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Imaging approach to joint diseases

Imaging approach to joint diseases. Werner Harmse July 2010. Arthritis. Indicates an abnormality of the joint as the result of a degenerative, inflammatory, infectious, or metabolic process. Affects articular surfaces on both sides of joint Results in joint space narrowing.

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Imaging approach to joint diseases

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  1. Imaging approach to joint diseases Werner Harmse July 2010

  2. Arthritis • Indicates an abnormality of the joint as the result of a • degenerative, • inflammatory, • infectious, or • metabolic process. • Affects articular surfaces on both sides of joint • Results in joint space narrowing

  3. Classification of arthritides • Degenerative • Osteoarthritis: Primary, Secondary • Inflammatory • Rheumatoid arthritis • Seronegative spondyloarthropathies: AS, Reiter’s, Psoriasis, Enteropathic arthropathies • Connective tissue disease: Scleroderma, SLE, Dermatomyositis • Erosive OA • Metabolic • Crystal deposition: Gout, CPPD, etc • Other deposition: Hemochromatosis, Wilson’s, Alkaptonuria, Amyloidosis • Endocrine: Acromegaly, Hyper-parathyroidism • Haemophilia • Infective • Pyogenic • TB • others

  4. Imaging of joint disease • X-ray • Ultrasound • MRI • CT • Arthrography • Nuclear medicine

  5. Ultrasound • Multiplanar real time soft tissue imaging • Helpful in diagnosing joint effusions especially in septic arthritis, as well as other fluid collections • Also used in evaluating for tendonitis and tendon rupture

  6. CT • Computed tomography (CT) is effective in evaluating degenerative and inflammatory changes of various joints • Findings are similar to plain film radiography, only being able to demonstrate it more clearly • Multiplanar reformations can be done with MDCT • Valuable in planning of surgery • In the assessment of spinal stenosis secondary to degenerative changes, CT examination may also be performed after myelography especially if MRI is contraindicated

  7. MRI • Excellent contrast between soft tissues and bone. • Articular cartilage, fibrocartilage, cortex, and spongy bone can be distinguished • excellent for demonstrating synovial abnormalities in rheumatoid arthritis. • Because synovitis is often accompanied by joint effusion, this too can be effectively demonstrated by MRI • Occasionally, MRI may provide some additional information in osteoarthritis and hemophilic arthropathy • Most important role is in evaluation of the spine. • Demonstrate hypertrophy of the ligamentum flavum or the vertebral facets • Grade foraminal and spinal stenosis • Evaluate degenerative and inflammatory disc disease • Also very valuable in evaluating joint related injuries

  8. Nuclear medicine • Used to evaluate the pattern of disease activity and monitor response • how many joints are affected, • which joints are the most affected, • are there unsuspected sites with disease involvement) • Investigate sites of possible infection • A negative bone scan is reassuring and confirms the absence of active arthritis, while a positive bone scan can demonstrate disease presence and activity before it becomes apparent on a radiograph. • Bone scans have been used to predict erosions in rheumatoid disease and has also been shown to be a good predictor of disease progression in osteoarthritis

  9. X-rays: what to look for • Alignment • Bone • Cartilage • Distribution • Soft tissues

  10. X-rays: what to look for • Alignment • Subluxation and/or dislocation • Common in RA and SLE • Bone • Osteoporosis • Periarticular osteoporosis in RA • Erosions • Aggressive with no sclerotis margin: RA, psoriasis • Non-aggressive (fine sclerotic border): gout, usually overhanging • Location: Marginal – inflammatory; Central – Erosive OA (gull wing) • Bone production • Osteophytes: at sites of cartilage loss and degeneration typical in OA • Subchondral sclerosis: typical of OA • Ankylosis: seronegative inflammatory arthropathies eg AS • Periosteal reaction: psoriasis, Reiter’s (distinguish from RA) • Subchondral cysts • OA and CPPD, also RA and AVN

  11. X-rays: what to look for • Cartilage • Joint space • Normal joint space: Gout; or any early arthropathy • Eccentric narrowing: OA • Uniform narrowing: All others • Wide joint space: early inflammatory process • Calcification: CPPD

  12. X-rays: what to look for • Distribution • Single joint: Infective; crystal deposition; post traumatic • Hands and feet • proximal: RA, CPPD, SLE • Distal: Reiter’s(feet), psoriasis(hands), scleroderma • Symmetrical: RA, SLE • SI joints • Asymmetrical: Reiter’s, Psoriasis • Symmetrical: AS, Enteropathic, Reiter’s, Psoriasis • Also DJD, infection, gout

  13. X-rays: what to look for • Soft tissues • Swelling • Symmetrical around joint: all inflammatory, but most common in RA • Assymmetrical: most commonly d.t. osteophytes rather than true swelling in OA • Lumpy, bumpy: gout (tophus) • Entire digit: Psoriasis, Reiter’s • Calcification • Soft tissue: Gout • Cartilage: CPPD • Subcutaneous: Scleroderma, dermatomyositis

  14. X-rays • First important decision to make is if arthritis is present or not • Almost all arthritides lead to joint space narrowing, except gout • Then decide if it falls in the broader degenerative or inflammatory group as most a fall in one of these two.

  15. DJD AVN Arthritis or not

  16. Inflammatory vs Degenerative • Joint inflammation is characterized by • bone erosions (marginal) • osteopenia • soft-tissue swelling • uniform joint space loss • Degenerative cause of joint space narrowing is characterized by • osteophytes • bone sclerosis • subchondral cysts or geodes • asymmetric joint space narrowing • lack of inflammatory features such as bone erosions

  17. Inflammatory

  18. Inflammatory • Evaluate the number of joints involved • If only a single joint is involved consider infective arthritis • Features of any inflammatory arthritis • But erosions often not acutely present • Joint space may be initially widened due to effusion • Seen easily with ultrasound • Widening also seen in more indolent infections i.e. TB and fungal • Phemister triad in TB arthritis • periarticular osteoporosis, • peripherally located osseous erosions, • gradual diminution of the joint space

  19. Progression of TB of the knee over 1 year

  20. Inflammatory • If multiple joints are involved consider a systemic arthritis • Now evaluate hands and feet • If proximal with no bony proliferation consider rheumatoid arthritis • If distal with features of bony proliferation consider seronegative spodyloarthropathies eg. AS, Reiter’s, psoriasis and enteropathic arthropathies

  21. Rheumatoid arthritis • Women aged 30 – 60 • Rheumatoid factor • General features of inflammatory arthritis • Additionally joint subluxation and subchondral cysts may also be present • In the hands, target sites include the MCP, PIP, midcarpal, radiocarpal, and distal radioulnar joints, with predilection for the ulnar styloid process • Involvement is usually bilateral and fairly symmetric

  22. Rheumatoid arthritis • Ulnar deviation occurs at the MCP joints. • Swan neck and Boutonniere deformities. • In the feet, target sites include the MTP, PIP (incl 1st IP) and intertarsal joints • Important to closely evaluate the lateral aspect of the fifth metatarsal head – often 1st site of bony erosion • Also affects tendon sheaths and bursae like the retrocalcaneal bursa: • Loss of the normal radiolucent triangle between the posterosuperior margin of the calcaneus and the adjacent Achilles tendon suggests the presence of bursal fluid, with subjacent calcaneal erosions indicating inflammation

  23. Rheumatoid arthritis • Other peripheral joints also affected include the knees, the hips, the sacroiliac and glenohumeral joints. • Spinal involvement affects the C1-C2 articulation • the odontoid process may be eroded • and the anterior atlantodens interval may be abnormally widened (3 mm in adults), especially with neck flexion

  24. Small erosions at the 5th MTP joint

  25. a) Normal shoulder X-rays in patient with rheumatoid arthritis. (b) Ultrasound of same patient demonstrates 1.5 cm erosion.

  26. Synovial enhancement with Gd-DTPA. (a) Three-dimensional gradient-echo image of a wrist following IV Gd-DTPA shows extensive enhancing synovitis and distention of the synovial cavity. (b) Repeat MRI with Gd-DTPA following 3 months of disease-modifying antirheumatic drug (DMARD) therapy shows marked reduction in the amount of enhancing tissue but similar distention of the synovial cavity (note the dorsally displaced extensor tendons).

  27. Seronegative spondyloarhtropathies • Psoriasis, AS, Reiter’s and enteropathic arthritides. • HLA B27 usually positive • Hands and feet show more distal involvement. • Osseous attachment sites of ligaments and tendons are more involved than in RA. • Entheseal involvement leads to increased density and irregular bone proliferation (perisotitis). • Ankylosis more common

  28. Psoriatic arthritis • Hallmarks • signs of inflammatory arthritis combined with • periostitis, enthesitis, and a distal joint distribution in the extremities • Findings may be bilateral or unilateral and symmetric or assymmetric • Hands more than feet • Involvement of several joints in a single digit, with soft-tissue swelling, produces what appears clinically as a “sausage digit” • Aggressive erosions leading to “Pencil in cup” appearance and resorption of terminal tufts • Fuzzy/fluffy bony proliferation and periostitis • Ivory phalanx • Mouse ears: Bone production adjacent to erosions • SI joint involvement usually bilateral – may be symmetrical or not

  29. Psoriatic arthritis. Dorsovolar radiograph of the hand of a 57-year-old woman shows the typical presentation of psoriatic polyarthritis. The “pencil-in-cup” deformity in the interphalangeal joint of the thumb is characteristic of this form of psoriasis.

  30. Psoriatic Arthritis. A. Cartilage loss at the PIP joints of the 3rd, 4th, and 5th digits in this hand is apparent, with erosions noted most prominently in the 4th digit (arrow). These erosions are not sharply demarcated but are covered with fluffy new bone. Note also the periostitis along the shafts of each of the proximal phalanges. B. Advanced psoriatic arthritis. Fusion across the PIP joints of the 2nd to 5th digits. Several of the DIP joints are also ankylosed. Severe joint space narrowing at the metacarpophalangeal joints is noted.

  31. Reactive arthritis (Reiter’s) • Sterile inflammatory arthritis following an infection at a different site • Young men aged 25-35 • Similar to psoriasis in inflammation, proliferation, periostitis and ethesitis • Feet more than hands – particularly MTP joints and heels • Axial skeleton may also be affected

  32. A CT scan through the SI joints shows unilateral SI joint sclerosis and erosions (arrows), typical for psoriatic arthritis or Reiter disease.

  33. Ankylosing spondylitis • Idiopathic inflammatory arthritis • 96% are HLA B27+, Men aged 20 – 40 • More commonly affects axial skeleton • Spine involvement is characterized • by osteitis, syndesmophyte formation, facet inflammation, and eventual facet joint and vertebral body fusion. • Sacroiliac joint disease is bilateral and symmetric. • Other peripheral joints, such as the hips and glenohumeral joints, may be involved.

  34. Ankylosing spondylitis • SI joints show early erosions best seen at inferior aspects • Sclerosis follows with eventual ankylosis • Spine involvement usually centered at thoracolumbar or lumbrosacral junction • Osteitis at anterior discovertebral junctions with erosions, sclerosis “shiny corner” and squaring of vertebral bodies • Syndesmophytes form with eventual fusion of the vertebral bodies (bamboo spine). • Also interspinous ligament calcification

  35. Enteropathic arthritis • Occur with Crohn’s disease, Ulcerative colitis and Whipple disease • Spine and sacroiliac and peripheral joints may be affected. • Spine: squaring of the vertebral bodies and the formation of syndesmophytes are common features. • Sacroiliitis, usually bilateral and symmetric • radiographically indistinguishable from ankylosing spondylitis • In addition, patients may also exhibit a peripheral arthritis, the activity of which generally approximates the activity of the bowel disease.

  36. Degenerative • Joint space narrowing, Osteophyte formation, Bone sclerosis and Subchondral cysts are seen in the absence of inflammatory changes • Consider age, joints involved and x-ray appearance to distinguish between • Typical osteoarthritis • Atypical osteoarthritis

  37. Typical osteoarthritis • Result of articular cartilage damage and wear and tear from repetitive microtrauma that occurs throughout life, although genetic, hereditary, nutritional, metabolic, pre- existing articular disease, and body habitus factors may contribute in some cases. Usually after 4th or 5th decade • Typical sites • AC joints – small osteophytes from 4th decade • 1st CMC joint, IP joints of hands, MCP to a lesser degree, 1st MTP (joint space narrowing may be symmetrical in hands, unlike larger joints) • Knee – medial joint space as well as patellofemoral. Often formation of osteochondral bodies • Hip – superior migration

  38. (A) Sagittal PD of pt with OA of the right knee shows involvement of the femoropatellar compartment. Note joint space narrowing, subchondral cyst (arrow), and osteophytes (open arrows). (B) Coronal T2 fatsat image shows complete destruction of articular cartilage of the lateral joint compartment (arrows), subchondral edema (open arrows), and tear of the lateral meniscus (curved arrow). (C) Sagittal T2-fatsat in another patient shows osteoarthritis of the knee complicated by multiple osteochondral bodies (arrows).

  39. Atypical osteoarthritis • Osteoarthritis, but • involved joint is not one commonly affected by osteoarthritis, • the severity of the findings are excessive or unusual, or • the age of the patient is unusual, • then other less common causes for cartilage damage and osteoarthritis should be considered. • Trauma, • Crystal deposition disease, • Neuropathic joint, • Hemophilia. • Other possible causes include congenital and developmental anomalies, such as dysplasia, that disrupt normal biomechanics.

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