Image-guided synovial biopsy with a focus on infection

Image-guided biopsy of the synovium is a relatively uncommon but safe procedure with a high-diagnostic yield in the correct clinical scenario. Whilst surgical and arthroscopic techniques are still commonly performed and remain the gold standard, they are more invasive, expensive and not widely available. Ultrasound and X-ray-guided synovial biopsy are being increasingly performed by radiologists to diagnose both native and periprosthetic joint infection (PJI) to guide surgical and microbiological management. The purpose of this review article is to present the historical background to synovial biopsy particularly related to potential joint infection, including common and uncommon pathogens encountered, sampling techniques and pitfalls, focusing mainly on its role in PJI and its role in patient pathways and decision-making within a joint infection multi-disciplinary framework.