+ All Categories
Home > Health & Medicine > Joint histopathology

Joint histopathology

Date post: 02-Nov-2014
Category:
Upload: amanj-gardi
View: 140 times
Download: 4 times
Share this document with a friend
Description:
 
Popular Tags:
107
Joint Joint Histopathology Histopathology Prepared by: Prepared by: Dr.Amanj Mohsin Mustafa Dr.Amanj Mohsin Mustafa 1 1 st st Year Orthopeadic Trainee At KBMS Year Orthopeadic Trainee At KBMS Supervised by: Supervised by: Dr.Zainab Abdulwahab Dr.Zainab Abdulwahab
Transcript
Page 1: Joint histopathology

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

Page 2: Joint histopathology

ContentsContents 1.Articular tissues A.Cartilage B.Synovium C.Meniscus

2.Arthroses Joint fluid analysis Non inflammatory arthritides Inflammatory arthritides Infectious arthritides Hemorrhagic effusions

Page 3: Joint histopathology

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

Page 4: Joint histopathology

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

Page 5: Joint histopathology

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

Page 6: Joint histopathology

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

Page 7: Joint histopathology

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

Page 8: Joint histopathology

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)

Page 9: Joint histopathology

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.

Page 10: Joint histopathology

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)

Page 11: Joint histopathology

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

Page 12: Joint histopathology
Page 13: Joint histopathology

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)

Page 14: Joint histopathology

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

Page 15: Joint histopathology

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.

Page 16: Joint histopathology

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.

Page 17: Joint histopathology

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

Page 18: Joint histopathology

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..

Page 19: Joint histopathology

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.

Page 20: Joint histopathology

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

Page 21: Joint histopathology

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).

Page 22: Joint histopathology

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.

Page 23: Joint histopathology

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.

Page 24: Joint histopathology

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.

Page 25: Joint histopathology
Page 26: Joint histopathology

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

Page 27: Joint histopathology

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

Page 28: Joint histopathology

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

Page 29: Joint histopathology

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

Page 30: Joint histopathology

Areas Areas that that Osteoarthritis Osteoarthritis AffectsAffects

Page 31: Joint histopathology

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.

Page 32: Joint histopathology
Page 33: Joint histopathology

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,

Page 34: Joint histopathology
Page 35: Joint histopathology

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

Page 36: Joint histopathology
Page 37: Joint histopathology

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

Page 38: Joint histopathology
Page 39: Joint histopathology

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

Page 40: Joint histopathology

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

Page 41: Joint histopathology

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)

Page 42: Joint histopathology

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.

Page 43: Joint histopathology

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)

Page 44: Joint histopathology

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

Page 45: Joint histopathology

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

Page 46: Joint histopathology
Page 47: Joint histopathology

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)

Page 48: Joint histopathology

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

Page 49: Joint histopathology

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.

Page 50: Joint histopathology

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.

Page 51: Joint histopathology

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.

Page 52: Joint histopathology

TreatmentTreatment

penicillin and salicylates.penicillin and salicylates.

Page 53: Joint histopathology

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

Page 54: Joint histopathology
Page 55: Joint histopathology

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

Page 56: Joint histopathology

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

Page 57: Joint histopathology

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

Page 58: Joint histopathology

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

Page 59: Joint histopathology

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

Page 60: Joint histopathology

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

Page 61: Joint histopathology

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

Page 62: Joint histopathology

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

Page 63: Joint histopathology

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

Page 64: Joint histopathology

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

Page 65: Joint histopathology

  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

Page 66: Joint histopathology
Page 67: Joint histopathology

TreatmentTreatment Goals:Goals:

Control synovitis and painControl synovitis and pain

Maintain joint functionMaintain joint function

Prevent deformitiesPrevent deformities

Page 68: Joint histopathology

““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.

Page 69: Joint histopathology

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.

Page 70: Joint histopathology

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.

Page 71: Joint histopathology

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

Page 72: Joint histopathology

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..

Page 73: Joint histopathology

  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

Page 74: Joint histopathology

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.

Page 75: Joint histopathology

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

Page 76: Joint histopathology

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

Page 77: Joint histopathology

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

Page 78: Joint histopathology

5.Relapsing 5.Relapsing polychondritis polychondritis

Page 79: Joint histopathology

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

Page 80: Joint histopathology

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

Page 81: Joint histopathology

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.

Page 82: Joint histopathology
Page 83: Joint histopathology

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..

Page 84: Joint histopathology
Page 85: Joint histopathology

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

Page 86: Joint histopathology

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.

Page 87: Joint histopathology

□ □ 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.

Page 88: Joint histopathology

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

Page 89: Joint histopathology
Page 90: Joint histopathology

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.

Page 91: Joint histopathology

B.ChondrocalcinosisB.ChondrocalcinosisC.Calcium hydroxyapatite crystal C.Calcium hydroxyapatite crystal

deposition diseasedeposition disease

Page 92: Joint histopathology

  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

Page 93: Joint histopathology

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

Page 94: Joint histopathology

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

Page 95: Joint histopathology

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

Page 96: Joint histopathology

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)

Page 97: Joint histopathology

3.Fungal arthritis 3.Fungal arthritis AIDSAIDSCandidiaCandidiaAntifungalAntifungal4.Lyme DiseaseUSAUSASelf limitingSelf limitingTick biteTick bite

Page 98: Joint histopathology

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.

Page 99: Joint histopathology

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..

Page 100: Joint histopathology

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.

Page 101: Joint histopathology

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)

Page 102: Joint histopathology

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

Page 103: Joint histopathology

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

Page 104: Joint histopathology

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.

Page 105: Joint histopathology

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

Page 106: Joint histopathology

RefferenceRefference

Review of Orthopeadic Six EditionMark D. Miller

ApleysSystem of orthopedic and Fracture

Internet for pictures

Page 107: Joint histopathology

THANK YOU


Recommended