Diagnosis of calcium pyrophosphate dihydrate crystal deposition disease: ultrasonographic criteria proposed

OBJECTIVE: To investigate by high frequency ultrasonography the appearance of calcium pyrophosphate dihydrate (CPPD) calcifications, in the most commonly affected sites in CPPD disease, and the relationship between ultrasonographic CPPD deposits and the presence of CPPD crystals in synovial fluid. METHODS: Three ultrasonographic patterns of CPPD calcification were identified and 11 patients enrolled. A control group comprised 13 patients with no evidence of CPPD deposits. Synovial fluid was aspirated from all patients and controls and examined for identification of crystals. All patients underwent a standard radiography examination at the same sites investigated by ultrasound. RESULTS: In all patients with ultrasonographically defined CPPD deposits, CPPD crystals were found in the synovial fluid. In two cases, standard radiographic examination did not show evidence of the calcific deposits that were identified by ultrasonography. CPPD crystals were not found in the synovial fluid of controls. In four control group patients, ultrasonography identified calcifications defined as deposits of another nature. CONCLUSIONS: The ultrasonographic pattern used in this study for the diagnosis of CPPD disease demonstrated a very high correlation with the presence of CPPD crystals in synovial fluid. Ultrasonography demonstrated a sensitivity and specificity at least equal to that of radiography in identifying CPPD crystal calcifications.     

Ultrasonographic findings of Achilles tendon and plantar fascia in patients with calcium pyrophosphate deposition disease

The aims of the study were to detect the frequency of involvement of the Achilles tendon and plantar fascia in patients with calcium pyrophosphate deposition disease (CPPD) by high-frequency gray-scale ultrasonography (US) and power Doppler sonography (PDS) and to correlate these findings with demographic and clinical data. Two groups of patients were enrolled: group I (38 patients with CPPD) and group II (22 patients with knee OA). US/PDS examination of the heels was performed to both groups. In the CPPD group, US/PDS examination of the Achilles tendon revealed: calcification in 57.9%, enthesophytosis in 57.9%, enthesopathy in 23.7%, vascular sign in 21%, bursitis in 13.2%, and cortical bone irregularity in 10.5%. US/PDS examination of plantar fascia in the CPPD group revealed: calcification in 15.8%, cortical bone irregularity in 78.9%, enthesophytosis in 60.5%, and planter fasciitis in 42.1%. In patients with CPPD, age was significantly correlated with enthesophytosis and deep retrocalcaneal bursitis (p = 0.01 and p = 0.04, respectively). Heel tenderness and posterior talalgia were significantly correlated with Achilles tendon enthesopathy, vascular sign, and deep retrocalcaneal bursitis (p = 0.0001 for each). Inferior talalgia was significantly correlated with plantar fasciitis (p = 0.0001). The sensitivity of ultrasonography for detection of calcifications in Achilles tendon and plantar fascia was 57.9% and 15.8%, respectively, and the specificity was 100% for both. To conclude, ultrasonographic Achilles tendon and plantar fascia calcifications are frequent findings in patients with CPPD. These calcifications have a high specificity and can be used as a useful indirect sign of CPPD.     

Local Deposition of Calcium Pyrophosphate Crystals in Evolution of Knee Osteoarthritis

The aim of the study was to investigate the frequency of development of local calcium pyrophosphate (CPPD) crystal deposition in patients with knee OA initially found negative for these crystals, as well as to discover whether prognostic indicators for this subset of patients can be found. A clinical follow-up of records of outpatients with idiopathic knee OA was established. An anteroposterior plain radiography of the knee joints was made initially and at the end of the observation period. The follow-up period needed to be more than 1 year. Patients were divided into two groups. The first included patients with knee OA who did not develop intra-articular CPPD crystal deposition during the observation period (OA group). The second included those patients whose X-rays or synovial fluid (SF) analysis in the follow-up showed these crystal deposits to be present (OA + CPPD group). There were 59 patients (42 women, 17 men) who met the selection criteria. During the observation period (8.1 ± 7.4 years in the OA group, 10.4 ± 6 years in the OA + CPPD group), intra-articular CPPD deposits were observed in 15 patients (25%): 10 on the X-rays, eight in the SF and three in both examinations. Age at diagnosis of OA and incidence of obesity were similar in both groups. There was a trend (P= 0.21) towards men developing intra-articular CPPD crystal deposits more frequently than women. OA in only one knee joint was significantly more frequent in the group with CPPD (P<0.01). Of those with CPPD deposits 40% required surgery at the end of the observation period, compared to 27.2% of those without deposits (P= 0.27). The waiting period before knee surgery was shorter in the OA + CPPD group but the difference was not statistically significant. In conclusion, local CPPD crystal deposition was observed in 25% of cases during the evolution of knee OA. No predictive factors were found. OA of the knee could, per se, favour the development of CPPD deposits. The occurrence of intra-articular CPPD deposits seemed to be related to a more rapid and severe evolution of OA of the knee. Received: 25 October 2000 / Accepted: 18 June 2001     

Spinal involvement with calcium pyrophosphate deposition disease in an academic rheumatology center: A series of 37 patients

BackgroundCalcium pyrophosphate dihydrate deposition disease (CPPD) has been reported to involve the spine, but few systematic studies have been published.ObjectiveTo further characterize the spinal involvement with CPPD by a review of CPPD patients hospitalized in a rheumatology department.MethodsWe retrospectively reviewed data for patients consecutively admitted with a diagnosis of CPPD in the rheumatology department of Lariboisière hospital in Paris, France over 5 years by using a standardized protocol and electronic case report forms. Imaging studies were also reviewed.ResultsSpinal CPPD was diagnosed in 37/152 (24.3%) CPPD patients. Patient with spinal involvement had more widespread peripheral CC. The cervical (n = 21) and lumbar (n = 19) segments were most involved. CT-scan was more sensitive than plain radiographs for detecting spinal calcifications. Crown dens syndrome was a prominent feature of cervical involvement. Inflammatory sterile spondylo-discitis was observed in 6 patients. Lesions were frequently multiple and were classified into 4 types. Ruling out septic discitis required image-guided biopsies in 3 patients. Sacroiliac involvement included calcification in 5 patients and severe sterile destructive arthropathy and joint fusion in one patient each. Degenerative changes were common, and CPPD could not be implicated because of the patients ‘age and lack of a control population. In 12 patients, severe clinical features requiring hospitalization were related to such degenerative changes.ConclusionSymptomatic involvement of the spine was observed in 24% of this series of hospitalized CPPD patients. Specific entities were the cause of hospitalisation in 25 of the 37 patients with spinal calcification and included inflammatory pain related to crystal deposits and destructive arthropathy of the spine and sacroiliac joints. Discitis exhibited a wide range of MRI features and biopsies were needed to rule out infection in 3 of the 6 discitis.     

高分辨力超声检查在类风湿关节炎膝肘腕关节滑膜炎的应用

目的本研究应用高分辨力超声及多普勒超声技术,观察类风湿关节炎(RA)膝关节、肘、腕关节超声声像特点及血流动力学特点,探讨超声检查在RA诊断中的价值。方法研究了40例RA患者(共240个关节)及20名健康志愿者(共120个关节)的膝关节、肘关节和腕关节滑膜炎的超声声像特征。每例均行双侧对比扫查,超声检查采用美国GE公司LogiQ-9彩色超声诊断仪,高频率线阵式探头,探头中心频率10MHz,直接扫查法扫查。结果RA组共检出191个关节积液,总阳性率79.5%,共检出174个关节滑膜增厚,总阳性率72.5%,检出165个关节内血管过度增生,总阳性率68.7%。结论超声检查为RA关节病变的诊断和炎症活动性的评估提供了一种简便易行,安全有效的方法。     

Imaging of tophaceous gout: computed tomography provides specific images compared with magnetic resonance imaging and ultrasonography

OBJECTIVE: To determine the usefulness of computed tomography (CT), magnetic resonance imaging (MRI), and Doppler ultrasonography (US) in providing specific images of gouty tophi. METHODS: Four male patients with chronic gout with tophi affecting the knee joints (three cases) or the olecranon processes of the elbows (one case) were assessed. Crystallographic analyses of the synovial fluid or tissue aspirates of the areas of interest were made with polarising light microscopy, alizarin red staining, and x ray diffraction. CT was performed with a GE scanner, MR imaging was obtained with a 1.5 T Magneton (Siemens), and ultrasonography with colour Doppler was carried out by standard technique. RESULTS: Crystallographic analyses showed monosodium urate (MSU) crystals in the specimens of the four patients; hydroxyapatite and calcium pyrophosphate dihydrate (CPPD) crystals were not found. A diffuse soft tissue thickening was seen on plain radiographs but no calcifications or ossifications of the tophi. CT disclosed lesions containing round and oval opacities, with a mean density of about 160 Hounsfield units (HU). With MRI, lesions were of low to intermediate signal intensity on T(1) and T(2) weighting. After contrast injection in two cases, enhancement of the tophus was seen in one. Colour Doppler US showed the tophi to be hypoechogenic with peripheral increase of the blood flow in three cases. CONCLUSION: The MR and colour Doppler US images showed the tophi as masses surrounded by a hypervascular area, which cannot be considered as specific for gout. But on CT images, masses of about 160 HU density were clearly seen, which correspond to MSU crystal deposits.     

Acute pseudogout in chronic renal failure.

Acute pseudogout (calcium pyrophosphate dihydrate deposition disease [CPPD disease]) developed in two patients with chronic renal failure. The disease had atypical features. The calcification of the involved joints was more diffuse than the usual linear stippled calcification. The first patient, age 39, was young to have pseudogout. The second patient had pseudogout and chondrocalcinosis limited to the elbow. Review of wrist roentgenograms of 82 patients (mean age, 49.0 years), undergoing hemodialysis for chronic renal failure revealed three patients (a 3.7% incidence) with chondrocalcinosis. The incidence increased to three of 19 (15.8%) in the patients over the age of 60. Although considered uncommon, pseudogout may cause acute arthritis in chronic renal failure more often than previously suspected. Joint aspiration and identification of CPPD cystals with compensated polarized light microscopy will establish the diagnosis of pseudogout.     

Ultrasonography in the assessment of peripheral joint involvement in psoriatic arthritis

The objective of our study was to investigate the role of musculoskeletal ultrasound (US) in the assessment of hand and foot small joints in psoriatic arthritis (PsA). Thirteen consecutive patients with PsA of hands or feet underwent B-mode US using a 9- to 13-MHz transducer and simultaneous magnetic resonance imaging (MRI), bone scintigraphy and radiography. US findings were compared with radiography, MRI and scintigraphy in 190, 182 and 109 joints, respectively. To assess the sensitivity and specificity of US, radiography was considered as gold standard for the detection of erosions and osteoproliferations and MRI as gold standard for the detection of joint effusion and synovitis. US, MRI and scintigraphy had a higher sensitivity in the detection of overall joint pathology than radiography in painful and/or swollen joints (71%, 72%, 82% vs 32%) and clinically unaffected joints (17%, 21%, 9% vs 2%). US and radiography detected more erosions and osteoproliferations than MRI, with low agreement between the methods in the detection of erosions. Radiography was superior to US in the visualisation of osteoproliferations. Joint effusions and/or synovitis were more frequently detected by MRI than US. Agreement between both imaging methods was better in carpal joints, carpometacarpal joint I, metacarpophalangeal (MCP)/metatarsophalangeal (MTP) joint I, II and V than in MCP/MTP III, IV, PIP and DIP joints. Compared with MRI, radiography and scintigraphy, the specificity of US ranges between 0.84 and 0.94, depending on the joint pathology. In conclusion, the diagnostic sensitivity of US in the detection of PsA-related synovitis of hands and feet is lower than MRI and depends on the joint region. However, the low cost and the acceptable specificity suggest that US is a useful imaging method in addition to radiography in PsA of hands and feet.     

Evidence for synovitis in active polymyalgia rheumatica: sonographic study in a large series of patients

OBJECTIVE: To determine the frequency and localization of synovitis and enthesitis in patients with active, untreated polymyalgia rheumatica (PMR) by ultrasonography (US). METHODS: Polyarticular sonographic evaluation was carried out in 50 consecutive patients with PMR at disease onset. Results were compared with 50 consecutive patients with seronegative spondyloarthropathies (SpA) and 50 with seronegative and seropositive rheumatoid arthritis (RA) at disease onset. RESULTS: Synovitis and/or effusion was detected, in at least one joint, in 100% of patients with PMR. The most frequent alterations observed in patients with PMR were effusion in the subacromial-subdeltoid (SA-SD) bursa in 70% of patients, tenosynovitis of the long head of the biceps tendon (LHBT) in 68%, glenohumeral joint effusion in 66%, tenosynovitis of the flexor tendons in the carpal tunnel in 38%, radiocarpal effusion in 18%, wrist extensors tenosynovitis in 18%, coxofemoral joint effusion in 40%. knee effusion in 38%, and ankle effusion in 10%. Enthesitis and tendonitis of the anchoring tendons were relatively rare in all the articular sites. Comparison of the SpA and PMR patients showed that enthesitis (mostly in the elbow, knee, and heel) was significantly more frequent in SpA. There was a significant difference in glenohumeral and coxofemoral effusion between the PMR and SpA patients (66% vs 16% and 40% vs 14%, respectively). Comparison of PMR and RA patients showed no significant difference in the involvement of entheses, shoulder, hip, or wrist flexor tendons in the carpal tunnel. Synovitis of the elbow, knee, and wrist was significantly more frequent in the SpA and RA patients than in those with PMR. CONCLUSION: Synovitis was detected in at least one site in 100% of patients with PMR. SA-SD bursitis, LHBT tenosynovitis, carpal tunnel syndrome, and glenohumeral, knee and hip synovitis were the most frequent alterations in PMR. Enthesitis was relatively rare at any articular site.     

Interobserver reliability of rheumatologists performing musculoskeletal ultrasonography: results from a EULAR "Train the trainers" course

Objective: To evaluate the interobserver reliability among 14 experts in musculoskeletal ultrasonography (US) and to determine the overall agreement about the US results compared with magnetic resonance imaging (MRI), which served as the imaging "gold standard". Methods: The clinically dominant joint regions (shoulder, knee, ankle/toe, wrist/finger) of four patients with inflammatory rheumatic diseases were ultrasonographically examined by 14 experts. US results were compared with MRI. Overall agreements, sensitivities, specificities, and interobserver reliabilities were assessed. Results: Taking an agreement in US examination of 10 out of 14 experts into account, the overall κ for all examined joints was 0.76. Calculations for each joint region showed high κ values for the knee (1), moderate values for the shoulder (0.76) and hand/finger (0.59), and low agreement for ankle/toe joints (0.28). κ Values for bone lesions, bursitis, and tendon tears were high (κ = 1). Relatively good agreement for most US findings, compared with MRI, was found for the shoulder (overall agreement 81%, sensitivity 76%, specificity 89%) and knee joint (overall agreement 88%, sensitivity 91%, specificity 88%). Sensitivities were lower for wrist/finger (overall agreement 73%, sensitivity 66%, specificity 88%) and ankle/toe joints (overall agreement 82%, sensitivity 61%, specificity 92%). Conclusion: Interobserver reliabilities, sensitivities, and specificities in comparison with MRI were moderate to good. Further standardisation of US scanning techniques and definitions of different pathological US lesions are necessary to increase the interobserver agreement in musculoskeletal US.     

Does extremity‐MRI improve erosion detection in severely damaged joints? A study of long‐standing rheumatoid arthritis using three imaging modalities

BACKGROUND: Long-standing rheumatoid arthritis produces unique challenges when assessing damage due to joint deformity. The use of extremity magnetic resonance imaging (eMRI) offers the possibility of improved disease assessment because of greater patient tolerability. OBJECTIVES: The aim of this cross-sectional study was to compare the identification of wrist erosions in a severe rheumatoid arthritis cohort by eMRI with a restricted field of view (eMRI-RV) to radiography and high field MRI, using the latter as the reference. METHODS: Fifteen patients (87% female, median age 56 years) with active rheumatoid arthritis (median DAS28 7.01 and disease duration 11 years) on leflunomide were enrolled. Radiography of hands, eMRI-RV (0.2 T MagneVu MV 1000) and high field MRI of unilateral wrist joints were performed. RESULTS: Of 86 comparable wrist joint areas, high field MRI identified 70 erosions, eMRI-RV 32 and radiography 4. With high field MRI considered the reference, the sensitivity, specificity and accuracy of eMRI-RV for erosions were 46%, 94% and 55%, and the corresponding values for x ray were 6%, 100% and 23%, respectively. CONCLUSIONS: In severely damaged rheumatoid arthritis joints, sensitivity of erosion detection was markedly higher for eMRI-RV than radiography, using high field MRI as the reference. eMRI-RV was, however, less sensitive than high field MRI.     

Prevalence of periarticular calcifications in pyrophosphate arthropathy and their relation to nodal osteoarthrosis.

X-rays of the shoulder, hand, and knee joints from 30 patients with pyrophosphate arthropathy (PA) and 30 age and sex matched control subjects were examined for periarticular, dense, homogeneous calcifications considered to be apatite deposits. They were found in 30% of the patients with PA compared with 3.3% of the controls. In addition in the PA group the incidence of Heberden's nodes was significantly increased in cases with periarticular calcifications, implying that mixed (calcium pyrophosphate dihydrate + apatite) crystal deposition disease could be related to nodal osteoarthrosis.     

Power Doppler sonography in the evaluation and follow-up of knee involvement in patients with juvenile idiopathic arthritis

INTRODUCTION: This study was undertaken to evaluate the role of ultrasound (US), conventional color (CD) and power Doppler (PD) in the detection and quantification of inflammatory signs of the knee in children with juvenile idiopathic arthritis (JIA) and to correlate these findings with patient history, clinical, laboratory and radiological findings. PATIENTS AND METHODS: Thirty patients with JIA who had clinical signs of knee involvement as well as 15 healthy children as a control group where subjected to full clinical examination and laboratory investigations on the same day of US examination. The knee joints were evaluated with plain radiography, US, and color Doppler in 13 patients, while the remaining 17 were assessed with power Doppler. Fourteen patients were subjected to follow-up assessment. RESULTS: A highly significant difference in synovial thickening and cartilage thickness detected by US between JIA affected knees and those of controls (p < 0.0001). Knee effusion was demonstrated in 93% of patients. Synovial vessels were detected by Doppler in 76.7% of patients. A significant correlation was detected between the degree of vascularity detected by PD and knee score (p < 0.05), and JAFAR score (P < 0.05). On comparing the findings of the follow-up with those of the initial examination, a significant positive correlation was detected between the differences in the knee score and those in synovial thickness (p < 0.05), and with the vascularity scale detected by PD (p < 0.05). CONCLUSION: This study suggests the Doppler sonography as a non-invasive, low-cost, and readily available tool for the evaluation and follow-up of articular involvement in knees of JIA patients.     

The detection of calcium pyrophosphate crystals in the synovial fluid of patients with rheumatoid arthritis using the cytospin technique: prevalence and clinical correlation

There are only a few studies dealing with the detection and clinical impact of calcium pyrophosphate (CPPD) crystals in patients with rheumatoid arthritis (RA) published to date. In particular, data determined by the cytospin technique, which is an effective tool to enhance the crystal detection rate, are lacking. The objectives of this study were to determine the prevalence of CPPD crystals in the synovial fluid (SF) of patients with RA and to investigate whether the detection of CPPD crystals is correlated with demographic, clinical and serological features. We examined 113 consecutive SF samples of patients with RA, obtained from therapeutic arthrocentesis of knee joints. After cytocentrifugation, the sediments were examined by polarized microscopy for the occurrence of CPPD crystals. Demographic, clinical and serological data, acquired from the medical records, were compared between crystal-positive and crystal-negative subjects. CPPD crystals were observed in 20 of the 113 cases, representing 17.7 %. CPPD-positive and CPPD-negative subjects did not differ significantly in sex, duration of disease, Steinbrocker radiologic stage, disease activity score 28, as well as serum rheumatoid factor and anti-CCP positivity. Patients positively tested for CPPD crystals had a significantly higher age than CPPD-negative patients (p < 0.0001). An age-independent association of long-time treatment with diuretics and CPPD crystal formation was not found. In conclusion, demographic, clinical and serological characteristics of patients with RA were not associated with the occurrence of CPPD crystals. Age was the only significant influencing factor on CPPD crystal formation in patients with RA.     

Clinical application of ultrasonography for detection of septic arthritis in children

For early detection of the effusion of infected joint, 40 children were examined by ultrasound scanner for suspected septic arthritis. Thirty-one patients were found with joint effusion, and the needle aspirations of these 31 joints confirmed septic arthritis in 22 patients. In 3 patients, in addition to the joint effusion, the joint surrounding subperiosteal abscess and cortical erosion also were found on sonography, resulting in a diagnosis of concurrent osteomyelitis. In two patients, sonography confirmed only soft tissue swelling and abscess formation on the buttock, but without hip joint effusion. These findings excluded the diagnosis of septic arthritis and helped us obviate the unnecessary attempts at joint aspiration. In one patient, sonography revealed only flexor tenosynovitis without wrist joint effusion. This case was later treated by tenosynovectomy rather than wrist arthrotomy and the pathological examination showed to be a tuberculous tenosynovitis. From the preliminary results, we find ultrasonography has the following advantages for the diagnosis of septic arthritis: 1.) ultrasonography is very sensitive in detecting the joint effusion of septic arthritis; 2.) ultrasonography can clearly define the pathological extent of septic arthritis and help clinicians to treat the concurrent osteomyelitis by appropriate surgical debridement; and 3.) ultrasonography can differentiate soft tissue abscess or tenosynovitis from septic arthritis and help clinicians obviate unnecessary needle joint aspiration.     

Ultrasonography of the metatarsophalangeal joints in rheumatoid arthritis: comparison with magnetic resonance imaging, conventional radiography, and clinical examination

OBJECTIVE: To compare ultrasonography (US) with magnetic resonance imaging (MRI), conventional radiography, and clinical examination in the evaluation of bone destruction and signs of inflammation in the metatarsophalangeal (MTP) joints of patients with rheumatoid arthritis (RA). METHODS: Two hundred MTP joints of 40 patients with RA and 100 MTP joints of 20 healthy control subjects were assessed with B-mode US, contrast-enhanced MRI, conventional radiography, and clinical examination for signs of bone destruction and joint inflammation. RESULTS: With MRI considered the reference method, the sensitivity, specificity, and accuracy of US for the detection of bone erosions were 0.79, 0.97, and 0.96, respectively, while the corresponding values for radiography were 0.32, 0.98, and 0.93. The sensitivity, specificity, and accuracy of US for the detection of synovitis were 0.87, 0.74, and 0.79, while for clinical examination, the corresponding values were 0.43, 0.89, and 0.71. Erosive disease was identified in 26 patients by US, compared with 20 patients by MRI and 11 patients by radiography. Evaluation by US indicated signs of inflammation in 36 patients, while MRI and clinical examination revealed signs of inflammation in 31 patients and 20 patients, respectively. US and MRI volume-based gradings of synovitis showed intraclass correlation coefficients of 0.56-0.72 (P < 0.0001). The MRI and radiographic visualizations of US-detected bone changes were closely related to their size-based gradings on US. CONCLUSION: US enables detection and grading of destructive and inflammatory changes in the MTP joints of patients with RA. By comparison with MRI, US was found to be markedly more sensitive and accurate than clinical examination and conventional radiography. Considering the early and frequent involvement of the MTP joints, evaluation of these joints by US may be of major clinical importance in RA.     

Investigation of calcium crystals in OA knees

For studies on matrix mineralization in osteoarthritis (OA), a clear analytical approach is necessary to identify and to quantify mineralization in the articular cartilage. The aim of this study is to develop an effective algorithm to quantify and to identify cartilage mineralization in the experimental setting. Four patients with OA of the knee undergoing total knee replacement and four control patients were included. Cartilage calcification was studied by digital contact radiography (DCR), field emission scanning electron microscopy (FE-SEM) X-ray element analysis and Raman spectroscopy (RS). DCR revealed mineralization in all OA cartilage specimens. No mineralization was observed in the control cartilage. Patient I showed rhomboid shaped crystals with a mean Ca:P molar ratio of 1.04 indicated the presence of calcium pyrophosphate dihydrate (CPPD) crystals, while Patients II, III and IV presented carbonate-substituted hydroxyapatite (HA). RS also showed the presence of CPPD crystals in Patient I while Patients II, III and IV revealed spectra confirming the presence of HA crystals. In the corresponding chondrocyte cell culture analyzed with SEM, the presence of CPPD crystals in the culture of Patient I and HA crystals in the culture of Patient II, III and IV was confirmed. No mineralization was found in the cell culture of the controls. The differentiation between BCP and CPPD crystals plays an important role, and the techniques presented here provide an accurate differentiation of these two types of crystals. For quantification of articular cartilage mineralization, DCR is a simple and accurate method.     

Imaging studies of crystalline arthritides

Gout, calcium pyrophosphate dihydrate (CPPD) deposition disease, and calcium hydroxyapatite deposition disease (HADD) are the three most common crystal-induced arthropathies. Multimodality imaging may help in their diagnosis, and is useful for a precise and comprehensive assessment and grading of the related osteoarticular damage. Plain film radiography, due to its low cost and wide availability, is the first imaging technique to be used in crystal deposition diseases, providing well-known and specific findings for CPPD deposition disease and HADD, while it may undergrade the early osteoarticular lesions in gouty patients. Ultrasonography (US) is a radiation-free approach that accurately depicts crystal deposits in cartilage, peri- and intra-articular soft tissues, but it does not give a panoramic view of the affected joints. Cross-sectional imaging techniques can examine crystal deposits in the spine and axial joints. CT has the potential to distinguish monosodium urate (MSU) crystals from calcium containing crystals, due to their different attenuation values. MRI may demonstrate synovitis, erosions and bone marrow edema in gouty patients and it may differentiate tophi from other soft tissue nodules due to its high contrast resolution and power of tissue characterization.     

Calcium pyrophosphate dihydrate crystal deposition disease of the wrist: trapezioscaphoid joint abnormality

OBJECTIVE: To determine whether trapezioscaphoid (TS) joint alterations are associated with calcium pyrophosphate dihydrate (CPPD) crystal deposition disease and, if so, to determine the nature of these alterations. METHODS: Radiographs of 160 wrists with evidence of chondrocalcinosis were evaluated with regard to TS joint abnormalities, and findings were compared with a similar number of radiographs in an age and sex matched control population in whom no evidence of chondrocalcinosis or other calcification in the wrist was seen. Two radiologists in consensus recorded radiographic findings in both groups, and a third radiologist blinded to the presence or absence of chondrocalcinosis reviewed wrist radiographs in both groups in a random order. Correlation of TS joint abnormalities with other changes in the wrist was also accomplished. RESULTS; TS arthropathy was found in 43.7% of CPPD wrists and in 14.4% of control wrists in the consensus evaluation. In the blind evaluation, 30% of CPPD wrists and 12.5% of control wrists had TS arthropathy. The degree of arthropathy was more extensive in the CPPD group than in the control group. Features associated with TS arthropathy in the patient population were first carpometacarpal arthropathy and subchondral cysts in the scaphoid or trapezium, or both bones. CONCLUSION: CPPD patients, compared to a control population, reveal frequent and significant radiographic abnormalities of the TS joint that may be suggestive of the diagnosis, even in patients in whom chondrocalcinosis is obscured or absent. The features associated with TS arthropathy are first carpometacarpal arthropathy and subchondral cysts in the scaphoid and trapezium.