22 Sari's SK slides

8/19/2019 22 Sari's SK slides

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Osteoarthritis

SBM Feb 13, 2014

Chris Burns MD


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Section of normal hip articular cartilage

stained with brilliant red shows

abundance of acid mucopolysaccharide

diffusely distributed, except for

superficial zone (lamina splendans).

Degenerative changes are now seen:

1. Diffuse hypercellularity

2. Extensive loss of acid mucopoly-saccharide from matrix with diminished

red dye fixation.


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As cartilage starts to give more

under repeated loading, damage

starts to occur, basically tearing &

cracking

Early degenerative changes are now

present in this articular cartilage:

1. Small tangential clefts on surface

of already altered hyaline cartilage

2. Deeper vertical cleft

3. Splitting process , fibrillation

4. Clumping of chondrocytes

1.

2.

4.

3.


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Arthroscopic pictures of normal knee cartilage on left;fibrillated and eroded cartilage on right with bare bone


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This section of the first MTP joint shows partial erosion on both surfaces of the

articular cartilage. Condensation of subchondral bone has developed adjacent to

areas of cartilage erosion, being more marked in the phalanx than in metatarsal

bone. An osteophyte extends above the dorsal margin of the metatarsal head.

(Masson trichrome, low power).


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Goldring & Goldring. J. Cell. Physiol. 213: 626–634, 2007.

The normally quiescent chondrocytes, as well as the synovial cells, respond to

repetitive excess mechanical loading via stress-induced intracellular signals.


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! Cytokines, chemokines, cartilage-degrading proteinases, etc., are produced.

! Matrix degradation products feed back & up-regulate these cellular events.


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! Anabolic factors, like BMPs & TGF , may be upregulated & cause osteophyte formation.

!

Chondrocyte proliferation (cloning), phenotypic modulaton (hypertrophy), increased

cartilage calcification (tidemark duplication), & microfractures with blood vessel invasion

from subchondral bone (angiogenesis) follow.


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Note throughout the following

examples, the recurrent theme

of cartilage loss, joint space

narrowing, osteophyte formation,

and deformity


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Bony enlargement can be seen in distal and proximal interphalangeal joints. The

changes in proximal interphalangeal joints (Bouchard's nodes) and distal

interphalangeal joints (Heberden's nodes) are common findings in degenerative joint

disease of the hands. These changes are more frequently found in women after

menopause and often show a genetic predisposition.


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Normal hand x-ray OA hand x-ray

Note that OA goes for DIP > 1st CMC > PIP

Note dec j space, osteophytes


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Basilar thumb, or 1st CMC, OA, a common site


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There is marked narrowing of the first carpometacarpal joint space, with extensive sclerosis of

adjacent bony margins. Osteophyte formation and subchondral cysts are present. Lateral

subluxation of the base of the metacarpal bone is a common finding but is not present in this

roentgenogram.


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A synovial cyst is seen on the dorsal surface of the distal interphalangeal joint

of the extended middle finger. Synovial cysts contain gelatinous material and

often evolve into Heberden's nodes.


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The left hip joint demonstrates narrowing with sclerosis and osteophyte formation of

adjacent bony margins. There is minimal flattening of the superolateral aspect of the

femoral head with reactive bone change. Buttressing of the femoral neck is present

medially and laterally as new bone formation widens the cortical margin. The right hip is

normal.


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Medial compartment is highest, which is why varus (bow-legged) knee is acommon finding in OA


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Normal Knee Knee with

Medial OA


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Left, The posteroanterior projection of the knee shows marked narrowing of the medial

compartment and moderate sclerosis of adjacent bony margins. Involvement of the

medial aspect of the knee joint is much more common than of the lateral compartment.

Right, The posteroanterior projection of the knee shows narrowing of the lateral

compartment and sclerosis of adjacent bony margins. Unicompartmental joint space

loss and reactive new bone formation help differentiate degenerative from inflammatory

arthritis.


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Bilateral varus deformity of the knees,

or bow-legged

knees,

due to medial compartment OA


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Hand x-ray of pt with hemochromatosis.

Note the extensive MCP & wrist disease


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Neisseria gonorrhoeae

Disseminated gonococcal infection (GC)

Type 1 dermatitis, tenosynovitis, migratory

polyarthritis

Type 2 septic arthritis

Chronic meningococcemia

Arthritis and dermatitis syndrome

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Nymphs feed veraciously as they emerge from dormancy in

May, June and July. Most cases occur in June-July, right around

that time. Nymphs are responsible for 90% of human infections

USA has Selective hotspots: more than two thirds of cases occur

in just 70 counties


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Post Lyme disease syndrome has replaced the notion of chronic

encephalomyelitis

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Two thirds with no clinical or laboratory evidence of Lyme

disease had received long antibiotic courses, many multiple

courses

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Babesiosis: hemolytic anemia, fever, splenomegally. Carried by

Ixodies scapularis, and same distribution as Lyme disease


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Rocky Mountain Spotted Fever, Rickettsia rickettsii

Carried by Dermacentor andersoni, Rocky Mountain wood tick.

RMSF Rickettsia rickettsii, in the west


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STARI Southern Tick Associated Rash Illness Amblyoma

americanum (lone star tick)

Southern Tick Associated Rash Illness STARI

spirochete Borrelia lonestarii

Ehrlichiosis

HME

Ehrlichia chaffeensis


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Argarid (soft shelled) tick Ornithodoros moubata. Tick Born

Relapsing Fever caused by other Borrelia species: Borrelia

hermsii, Borrelia duttonii, Borrelia turicatae. Louse Born

Relapsing Fever is caused by Borrelia recurrentis.


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AP view (left) looks almost normal except for the absence of j

space, which could be due to arthritis (but the rest of the j is

normal, so no) or posterior dislocation

This is why the axillary view is key to dx’ing post. Dislocations

– note the abnormal appearance in the top right pic vs the normal

bottom pic. The reason axillary view is unpopular (esp for a pt

w/ joint pain) is that it requires keeping the arm abducted for the

pic, c/ the resident may need to do himself

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Acute or reccurent dislocation will p/w apprehension sign, where

holding the pt in the shown position will make them stressed

(because they’ve learned that the abducted extended arm is

likely to dislocate), You then put your hand on the head of the

humerus to keep it in place and ask them if that makes them less

worried, and they say yes

Global instability often p/w Sulcus sign – a sulcus is visible

under the acromion when the arm is adducted

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MR arthrogram shows a reduced dislocation with a +ve Bankart

lesion (small arrows pointing to a torn ant-inf labrum) and a

Hill-Sachs lesion (big arrow)

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Typical fracture is middle 3rd of clavicle, which can get displaced

(top right)

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Operative = surgical decompression (acromioplasty) to shave the

acromion and make it flat -> get more space for the rotator cuff.

This can be done arthroscopically

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Hx is much more acute – pt developed limited ROM within a

few days

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Right side shows massive rotator cuff tear 2/2 chronic rotator

cuff tear and arthropathy

Note muscle atrophy on MRI w/ fatty infiltration. This occurs bc

the joint is not movable w/ the slowly progressing limitation of

ROM

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3/25/14

1

Radiographic Evaluation of Arthritis

Douglas Goodwin, MD

Department of Radiology

Radiographic Signs

1 soft tissue swelling

2 mineralization

3 joint space narrowing

4 erosions

5 subluxation

6 bone production

7 calcification

8 distribution of disease


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2

1. Soft Tissue Swelling

A.

Centered at the joint

B. Asymmetric (mass-like)

C. Fusiform (“sausage digit”)

Rheumatoid Arthritis: soft tissue swelling at joint


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Gout: asymmetric mass-like swelling

Psoriatic arthritis: sausage digits


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2. Mineralization

• Normal

• Juxta-articular decrease

• diffusely decreased

•

increased

Hyperemia: septic joint


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Rheumatoid Arthritis: demineralization

WARNING: This sign is of very limited usefulness

Increased density: psoriatic arthritis


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3. Joint space narrowing

•

Reflects the width of

articular cartilage

•

difficult to assess due

to the irregular

contour of joint

surfaces

•

weight bearing filmsmay help

Joint space narrowing

•

Reflects the width of

articular cartilage

•

difficult to assess due

to the irregular

contour of joint

surfaces

•

weight bearing films

may help


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7

Joint Space Narrowing

•

UNIFORM

– reflects diffuse and uniform loss of articular

cartilage

– RA

– septic arthritis

–

seronegative• THINK INFLAMMATION

cartilage

capsule

synovium

Uniform Joint Space Narrowing

INFLAMMATION


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Rheumatoid arthritis: uniform joint space narrowing


•

NONUNIFORM

– reflects regional loss of articular cartilage

• Osteoarthrosis

• Pyrophosphate arthropathy (CPPD)

–

“DEGENERATIVE”


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Nonuniform Joint Space Narrowing

cartilage

capsule

synovium

weight bearing

OA: nonuniform joint space narrowing


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OA: medial compartment narrowing

OA: single compartment narrowing


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Joint space narrowing

Rheumatoid arthritis Osteoarthritis


•

PRESERVED

– reflects very focal damage to cartilage

• Gout

• Pigmented Villonodular Synovitis

• “early” OA

•

SMALL OR FOCAL DEFECTS


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Gout: joint space preservation

Gout: joint space preservation


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OA: joint space preservation

Small chondral lesion

4. Marginal Erosions

•

destruction of bone by inflammatory

pannus

• occur first at “uncovered” bone at the

margin of the joint

• inflammatory arthritis

– RA, Psoriatic arthritis, Reactive arthritis


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14

cartilage

capsule

synovium

Marginal Erosions • destruction of bone

by inflammatory

pannus

•

occur first at

“uncovered” bone at

the margin of the

joint

MARGINAL EROSION

• destruction of bone byinflammatory pannus

• occur first at “uncovered”

bone at the margin of

the joint


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Rheumatoid Arthritis: marginal erosions

Gout: erosions

•

May be remote from

joint

•

well-defined

•

overhanging edge of

bone


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5. Subluxation

•

“incomplete or partial dislocation”

• Due to laxity or disruption of ligamentous

support

• with erosions: Rheumatoid arthritis

• without erosions: SLE

Swan neck deformity

Boutonnière deformity


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Subluxation with erosions: Rheumatoid arthritis

Alignment: Rheumatoid arthritis


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Lupus: subluxation without erosions

Lupus: subluxation without erosions


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6. Bone Production

•

Osteophytes

• Subchondral bone

•

Periosteal new bone

•

Ankylosis

•

Overhanging edge GOUT

OSTEOARTHRITIS

SERONEGATIVE

Osteophytes

• enchondral boneformation

• extension of the

articular surface


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Osteoarthritis: DIP osteophytes

Subchondral bone

•

dense eburnation on Xray

• thickening of bone, possibly

healing of trabecular injury


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Periosteal new bone

•

SeronegativeSpondyloarthropathies

•

sign of inflammation

at the enthesis

• joint margins

•

shafts of small tubular

bones

•

spineNature Medicine Volume:18, 1069–1076: (2012)

Entheseal inflammation

CT

FDG PET

PET-CT

•


•

sign of inflammation

at the enthesis

• joint margins

•

shafts of small tubular

bones•

spine

ucdmc.ucdavis.edu


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Increased density: enthesopathy

•


• sign of inflammation

at the enthesis

• joint margins

• shafts of small tubular

bones• spine

Psoriatic arthritis: proliferative bone


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Proliferative bone formation

Reiter’s syndrome / Reactive Arthritis


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Ankylosis

•

fusion of bone due to joint destruction

and inflammation

• Seronegative Spondylitis

• Rheumatoid arthritis (only carpal and

tarsal bones)

•

Inflammatory OA (IP joints)

Psoriatic arthritis: ankylosis


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Ankylosing spondylitis

Ankylosing

Spondylitis


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Ankylosing Spondylitis vs. DISH

Ankylosing spondylitis DISH


Ankylosing spondylitis


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DISH


Ankylosing spondylitis DISH


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Overhanging edge

• Sign of Gout

• excresence of bone

extending beyond the

margin of the bone

• reactive bone

adjacent to tophus

Overhanging edge

• Sign of Gout

• excresence of bone

extending beyond the

margin of the bone

• reactive bone

adjacent to tophus


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7. Calcification

• mass calcification

• chondrocalcification

• tendon and soft tissue calcification

Calcification: Scleroderma


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Calcification: pyrophosphate arthropathy

Chondrocalcinosis


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Calcification: “calcific tendonitis”

Gout 7/11! 1/13


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Gout

8. Distribution

• distribution may be characteristic of a

specific disease

•

Gout: 1st MTP

• OA: DIP, 1st CMC,

•

Rheumatoid arthritis: MCP and MTP joints


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Distribution: Gout

Radiographic signs

• Soft tissue swelling -- inflammation

• Demineralization -- vascularity / bone

resorption

• Joint space narrowing -- loss of cartilage

•

Erosions -- bone destruction


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Radiographic signs

• Alignment -- breakdown of supporting

structures or asymmetric joint narrowing

•

Bone formation -- inflamed or healing

bone

• Calcification -- clue to specific diagnosis

•

Distribution


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•

preserved bone

density

•

soft tissue swelling

•

marginal erosions

• periostitis


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Documents

22 Sari's SK slides