Date post: | 02-Nov-2014 |
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Joint Joint HistopathologyHistopathology
Prepared by: Prepared by:
Dr.Amanj Mohsin MustafaDr.Amanj Mohsin Mustafa
11stst Year Orthopeadic Trainee At KBMS Year Orthopeadic Trainee At KBMS
Supervised Supervised by:by:
Dr.Zainab Dr.Zainab AbdulwahabAbdulwahab
ContentsContents 1.Articular tissues A.Cartilage B.Synovium C.Meniscus
2.Arthroses Joint fluid analysis Non inflammatory arthritides Inflammatory arthritides Infectious arthritides Hemorrhagic effusions
1.Articular Tissues
A.Cartilage
Function : -decreases friction and distributes decreases friction and distributes
loadsloads -avascular, aneural, and avascular, aneural, and
alymphaticalymphatic -Receives nutrients and oxygen -Receives nutrients and oxygen
from synovial fluid via diffusionfrom synovial fluid via diffusion - Ph 7.4- Ph 7.4
Types of CartilageTypes of Cartilage
Growth plate------ (physeal) Growth plate------ (physeal) cartilagecartilage
Fibrocartilage ------ tendon & Fibrocartilage ------ tendon & ligament ligament
Elastic cartilage ---- tracheaElastic cartilage ---- trachea Fibroelastic cartilage--- menisciFibroelastic cartilage--- menisci
Composition Composition 1.Water 1.Water
(65% to 80% of wet weight)(65% to 80% of wet weight) Shifts in & out of cartilage to Shifts in & out of cartilage to
allow deformation of surface in allow deformation of surface in response to stressresponse to stress
-Distribution 80% at surface-Distribution 80% at surface - responsible for nutrition and - responsible for nutrition and
lubricationlubrication
2.Collagen2.Collagen
(10% to 20% of wet weight; more than (10% to 20% of wet weight; more than 50% of dry weight) 50% of dry weight)
Glycine, proline, hydroxyproline, and Glycine, proline, hydroxyproline, and hydrogen bonding: responsible for hydrogen bonding: responsible for collagen’s unique characteristicscollagen’s unique characteristics
Hydroxyproline is unique to collagen, Hydroxyproline is unique to collagen,
measured in urine assess bone turnover.measured in urine assess bone turnover. 95% of collagen,II in articular cartilage95% of collagen,II in articular cartilage Very stable, with a half-life of Very stable, with a half-life of
approximately 25 yearsapproximately 25 years
Type LocationI Bone . Tendon . Meniscus, annual vert. disc , skin
II Articular cartilage, nucleus puplosus
III Blood vessels , skin
IV Basement membrane
V Articular cartilage small amount
VI Articular cartilage small amount
VII Basement membrane
VIII Basement membrane
IX Articular cartilage small amount
X Hypertrophic cartilage, callus, G.plate
XI Articular cartilage small amount
XII tendon
XIII Endothelial cell
3.Proteoglycan3.Proteoglycan
(10% to 15% of wet weight)(10% to 15% of wet weight) Have a half-life of 3 monthsHave a half-life of 3 months chiefly compressive and elastic strengthchiefly compressive and elastic strength Trap and hold waterTrap and hold water Composed of subunits Composed of subunits
glycosaminoglycans (disaccharide glycosaminoglycans (disaccharide polymers)polymers)
Glycosaminoglycans :Glycosaminoglycans : Chondroitin sulfate (most prevalent Chondroitin sulfate (most prevalent
glycosaminoglycan in cartilage)glycosaminoglycan in cartilage) Chondroitin-4-sulfate concentration Chondroitin-4-sulfate concentration
decreases with age.decreases with age. Chondroitin-6-sulfate concentration remains Chondroitin-6-sulfate concentration remains
essentially constant.essentially constant. Keratin sulfate concentration increases with Keratin sulfate concentration increases with
age.age.
4.Chondrocytes4.Chondrocytes
((5% of wet weight)5% of wet weight) mesenchymal precursorsmesenchymal precursors active in protein synthesis.active in protein synthesis. They produce collagen proteoglycans They produce collagen proteoglycans
&enzymes.&enzymes. least active in the calcified zone.least active in the calcified zone. Chondroblasts derived from undifferentiated Chondroblasts derived from undifferentiated
mesenchymal cells (stimulated by motion)mesenchymal cells (stimulated by motion)
5.Other matrix:5.Other matrix:
1.AdhesivesAdhesives Noncollagenous proteins, fibronectin, Noncollagenous proteins, fibronectin,
chondronectin & anchorin CIIchondronectin & anchorin CII Fibronectin may be associated with Fibronectin may be associated with
osteo arthritis.osteo arthritis.
2.Lipid: unknown functionunknown function
Articular cartilage Articular cartilage growth factorsgrowth factors
Regulate cartilage synthesis; may have a role Regulate cartilage synthesis; may have a role in osteoarthritisin osteoarthritis
PDGF PDGF
TGF-BTGF-B
Fibroblast growth factor (basic) (b-FGF)Fibroblast growth factor (basic) (b-FGF)
Insulin-like growth factor-I (IGF-I)Insulin-like growth factor-I (IGF-I)
Lubrication & wear mechanisms Lubrication & wear mechanisms of articular cartilageof articular cartilage
The coefficient of friction for human joints varies The coefficient of friction for human joints varies from 0.002 to 0.04.from 0.002 to 0.04.
Factors decreasing articular cartilage coefficient of Factors decreasing articular cartilage coefficient of friction:friction:
-Fluid film formation-Fluid film formation
- Elastic deformation of articular cartilage- Elastic deformation of articular cartilage
- Synovial fluid- Synovial fluid
- Efflux of fluid from the cartilage- Efflux of fluid from the cartilage
Factor increasing the coefficient of friction: fibrillationFactor increasing the coefficient of friction: fibrillation
Specific types of Specific types of lubrication lubrication
1. Elastohydrodynamic lubrication Elastohydrodynamic lubrication Predominant during dynamic joint functionPredominant during dynamic joint function Elastic deformation of articular surfaces & thin Elastic deformation of articular surfaces & thin
films of joint lubricants separate the surfaces.films of joint lubricants separate the surfaces. Coefficient of friction is generally low.Coefficient of friction is generally low.
2. Boundary lubrication (slippery 2. Boundary lubrication (slippery surfaces)surfaces)
Lubricant only partially separates the surfaces.Lubricant only partially separates the surfaces. Superficial zone protein (lubricin) appears to Superficial zone protein (lubricin) appears to
have a role in boundary lubrication.have a role in boundary lubrication.
3.Boosted lubrication (fluid entrapment)3.Boosted lubrication (fluid entrapment) Concentration of lubricating fluid in pools Concentration of lubricating fluid in pools
trapped by regions of bearing surfaces that trapped by regions of bearing surfaces that are making contactare making contact
4.Hydrodynamic lubrication4.Hydrodynamic lubrication Fluid separates the surfaces when one of Fluid separates the surfaces when one of
the surfaces is sliding on the other.the surfaces is sliding on the other.
5.Weeping lubrication5.Weeping lubrication Fluid shifts out of articular cartilage in Fluid shifts out of articular cartilage in
response to load, separating the surfaces response to load, separating the surfaces by hydrostatic pressure.by hydrostatic pressure.
Parameter Effect of Aging Effect of
Osteoarthritis
Water content Decrease Increase
Proteoglycan conc. Decrease Decrease
Proteoglycan Syn. Decrease Increase
Proteoglycan Deg. Decrease Increase
Chondroitin 4 sulfate Decrease Increase
Chondrocyte No. Decrease
Collagen Relatively unchaged Decrease in severe OA
Keratin sulfate Increase Decrease
Chondrocyte size Increase
Modulus of elasticity Increase Decrease
Articular cartilage Articular cartilage healinghealing
1.Damage above the tidemark:1.Damage above the tidemark: Limited to the chondrocytes (type 1 injury) or articu Limited to the chondrocytes (type 1 injury) or articu
lar cartilage surface (type 2 injury)lar cartilage surface (type 2 injury)
2.Lacerations extending below the tidemark:2.Lacerations extending below the tidemark: Penetrate underlying subchondral bone (t3 injuriesPenetrate underlying subchondral bone (t3 injuries inflammatory response ,heal with fibrocartilageinflammatory response ,heal with fibrocartilage Fibrocartilage is not as durable as hyaline cartilage.Fibrocartilage is not as durable as hyaline cartilage.
3.Blunt trauma induce cartilage changes similar to 3.Blunt trauma induce cartilage changes similar to those with osteoarthritisthose with osteoarthritis..
Continuous passive motion is benefit Continuous passive motion is benefit cartilage healing.cartilage healing.
immobilization leads atrophy or cartilage immobilization leads atrophy or cartilage degeneration.degeneration.
animal models, 4 weeks of joint animal models, 4 weeks of joint immobilization decreases immobilization decreases proteoglycan/collagen ratio. proteoglycan/collagen ratio.
This ratio returns to normal after 8 weeks of This ratio returns to normal after 8 weeks of joint mobilization.joint mobilization.
Joint instability initially decreases the Joint instability initially decreases the proteoglycan/ collagen ratio (at 4 weeks).proteoglycan/ collagen ratio (at 4 weeks).
Later (12 weeks), the ratio of proteoglycan to Later (12 weeks), the ratio of proteoglycan to collagen is elevated, and hydration is collagen is elevated, and hydration is increased.increased.
Instability markedly decreases hyaluronan, Instability markedly decreases hyaluronan, disuse does not.disuse does not.
B. SynoviumB. Synovium
1.Vascularized connective tissue lacks a 1.Vascularized connective tissue lacks a basement membranebasement membrane
2.2.Mediates nutrient exchange between Mediates nutrient exchange between blood and joint (synovial) fluidblood and joint (synovial) fluid
Cell typesCell types Type A: phagocytosisType A: phagocytosis Type B : produce synovial fluidType B : produce synovial fluid undifferentiated cells: have a reparative undifferentiated cells: have a reparative
rolerole
Synovial fluidSynovial fluid H. acid, lubricin, proteinase, collagenases & PGH. acid, lubricin, proteinase, collagenases & PG ultrafiltrate of blood plasma added to fluid produced ultrafiltrate of blood plasma added to fluid produced
by synovial membraneby synovial membrane Contains no RBCs, clotting factors, or hemoglobinContains no RBCs, clotting factors, or hemoglobin Lubricates articular cartilage and provides nourishment Lubricates articular cartilage and provides nourishment Exhibits nonnewtonian Exhibits nonnewtonian Viscosity increases as the shear rate decreases.Viscosity increases as the shear rate decreases. Lubricin is key lubricating glycoprotein .Lubricin is key lubricating glycoprotein . Hyaluronan molecules knee become entangled & Hyaluronan molecules knee become entangled &
behave like an elastic solid during high-strain activities behave like an elastic solid during high-strain activities (running, jumping).(running, jumping).
C. MeniscusC. Meniscus
1.1. Deepens articular surface synovial jointsDeepens articular surface synovial joints
The meniscus broadens contact area & distributes load.The meniscus broadens contact area & distributes load.
joints include AC, SC, GH, hip & knee .joints include AC, SC, GH, hip & knee .
2.2. More elastic & less permeable than articular cartilageMore elastic & less permeable than articular cartilage
3. 50% force in extension, 90% deep flexion3. 50% force in extension, 90% deep flexion
4.3 years after total meniscectomy , 20% of patients have 4.3 years after total meniscectomy , 20% of patients have significant arthritic lesions and 70% have radiographic significant arthritic lesions and 70% have radiographic changes.changes.
5.All patients experience arthrosis after 20 years.5.All patients experience arthrosis after 20 years.
The severity of degenerative changes is proportional to the The severity of degenerative changes is proportional to the amount of meniscus excised.amount of meniscus excised.
5.Anatomy (knee meniscus)5.Anatomy (knee meniscus)
Triangular semilunar structureTriangular semilunar structure
Peripheral border attached to the joint capsulePeripheral border attached to the joint capsule
medial meniscus: semicircular; lateral meniscus: medial meniscus: semicircular; lateral meniscus: circularcircular
6.Histologic findings6.Histologic findings Fibroelastic cartilage Fibroelastic cartilage An interlacing network of collagen fibers (90% type I)An interlacing network of collagen fibers (90% type I) Proteoglycans, glycoproteins, and cellular elements Proteoglycans, glycoproteins, and cellular elements a The concentration of mechanoreceptors is highest a The concentration of mechanoreceptors is highest
in the posterior horns.in the posterior horns.
Blood supply ----- geniculate arteries.Blood supply ----- geniculate arteries. peripheral 25% of meniscus. peripheral 25% of meniscus. remaining meniscus receives nutrition through remaining meniscus receives nutrition through
diffusion.diffusion. Tears peripheral, vascularized region (“red Tears peripheral, vascularized region (“red
zone”)zone”)
can heal by means of fibrovascular scar formation.can heal by means of fibrovascular scar formation. central tears in the avascular region (“white central tears in the avascular region (“white
zone”) cannot.zone”) cannot. The fibrochondrocyte is responsible for meniscal The fibrochondrocyte is responsible for meniscal
healing.healing.
II. ARTHROSESII. ARTHROSES
A.Joint fluid analysis A.Joint fluid analysis 1.1. Noninflammatory arthritidesNoninflammatory arthritides (WBC) count: 200/mm(WBC) count: 200/mm33, 25% (PMN), 25% (PMN) Equal serum values of glucose and Equal serum values of glucose and
proteinprotein Normal viscosity (high)Normal viscosity (high) Straw colorStraw color Firm mucin clotFirm mucin clot
2.Inflammatory 2.Inflammatory arthritidesarthritides WBC count: 2000/mmWBC count: 2000/mm33 to 75,000/mm to 75,000/mm33, ,
50% PMNs50% PMNs Moderately decreased glucose level (25 Moderately decreased glucose level (25
mg/dL lower than serum glucose level)mg/dL lower than serum glucose level) Low viscosityLow viscosity Yellow-greenYellow-green Friable mucin clotFriable mucin clot Synovial fluid complement decreased in Synovial fluid complement decreased in
(RA), normal in ankylosing spondylitis(RA), normal in ankylosing spondylitis
3.Infectious arthritides3.Infectious arthritides
WBC count: more than 80,000/mmWBC count: more than 80,000/mm33 75% PMN75% PMN
Positive Gram stain (positive cultures Positive Gram stain (positive cultures later)later)
Low glucose level (25 mg/dL lower Low glucose level (25 mg/dL lower than serum glucose level)than serum glucose level)
Opaque fluidOpaque fluid Increased synovial lactateIncreased synovial lactate
B.Noninflammatory ArthritidesB.Noninflammatory Arthritides 1. Osteoarthritis 1. Osteoarthritis
(degenerative Joint disease)(degenerative Joint disease) Inflammation, overload, or decreased matrix Inflammation, overload, or decreased matrix
productionproduction Osteoarthritic cartilageOsteoarthritic cartilage Collagen abnormalities (disrupted by collagenase)Collagen abnormalities (disrupted by collagenase) Binding of proteoglycans to hyaluronic acidBinding of proteoglycans to hyaluronic acid Cathepsins B and D levels and metalloproteinases Cathepsins B and D levels and metalloproteinases
(collagenase, gelatinase, stromelysin) increase.(collagenase, gelatinase, stromelysin) increase. IL-1 enhances enzyme synthesis and have a IL-1 enhances enzyme synthesis and have a
catabolic effect leading to cartilage degeneration.catabolic effect leading to cartilage degeneration. a Genetic predisposition important in osteoarthritisa Genetic predisposition important in osteoarthritis
Areas Areas that that Osteoarthritis Osteoarthritis AffectsAffects
A Rapidly destructive A Rapidly destructive osteoarthritisosteoarthritis
common in the hip.common in the hip. mimic septic arthritis, RA, mimic septic arthritis, RA,
seronegative arthritis, neuropathic seronegative arthritis, neuropathic arthritis, or osteonecrosis.arthritis, or osteonecrosis.
The femoral head may be so flat as to The femoral head may be so flat as to appear sheared off.appear sheared off.
General characteristicsGeneral characteristics
primary or secondary (trauma, primary or secondary (trauma, infection, congenital)infection, congenital)
Begins with deterioration & loss of the Begins with deterioration & loss of the weight bearing surfaceweight bearing surface
Followed by osteophyte development Followed by osteophyte development and osteochondral junction breakdownand osteochondral junction breakdown
Later, cartilage disintegration and Later, cartilage disintegration and subchondral microfractures expose the subchondral microfractures expose the bony surface, bony surface,
Radiographic findings:Radiographic findings:
Subchondral cysts (secondary to Subchondral cysts (secondary to microfracture, may contain amorphous microfracture, may contain amorphous gelatinous material)gelatinous material)
OsteophytesOsteophytes Joint space narrowingJoint space narrowing Ebumation of boneEbumation of bone Best shown on tomograms or CT scansBest shown on tomograms or CT scans
Microscopic changes Microscopic changes
Loss of superficial chondrocytesLoss of superficial chondrocytes Chondrocyte cloning (more than 1 Chondrocyte cloning (more than 1
chondrocyte per lacuna)chondrocyte per lacuna) Replication and breakdown of the Replication and breakdown of the
tidemarktidemark FissuringFissuring Cartilage destruction with eburnation Cartilage destruction with eburnation
of subchondral “pagetoid” boneof subchondral “pagetoid” bone
Physical examinationPhysical examination
Decreased ROMDecreased ROM CrepitusCrepitus Knee: asymmetric involvementKnee: asymmetric involvement Hand: (DIP),(PIP), and CMC jointsHand: (DIP),(PIP), and CMC joints Hip: superolateral involvement Hip: superolateral involvement
TreatmentTreatment
a Supportive measures ( activity a Supportive measures ( activity modification, use of a cane), modification, use of a cane), including NSAIDs ,including NSAIDs ,
Surgical proceduresSurgical procedures
range from arthroscopic range from arthroscopic debridement to total joint debridement to total joint arthroplastyarthroplasty
2.Neuropathic 2.Neuropathic ArthropathyArthropathy(charcot Joint Disease)(charcot Joint Disease) extreme form of osteoarthritis caused by disturbed extreme form of osteoarthritis caused by disturbed
sensory innervationsensory innervation
CausesCauses
1.Diabetes (Most common)1.Diabetes (Most common) Charcot joint disease develops in 1% of Charcot joint disease develops in 1% of
patients with diabetic neuropathypatients with diabetic neuropathy Foot and ankle most commonly Foot and ankle most commonly Other anatomic sites , including knee and hipOther anatomic sites , including knee and hip
2.Tabes dorsalis 2.Tabes dorsalis (syphilitic myelopathy; lower (syphilitic myelopathy; lower extremity)extremity)
3. Syringomyelia3. Syringomyelia most common cause of upper-most common cause of upper-
extremity neuropathic arthropathy extremity neuropathic arthropathy (shoulder and elbow).(shoulder and elbow).
Charcot joint disease develops in 25% Charcot joint disease develops in 25% of patients with syringomyelia; 80% of of patients with syringomyelia; 80% of cases involve the upper extremity.cases involve the upper extremity.
4. Hansens disease4. Hansens diseaseSecond most common cause of upper Second most common cause of upper
extremity neuropathic arthropathyextremity neuropathic arthropathy5. Myelomeningocele5. Myelomeningocele: ankle and foot : ankle and foot 6.Congenital insensitivity to pain6.Congenital insensitivity to pain: :
ankle and foot ankle and foot 7.Other neurologic problems7.Other neurologic problems (such as (such as
spinal cord injury)spinal cord injury)
DiagnosisDiagnosis
Typically in older patient with Typically in older patient with unstable, painless, swollen unstable, painless, swollen jointjoint
May manifest with May manifest with hemarthrosishemarthrosis
a Radiographic a Radiographic findingsfindings Advanced (severe) destructive Advanced (severe) destructive
changes on both sides of the jointchanges on both sides of the joint Scattered “chunks” of bone Scattered “chunks” of bone
embedded in fibrous tissueembedded in fibrous tissue Joint distension by fluidJoint distension by fluid Heterotopic ossificationHeterotopic ossification
Charcot’s arthropathy & osteomyelitis Charcot’s arthropathy & osteomyelitis by physical examination & radiographsby physical examination & radiographs
Symptoms : swelling, warmth, Symptoms : swelling, warmth, erythema, minimal pain, a variable erythema, minimal pain, a variable WBC count & (ESR)WBC count & (ESR)
Both common in diabetic Both common in diabetic Technetium bone scan: may look “hot” Technetium bone scan: may look “hot”
(positive) (positive) Indium leukocyte scan: “hot” (positive) Indium leukocyte scan: “hot” (positive)
TreatmentTreatment
Limitation activity, bracing or castingLimitation activity, bracing or casting Skin temperature involved side that is Skin temperature involved side that is
similar to uninvolved side is best similar to uninvolved side is best indicator for discontinuing a total indicator for discontinuing a total contact cast.contact cast.
Charcot joint disease: usually Charcot joint disease: usually a contraindication for TJA and a contraindication for TJA and use orthopaedic hardware use orthopaedic hardware
3.Acute rheumatic 3.Acute rheumatic fever fever
most common cause of childhood most common cause of childhood arthritis.arthritis.
Rare since the advent of antibioticsRare since the advent of antibiotics Arthritis and arthralgias can follow Arthritis and arthralgias can follow
untreated group A hemolytic untreated group A hemolytic streptococcal infections.streptococcal infections.
The onset of red, tender, extremely The onset of red, tender, extremely painful joint effusions is acute.painful joint effusions is acute.
Systemic manifestations include :Systemic manifestations include : CarditisCarditis Erythema marginatum (painless macules with red Erythema marginatum (painless macules with red
margins, usually on the abdomen but never on the face)margins, usually on the abdomen but never on the face) Subcutaneous nodules (extensor surfaces of the upper Subcutaneous nodules (extensor surfaces of the upper
extremities)extremities) ChoreaChorea Arthritis is migratory and typically involves multiple large Arthritis is migratory and typically involves multiple large
joints.joints.
Jones criteriaJones criteria
Preceding streptococcal infection with two of the Preceding streptococcal infection with two of the following major criteria:following major criteria:
Carditis, polyarthritis, chorea, erythema Carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodulesmarginatum, subcutaneous nodules
Or with one major criterion and two of the Or with one major criterion and two of the following minor criteria:following minor criteria:
Fever, arthralgia, prior rheumatic fever, elevated Fever, arthralgia, prior rheumatic fever, elevated ESR, prolonged PR interval on ECG studyESR, prolonged PR interval on ECG study
Antistreptolysin O titers are elevated in 80% of Antistreptolysin O titers are elevated in 80% of affected patients.affected patients.
TreatmentTreatment
penicillin and salicylates.penicillin and salicylates.
4.Ochronosis4.Ochronosis
Degenerative arthritis resulting from alkaptonuriaDegenerative arthritis resulting from alkaptonuria A rare inborn defect of the homogentisic acid A rare inborn defect of the homogentisic acid
oxidase enzyme system (tyrosine and oxidase enzyme system (tyrosine and phenylalanine catabolism)phenylalanine catabolism)
Excess homogentisic acid deposited in the jointsExcess homogentisic acid deposited in the joints can be deposited in other tissues , heart valves.can be deposited in other tissues , heart valves. Affected patients may present with black urineAffected patients may present with black urine Ochronotic spondylitis Ochronotic spondylitis Usually occurs during the 4Usually occurs during the 4thth decade of life decade of life
Includes progressive degenerative changes, disc Includes progressive degenerative changes, disc space narrowing, and calcificationspace narrowing, and calcification
5.5. Secondary pulmonary Secondary pulmonary hypertrophic hypertrophic osteoarthropathyosteoarthropathy A clinical diagnosisA clinical diagnosis Involves a lung tumor mass, Involves a lung tumor mass,
joint pain and stiffness, joint pain and stiffness, periostitis of the long bones, periostitis of the long bones, and clubbing of the fingersand clubbing of the fingers
C. Inflammatory C. Inflammatory arthritidesarthritides
Radiographic findings: generally Radiographic findings: generally evidence of destruction on both evidence of destruction on both sides of a jointsides of a joint
Laboratory findings: confusingLaboratory findings: confusing
Finding Positive Negative
Rheumatoid Factor R.ASjogren Syndrome
SarcoidSLE
A.SpondylitisGout
Psoriatic ArthritisReiter Syndrome
HLA A.SpondylitisReiter SyndromePsoriatic Arthritis
Enteropathic aryhritis
ANA SLESjogren Syndrome
Scleroderma
1.1. Rheumatoid arthritis Rheumatoid arthritis
The most common inflammatory arthritisThe most common inflammatory arthritis Affects 3% of women and 1% of menAffects 3% of women and 1% of men
Diagnostic criteria of the American Diagnostic criteria of the American Rheumatism Association:Rheumatism Association:
Morning stiffnessMorning stiffness Swelling a NodulesSwelling a Nodules a Positive laboratory test resultsa Positive laboratory test results Radiographic findingsRadiographic findings
CausesCauses Unclear; a cell-mediated immune response (T cell):Unclear; a cell-mediated immune response (T cell):
Incites an inflammatory responseIncites an inflammatory response
Response is initially against soft tissuesResponse is initially against soft tissues
Response is later against cartilage (chondrolysis) Response is later against cartilage (chondrolysis) & bone (periarticular bone resorption)& bone (periarticular bone resorption)
Mononuclear cells: primary cellular mediators of Mononuclear cells: primary cellular mediators of tissue destruction in RAtissue destruction in RA
associated with infectious cause or human leukocyte associated with infectious cause or human leukocyte antigen (HLA) locus (HLA-DR4 and HLA-DW4)antigen (HLA) locus (HLA-DR4 and HLA-DW4)
Lymphokines, cytokines and other inflammatory Lymphokines, cytokines and other inflammatory mediators: initiate a destructive cascade that leads to mediators: initiate a destructive cascade that leads to joint destructionjoint destruction
General characteristicsGeneral characteristics
1.Insidious onset, morning stiffness, and 1.Insidious onset, morning stiffness, and polyarthritispolyarthritis
2.Hands (ulnar deviation and subluxation 2.Hands (ulnar deviation and subluxation of the meta carpophalangeal [MCP] of the meta carpophalangeal [MCP] joints) and feet (metatarso phalangeal joints) and feet (metatarso phalangeal joints, claw toes, and hallux valgus) joints, claw toes, and hallux valgus) affected earlyaffected early
3.Also common in the knees, elbows, 3.Also common in the knees, elbows, shoulders, ankles, and cervical spineshoulders, ankles, and cervical spine
4.Subcutaneous nodules Observed in 20% of RA 4.Subcutaneous nodules Observed in 20% of RA patients during their lifetimepatients during their lifetime
5. Synovium and soft tissues affected first5. Synovium and soft tissues affected first Joints significantly involved only laterJoints significantly involved only later
A. Early disease processA. Early disease process, the RA-, the RA-inflamed synovium shows a proliferation of inflamed synovium shows a proliferation of blood vessels blood vessels
B. Late synovial changesB. Late synovial changes Hyperplastic cellsHyperplastic cells Intimal hyperplasiaIntimal hyperplasia Increased blood vesselsIncreased blood vessels Abundant lymphocytes and rare neutrophilsAbundant lymphocytes and rare neutrophils
Laboratory findingsLaboratory findings
ESR and CRP are elevated.ESR and CRP are elevated. (RF) positive in 80% affected patients.(RF) positive in 80% affected patients. RF autoantibodies are directed against RF autoantibodies are directed against
crystallizable fragment (Fc) portion of crystallizable fragment (Fc) portion of immunoglobulin G (IgG).immunoglobulin G (IgG).
RF is most commonly (IgM) but any can RF is most commonly (IgM) but any can be immunoglobulin type.be immunoglobulin type.
Joint fluid assays also demonstrate RF, Joint fluid assays also demonstrate RF, decreased complement levelsdecreased complement levels
Systemic Systemic manifestationsmanifestations Rheumatoid vasculitisRheumatoid vasculitis PericarditisPericarditis Pulmonary disease (pleurisy, Pulmonary disease (pleurisy,
nodules, fibrosis)nodules, fibrosis) Popliteal cysts in rheumatoid Popliteal cysts in rheumatoid
patients (U/S), which can mimic patients (U/S), which can mimic thrombophlebitis thrombophlebitis
Felty’s syndromeFelty’s syndrome RA with splenomegaly and leukopeniaRA with splenomegaly and leukopenia
Still’s diseaseStill’s disease (JRA) with fever, rash, and splenomegaly (JRA) with fever, rash, and splenomegaly
Sjogren’s syndromeSjogren’s syndrome autoimmune exocrinopathy associated with RA.autoimmune exocrinopathy associated with RA. Decreased salivary and lacrimal gland secretionDecreased salivary and lacrimal gland secretion
and lymphoid proliferationand lymphoid proliferation
Radiographic Radiographic characteristics characteristics Periarticular erosions and osteopeniaPeriarticular erosions and osteopenia All three knee compartments may show All three knee compartments may show
osteoporosis and erosions.osteoporosis and erosions. Protrusio acetabuliProtrusio acetabuli
Medial displacement of the acetabulum Medial displacement of the acetabulum beyond the radiographic teardrop with medial beyond the radiographic teardrop with medial migration of the femoral head into the pelvismigration of the femoral head into the pelvis
Common in RA, ankylosing spondylitis, Common in RA, ankylosing spondylitis, Paget’s disease, metabolic bone diseases, Paget’s disease, metabolic bone diseases, Marfan’s syndrome, Otto’s pelvisMarfan’s syndrome, Otto’s pelvis
TreatmentTreatment Goals:Goals:
Control synovitis and painControl synovitis and pain
Maintain joint functionMaintain joint function
Prevent deformitiesPrevent deformities
““pyramid” approach pyramid” approach to RA drug therapyto RA drug therapy
Begins with NSAIDsBegins with NSAIDs antimalarials, remittent agents (methotrexate, antimalarials, remittent agents (methotrexate,
sulfasalazine, gold &penicillamine), steroid & cytotoxic sulfasalazine, gold &penicillamine), steroid & cytotoxic drugsdrugs
Doxycycline has shown early promise in reducing Doxycycline has shown early promise in reducing inflammation in RA.inflammation in RA.
DMARDs address underlying causes for disease DMARDs address underlying causes for disease ( autoimmune ) rather than only effects ( autoimmune ) rather than only effects ( inflammation).( inflammation).
methotrexate, azathioprine & anakinra (IL-1 inhibitor).methotrexate, azathioprine & anakinra (IL-1 inhibitor). Most new DMARDs, infliximab & etanercept target Most new DMARDs, infliximab & etanercept target
TNF-a.TNF-a. a These drugs should be discontinued before elec tive a These drugs should be discontinued before elec tive
surgery, to decrease risk of infection.surgery, to decrease risk of infection.
SurgerySurgery Synovectomy, only if aggressive drug therapy failsSynovectomy, only if aggressive drug therapy fails Soft tissue realignments Usually not favored Soft tissue realignments Usually not favored
because deformity progressesbecause deformity progresses Various reconstructive proceduresVarious reconstructive procedures
Risk of infection after TJA is increasedRisk of infection after TJA is increased Operative synovectomy in the kneeOperative synovectomy in the knee
1.Decreases pain and swelling 1.Decreases pain and swelling
2. Does not prevent radiographic progression or the 2. Does not prevent radiographic progression or the need for future y (TKA)need for future y (TKA)
3.Does not improve joint ROM3.Does not improve joint ROM a Preoperative evaluation of the cervical spine a Preoperative evaluation of the cervical spine
with radiographs is important.with radiographs is important.
2.Systemic lupus 2.Systemic lupus erythematosuserythematosus SLE is a chronic inflammatory disease SLE is a chronic inflammatory disease
of unknown origin.of unknown origin. Usually affects women (especially Usually affects women (especially
African Americans)African Americans) related to the immune complex related to the immune complex Patients with SLE typically have Patients with SLE typically have
positive (ANA) & HLA-DR3 titers and positive (ANA) & HLA-DR3 titers and may have positive RF titers.may have positive RF titers.
ManifestationsManifestations
FeverFever Butterfly malar rashButterfly malar rash Pancytopenia Pancytopenia Pericarditis Pericarditis Nephritis Nephritis PolyarthritisPolyarthritis Joint is most common feature, more than 75% of Joint is most common feature, more than 75% of
patients with SLEpatients with SLE arthritis in SLE typically manifests as acute, red, arthritis in SLE typically manifests as acute, red,
tender swelling of the PIP joints, MCP joints, tender swelling of the PIP joints, MCP joints, carpus, kneescarpus, knees
SLE is typically not as destructive as RASLE is typically not as destructive as RA
TreatmentTreatment
same medications as for RA.same medications as for RA. Mortality in SLE is usually Mortality in SLE is usually
related to renal disease.related to renal disease. DDX:DDX:
polymyositis polymyositis dermatomyositisdermatomyositis..
3.Polymyalgia 3.Polymyalgia rheumaticarheumatica elderly personselderly persons Aching and stiffness of the shoulder and pelvic girdle, Aching and stiffness of the shoulder and pelvic girdle,
associated with malaise, headaches, and anorexiaassociated with malaise, headaches, and anorexia Physical examination :unremarkablePhysical examination :unremarkable laboratory, Markedly elevated ESR ,ALP,Immune laboratory, Markedly elevated ESR ,ALP,Immune
comlpex, Anemia comlpex, Anemia Usually treated symptomatically Usually treated symptomatically Steroids for refractory casesSteroids for refractory cases May be associated with temporal arteritisMay be associated with temporal arteritis
Biopsy for definitive diagnosisBiopsy for definitive diagnosis
requires treatment high-dose steroids; requires treatment high-dose steroids;
if untreated, may rapidly result in total blindnessif untreated, may rapidly result in total blindness
4.Juvenile rheumatoid 4.Juvenile rheumatoid arthritisarthritis
Seronegativity negative RF titers.Seronegativity negative RF titers. Seropositivity positive RF titers.Seropositivity positive RF titers.
-incidence of seropositivity is estimated less than 15% of -incidence of seropositivity is estimated less than 15% of JRAJRA
- incidence of chronic, active, and progressive dis. is incidence of chronic, active, and progressive dis. is higher.higher.
- In early-onset JRA, onset of disease occurs before the In early-onset JRA, onset of disease occurs before the teens; in late-onset JRA, onset of disease occurs teens; in late-onset JRA, onset of disease occurs during the teens or later.during the teens or later.
Types :Types :
1.Systemic (20%)1.Systemic (20%)
2.Polyarticular (50%)2.Polyarticular (50%)
Five or more joints are involved.Five or more joints are involved.
Seronegative polyarticular JRA is more Seronegative polyarticular JRA is more frequent in girls.frequent in girls.
Seropositive polyarticular JRA is also more Seropositive polyarticular JRA is also more frequent in girls.frequent in girls.
Exhibits destructive degenerative joint Exhibits destructive degenerative joint disease Frequently develops into adult RA disease Frequently develops into adult RA aa
3. Pauciarticular (30%)3. Pauciarticular (30%)
Four or fewer joints are involved.Four or fewer joints are involved.
Onset peaks at ages 2 to 4 years.Onset peaks at ages 2 to 4 years.
Average duration of disease is 2 years, 9 months.Average duration of disease is 2 years, 9 months.
Early-onset pauciarticular JRA has two distinctive Early-onset pauciarticular JRA has two distinctive characteristics:characteristics:
More frequent in girlsMore frequent in girls Associated with iridocyclitis in 50%Associated with iridocyclitis in 50%
Late-onset pauciarticular JRA has one distinctive Late-onset pauciarticular JRA has one distinctive characteristic:characteristic:
Observed in boys more commonly than in girlsObserved in boys more commonly than in girls
Treatment:Treatment:
High-dose aspirinHigh-dose aspirin Occasionally gold or remittent agents Occasionally gold or remittent agents
(refractory polyarticular)(refractory polyarticular) Frequent ophthalmologic examinations Frequent ophthalmologic examinations
(with a slit lamp) for asymptomatic ocular (with a slit lamp) for asymptomatic ocular involvementinvolvement
Most common joint affected: the knee, Most common joint affected: the knee, followed by the finger/wrist, ankle, hip, and followed by the finger/wrist, ankle, hip, and cervical spinecervical spine
C-spine fusion or instability can occurC-spine fusion or instability can occur
5.Relapsing 5.Relapsing polychondritis polychondritis
6.Spondyloarthropathies/6.Spondyloarthropathies/enthesopathies enthesopathies A.Ankylosing Spondylitis
Diagnostic criteriaDiagnostic criteria::
1.Bilateral sacroiliitis1.Bilateral sacroiliitis
2.With or without acute anterior uveitis2.With or without acute anterior uveitis
3.HLA-B27-positive male patient3.HLA-B27-positive male patient
Insidious onset of back painInsidious onset of back pain Associated morning stiffnessAssociated morning stiffness Hip painHip pain Third to fourth decades of life)Third to fourth decades of life) Squaring of the vertebraeSquaring of the vertebrae Obliteration of sacroiliac jointsObliteration of sacroiliac joints ° Spinal manifestation “Chin on chest” deformity ° Spinal manifestation “Chin on chest” deformity
B.Reiters SyndromeB.Reiters Syndrome
Classical presentation is of a young man with the Classical presentation is of a young man with the triad of conjunctivitis, urethritis, and oligoarticular triad of conjunctivitis, urethritis, and oligoarticular arthritis.arthritis.
Mnemonic: “Mnemonic: “Can’t see, pee, or bend the Can’t see, pee, or bend the kneeknee””
Other common findings include :Other common findings include : Painless oral ulcersPainless oral ulcers Penile lesionsPenile lesions Pustular lesions on the extremities, palms, and Pustular lesions on the extremities, palms, and
soles (keratoderma blennorrhagicum)soles (keratoderma blennorrhagicum) Plantar heel painPlantar heel pain
c.Psoriatic arthropathyc.Psoriatic arthropathy
Affects approximately 5% to 10% of patients with Affects approximately 5% to 10% of patients with psoriasispsoriasis
HLA-B27 is found in 50% of patients.HLA-B27 is found in 50% of patients. Many forms exist; most patients have the Many forms exist; most patients have the
oligoarticular form.oligoarticular form. Asymmetrically affects small joints of the hands Asymmetrically affects small joints of the hands
and feetand feet Nail pitting (also fragmentation and discoloration)Nail pitting (also fragmentation and discoloration) ““Sausage” digitsSausage” digits ““Pencil-in-cup” deformity Pencil-in-cup” deformity Treatment is similar to that for RA.Treatment is similar to that for RA.
D.D. Enteropathic Enteropathic arthritis arthritis of patients with Crohn’s disease and ulcerative colitis,of patients with Crohn’s disease and ulcerative colitis, 10% to 20% experience peripheral joint arthritis.10% to 20% experience peripheral joint arthritis. Five percent or more experience axial disease, a Non Five percent or more experience axial disease, a Non
deforming arthritisdeforming arthritis Occurs more commonly in large, weight-bearing Occurs more commonly in large, weight-bearing
jointsjoints Usually manifests as an acute monarticular synovitis Usually manifests as an acute monarticular synovitis
that may precede any bowel symptomsthat may precede any bowel symptoms 50% HLA-B27 positive.50% HLA-B27 positive. 10-15% of cases are associated with anky losing 10-15% of cases are associated with anky losing
spondylitisspondylitis..
7.7. Crystal deposition Crystal deposition diseasediseaseA. GoutA. Gout Disorder of nucleic acid metabolism Disorder of nucleic acid metabolism
causing hyperuricemiacausing hyperuricemia Deposition of monosodium urate crystals Deposition of monosodium urate crystals
in jointsin joints
CauseCause
The crystals activate inflammatory mediators.The crystals activate inflammatory mediators. mediators include proteases, chemotactic factors, mediators include proteases, chemotactic factors,
PG, leukotriene BPG, leukotriene B44, and free oxygen radicals., and free oxygen radicals. inflammatory mediators are inhibited by inflammatory mediators are inhibited by
colchicine.colchicine. crystals also activate platelets, IL-1 production, crystals also activate platelets, IL-1 production,
and complement system.and complement system. Local polypeptides may inhibit the crystal Local polypeptides may inhibit the crystal
inflammatory response by means of a inflammatory response by means of a glycoprotein “coating.”glycoprotein “coating.”
Gout may be precipitated by chemotherapy for Gout may be precipitated by chemotherapy for myeloproliferative disorders.myeloproliferative disorders.
□ □ DiagnosisDiagnosis
Recurrent arthritis attacks, in men 40 to 60 Recurrent arthritis attacks, in men 40 to 60 Usually in the lower extremity, great toe Usually in the lower extremity, great toe Crystal deposition as tophiCrystal deposition as tophi- Ear helix, eyelid, olecranon, Achilles tendon Ear helix, eyelid, olecranon, Achilles tendon - Usually observed in the chronic formUsually observed in the chronic form Renal disease or stonesRenal disease or stones Kidneys are second most commonly affected.Kidneys are second most commonly affected. not diagnostic.not diagnostic.
Radiographic findings:Radiographic findings:
Soft tissue changesSoft tissue changes “ “Punched-out” periarticular erosions Punched-out” periarticular erosions
with sclerotic overhanging borders with sclerotic overhanging borders Monosodium urate crystals—thin, Monosodium urate crystals—thin,
tapered intra cellular crystals that are tapered intra cellular crystals that are strongly negatively birefringent in joint strongly negatively birefringent in joint aspirate must be present for the aspirate must be present for the diagnosis.diagnosis.
Elevated serum uric acid level is not Elevated serum uric acid level is not diagnosticdiagnostic
Treatment:Treatment:
acute attacks with indomethacin (50 mg three acute attacks with indomethacin (50 mg three times daily)times daily)
A rheumatology consultation is necessary A rheumatology consultation is necessary afterwards.afterwards.
intravenous colchicine for pt. with GIT diseaseintravenous colchicine for pt. with GIT disease Allopurinol for chronic gout.Allopurinol for chronic gout.
-xanthine oxidase inhibitor; xanthine oxidase is -xanthine oxidase inhibitor; xanthine oxidase is needed for the conversion of hypoxanthine to needed for the conversion of hypoxanthine to xanthine and xanthine to uric acid.xanthine and xanthine to uric acid.
Colchicine is used for prophylaxis after recurrent Colchicine is used for prophylaxis after recurrent attacks.attacks.
B.ChondrocalcinosisB.ChondrocalcinosisC.Calcium hydroxyapatite crystal C.Calcium hydroxyapatite crystal
deposition diseasedeposition disease
E. Infectious E. Infectious arthritidesarthritides1. Pyogenic arthritis1. Pyogenic arthritis CauseCause
Hematogenous spreadHematogenous spread
Extension of osteomyelitis Extension of osteomyelitis Posttraumatic (fight bites, open injuries) Posttraumatic (fight bites, open injuries)
Postoperative (iatrogenic)Postoperative (iatrogenic) Commonly occurs in childrenCommonly occurs in children Adults at high risk include the following:Adults at high risk include the following:
Intravenous drug abusersIntravenous drug abusers
Sexually active young adults (Neisseria gonorrhoeae)Sexually active young adults (Neisseria gonorrhoeae)
Patients with DMPatients with DM
Patients with RAPatients with RA
Histologic findings:Histologic findings:
Synovial hyperplasia may be demonstrated.Synovial hyperplasia may be demonstrated. Numerous PMNs are present.Numerous PMNs are present. Cartilage destruction is evident.Cartilage destruction is evident.
direct (from proteolytic enzymes) direct (from proteolytic enzymes)
indirect (from pressure and lack of nutrition)indirect (from pressure and lack of nutrition)
Treatment:Treatment: ° Incision and drainage ° Antibiotics for up to ° Incision and drainage ° Antibiotics for up to
several weeksseveral weeks
B.Tuberculous arthritis B.Tuberculous arthritis
Chronic granulomatous infection n Chronic granulomatous infection n Mycobacterium tuberculosisMycobacterium tuberculosis
Usually invades joints by Usually invades joints by hematogenous spreadhematogenous spread
Spine and lower extremities most Spine and lower extremities most often involvedoften involved
Common in Mexico and AsiaCommon in Mexico and Asia 85% are monarticular85% are monarticular
Characteristic Characteristic radiographic findings:radiographic findings: Osteolytic changes on both sides of Osteolytic changes on both sides of
the joint ° Subchondral osteoporosisthe joint ° Subchondral osteoporosis Cystic changesCystic changes Notchlike, bony destruction at the joint Notchlike, bony destruction at the joint
edge n Joint space narrowingedge n Joint space narrowing
DiagnosisDiagnosis Positive results of purified protein derivative test Positive results of purified protein derivative test Acid-fast bacilli and “rice bodies” (fibrin) in synovial fluidAcid-fast bacilli and “rice bodies” (fibrin) in synovial fluid Cultures may take several weeks to yield positive resultsCultures may take several weeks to yield positive results Histologic study: may demonstrate characteristic Histologic study: may demonstrate characteristic
granulomas with Langerhans giant cells granulomas with Langerhans giant cells
Treatment:Treatment: Incision and drainageIncision and drainage Long-term (6 months) antibiotics (isoniazid, rifampin or Long-term (6 months) antibiotics (isoniazid, rifampin or
rifabutin, pyrazinamide, and pyridoxine)rifabutin, pyrazinamide, and pyridoxine)
3.Fungal arthritis 3.Fungal arthritis AIDSAIDSCandidiaCandidiaAntifungalAntifungal4.Lyme DiseaseUSAUSASelf limitingSelf limitingTick biteTick bite
E Hemorrhagic E Hemorrhagic effusionseffusions 1. Hemophilic arthropathy1. Hemophilic arthropathy X-linked recessive disorderX-linked recessive disorder Factor VIII deficiency: hemophilia A (classic)Factor VIII deficiency: hemophilia A (classic) Factor IX deficiency: hemophilia B (Christmas Factor IX deficiency: hemophilia B (Christmas
disease)disease) repeated hemarthrosis by minor traumarepeated hemarthrosis by minor trauma leads to synovitis, cartilage destruction & joint leads to synovitis, cartilage destruction & joint
deformity,Repeated episodes lead to deformity,Repeated episodes lead to replacement of the normal joint capsule with replacement of the normal joint capsule with dense scar tissue.dense scar tissue.
severity related to degree of factor VIII severity related to degree of factor VIII deficiency:deficiency:
Mild disease: levels of factor VIII are 5% Mild disease: levels of factor VIII are 5% to 25%to 25%
Moderate disease: 1% to 5% Moderate disease: 1% to 5% Severe disease: 0% to 1%Severe disease: 0% to 1%Home factor treatment has reduced Home factor treatment has reduced
incidence substantiallyincidence substantially..
Diagnosis:Diagnosis: Most commonly: kneeMost commonly: knee Followed by elbow, ankle, shoulder, and spine n Joint Followed by elbow, ankle, shoulder, and spine n Joint
swelling, decreased ROM, and painswelling, decreased ROM, and pain a Concomitant infection: ruled out by examination of a Concomitant infection: ruled out by examination of
joint aspiratejoint aspirate Radiographic :Radiographic : ““Squared off’ patella (Jordan’s sign)Squared off’ patella (Jordan’s sign) Widening of the intercondylar notchWidening of the intercondylar notch Enlarged femoral condyles,Enlarged femoral condyles, appearing to “fall off’ the tibia appearing to “fall off’ the tibia U/S: diagnose & monitor IM bleedingU/S: diagnose & monitor IM bleeding Iliacus hematomas can cause femoral nerve palsies.Iliacus hematomas can cause femoral nerve palsies.
Treatment:Treatment:
Correction of factor levelsCorrection of factor levels Factor VIII: to 40% to 50% of normal Factor VIII: to 40% to 50% of normal
levels levels Splints and bracingSplints and bracing Compressive dressings a AnalgesicsCompressive dressings a Analgesics Steroids (occasionally helpful)Steroids (occasionally helpful)
Surgical managementSurgical management
Synovectomy for recurrent Synovectomy for recurrent hemarthroses refractory to medical hemarthroses refractory to medical treatmenttreatment
Reduces incidence of recurrent Reduces incidence of recurrent hemarthroses; causes less pain and hemarthroses; causes less pain and swellingswelling
TJA for end-stage arthropathyTJA for end-stage arthropathy Arthrodesis, especially for the ankleArthrodesis, especially for the ankle
2. Sickle cell disease2. Sickle cell disease
Hemoglobin SS is found in 1% of black North Hemoglobin SS is found in 1% of black North Americans.Americans.
This hemoglobin type leads to local infarction as a This hemoglobin type leads to local infarction as a result of capillary stasis.result of capillary stasis.
Bony infarcts and ischemic necrosis may occur in Bony infarcts and ischemic necrosis may occur in multiple bones.multiple bones.
a Osteonecrosis, femoral head, is common among a Osteonecrosis, femoral head, is common among SCASCA
Dactylitis with metacarpal/metatarsal periosteal new Dactylitis with metacarpal/metatarsal periosteal new bone formation may also be observed.bone formation may also be observed.
Osteomyelitis is not uncommon (Salmonella)Osteomyelitis is not uncommon (Salmonella) Staphylococcus species are the most common Staphylococcus species are the most common
infecting organismsinfecting organisms
Pigmented villonodular Pigmented villonodular synovitissynovitis
Synovial disease often affects young Synovial disease often affects young adults with PVNS.adults with PVNS.
Synovium is frequently rust colored or Synovium is frequently rust colored or brown, a Extensive hemosiderin brown, a Extensive hemosiderin deposits are present.deposits are present.
Pain, swelling, synovitis, and a rust Pain, swelling, synovitis, and a rust colored or bloody effusioncolored or bloody effusion
The knee is the most frequent site.The knee is the most frequent site.
Radiographic findings:Radiographic findings:
Well-defined juxtacortical erosions with sclerotic Well-defined juxtacortical erosions with sclerotic marginsmargins
Histologic findings:Histologic findings: Pigmented synovial histiocytes n Foam cells (lipid-Pigmented synovial histiocytes n Foam cells (lipid-
laden histiocytes)laden histiocytes) Multinucleated giant cellsMultinucleated giant cells
Treatment:Treatment:Surgical Excision (total Synovectomy)Surgical Excision (total Synovectomy)
Local PVNS only nodule resectionLocal PVNS only nodule resection
RefferenceRefference
Review of Orthopeadic Six EditionMark D. Miller
ApleysSystem of orthopedic and Fracture
Internet for pictures
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