Biopsy

@ Introduction/Def @ Aim @
Indications
@ Contraindication @ Classification @
Principles
@ Complication @ Conclusion

Introduction:
 Biopsy is derived from a Greek word. Bio – LIFE,
opsy – TO LOOK
 This is the surgical removal of a tissue specimen in
a living body for the purpose of microscopic examination
usually to perform a diagnosis.
 It could be also therapeutic

Aim:
1. To establish tissue diagnosis 7.
Research purpose
2. Grading tumors 8.
Microbiology
3. To detect receptors 9.
Medicolegal
4. For screening purpose
5. Detecting enzyme and antigens
6. Monitoring, treatment, recurrence, prognosis

Indications:
1. Any lesion that persist > 2wk with no apparent
etiological basis
2. Any inflammatory lesions that does not respond to
local treatment after 10 – 14 days
3. Persistent hyperkeratotic changes in surface tissue
4. Any persistent tumor, either visible or palpable
beneath relatively normal tissue
5. Evaluation and monitoring of tissue rejection after
transplantation – kidney and liver
6. Inflammatory changes of unknown cause that persist
for long periods
7. Lesions that interfere with local function
8. Bone lesions not specifically identified by clinical and
x-ray findings
9. Any lesion that has the characteristics of malignancy.

Contraindications:
1. Uncontrolled bleeding diasthasis
2. Anticoagulant therapy
3. Overwhelming sepsis
4. Severe impaired lung function
 5. Uncooperative patient
6. Local infection near the site

Principals/precautions
1. A biopsy should be planned as carefully as the
definitive procedure.
2. Biopsy should be done only after clinical,
laboratory, and radiographic examinations are complete
3. It should be done in operation theatre, under
anaesthesia(G/A or L/A) with full aseptic precaution
4. For deep-seated lesions, fluoroscopic control of the
needle insertion is essential.
5. If a tourniquet is used exsanguinations by
compression is avoided
6. Transverse incisions should be avoided because
they are extremely difficult or impossible to excise with the
specimen.
7. The deep incision should go through a single
muscle compartment rather than contaminating an
intermuscular plane.
8. Major Neurovascular structures should be avoided.
9. Soft-tissue extension of a bone lesion should be
sampled, if possible.
10. If a hole must be made in the bone, it should be
round or oval to minimize stress concentration and prevent a
subsequent fracture,
11. The hole should be plugged with minimal amount
of methacrylate to limit hematoma formation.
 12. Adequate representative tissue (tumor +
pseudocapsule + surrounding normal tissue) must be carefully
taken
13. Single stage definitive procedure is considered
after intraoperative confirmation by frozen section biopsy only
14. If a drain is used, it should exit in line with the
incision so that the drain track also can be easily excised en
bloc with the tumor.
15. The wound should be closed tightly in layers. Wide
retention sutures should not be used.

Arthrocentesis (SYNOVIAL FLUID ANALYSIS)

Introduction:
Arthrocentesis and synovial fluid analysis is a much neglected
diagnostic procedure; but it can yield valuable information.
It should be considered in the following conditions.
1. Acute joint swelling after injury
2. Acute atraumatic synovitis in adults
3. Suspected infection
4. Chronic synovitis

Technique
 Joint aspiration should always be performed under strict
aseptic conditions.
 Gross physical examination is done
 A single drop of fresh synovial fluid is placed on a glass slide
for microscopic examination.
 For cytology - Wright’s staining and for bacteriology Gram’s
staining is done
 Few drops of fluid is sent to lab for biochemical examination

Charecteristic of normal synovial fluid

Physical examination Microscopic Biochemical
examination examination
Apperance: clear, pale ylleow Bacteriology: sterile Protein – 2g/dl
Viscocity: High(due to mucin Cytology: 60 – (A:G=20:1)
Amount: 0.13 -3.5 ml(knee) 3000/cmm Glucose – same as
Intra articular pressure: - 8 cm Avg – blood
to – 12 cm H2O 65/cmm Fibrinogen – nil, hence
Specific gravity: 1.008 – 1.015 Mostly does not clot
lymphocytes Enzyme – amylase,
lipase, protease, Alk.
 monocytes phosphatase

Synovial fluid analysis

Condition Appearan Viscosi Cytology Bact Protein Glucos Crystals
ce ty er e
iolog
y
Septic Purulent, Low ↑↑↑(>80,000/ + ↓ -
arthritis clots cmm) mostly
neutrophil
Tuberculo Turbid Low ↑ (>3,000/ cmm) + ↓ -
us mostly
arthritis lymphocyte
Rheumat Cloudy, Low ↑(>3,000/ - ↑(>8g/dl ↓ -
oid clots cmm)mostly )Albumi
arthritis neutrophil n
<50%
Gout Cloudy Normal ↑↑ - - Sodium
biurate
-
brisfringence
Pseudogo Cloudy Normal ↑ - - Pyrophospha
ut te
+
brisfringence
Osteo Clear High 60-3000/ cmm, - Not -
arthritis yellow mostly > 5.5
mononuclear g/dl
Traumatic Clear High 60-3000/ cmm, - Not -
arthritis yellow mostly > 5.5
/blood mix neutrophil g/dl
Albumin
>60%

Importance:
1. difference between synovitis and bleeding
2. Early diagnosis of suspected infection
3. Distingushing infection, gout, pseudogout, in case of acute
synovitis in adult
4. Diagnosis of TB, atypical RA in case of chronic synovitis

Conclusion:
Strict asepsis and careful tecqnique is a must for optimum and
accurate information and for patient’s safety.
RADIONUCLIDE IMAGING/Radio isotope
scanning/Scintigraphy

Introduction:
Bone scintigraphy is relatively sensitive but nonspecific.

The radiopharmaceutical used for radionuclide imaging has two

components:
1. A chemical compound that is chosen for its metabolic
uptake in the target tissue or organ, and
2. A radioisotope tracer (99mTc) that will emit photons for
detection.
Mode of action:
 The bone seeking radioisotope is injected
intravenously and
 the photons emitted by them are taken up in specific
tissues
 is recorded by a gamma camera. Produce an image
 which reflects physiological activity in that tissue or
organ.
Two stages:
i. the early perfusion phase –
shortly after injection, while the isotope is still in the
blood stream or the perivascular space.
ii. the delayed bone phase –
3 hours later, when the isotope has been taken up in
bone tissue.

Interpritation:
the greatest activity appearing in the cancellous tissue at the ends
of the long bones.

1. Early perfusion phase

a. Normally - Periarticular vascular soft tissues produce the
sharpest (most active) image
b. Increased activity - increased soft-tissue blood flow
@Inflammation (e.g. acute or chronic synovitis),
@A fracture,
@A highly vascular tumour @Regional sympathetic
dystrophy.
c. Decreased activity - local vascular insufficiency
2. Delayed bone phase
a. Normally - 3 hours later this activity has faded and the
bone outlines are shown more clearly
b. Increased activity - Increased ostegenic activity
@fracture, @implant loosening,
@infection, @a local tumour or
@healing after necrosis
c. Decreased activity - absent blood supply or replacement
of bone by pathological tissue
In the femoral head after Fracture neck of femur

Radionuclide imaging is useful in many situations:

(1) the diagnosis of stress fractures or
other undisplaced fractures that are not detectable on the
plain x-ray;
 (2) the detection of a small bone abscess,
or an osteoid osteoma;
(3) the investigation of loosening or
infection around prostheses;
(4) the diagnosis of femoral head
ischaemia in Perthes’ disease or avascular necrosis in
adults;
(5) the early detection of bone
metastases.

Advantage
 whole body can be imaged to
look for multiple sites of pathology (occult metastases, multi-
focal infection and multiple occult fractures).
 give information about
physiological activity in the tissues being examined
(essentially osteoblastic activity).
Disadvantage
 significant radiation burden (equivalent to approximately 200
chest x-rays)
 images yielded make anatomical localization difficult (poor
spatial resolution).

Isotopes commonly used

1. Technetium-labelled hydroxymethylene diphosphonate
 For bone imaging the ideal isotope is technetium 99m
 it has a relatively short half-life (6 hours) and
 it is rapidly excreted in the urine.
 A bone-seeking phosphate compound is used as the
substrate as it is selectively taken up and concentrated in
bone.

2. Technetium-labelled sulfer colloid SC)

 Better indicator of marrow vascularity

 It taken up phagocytes of RE system
 Used in early diagnosis of femoral head ishchemia

3. Gallium-67
 concentrates in inflammatory cells
 used to identify sites of hidden infection: for
example, in the investigation of prosthetic loosening after
joint replacement. However,

4. Indium-111-labelled leucocytes ***

 Used as a marker of infection
  distinguish sites of active infection from chronic
inflammation.

Conclusion: In most cases the isotope scan serves chiefly to

pinpoint the site of abnormality and is relatively sensitive but
nonspecific. It should always be viewed
in conjunction with other modes of imaging.

Computed tomography
*** The patient’s own white blood cells are removed and labelled with indium-111 before re-injected
into the patient’s blood stream.Preferential uptake in areas of infection is expected, thereby hoping
to distinguish sites of active infection from chronic inflammation. For example, white cell uptake is
Introduction:
more likely to be seen with an infected total hip replacement as opposed to mechanical loosening.
However,Computed tomography
as this technique is expensive is an advanced imaging technique that
produces sectional images through selected tissue planes – but with
much greater resolution. It is important in detecting bony lesions
that are missed in plain radiograph.

Mode of action:
the region of interest is selected and a series of crosssectional
images is produced and digitally recorded.

Modern advancement
 Spiral helical CT scan
 Contrast CT scan
 3D saggital

Role in orthopaedics:
1. Diagnosis of fracture in complex anatomical sites – spine,
pelvis, tibial platue, calcaneum
2. Assisting in the management of trauma patient with complex
fracture – while fracture is easily visualized in plain x-ray but
the exact position, number and size of the fragment is difficult
to identify
i. Vertebral body, tibial condyle, tarsal carpal bone
ii. Intra articular bone fragment
iii. Planning for operative treatment
3. Non traumatic condition – evaluation of bone and cartilage
based tumors
4. Useful in the asssement of tumor extent of the ossifying or
calcified portion wich an MRI can underestimate

Advantage Disadvantage
a. Rapid acquisition of images a. High radiation
exposure
b. Very high resolution b. Expansive
c. 3D helps in detecting proper site c. Only available
locally
d. Good for obese person d. Contraindicated in
pregnancy
Conclusion:
Despite few limitations CT scan is now a days essential imaging
technique in the modern orthopaedics.

Ultrasonography
Introduction:
It is used to diagnose a number of musculoskeletal
disorders depending on the echogenic contrast between
the cystic & solid mass

Mode of action:
High-frequency sound waves, generated by a transducer,
can penetrate several centimetres into the soft tissues;
some of these waves are reflected back (like echoes) to the
transducer, where they are registered as electrical signals and
displayed as images on a screen.

 Highly echogenic – fat is highly echogenic

 Mildly echogenic – semi-solid organs manifest varying degrees
of ‘echogenicity’
 Echo-free – Fluid-filled cysts are echo-free

Role in orthopaedics
1. identifying hidden ‘cystic’ lesions such as
i. haematomas,
ii. abscesses,
iii. popliteal cysts and
iv. arterial aneurysms.
2. detecting intra-articular fluid
3. diagnose a synovial effusion
4. monitor the progress of an ‘irritable hip’.
5. assessing tendons and diagnosing conditions such as
tendinitis and partial or complete tears. typical examples are
The rotator cuff, patellar ligament, quadriceps tendon, Achilles
tendon, flexor tendons and peroneal tendons
6. screening of newborn babies for congenital dislocation
(or dysplasia) of the hip; the cartilaginous femoral head and
acetabulum (which are, of course, ‘invisible’ on x-ray)
Advantage:
 Ultrasound imaging is quick, cheap, simple and readily
available.
 No radiation hazard
 Equipment is simple & easily portable

Disadvatage
 Result obtained is highly operator dependent
 Not suitable for obese person
 Little or no information from bony structure

Conclusion:
Important diagnostic role of musckuloskeletal
ultrasonography depends on skill and experience of the operator.
Unlike xrays, the image does not depend on tissue density but rather on reflective
BONE MINERAL DENSITOMETRY
surfaces and soft-tissue interfaces. This is the same principle as applies in sonar
detection for ships or submarines.
Introduction:
Bone mineral density (BMD) measurement is now widely used
in identifying patients with osteoporosis and an increased risk
of osteoporotic fractures.

Various techniques have been developed, including

1. Radiographic absorptiometry (RA),
uses conventional radiographic equipment and
measures bone density in the phalanges
2. Quantitative computed tomography (QCT)
measures trabecular bone density in vertebral bodies
but is not widely available and involves a higher dose of
ionizing radiation
3. Quantitative ultrasonometry (QUS)
assesses bone mineral density in the peripheral
skeleton (e.g. the wrist and calcaneus) by measuring
both the attenuation of ultrasound
and the variation of speed of sound through the bone.
4. Dual energy x-ray absorptiometry (DXA) the most widely used
technique
principle that calcium in bone attenuates passage of X-
ray beams in proportion to the amount of mineral
present.

By World Health Organization (WHO) criteria,

T scores of <–1.0 indicate ‘osteopenia’ and
T scores of <–2.5 indicate ‘osteoporosis’.