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Approaches to Joint disease Leila. Aghaghazvini MD Dr. Shariati Hospital Tehran university of medical science

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Conventional Radiography Arthrography Ultrasound Nuclear Medicine Studies CT MRI

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Infectious arthritis can generally be divided into two categories: Pyogenic or septic arthritis Most commonly caused by Staphylococcus aureus, Neisseria gonorrhea, Klebsiella pneumoniae, Candida albicans, and Serratia marcescens Non-pyogenic arthritis Most commonly caused by tuberculosis or fungal infections including actinomycosis, cryptococcosis, coccidioidomycosis,histoplasmosis, and sporotrichosis

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Infectious agents can enter the joint space in several ways Direct invasion of the synovial membrane Penetrating wound Post-surgical following joint replacement Infection of adjacent soft tissue Hematogenous spread from a blood borne infection Spread from a focus of osteomyelitis in adjacent bone

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Modality of choice for initial evaluation of suspected joint infections Diagnosis can be made when characteristic findings are present Early plain film findings: Periarticular osteoporosis Soft tissue swelling Joint effusion Joint space loss Later plain film findings: Periosteal reaction Marginal and central erosions and destruction of subchondral bone Subluxation or dislocation Intra-articular bony ankylosis

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Alone, US is unable to confirm the diagnosis of septic arthritis However, US is a very sensitive modality for demonstrating joint effusion May be effective in guiding needle aspiration of joint

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3-phase T99 MDP Bone Scan findings Increased blood flow adjacent to the joint Prominent activity on blood pool images on both sides of the affected area A fourth phase (delayed 24 hour imaging) shows: Diminution of activity This is in contrast to osteomyelitis which invariably has increased activity on delayed images

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Click Her Tc99m-MDP bone scan including blood pool image (upper left corner) and 4-hour delay images (lower and upper right corner) shows markedly increased uptake of radionuclide tracer at interphalangeal joint with osteomyelitis of proximal and distal phalanges of the left great toe. RT = right; LT = left; HR = hour.

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Early Stages of Infection: T2 images reveal distention of joint capsule by nonspecific high- intensity fluid Later Stages of Infection: Can detect joint effusion, cartilage destruction, narrowing of joint and cellulitis around joint MRI can readily detect extension of the infectious process into adjacent bone marrow and the transition to osteomyelitis T2 images reveal infected fluid and blood in the joint of inhomogeneous intermediate signal intensity T2 images also reveal an area of signal hyperintensity in the soft tissue around the affected joint

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Coronal Stir Image of Pelvis

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Conventional radiography and joint aspiration are the mainstays of infectious arthritis diagnosis Arthrography and less commonly CT or Ultrasound may play a role in guiding joint aspiration MRI has little role in the dx of infection arthritis but may be used to evaluate for complications, particularly osteomyelitis

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hallmarks -soft tissue swelling -osteoporosis - joint space narrowing - marginal erosions proximal process, bilaterally symmetric away from the weight-bearing portion of the joint. Hip : RA: the femoral head tends to migrate axially OA: migrate superolaterally Shoulder: high riding ( torn rotator cuff, CPPD)

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Hallmarks of Rheumatoid Arthritis Soft tissue swelling Osteoporosis Joint space narrowing Marginal erosions Proximal distribution (hands) Bilateral symmetry

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- Soft tissue edema - Erosion( far from articular cortex) - No osteoporosis - Tophus MTP the most common site

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1) Decrease in joint space - hip: superolateral - Knee: 2) Osteophyte 3) subchondral Sclerosis 4) subchondral Cyst DD: erosion( lateral view) Loose body (Knee)

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-Decrease in joint space Sclerosis osteophyte

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Joint narrowing OA: weight bearing RA: sym Erosion OA: neg, irregularity RA: pos Subchondral sclerosis and cyst: OA: pos RA: neg (erosion in AP view ) Sclerosis: OA: common RA: neg, secondary Osteoporosis: OA: neg RA: often

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The only disorder that will cause osteophytes without sclerosis or joint space narrowing is diffuse idiopathic skeletal hyperostosis

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Charcot Disease Charcot Disease:

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The most common site, intraarticular portion of bone plain graphy: -steroid, cvd, radiation, sca, casson dis, fracture 1 )No 2) osteoporosis and sclerosis 3)subcortical lucency 4) Flattened and scleroisis 5) osteoarthritis MRI the best modality

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Freiberg: metatars Kohler: navicular Osgood schlatter: Tibial tubersity Kienback: Lunate Osteochondritis Dis: The most common site site, knee,ankle

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