imaging . Histological
evaluation is the method of choice in diagnosis of undifferentiated
arthritis and remains gold standard for the assessment for
the inflammation grade in arthritis . In septic arthritis or
periprosthetic joint infection, synovial biopsy has a higher
diagnostic sensitivity and specificity compared to synovial fluid
aspiration alone . Synovial biopsy is commonly performed
during arthroscopy, an invasive procedure that requires general
or spinal anaesthesia. Historically, synovial biopsy has been
done by blind needle biopsy e.g. using a Parker Pearson needle
. A new retrograde synovial biopsy device has recently been
developed which can be applied without concomitant imaging
. Today, ultrasound-guidance is increasingly applied for
synovial biopsy, as summarized by Lazarou et al. . Visualization
of the procedure by high resolution musculoskeletal ultrasound
(hrMSUS) increases its precision, safety and diagnostic reliability
as hypertrophic synovial lesions can be detected and targeted
for biopsy e.g. in rheumatoid arthritis both in small and large
joints . HrMSUS currently is performed either by a forcepsor
a needle-sampling approach. Technically, forceps- or portal
and forceps- based interventions are applied despite creating
a portal is time intensive and technically demanding . For
needle sampling, semi-automatic guillotine-type biopsy needles
such as Quick Core biopsy frequently used . So far, there has
been no systematic study directly comparing different devices for
hrMSUS-guided synovial biopsy.
Study set up
The study was performed with cadaver knee joints at
the anatomic institute of the University of Basel, Switzerland.
Synovial biopsy of the suprapatellar recess was performed by
four senior rheumatologists. For ultrasound guidance we used
a GE Logic S8XD Clear R3 machine with a ML6-15 probe and a
frequency of 9-12 MHz. All interventions were recorded as static
images and video clips.
Four different synovial biopsy instruments were
tested. 1. A core biopsy needle (Quickcore, 14G, Cook Medical,
Bloomington, IN, USA), 2. A retrograde synovial biopsy needle
(Retroforce, Karl-Storz GmbH, Tuttlingen, Germany) , 3.
An anterograde forceps for arthroscopy (Karl-Storz GmbH,
Tuttlingen, Germany) and 4. An integrated core needle system
with a convexly shaped semi-blunt trochar (Synovex, Hipp
Medical, Tuttlingen, Germany) .
Prior to the intervention, 20 ml saline fluid was injected
in the suprapatellar recess. The recess was sonographically
visualized by a transverse view. After stab incision, the
instruments were advanced through the capsule into the articular
space until full ultrasound visibility. If necessary, transcutaneous
pressure was applied to improve tissue yield. For each procedure,
the rheumatologists rated from 0-5 (highest) the following issues:
1. visualization, 2. handiness, 3. accuracy, 4. synovial tissue yield,
5. invasiveness, and 6. overall suitability for ultrasound guided
synovial biopsy. Mean scores were round up to whole numbers.
All instruments were well visualized by hrMSUS (Figure
1). The closing mechanism was best seen in the core biopsy
needle and the integrated needle system due to their horizontal
shape. Both the anterograde and the retrograde forceps were
visualized albeit the lower part of the anterograde forceps was
seen less clear due to ultrasound reflection of the upper plier.
The needle systems, notably the core biopsy needle were less
invasive than the forceps but less handy e.g. due to tensioning
and release of the spring. Accuracy and controllability were
highest in the anterograde forceps as the tip can be directed to
the target tissue by the distally located handle. The retrograde
biopsy location of the retrograde forceps is determined by the
site of capsule penetration. In contrast, the core needle has to be
placed horizontally to the anterior wall of the joint capsule for full
visibility and tissue yield. This horizontal contact guarantees a
large yield of synovial layer, which is of notable interest in synovial
biopsy. Horizontal pressure of the instrument against the capsule
increased sonographic visualization of the core biopsy needle
whilst this was not necessary with the integrated needle system
due to its convex shape. Overall suitability for sonography-guided
synovial biopsy was rated highest for the core biopsy system
Figure 1:Synovial biopsy using different devices 1. Core needle biopsy
2. retrograde forceps 3. Anterograde forceps and 4. Integrated core needle
system. Pictures on the left shows high resolution musculoskeletal
ultrasound (hrMSUS)-guided biopsy with the tissue yield in the upper
picture. On the right, hrMSUS view with the instruments in closed (top)
and opened (bottom) position (arrow).
Synovial tissue yield
Mean scores by four rheumatologists round up to whole numbers (0-
5, 5 highest).
This is the first study comparing different devices for
their suitability in hrMSUS-guided synovial biopsy, a procedure
of increasing interest. The results indicate that or the knee joint
core needle biopsy is the most suitable procedure in this setting
notably due to a low invasiveness, high superficial synovial layer
tissue yield and good visualization. The results presented here
are in line with the recommendations of the EULAR synovitis
study group favoring needle-based approach for synovial biopsy
over arthroscopy despite arthroscopy-guided techniques still are
applied in current studies . The integrated needle system
demonstrated here seemed also suitable for hrMSUS-guided
biopsy. The convexly shaped trochar improves horizontal contact
to the synovial layer and unlike to the Quickcore instrument,
synovial fluid aspiration can be performed. Clinical studies of
this device are necessary. Both the anterograde and retrograde
forceps were better controllable than the core needle due to the
distally located handle and the procedure was performed more
rapidly. On the other hand forceps are more invasive due to their
mechanical construction. The retrograde forceps originally has
been designed for a rapid synovial biopsy without concomitant
imaging . Aspiration of synovial fluid indicates intraarticular
positioning and retraction of the open forceps is applied for
contact to the capsule and synovial tissue, respectively. This
instrument potentially is of higher value in orthopaedic situations
such as prosthetic infection were targeting of specific lesions is
not required .
Clearly, the results of this cadaver study have a strong
technical aspect and the assessment might differ in the clinical
setting taking into accounts variables such as pain, tolerability
or capsule fibrosis. Fluid channels as in the retrograde forceps
instrument or integrated needle system can be of additional value
in the clinical setting e.g. allowing concomitant fluid aspiration or
As a limitation of this technical study, we did not
perform histological analysis of the obtained specimen. The yield
of synovial tissue with those instruments has been demonstrated
previously [5, 9].
Taken together, needle based instruments, notably core
needle biopsy are suitable for hrMSUS -guided synovial biopsy.
Larger clinical studies are necessary to assess notably the newer
instruments for synovial biopsy.
•Core needle sampling seems most suitable for hrMSUS-guided
synovial biopsy due to low invasiveness, good visualization and
•Forceps-techniques are handy and accurate but more invasive
than biopsy needles
Conflict of Interest
Dr. Hügle contributed to the development of the
Retroforce and Synovex instruments and receives royalties from
Karl-Storz GmbH and Hipp Medical AG.
No funding was received for this study.
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