Chondrocalcinosis of the Wrist

Calcium pyrophosphate dihydrate deposition (CPDD) disease has characteristic radiographic features including soft tissue calcification, joint space narrowing, bone sclerosis, subchondral cyst formation without osteophyte formation, and large intraosseous geodes. Triangular fibrocartilage calcification is frequently found and isolated scapho-trapezio-trapezoid (STT) arthritis is specific for CPDD. Distal radio-ulnar (DRUJ), isolated midcarpal joint and piso-triquetral joint involvement also occur. 127 patients were reviewed. Seventy-eight had symptomatic STT joint arthritis, for which 36 underwent surgery. Twenty-two patients had a SLAC wrist deformity for which ten underwent surgery. Eight patients had isolated midcarpal arthritis for which three midcarpal arthrodeses, two four-bone arthrodeses and two carpal tunnel releases were performed. Nineteen patients had a generalized arthritis and seven of the patients underwent surgery: fourcorner arthrodesis+scaphoidectomy (one case), carpal tunnel relaease (two cases) extensor synovectomy (two cases) and trigger finger release (two cases).

[From chondrocalcinosis to rheumatism with calcium pyrophosphate dehydrate]

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease is a joint pathology that affects joints, fibrocartilages and periarticular structures. Chondrocalcinosis refers to CPPD deposits on the X-ray that does not summarize the disease. It willingly affects the knees and the wrists, but all the joints can be affected. There are primitive and secondary forms of the disease to particularly look for in patients less than 50 years. The diagnosis is usually easy with standard radiography, ultrasound and synovial fluid analysis that shows the microcrystals. The therapeutics of the acute attacks are nonspecific and close to those used for acute attacks of gout.

Destructive pseudo-neuroarthropathy associated with calcium pyrophosphate deposition

BACKGROUND

Calcium pyrophosphate deposition (CPPD) disease is a metabolic disorder characterized by soft tissue calcific deposits formed primarily in articular cartilage. What can result is a crystal-induced arthropathy often referred to as pseudogout, which is variable in both presentation and severity. A particularly destructive and deforming arthritis is an uncommon but well-recognized subtype of this disease. Radiologically resembling the neuroarthropathy described by Charcot, a pattern of joint fragmentation and structural collapse occurs in the absence of peripheral neuropathy. This pseudo-neuroarthropathy is rarely reported in the foot and ankle.

METHODS

A total of 15 cases of pseudo-neuroarthropathy involving some previously unreported joints within the foot and ankle are described in this case series of 9 patients.

RESULTS

All patients presented with disease involving multiple joints. Clinical deformity was apparent in each case, and extensive joint destruction was seen on plain radiographs. In 6 patients, histopathological CPPD disease was confirmed on tissue biopsy of the affected joints. In the remaining 3 patients a clinical diagnosis was made on the basis of the classic appearance of pseudo-neuroarthropathy in the foot, with additional recognized features of CPPD. Operative management with deformity correction using joint arthrodesis produced satisfactory clinical and radiological results.

CONCLUSIONS

In the absence of peripheral neuropathy and systemic disease, the pseudo-neuroarthropathy of CPPD should be considered when a progressively deforming and destructive arthritis is seen in the foot and ankle.

LEVEL OF EVIDENCE

Level IV, case series.

Role of Newman's classification in predicting outcomes in patients with crystal arthritis

PURPOSE

The aim of the study was to evaluate the utility of Newman's classification in predicting outcomes in patients presenting with crystal arthritis.

METHODS

Between January and December 2009, all patients who presented to our institution with acute crystal arthritis and were investigated with microbiological assessment of their synovial fluid were included in the study. Patients were divided into two groups depending on the fulfilment of Newman's criteria for culture-negative septic arthritis. Group 1 included patients that fulfilled Newman's B criteria. Group 2 included patients that fulfilled Newman's C criteria. A database looking at the demographics, mode of presentation, investigations, treatment and outcomes was then established and the results compared between the two groups.

RESULTS

A total of 58 patients were identified (group 1: n = 13; group 2: n = 45). The average age was 71 years (range 33-96). The joint most commonly involved was the knee followed by the wrist. Clinical findings at presentation were comparable in both groups; however, WBC and C-reactive protein (CRP) were more likely to be raised in group 1. Although most patients in group 1 were treated with antibiotics (62%) there was still a higher rate of morbidity, greater use of supportive therapy and a longer hospital stay (22.3 days, SD 17.4) in comparison with group 2, where most patients were treated by observation only (76%, mean hospital stay 3.5 days, SD ± 4.4). The difference in length of hospital stay was statistically significant (p < 0.0001).

CONCLUSIONS

Newman's criteria are a good indicator for prognosis in patients with crystal arthritis. However, the presence of crystals in an acutely inflamed joint does not exclude the need for supportive therapy and long hospital stay even in the absence of positive synovial fluid culture.

The forgotten crystal arthritis: calcium pyrophosphate deposition

Calcium pyrophosphate crystals are related to a variety of articular manifestations known as calcium pyrophosphate deposition (CPPD) arthritis. Acute CPPD arthritis is commonly known as pseudogout, but there are many other presentations. Diverse endocrine and metabolic diseases may be related to CPPD arthritis. Septic arthritis is in the differential diagnosis of acute CPPD arthritis. The treatment options for CPPD arthritis include non-steroidal anti-inflammatories and steroids.

[Pseudo-gout]

Pseudo-gout or calcium pyrophosphate crystal deposition disease (CPPD) is mainly a disease of the elderly. Diagnosis is obtained by identyfication of calcium pyrophosphate (CPP) crystals in the synovial fluid. Typical X-ray result is chondrocalcinosis (CC) mostly of the knee. CPPD is most frequently asymptomatic and not requires medical therapy. Treatment of acute form of desease is usualy joint aspiration and intra-articular injection.

[Chondrocalcinosis]

Chondrocalcinosis refers to deposition of calcium pyrophosphate crystals within cartilage or fibrocartilage, as visualised on plain radiograph. Clinical features of chondrocalcinosis are various. The two common presentations of chondrocalcinosis are acute synovitis (pseudogout) and chronic arthritis, which can lead to a severe disability. Sporadic form of the disease is by far the most frequent. Aging is the main risk factor for the occurrence of sporadic chondrocalcinosis. Prevalence of chondrocalcinosis varies from 7 to 10% in people aged around 60 years old. A primary metabolic disorder or familial predisposition should be considered if chondrocalcinosis occurs in patients younger than 60 years. There is good evidence that hereditary hemochromatosis, hyperparathyroidism and hypomagnesemia are metabolic disorders that predispose to secondary chondrocalcinosis.

Efficacy of tidal irrigation in Milwaukee shoulder syndrome

OBJECTIVE

To assess the efficacy of tidal irrigation in patients with Milwaukee shoulder syndrome (MSS).

METHODS

Ten patients with clinical diagnosis of MSS underwent ultrasound examination and tidal irrigation followed by instillation of methylprednisolone and tranexamic acid. A single shoulder was treated in 9 cases; in one patient with bilateral shoulder involvement, both shoulders were treated at different times. Six patients had longlasting disease (Group A) unsuccessfully treated with repeated joint fluid aspirations and intraarticular corticosteroid injections. Four patients had recent-onset illness without radiologic damage but with clinical findings similar to classic MSS (Group B), not previously treated with corticosteroid injections with symptoms dating from 3 months or less. Clinical examination including evaluation of adverse events, range of motion, and pain score by a 100 mm horizontal visual analog scale was scheduled just before tidal irrigation and after 2 and 6 months following the procedure in all cases.

RESULTS

Short- and longterm safety was excellent in all patients. Group A patients experienced short-lived improvement so that tidal irrigation had to be repeated within 6 to 10 months. No further therapy was necessary in any of the Group B patients during a mean followup of 16.5 months (range 12-24) due to a persistent clinical improvement without clinically detectable joint effusion.

CONCLUSION

Closed-needle joint irrigation is a minimally invasive procedure, which led to a significant improvement in both pain and active motion in patients with longstanding symptoms. Patients with recent-onset disease recovered completely.

Pseudogout after total knee arthroplasty

We report a case of a patient who presented with signs and symptoms of acute septic arthritis of the knee 9 years after total knee arthroplasty. Thick white purulent fluid was aspirated from the knee. Microscopy of the fluid demonstrated calcium pyrophosphate dihydrate crystals, and no organisms were cultured. The patient made a rapid recovery after the single aspiration, rest, and nonsteroidal antiinflammatory drugs alone. Eight years after this episode, the patient remains asymptomatic. To the best of our knowledge, no case of calcium pyrophosphate dihydrate arthropathy after total knee arthroplasty has been reported previously.

[Chondrocalcinosis: a disease frequently occurring in the second half of life]

Articular chondrocalcinosis (ACC) is a metabolic arthropathy caused by calcium pyrophosphate crystal deposits. It is frequent in the second half of the life (6% of the population aged between 60 and 70 years, 30% of the elderly after 80 years). Both males and females, are involved in the same proportion. Clinical manifestations include pseudogout attacks, mainly of the knee and wrist joints, secondary osteoarthritis and destructive arthropathy (mainly of the knee and hip joints). There is no basis therapy. The pyrophosphate calcium deposits do not disappear during the evolution of the disease. Symptomatic therapy with NSAIDS, analgesic drugs or intra-articular corticosteroids may be very useful. Orthopaedic surgery is necessary in cases with severe destructive arthropathy.

[Crystal-induced arthritides]

Crystal-induced arthritides are problems the general practitioner is often confronted with. Most patients present themselves more with acute than with chronic inflammatory joint diseases. However, secondary osteoarthritis is a frequent cause of disability in chronic disease. Problems of differential diagnosis arise because of constitutive symptoms such as fever and malaise in acute states of the disease and require exclusion of bacterial infection and of other systemic rheumatic diseases. This minireview will cover the clinical presentation and differential diagnosis of as well as the therapeutic approaches to the most frequent forms of crystal-induced arthritides.

Clinical trials review: crystal deposition diseases

This review focuses on several recent clinically-related observations concerning Calcium Pyrophosphate Deposition Disease (CPPDD). Developments include new information on the epidemiology of idiopathic CPPDD in aging, on familial CPPDD, and on associated conditions that predispose to secondary CPPDD. Factors that may precipitate pseudogout, including the use of intra-articular hyaluronan and systemic G-CSF, are also discussed.

Ankylosing spondylitis with severe chondrocalcinosis: case report

The term chondrocalcinosis is often used to describe the radiological or pathological features of calcified joint cartilage, and it usually indicates the deposition in cartilage of calcium pyrophosphate dihydrate. The prevalence of chondrocalcinosis increases with age, with dramatic increases occurring in the decades past age 60. In younger patients with chondrocalcinosis, either clinical evidence of associated metabolic diseases leading to the chondrocalcinosis or familial disease occurrence usually can be detected. We report a 42-year-old Chinese woman with ankylosing spondylitis and arthritis involving multiple peripheral joints. Severe chondrocalcinosis was detected incidentally in this patient, however, subsequent studies revealed no associated metabolic disease or familial susceptibility and the clinical features of this patient were different from those of ankylosing chondrocalcinosis (pseudoankylosing spondylitis). The cause of chondrocalcinosis in this patient remains unknown, but joint damage and repair could have been initiating or aggravating factors of the chondrocalcinosis.

Management of a patient with calcium pyrophosphate deposition disease and meniscal tear of the knee: a case report

OBJECTIVE

To describe the chiropractic management of a patient suffering from a right lateral meniscus tear concurrent with calcium pyrophosphate dihydrate (CPPD) deposition disease.

CLINICAL FEATURES

A 51-yr-old bus driver suffered from right knee pain (7 on a 1-10 pain scale). The onset of the pain was gradual and increased during braking and accelerating. Palpatory tenderness was noted at the right lateral knee joint line and the inferior lateral margin of the patella. Active resistive range of motion (ROM) in the knee during extension was painful throughout the full ROM, whereas passive ROM was restricted in flexion at 110 degrees. A positive McMurray's test reproduced pain at the knee. Radiographic analysis revealed CPPD deposition disease, and magnetic resonance imaging revealed a probable "parrot's beak" tear in the posterior horn of the right lateral meniscus.

INTERVENTION AND OUTCOME

The patient was treated conservatively. He was instructed not to put weight on the knee and not to return to work for 5 days. Initial treatments involved the use of ice and interferential electrical stimulation along with glucosamine sulfate supplements. Bicycling, weight lifting for general fitness and general knee strengthening exercises were prescribed. Approximately 5 months after initial treatment, the patient was lost to follow-up; 12 months later, he returned for treatment because of a recurrence. Physical examination at that time revealed knee pain rated at 3/10 but there was no pain upon palpation, McMurray's test was negative and right knee ROM was full without pain.

CONCLUSION

A patient suffering from CPPD can be managed by conservative means. The pathophysiology, clinical features and management considerations in the treatment of the patient's condition(s) are also discussed.

Calcium pyrophosphate in joint disease

Shedding of crystals from cartilage into a joint space can cause pseudogout, the most common acute monarthritis in the elderly. The calcification may also be associated with structural change identical to osteoarthritis. Treatment seeks to reduce symptoms and improve function.

CPPD crystal deposition disease as a cause of unrecognised pyrexia

We describe three cases of CPPD crystal deposition disease in elderly patients whose main symptom was fever. Misdiagnosis of such cases is possible because of the similarity of the clinical picture to that of septic fever. The probable mechanisms causing the fever are discussed. There was spectacular improvement in these patients after a high dose of oral colchicine and loperamide and no relapse was observed during the long term administration of colchicine in a conservative dose together with supplementary magnesium.

Probenecid inhibits transforming growth factor-beta 1 induced pyrophosphate elaboration by chondrocytes

OBJECTIVE

The elaboration of excess extracellular inorganic pyrophosphate (ePPi) by cartilage contributes to calcium pyrophosphate dihydrate (CPPD) crystal deposition disease. Transforming growth factor-beta 1 (TGF beta 1) is the only defined physiologic stimulant of cartilage ePPi elaboration. The mechanism of ePPi generation by chondrocytes is unknown, but current evidence suggests that TGF beta 1 induced ePPi is made intracellularly. An active transport mechanism such as an anion transporter would then be necessary to export ePPi to the matrix where crystals form. We determined the effect of probenecid (PB), an anion transport inhibitor, on TGF beta 1 induced ePPi elaboration.

METHODS

Porcine hyaline articular chondrocytes in high density monolayer cultures were exposed to serum-free media with and without TGF beta 1 and/or PB. ePPi was measured in the media after 48-96 h of exposure. Cell injury was measured by examining the release of 3H-deoxyglucose from chondrocytes. The activity of the ePPi generating ectoenzyme nucleoside triphosphate pyrophosphohydrolase (NTPPPH) and media lactate concentrations were measured with standard colorimetric assays. As PB may inhibit phosphodiesterase (PDE), its effects on ePPi generation were compared with isobutylmethylxanthine (IBMX), a specific PDE inhibitor.

RESULTS

PB inhibited TGF beta 1 induced ePPi elaboration by chondrocytes. PB did not cause membrane injury or decrease NTPPPH activity. Lactate production was decreased by PB but did not correlate with the effects of PB on ePPi elaboration. IBMX did not inhibit TGF beta 1 effect on ePPi elaboration.

CONCLUSION

PB blocks TGF beta 1 induced ePPi elaboration. This effect is independent of cell membrane injury, decreased NTPPPH activity, or PDE inhibition. Our data implicate a role for anion transport in TGF beta 1 induced ePPi elaboration, and suggest a potential therapy for CPPD disease.

Gout and 'pseudogout'. When are arthritic symptoms caused by crystal deposition?

The proper diagnosis of gout and pseudogout (ie, calcium pyrophosphate dihydrate crystal deposition disease) leads to correct treatment. The two disorders can be easily confused and misdiagnosed in certain situations. Thus, in every case, synovial fluid aspiration and microscopic synovial fluid analysis under compensated polarized light should be done to confirm the suspicion of crystal-induced arthropathy. Underlying diseases should always be sought, because many are treatable.

Gout and pseudogout in hospitalized patients

BACKGROUND

We determined the clinical characteristics of acute gout and pseudogout in hospitalized patients and examined the morbidity of inappropriate treatment and misdirected investigation when the diagnosis of acute crystal-induced synovitis was delayed.

PATIENTS AND METHODS

We reviewed the medical records of 67 hospitalized adults seen in consultation consecutively by one hospital-based rheumatologist during a 64-month period between 1986 and 1991 with the diagnosis of acute gout or pseudogout.

RESULTS

Gout was diagnosed in 41 patients, pseudogout in 24, and both crystal-induced diseases in two. The average age was 75.3 years. Polyarticular disease was common in both gout (49%) and pseudogout (42%). Fever attributable to synovitis was present in 34% of the patients and was more prevalent in patients with polyarticular (50%) than monoarticular (20%) inflammation. A quarter of the patients encountered errors in diagnosis, treatment, or both before rheumatologic consultation. Eleven patients experienced delays in diagnosis, and six patients had the correct diagnosis but received ineffective treatment.

CONCLUSIONS

Fever and polyarticular arthritis are noteworthy features in the hospitalized patient with acute gout or pseudogout. When the diagnosis of crystal-induced synovitis is overlooked, misdirected investigation and inappropriate treatment compound the morbidity of continued pain.

Gout and pseudogout

This article describes the clinical spectrum of gout and pseudogout and discusses the role of colchicine, NSAIDs, and uric acid--lowering agents in the management of different stages of gout. A great majority of patients with gout are now seen and treated by primary care physicians. Strategy for successful management of gout and prevention of its disabling complications are discussed also.

[Tuberculous arthritis and chondrocalcinosis. Apropos of 2 cases]

Two cases of tuberculous arthritis in a joint affected with chondrocalcinosis are reported. No similar cases have been published. Diagnosis was established by demonstration of the tubercle bacillus and calcium pyrophosphate crystals in the joint fluid. Both patients were elderly French females. One patient with involvement of a knee required amputation. The other patient had involvement of a shoulder and developed inferior dislocation of the humeral head and drooping shoulder despite antituberculous therapy. Concomitant occurrence of the two conditions was apparently coincidental but may have adversely affected prognosis. Despite its rarity, tuberculous arthritis should be looked for in patients with arthritis and chondrocalcinosis to allow early specific therapy.

[Arthroscopy of the hip. Methods and values]

The authors report on their experience with 225 arthroscopies of the hip (performed in 241 patients from January 1983 through September, 1991). Only 15 arthroscopies were performed using traction. For 228 procedures they used their simplified method without traction which does not visualize the congruent cartilage surfaces or acetabular fossa. To determine whether this method ensures a satisfactory diagnostic and therapeutic approach to the hip, 100 patients belonging to three groups (normal arthroscopy, indeterminate diagnosis, and chondromatosis) were sent a questionnaire on one to three occasions. Follow-up at the time of the first questionnaire was at least six months. Mean follow-up was 3 years (range 8 to 83 months). Arthroscopic diagnosis was based on direct evidence for the peripheral part of the joint and indirect evidence for lesions of the congruent joint surfaces and acetabular fossa. Sixty four responses were obtained, rates of error were only 5% for patients with normal arthroscopies and 22% for those with indeterminate arthroscopies (i.e., the group with the highest potential for error). Therapeutic results with the simplified method were satisfactory in 40% (15/35) of patients with chondromatosis; however, 7 of 44 patients (16%) had a repeat arthroscopy which was unsuccessful in more than half the cases (4/7). No complications or technical failures occurred in this series. In conclusion, simplified arthroscopy without traction is advocated as the routine arthroscopy procedure for investigating and treating hip disorders. The conventional technique with traction remains necessary when imaging procedures (especially the CT scan or arthroscan) demonstrate lesions of the congruent articular surfaces or acetabular fossa.

Lumbar spinal stenosis secondary to calcium pyrophosphate crystal deposition (pseudogout)

A 62-year-old man demonstrated symptoms, signs, and radiographic evidence of lumbar spinal stenosis and intraoperative pathologic findings of tophaceous deposition in the ligamentum flavum. Although there have been reports of cervical calcium pyrophosphate dihydrate crystal deposition (CPPD) with neurologic compression, this report appears to be the first case of lumbar spinal stenosis secondary to CPPD. Cervical calcium pyrophosphate dihydrate crystal deposition should be added to the differential diagnosis of spinal stenosis.

Crystal arthritis: a clinician's view

Arthritis, which can be acute, chronic or asymptomatic, is caused by a variety of crystal deposition in joints. The three main types of crystal arthritis are monosodium urate (gout), calcium pyrophosphate dihydrate, and calcium phosphate (usually hydroxyapatite). A clinical approach to diagnosis and management.

Pseudogout of the ankle: a case study and arthroscopic-assisted treatment

Chondrocalcinosis, also known as pseudogout, a calcium pyrophosphate dihydrate crystal deposition disease, has been reported in many joints of the human body. A review of the literature reveals few reported cases of pseudogout of the ankle and various uncertainties of the etiology of pseudogout. The authors offer a review of the disease and a case presentation with the use of arthroscopy to assist in the diagnosis and treatment of pseudogout of the ankle.

[Chondrocalcinosis: a diagnostic-therapeutic approach. Presentation of 10 clinical cases]

The disease caused by the deposition of dehydrated calcium pyrophosphate crystals (chondrocalcinosis) is a metabolic joint disease poorly known outside rheumatologic media. It is estimated that about 5% of the adult population has deposits in the knees and that prevalence increases with age. The incidence of symptomatic disease is about the same as that of gout. The clinical presentation is variable, from pseudogouty forms, pseudorheumatoid arthritis or secondary degenerative joint disease, to 20% of asymptomatic cases. In the systematic evaluation family history should be sought, and metabolic diseases such as gout, diabetes, hemochromatosis, hyperparathyroidism and hypothyroidism should be ruled out. The condition is treated with nonsteroidal antiinflammatory drugs, and although the outcome is generally favorable, severe destructive joint disease may develop. In the present article we review this condition on the basis of the presentation forms of 10 of our patients.

Clinical features of pseudogout attack. A survey of 50 cases

Fifty patients (15 men and 35 women; average age, 70.8 years) with pseudogout were studied. Arthroscopic biopsy was useful for diagnosis in one case with no light microscopic evidence of crystals in the synovial fluid. Attacks affected 93 sites in 50 patients. Attacks in ten patients occurred after mild trauma, long distance walks, total knee arthroplasty, or intraarticular injection of microcrystalline glucocorticoid. Twenty-five patients had fevers averaging 38 degrees. In five patients the fever was associated with mental confusion. Fourteen patients were initially suspected or misdiagnosed as having septic arthritis. Six patients were treated surgically under this misdiagnosis, with synovectomy complicated by limitation of motion of both knees in one patient. The involvement of more than one joint was noted in 21 patients. Polyarthritis could be an important clue to the diagnosis performed early; the combination of arthrocentesis and injection of microcrystalline glucocorticoid provided excellent therapy.