1. Arthritis Dr. Ahmed Refaey

2. Arthritis Degenerative arthritis “ osteo-arthritis” Inflammatory arthritis * autoimmune ( RA – scleroderma- SLE-dermatomyositis ) * seronegative ( AS- psoriasis-Reiters- enteropathic ) * erosive Metabolic arthritis

3. Degenerative arthritis ( OA ) 1ry : age related 2ry : underlying disease Joints involved : weight bearing joints * hip- knee- spine- DIP-PIP-1 st CMC- 1 st MTP * Joints spared : MCP, wrist, elbow, shoulder, ankles

5. Radiographic features 5 hallmark signs: Narrowing of joint space, usually asymmetrical Subchondral sclerosis Subchondral cysts Osteophytes Lack of osteoporosis

8. Degenerative OA Spine * posterior joints ( facets ) * uncovertebral joints ( Luschka) * costovertebral joints * IVD - decrease disc space, osteophytes, misalignment, vaccum phenomenon, schmorl’s nodules

9. SIJ : usually unilateral, targets the middle of the joint Shoulder : AC joint is more commonly involved than glenohumeral joint Hands : Heberden’s & Bouchard’s nodules Knees : the 3 compartments, but medial femero-tibial compartment is most often involved

11. Isolated DJD of patello-femoral articulation is unusual, underlying conditions like CPPD, hemochromatosis, old trrauma should be considered

12. Arthritis Degenerative arthritis “ osteo-arthritis” Inflammatory arthritis * autoimmune ( RA – scleroderma- SLE-dermatomyositis ) * seronegative ( AS- psoriasis-Reiters- enteropathic ) * erosive Metabolic arthritis

13. Inflammatory arthritis * autoimmune ( RA – scleroderma- SLE-dermatomyositis ) * seronegative ( AS- psoriasis-Reiters- enteropathic ) * erosive

14. * autoimmune ( RA – scleroderma- SLE- dermatomyositis )

15. ”Rheumatoid arthritis “RA Symmetric, may involve any synovial joint Inflammatory process with hyperplastic synovitis “ pannus “ F > M …… after 50 y, F = M General radiographic features reflect the underlying pathologic changes of chronic synovial joint inflammation with associated hyperemia, edema & pannus formation

17. Radiographic features The 1 st feature is fusiform periarticular soft tissue swelling arising from capsular distension by exessive fluid accumulation. blood flow to the synovium leads to a 2 nd early radiographic feature of juxta-articular osteoporosis, due to hyperemia.

18. After1-2 years, osseous erosions become apparent, occuring at the unprotected bone margins “ bare areas” in which the pannus has direct osseous contact, but later involving the subchondral bone giving subchondral cysts Joint spaces narrow uniformly as the cartilage is destroyed by the enzymatic nature of pannus

19. Later stages of the disease give rise to joint deformities resulting from tendon and ligaments laxity and ruptures & contractures. Later, 2ry OA may develop

20. Radiological features sequences of RA Soft tissue swelling Periarticular osteoporosis Marginal erosions Symmetrical decrease joint space Joint deformity 2ry OA

22. OA vs RA

23. Hands * bilateral symmetrical involvement of MCP & PIP * characteristic joint deformities include swan neck deformity, boutenniere deformity & Z-shaped deformity of thumb. * ulnar deviation of MCPs. Wrist * erosions involving the radial & ulnar styloid processes, distal radio- ulnar, radio-carpal joints and waist of scaphoid, triquatral and pisiform.

29. Feet * bilateral symmetrical involvement of MTPs * fibular deviation of MTPs

30. Elbow * joint effusion is recognized by a +ve fat pad sign Schoulder * gleno-humeral & acromio-clavicular joints may be affected * resorption of distal clavicle * rotator cuff tear

33. DD of resorption of distal clavicle Rheumatoid arthritis Hyperparathyroidism Scleroderma

34. Hips * symmetrical decrease in all joint components * absence of sclerosis & osteophytes formation unless 2ry OA has developed. Knees * symmetrical, tricompartmental narrowing * soft tissue swelling in the form of suprapatellar effusion or large Backer;s cyst.

37. Cervical spines * affected in > 50% of patients * preference of atlanto-axial joints * the more chronic the disease, the greater of cervical involvement. * most of patients are asymptomatic despite cervical involvement * lateral views in flexion & extension ( atlanto-axial subluxation), due to laxity of transverse ligament

39. Lateral radiograph of the neck with the head in flexion shows an increased distance between the anterior border of the dens and the posterior border of the anterior tubercle of C1 (blue line) from ligamentous laxity caused by rheumatoid arthritis. The "pre-dentate space," as this is called, should be less than 3 mm in the adult. The red line above should smoothly connect all of the spinolaminar white lines of each vertebral body but clearly is directed posterior to the spinolaminar white line of C1 (green arrow) since C1 is subluxed forward on C2.

40. In atlanto-axial subluxation, ADI ( anterior atlanto-axial interval) > 3 mm, or vertical atlanto-axial subluxation and superior migration of odontoid process, necessitate an MRI for evaluation of true cord space.

41. Rheumatoi factor is +ve in 70-80 % of patients with RA, also +ve in 5% of individuals who don’t have RA. Diseases need flexion/extension views of C.spine * RA * trauma * down syndrome Olecranon bursitis seen only in * RA * gout

42. Protrusio acetabuli

43. Protrusio-acetabuli, seen only in PROT * paget disease * RA * osteogenesis imperfecta * trauma

44. Scleroderma Soft tissue abnormalities + erosive arthritis Radiographic features : * soft tissue calcification * acro-osteolysis “ tuft resorption” * erosive changes of PIP & DIP

46. Systemic lupus erythematosis “ SLE “ Non-erosive arthritis ( > 90% ) Distribution similar to RA Soft tissue swelling may be the only indicator

47. Dermatomyositis Widespread cutaneous and subcuataneous, sheath like calcification is the hallmark.

49. Arthritis Degenerative arthritis “ osteo-arthritis” Inflammatory arthritis * autoimmune ( RA – scleroderma- SLE-dermatomyositis ) * seronegative ( AS- psoriasis-Reiters- enteropathic ) * erosive Metabolic arthritis ( crystal deposition – endocrine )

50. seronegative ( AS- psoriasis-Reiters- enteropathic )

51. Ankylosing spondylitis “ AS” Chronic,progressive, inflammatory condition involving mainly the synovial and cartilagenous joints of axial skeleton and the large proximal appendicular skeleton Joint involvement in axial & appendicular skeleton is typically bilateral & symmetrical. Enthesopathy is a prominent feature

52. SIJ * the classic site of initial involvement * changes involving both the ligamentous and synovial portions of the joint, but predominent in middle & lower thirds. The iliac side shows earlier and greater radiographic involvement than sacral side *changes : erosions  reactive sclerosis  ankylosis

54. Spine * typically ascends the spine contiguously without skip lesions and progress bilaterally and symmetrically Contiguous thoracolumbar involvement -Vertebral body "squaring": early osteitis - Syndesmophytes (Calcification of the outer portion of the anulus fibrosus ) - Bamboo spine: late fusion and ligamentous ossification

55. the classic spinal findings are thin, vertical ossification ( syndesmosis), that bridge adjacent vertebrae and cause ankylosis of multiple segments resemble a piece of bamboo >> ( bamboo sign ). The classic bamboo sign occurs in a minority of patients and takes an average of 10 years to develop.

57. Appendicular skeleton * usually the proximal large joints “ hip & shoulders”, giving a picture of any inflammatory disorder as bilateral symmetrical concentric joint space narrowing, mild erosions, subchondral cyts, ankylosis

58. Psoriatic arthritis 2:1 hand to feet ratio Axial involvement in 50% of patients

59. Hands and feet * normal bone density * sausage digit = swelling and inflammation of entire length of finger “ dactylitis” * erosions in bare area like RA with subsequent fluffy periosteal newbone formation, produces “ mouse ear “ appearance * An “ ivory phalanx” is uncommon presentation but unique and specific for psoriatic arthritis * erosions may progress centrally in distal articular surface giving “ pencil in a cup” deformity. * acro-osteolysis “ terminal tuft resorption”

60. A characteristic feature of psoriatic arthritis is its propensity to involve all of the joints in one digit, this termed as “ ray pattern “.

61. So, changes in psoriatic arthritis are mixture of bone resorption and bone production * bone resorptions : pencil in a cup, marginal erosions, resorption of terminal tufts * bone production : mouse ear appearance, ivory phalanx

66. Reiter’s arthritis Polyarthritis that targets the large joints of lower extremity, small joints of feet and axial skeleton. A minority of patients have the classic triad ( conjunctivitis – urethritis – arthritis ) * Reiter’s syndrome considered a form of reactive arthritis pericipitated by bacterial infection in GU or GIT.

67. Radiographic features Feet * the most commonly involved site “ calcaneous – MTP & IPJ of 1 st digit “ being specifically affected. * calcaneal erosions followed by fluffy periosteal new bone occurs at the insertion of the plantar fascia & Achilis tendon “ enthesitis”. * these inflammatory heel spurs are typically bilateral, present in 60% of patients and highly suggestive of Reiter’s disease.

68. Large joints of lower extremity * knee and ankle joints are frequently affected. The radiographic findings are consistent with other inflammatory arthritis: soft tissue swelling, joint effusion, loss of joint space, and erosions, in addition to bony productive changes and typically no osteopenia

69. SIJ & spine * the same as psoriatic arthritis * radiologic differentiation between spondylitis caused by psoriatic arthritis and spondylitis caused by reiter’s arthritis is impossible, only on clinical bases.

70. SI and spine involvement of psoriatic arthritis is indistinguishable from Reiter's disease. * Hand disease predominates in psoriasis; foot disease predominates in Reiter's disease. Spine disease can be differentiated from AS by asymmetrical osteophytes and lack of syndesmophytes.

72. Enteropathic arthritis Sero-ve spondyloarthropathy associated with inflammatory bowel disease. Radiographic features of the axial skeleton mimic ankylosing spondylitis. Radiographic features of appendicular skeleton mimic RA

73. Erosive arthritis Among postmenopausal women. Most common bilaterally affecting IPJ, distal > proximal Central joint erosion resemble gull wing on AP view Differentiated from psoriatic arthritis by the central erosion affect the proximal articular surface while in psoriasis, central erosion of distal articular surface.

76. Arthritis Degenerative arthritis “ osteo-arthritis” Inflammatory arthritis * autoimmune ( RA – scleroderma- SLE-dermatomyositis ) * seronegative ( AS- psoriasis-Reiters- enteropathic ) * erosive Metabolic arthritis ( crystal deposition – endocrine )

77. Metabolic arthritis Metabolic deposition diseases result in accumulation of crystals or other substances in cartilage and soft tissues.

78. Types: * crystal deposition diease - sodium urate ( gout ) - CPPD - basic calcium phosphate * other depostion diseases - hemochromatosis - Wilson,s diseaase - Alkaptonuria -

79. Gout Recurrent attacks of arthritis, 2ry to deposition of sodium urate crystals. 90 % of patients are males Acute gout has non-specific radiological findings, while chronic gout is well demonstrated on the plain films Radiologic features usually not seen untill 6-12 years after initial attack Tophi seen only on longstanding disease 50% of tophi are calcific “ tophi are radiolucent, becaome radio-opaque only after calcium depostion

80. Radiological features: -Eccentric, well marginated osseous lesions that have an overhanging edges of bone -Tophi : dense lobulated soft tissue masses, may contain calcifications, asymmetric in distribution, causing adjacent bone erosions -Normal bone density -Preserved joint space -1 st MTP is the most commonly involved

83. gout

85. CPPD ( calcium pyrophosphate deposition disease ) Intra-articular deposition of CPP, resulting in chondrocalcinosis and DJD in atypical joints Chondrocalcinosis : calcification of hyaline and fibrocartilage, synovium, tendons and ligaments

86. Radiological features : - chondrocalcinosis - DJD like OA, but differes in distribution Destinctive features : - patello-femoral & radiocarpal predilection - large subchondral cysts

89. Hemochromatosis 2ry to deposition of iron in joints Changes similar to CPPD Destinctive features: - beaklike osteophytes on MCP heads ( 4 th & 5 th ) - generalized osteoporosis

91. Wilson’s disease Deposition of copper in joints and liver, basal ganglia and other tissues Same distribution as CPPD Destinctive features : - subchondral fragmentation - generalized osteoporosis

92. Alkaptonuria ( Ochronosis ) Deposition of homogentesic acid in tissues Same distribution as CPPD Radiologic features: - IVD are most commonly affected

94. Hemophilia Arthropathy is 2ry to repeated spontaneous hemarthrosis, which occurs in 90% of hemophiliacs Radiographic features: -Acute : joint effusion & periarticular osteoporosis -Chronic : epiphyseal overgrowth, subchondral cysts, 2ry OA -Distinctive features in knee : widened intercondylar notch, squared patella -Distinctive features in elbow : enlarged radial head and trochlear notch

95. hemophilia extensive osteoporosis, enlargement of the epiphyses a widened intercondylar notch (arrows).

96. There is widening of the interconylar notch, accentuation of the trabeculae and enlargement of the medial epicondyle

97. Arthritis Degenerative arthritis “ osteo-arthritis” Inflammatory arthritis * autoimmune ( RA – scleroderma- SLE-dermatomyositis ) * seronegative ( AS- psoriasis-Reiters- enteropathic ) * erosive Metabolic arthritis

98. www.ahmedrefaey.com

100. Short cases Arthritis

138. 1- erosive arthritis 2- psoriasis/Rhiters 3- gout 4- AS 5- erosive arthritis 6- CPPD 7- scleroderma 8- RA 9- hemochromatosis 10-hemophilia 11-AS 12-scleroderma 13-RA 14-dermatomyositis 15-CPPD 16-OA 17-gout 18-psoriasis 19-CPPD 20-scleroderma 21-marginal erosion 22-CPPD 23-psoriasis 24-psoriasis 25-ochronosis 26-OA 27-gout 28-hemophilia 29-ochronosis 30-gout 31-erosive arthritis 32-AS 33-gout 34-gout 35-AS 36-gout 37-psoriasis