International Journal of Clinical Medicine, 2013, 4, 1-5
Published Online December 2013 (
Open Access IJCM
Experience of Patients Undergoing Mini-Arthroscopy
Compared to MRI in the Earliest Phases of Arthritis*
Maria J. H. de Hair1#, Marleen G. H. van de Sande1, Mario Maas2, Danielle M. Gerlag1, Paul P. Tak1
1Department of Clinical Immunology and Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, The
Netherlands; 2Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Received October 18th, 2013; revised November 10th, 2013; accepted December 1st, 2013
Copyright © 2013 Maria J. H. de Hair et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In
accordance of the Creative Commons Attribution License all Copyrights © 2013 are reserved for SCIRP and the owner of the intel-
lectual property Maria J. H. de Hair et al. All Copyright © 2013 are guarded by law and by SCIRP as a guardian.
Objective: To evaluate the expectations and experience of patients undergoing mini-arthroscopy compared to contrast
enhanced MRI for research purposes. Methods: Seventeen patients with early, active arthritis (Group A) and 21 autoan-
tibody-positive individuals without any evidence of arthritis upon physical examination (Group B) were included. All
subjects underwent both contrast enhanced MRI and synovial biopsy sampling by mini-arthroscopy of the same joint
within one week. At inclusion and after bo th procedures, su bjects filled in questionnaires with ite ms about expectation s
and experience with regard to the procedures. Results: Before procedures, subjects in group B had a higher fear of and
reluctance to undergo mini-arthroscopy compared to MRI (p < 0.0001 and p = 0.001, respectively). Before procedures,
42% of the subjects preferred MRI, 11% of the subjects preferred mini-arthroscopy and 47% had no preference for ei-
ther procedure. After both procedures, subjects preferences changed to 39% for MRI, 32% for mini-arthroscopy and
29% for no preference for one or the other procedure. When comparing Group A with Group B, there were no signifi-
cant differences in preference before and after the procedures. Conclusion: Synovial biopsy sampling by mini-arthro-
scopy for analysis of synovial inflammation is a well-experienced procedure when compared to contrast enhanced MRI.
These results support the use of mini-arthroscopy in a research setting from a patient perspective.
Keywords: Arthritis; Rheumatoid; Synovium; Arthroscopy; MRI
1. Introduction
Rheumatoid arthritis (RA) is a chronic autoimmune dis-
ease characterised by inflammation of synovial tissue
leading to joint destruction and deformity [1]. Since the
synovium is the main target tissue affected in RA, analy-
sis of the features of the synovial in flammation is of ma-
jor importance for pathogenetic studies. For analysis of
synovial inflammation imaging but also histologic stud-
ies can be used. Analysis of the synovial tissue can be
used to give insight into disease pathogenesis and to
evaluate the effects of new treatments and the mecha-
nisms of action of therapeutic compounds. Mini-arthro-
scopy, performed under local anaesthetics at the outpa-
tient clinic, is a feasible means of synovial biopsy sam-
pling. It has been used for research purposes and is gen-
erally well tolerated with low complication rates [2-4].
Still, mini-arthroscopy is regarded as a rather invasive
procedure and only performed in a few specialised cen-
Imaging of synovial inflammation can be done making
use of MRI. MRI gives information about the degree of
synovial inflammatio n, and additionally the co mpartment
surrounding the synovium can be evaluated, including
the bone (marrow) and cartilage. In the current project
we performed dynamic contrast enhanced (DCE) MRI,
by injecting a contrast agent intravenously during and
after which time-dependent changes in MRI signal can
be registered. DCE-MRI clearly visualizes the degree of
synovial inflammation [5], enables to study physiologic
characteristics of the inflamed synovium, such as vessel
*This study was financially supported by the Dutch Arthritis Associa-
tion (grant 06-1-303) and the European Community’s FP6 funding
#Corresponding autho
Experience of Patients Undergoing Mini-Arthroscopy Compared to MRI in the Earliest Phases of Arthritis
Open Access IJCM
permeability, and has been shown to be a sensitive too l to
detect changes after treatment [6-11].
At international scientific meeting s, when results from
studies using synovial biopsy sampling by mini-arthro-
scopy are presented by researchers of our Department of
Clinical Immunology and Rheumatology of the Acade mic
Medical Center (AMC) Amsterdam, questions are raised
concerning patient’s experience of synovial biopsy sam-
pling by mini-arthroscopy, especially in individuals with-
out arthritis. It seems that there is a general idea that
mini-arthroscopy is an invasive procedure and a burden
for patients, which seems to hamper the use of mini-ar-
throscopic synovial biopsy sampling in some research
centres. Patient expectations and experience of mini-ar-
throscopy have never been studied. Therefore, we inves-
tigated patient’s expectations before and experience after
mini-arthroscopic synovial biopsy sampling and com-
pared those with expectations before and experience after
undergoing dynamic contrast-enhanced MRI, which is
generally seen as a non -invasive procedure.
2. Methods
2.1. Study Subjects
Group A consisted of early arthritis patients (arthritis
duration less than 1 year) with an inflamed knee, ankle or
wrist, who were disease modifying antirheumatic drug
naive (AMC’s “Synoviomics” program) [12]. Group B
consisted of individuals at risk for developing RA, de-
fined by the presence of IgM-rheumatoid factor and/or
anti-citrullinated protein antibodies, but no evidence of
arthritis upon physical examination [13] (AMC’s “Pre-
Synoviomics” program) [14]. The study was performed
according to the principles of the Declaration of Helsinki,
approved by the medical ethical committee of the AMC,
and all study subjects gave written in formed consent.
2.2. MRI
All study subjects underwent DCE-MRI as previously
described [6]. In Group A, a clinically inflamed (swo llen
and painful) wrist, knee or ankle joint was examined and
in Group B an arbitrarily chosen knee joint was exam-
ined in all cases. Briefly, images were acquired on either
a closed (1.5 Tesla GE Signa Horizon Echospeed, LX9.0,
General Electric Medical Systems, Milwaukee, Wiscon-
sin, USA) or open (Panorama 1 Tesla Open, Philips, Best,
the Netherlands) MRI scanner, depending on the avail-
ability of the machine. Three scans were performed after
which a contrast agent gadolinium (Magnevist, Schering,
Berlin, Germany) was injected intravenously and 2 addi-
tional scans were performed. Total duration of the pro-
cedure was 60 minutes.
2.3. Synovial Biopsy Sampling by
Within one week after the MRI, synovial biopsy sam-
pling was performed at the outpatient clinic by means of
mini-arthroscopy under local anaesthetics, as previously
described [2,15]. The same joint was chosen for both
procedures. For each study group 24 up to 32 synovial
tissue biopsies were obtained during one procedure. The
duration of the t ota l proce du re was 45 to 60 minut es.
2.4. Questionnaires
Before and after both procedures, subjects filled in ques-
tionnaires with items about expectations and the experi-
ence they had with regard to the procedures. Questions
asked were 1) Do you have preference for MRI or mini-
arthroscopy or do you have “no preference”? 2) Please
mark how well you think you are prepared for (a) MRI
and (b) mini-arthroscopy 3) Please mark the level of fear
you experience of (a) MRI and (b) mini-arthroscopy? 4)
Please mark if you are reluctant to undergo (a) MRI and
(b) mini-arthroscopy. The first question was multiple
choice; the latter three questions were depicted on a vis-
ual analogue scale (VAS) of 0 - 100 mm. In addition,
study subjects could comment their choice of preference
for one of the procedures. The first questionnaire was
completed and handed in before and the second ques-
tionnaire was filled in after both procedures.
2.5. Statistical Analysis
We describe preference for either of the procedures be-
fore and after the procedures or compared preference in
Group A with Group B using Chi-square test. In addition,
differences in baseline emotional aspects with respect to
both procedures and differences in preference after pro-
cedures compared to baseline were analysed using Wil-
coxon signed rank test for related samples. P-value <
0.05 was considered statistically significant. Statistical
analysis was performed using PASW Statistics 18 (SPSS
Inc., Chicago, IL).
3. Results
Of 38 subjects baseline and follow-up questionnaires were
available: 17 from Grou p A and 21 fro m Group B. Table
1 shows the disposition of study subjects with regard to
type of joint examined and MRI machine used.
3.1. Emotional Aspects
With respect to emotional aspects subjects generally felt
well prepared fo r both procedures. In Group B scores for
fear and reluctance were higher for mini-arthroscopy
compared to MRI, see Table 2. This was not the case for
Experience of Patients Undergoing Mini-Arthroscopy Compared to MRI in the Earliest Phases of Arthritis
Open Access IJCM
Table 1. Disposition of study subjects.
Group A* Open MRI Closed MRI
Wrist 0 1
Knee 2 10
Ankle 1 3
Group B* Open MRI Closed MRI
Knee 6 15
*Group A represents early arthritis patients; *Group B represents autoanti-
body-posit ive individu als without arthritis at ri sk for developing RA.
Table 2. Emotional aspects regarding DCE-MRI and mini-
arthroscopy at baseline.
Group A* Mini-arthroscopy DCE-MRIP-value
Preparation for
procedure 85 (52 - 91) 82 (60 - 94)0.504
Fear of procedure 25 (6 - 46) 5 (0 - 51)0.084
Being reluctant to
undergo procedure 18 (6 - 31) 4 (0 - 43)0.248
Group B* Mini-arthroscopy DCE-MRI P-value
Preparation for
procedure 90 (59 - 96) 89 (62 - 96)0.316
Fear of procedure 21 (7 - 57) 3 (0 - 7) 0.000
Being reluctant to
undergo procedure 16 (4 - 47) 1 (0 - 5) 0.001
DCE-MRI: dynamic contrast enhanced MRI; All items measured on a visual
analogue scale of 0 - 100 mm; Results depicted as median (IQR); *Group A
represents early arthritis patients; *Group B represents autoantibody-positive
individuals w ithout arthritis at risk for developing RA.
Group A. However, there were no statistically significant
differences between Groups A and B at baseline for indi-
vidual emotional aspects (Table 3).
3.2. Experience of Mini-Arthroscopy and
In the total study population, before undergoing both
procedures 42% of the subjects preferred MRI, 11% pre-
ferred mini-arthroscopy and 47% had no preference for
either procedure. After both procedures subjects prefer-
ence changed to 39% preferring MRI, 32% mini-arthro-
scopy and 29% having no preference for one of the pro-
cedures for studying synovitis. This sh ows that there was
not a clear preference for one of the procedures. In addi-
tion, preference after both procedures was not signifi-
cantly different from baseline preference (P = 0.602).
When focusing on the subgroups, within Group A pre f-
erence was as follows: at baseline 47% of the subjects
did not have preference for either procedure, 35% pre-
ferred MRI and 18% preferred mini-arthroscopy. After
both procedures 29% did not have preference, 24% pre-
ferred MRI and 47% preferred mini-arthroscopy (no dif-
ference was observed between preference after both pro-
cedures and before, p = 0.755).
Table 3. A comparison of emotional aspects regarding D CE-
MRI and mini-arthroscopy at baseline between group A
and group B.
Group A* Group B* P-value
Preparation for MRI 82 (60 - 94) 89 (62 - 96)0.521
Preparation for
mini-arthroscopy 85 (52 - 91) 90 (59 - 96)0.293
Fear of MRI 5 (0 - 51) 3 (0 - 7) 0.318
Fear of mini-arthroscopy 25 (6 - 46) 21 (7 - 57) 0.751
Being reluctant to
undergo MRI 4 (0 - 43) 1 (0 - 5) 0.237
Being reluctant to undergo
mini-arthroscopy 18 (6 - 31) 16 (4 - 47) 0.894
DCE-MRI: dynamic contrast enhanced MRI; All items measured on a visual
analogue scale of 0 - 100 mm; Results depicted as median (IQR); *Group A
represents early arthritis patients; *Group B represents autoantibody-positive
individuals w ithout arthritis at risk for developing RA.
Within group B, at baseline, 38% did not have prefer-
ence for either procedure, 57% preferred MRI and 5%
preferred mini-arthroscopy. After both procedures, these
percentages were, 29%, 52% and 19%, respectively (no
difference was observed between preference after both
procedures and before (P = 0.715). In addition, compar-
ing study groups, there was no difference in preference
between Groups A and B at baseline (P = 0.271) or after
both procedures (P = 0.115).
Of importance, after both procedures, 6 individuals of
Group A who did not have preference (n = 2) or pre-
ferred MRI (n = 4) at baseline changed to preference for
mini-arthroscopy. Four of the individuals of Group B
changed towards preference for mini-arthroscopy, of
which 3 individuals preferred MRI at baseline. In both
groups, none of the subjects who preferred mini-arthro-
scopy at baseline changed to MRI and, of those, only 1
individual changed to “no preference”. See Figure 1 for
preference at baseline, after both procedures and change
in preference.
Of subjects who underwent MRI in the open scanner,
nobody changed to preference for MRI afterwards. Main
remarks with regard to DCE-MRI were complaints about
the noise coming from the MRI machine and being im-
mobile for a long period of time, the latter in particular in
patients with arthritis. Some patients indicated that mini-
arthroscopy was better tolerated than expected, but two
subjects complained about having more joint complaints
until a few days after mini-arthroscopy. All study sub-
jects were contacted by telephone one week after the
procedures or consulted their rheumatologist within 3
weeks time and otherwise the procedures were well tol-
erated; no co mplicati o n s were reported.
4. Discussion
In this small study, we show that synovial biopsy sam-
Experience of Patients Undergoing Mini-Arthroscopy Compared to MRI in the Earliest Phases of Arthritis
Open Access IJCM
Figure 1. Preference of mini-arthroscopy or dynamic con-
trast enhanced MRI. Preference at baseline a, change in
preference b and preference after both procedures c. Re-
sults are depicted as perc entage within study Group A or B.
Group A represents early arthritis patients; Group B repre-
sents autoantibody-positive individuals without arthritis at
risk for developing RA.
pling by means of mini-arthroscopy is well experienced
when compared to DCE-MRI for studying synovial in-
flammation, both in early arthritis patients and in indi-
viduals without arthritis at risk for developing RA. Inter-
estingly, we observed an increase, although not statisti-
cally significant, in the percentage of early arthritis pa-
tients preferring mini-arthroscopy after both procedures.
Although at baseline the group of autoantibody-positive
individuals without arthritis had higher levels of fear of
and reluctance to undergo mini-arthroscopy than MRI, in
this group the percentage of individuals preferring mini-
arthroscopy increased after procedures as well. Overall,
these results refute assumptions that mini-arthroscopy
would be a procedure not well-experienced by study sub-
A factor that could be in favour of mini-arthroscopy
may be that during mini-arthroscopy patients have direct
contact with physicians and nurses, whereas during MRI
they are completely on their own in a distinct room. After
having undergone both pro cedures, most arthritis p atients
preferred mini-arthroscopy, which may be explained in
part by the more stringent need for immobilisation during
MRI. In contrast to the arthritis group, most individuals
without arthritis still favoured MRI, which might be due
to a short period of relative rest necessary after mini-
arthroscopy whereas after MRI no restrictions are im-
posed. Still, 19% of the subjects without arthritis favoured
mini-arthroscopy after both procedures and none of these
individuals preferring mini-arthroscopy at baseline c h a ng e d
to a preference for DCE-MRI. Of importance, the results
of our study cannot be extrapolated to studies using con-
ventional MRI, because scanning duration is generally
longer for DCE-MRI and requires venipuncture in all
cases, but do support the notion that mini-arthroscopy is
generally well experienced, even in individuals without
In summary, our results show the important observa-
tion that mini-arthroscopy, compared to DCE-MRI, is
well experienced in patients with early arthritis as well as
in autoantibo dy-positive individuals without arthritis who
are at risk of developing RA. These results support the
use of mini-arthroscopy in a research setting from a pa-
tient perspective, which, together with the low complica-
tion rates [2-4] should help to start using mini-arthro-
scopy in additional research centres.
5. Acknowledgements
We thank our study subj ects for participation in th e study
and the AMC mini-arthroscopy team for synovial biopsy
sampling. We thank the Dutch Arthritis Association (grant
06-1-303) and the European Community’s FP6 funding
(Autocure ) for financia l sup po rt .
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