Osteoarthritis

SBM Feb 13, 2014

Chris Burns MD

Section of normal hip articular cartilage

stained with brilliant red shows
abundance of acid mucopolysaccharide
diffusely distributed, except for
superficial zone (lamina splendans).

Degenerative changes are now seen:

1. Diffuse hypercellularity
2. Extensive loss of acid mucopolysaccharide from matrix with diminished
red dye fixation.

As cartilage starts to give more

under repeated loading, damage
starts to occur, basically tearing &
cracking

1.

2.

Early degenerative changes are now

present in this articular cartilage:
1. Small tangential clefts on surface
of already altered hyaline cartilage
2. Deeper vertical cleft
3. Splitting process , fibrillation
4. Clumping of chondrocytes

3.

4.

Arthroscopic pictures of normal knee cartilage on left;

fibrillated and eroded cartilage on right with bare bone

This section of the first MTP joint shows partial erosion on both surfaces of the
articular cartilage. Condensation of subchondral bone has developed adjacent to
areas of cartilage erosion, being more marked in the phalanx than in metatarsal
bone. An osteophyte extends above the dorsal margin of the metatarsal head.
(Masson trichrome, low power).

The normally quiescent chondrocytes, as well as the synovial cells, respond to

repetitive excess mechanical loading via stress-induced intracellular signals.

Goldring & Goldring. J. Cell. Physiol. 213: 626634, 2007.

!Cytokines, chemokines, cartilage-degrading proteinases, etc., are produced.

!Matrix degradation products feed back & up-regulate these cellular events.

Goldring & Goldring. J. Cell. Physiol. 213: 626634, 2007.

!Anabolic factors, like BMPs & TGF, may be upregulated & cause osteophyte formation.
!Chondrocyte proliferation (cloning), phenotypic modulaton (hypertrophy), increased
cartilage calcification (tidemark duplication), & microfractures with blood vessel invasion
from subchondral bone (angiogenesis) follow.
Goldring & Goldring. J. Cell. Physiol. 213: 626634, 2007.

Note throughout the following

examples, the recurrent theme
of cartilage loss, joint space
narrowing, osteophyte formation,
and deformity

Bony enlargement can be seen in distal and proximal interphalangeal joints. The
changes in proximal interphalangeal joints (Bouchard's nodes) and distal
interphalangeal joints (Heberden's nodes) are common findings in degenerative joint
disease of the hands. These changes are more frequently found in women after
menopause and often show a genetic predisposition.

Note that OA goes for

DIP > 1st CMC > PIP
Note dec j space, osteophytes

Normal hand x-ray

OA hand x-ray

Basilar thumb, or 1st CMC, OA, a common site

There is marked narrowing of the first carpometacarpal joint space, with extensive sclerosis of
adjacent bony margins. Osteophyte formation and subchondral cysts are present. Lateral
subluxation of the base of the metacarpal bone is a common finding but is not present in this
roentgenogram.

A synovial cyst is seen on the dorsal surface of the distal interphalangeal joint
of the extended middle finger. Synovial cysts contain gelatinous material and
often evolve into Heberden's nodes.

The left hip joint demonstrates narrowing with sclerosis and osteophyte formation of
adjacent bony margins. There is minimal flattening of the superolateral aspect of the
femoral head with reactive bone change. Buttressing of the femoral neck is present
medially and laterally as new bone formation widens the cortical margin. The right hip is
normal.

Medial compartment is highest, which is

why varus (bow-legged) knee is a
common finding in OA

Normal Knee!

Knee with
Medial OA!

Left, The posteroanterior projection of the knee shows marked narrowing of the medial
compartment and moderate sclerosis of adjacent bony margins. Involvement of the
medial aspect of the knee joint is much more common than of the lateral compartment.
Right, The posteroanterior projection of the knee shows narrowing of the lateral
compartment and sclerosis of adjacent bony margins. Unicompartmental joint space
loss and reactive new bone formation help differentiate degenerative from inflammatory
arthritis.

Bilateral varus deformity of the knees,

or bow-legged knees,
due to medial compartment OA

Hand x-ray of pt with hemochromatosis.

Note the extensive MCP & wrist disease

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Acute,'monoarticular,'pain'at'rest:'''''gout'or'septic'arthritis'
Structural'damage'from'arthritis'or'trauma:'''10X'more'likely'
to'get'infected'than'a'normal'joint'
Signs'of'systemic'illness,'fever,'malaise,'anorexia:''consider'
SBE,'Lupus,'Rheumatic'Fever'
Diuse'Rash'(drug'reaction),'Discrete'skin'lesions'
('disseminated'GC'or'SBE)'
Urethrits,'conjunctivitis,'arthritis'1K2'weeks'after'diarrhea'or'
new'sexual'partner'(Reiters'Syndrome),''

24

High'fever'and'marked'leukocytosis,'with'a'left'shift,'are'a'bit'
unusual'for'septic'arthritis'

25

Three'reasons'for'early'arthrocentesis'of'any'monoarticular'
arthritis.''

26

27

28

29

Septic'total'hip'arthroplasty:'loosening'of'the'stem'and'the'
acetabular'components'

30

31

Her'physician'noted'the'left'ankle'was'almost'normal;'slightly'
tender'on'motion.'The'right'wrist'was'now'swollen,'red,'
warm,'and'painful'with'motion.''
There'was'tenderness'of'the'extensor'tendons,'with'swelling'
of'the'dorsum'of'both'hands.'Cardiac'and'chest'exams'were'
normal.'
There'was'tenderness'around'the'liver'in'the'RUQ,'with'some'
diuse'rebound'tenderness'
'
'

32

Neisseria gonorrhoeae
Disseminated gonococcal infection (GC)
Type 1
polyarthritis

dermatitis, tenosynovitis, migratory

Type 2

septic arthritis

Chronic meningococcemia
Arthritis and dermatitis syndrome
'

33

34

Urticarial'rash'often'seen'with'chronic'active'hepatitis'

35

Gout'with'soft'tissue'tophus,'cystic'erosions,'diaphyseal'
erosion,'kissing'lesion.'
'
Rheumatoid'arthritis'with'marginal'errosions,'cockup'
deformities,'subluxations'
'

36

37

38

Nymphs feed veraciously as they emerge from dormancy in

May, June and July. Most cases occur in June-July, right around
that time. Nymphs are responsible for 90% of human infections
USA has Selective hotspots: more than two thirds of cases occur
in just 70 counties

39

Post Lyme disease syndrome has replaced the notion of chronic

encephalomyelitis

40

41

Two thirds with no clinical or laboratory evidence of Lyme

disease had received long antibiotic courses, many multiple
courses

42

Babesiosis: hemolytic anemia, fever, splenomegally. Carried by

Ixodies scapularis, and same distribution as Lyme disease

43

44

Rocky Mountain Spotted Fever, Rickettsia rickettsii

Carried by Dermacentor andersoni, Rocky Mountain wood tick.
RMSF Rickettsia rickettsii, in the west

45

STARI Southern Tick Associated Rash Illness Amblyoma

americanum (lone star tick)
Southern Tick Associated Rash Illness STARI
spirochete Borrelia lonestarii
Ehrlichiosis
HME
Ehrlichia chaffeensis

46

Argarid (soft shelled) tick Ornithodoros moubata. Tick Born

Relapsing Fever caused by other Borrelia species: Borrelia
hermsii, Borrelia duttonii, Borrelia turicatae. Louse Born
Relapsing Fever is caused by Borrelia recurrentis.

47

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Blood%vessel%w/%thousands%of%inltrating%NN%and%dec%
lumen%

49

Henoch%%Schnoelin%purpura%

50

1. Stellate%lesions%
2. Gangrene%2/2%to%ischemia%
3. Livido%reticularis%
4. Stellate%lesion%on%ear%

51

1. Giant%ulcer%%at%this%size,%its%hard%to%tell%if%the%
primary%process%is%vasculitis%
2. Ulcers%can%also%aect%nonIskin%areas%
3. Red%bump%of%inammation%along%the%vascular%arch%
of%the%hands%

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Poylarteritis%nodosa%

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PAN%

54

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H&E%shows%occluded%temporal%a%

56

NOT%vasculitis%

57

58#

1. Malar'rash,'c/'maybe'misDxed'as'rosacea,'but'the'nasolabial'
sparing'is'the'clue'
2. Malar'rash'w/'chin'involvement'and'some'telangiectasia'
3. Malar'rash'in'male'(males'do'get'lupus,'just'8x'less'than'F)'
that'looks'thicker'
4. Alopecia'can'be'seen'with'lupus,'and'is'irreversible'if'its'2/2'
discoid'
5. Discoid'rash'with'a'buttery'pattern'and'scalp'involvement'
6. Malar'and'photosensitive'rash'following'brief'sun'exposure'
7. Apthous'ulcers'are'very'common'in'lupus'and'pts'may'
mistake'them'for'cold'sores'that'are'asymptomatic'or'painful'

59#

60#

61#

Note#that#SLE#does#NOT#involve#any#bony#erosions#

62#

63#

64#

Note'the'increased'thickness'of'the'GBM'with'wirePlooping'
In'4,'note'the'intraPendothelial'reticular'deposits,'which'are'ccc'
of'membranous'lupus''

65#

More'severe'forms'of'lupus''membranoproliferative'forms'
1'shows'wireloops'
3'shows'the'ccc'tubuloreticular'structures'

66#

67#

68#

69#

70#

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1. right(ankle(synovitis(and(right(knee(synovitis(that(are(
stimulating(growth(of(this(leg,(making(it(longer(than(the(
left(until(the(epiphyseal(plates(close(
2. Hand(XR(shows(overgrowth(in(2nd(MCP(
3. Pic(and(XR(show(shortening(of(2nd(meatarsal(bone(
4. (lower(left(pic)(is(CFspine(
5. Micrognathia(
6. Uveitis(

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Linear'scleroderma:'facial'hemiatrophy'(clinical'and'skull'
radiograph)'
This(patient(demonstrates(the(facial(features(of(hemiatrophy(
and(coup(de(sabre(with(atrophy(of(the(subcutis,(muscle,(and(
bone(of(oneFhalf(of(the(face(and(part(of(the(scalp.(The(
radiograph(shows(skull(abnormality(with(thinning(similar(to(
what(would(be(seen(with(linear(scleroderma(elsewhere(in(the(
body.(Parry(Romberg(syndrome(may(also(present(with(facial(
hemiatrophy.(Classically(the(syndrome(is(primarily(of(the(skin(
and(subcutaneous(tissue(versus(linear(scleroderma(where(
there(is(an(impaired(growth(of(the(face(and(skull(due(to(the(
overlying(linear(bands.(
(

77

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1.
2.
3.
4.
5.
6.

Spiking(fever(for(at(least(5(days.(
Bilateral(conjunctival(injection(
Polymorphous(erythematous(rash(
Oropharyngeal(involvement((
Cervical(lymphadenopathy(
Extremity(involvement((
( (F(indurative(edema(of(hands(or(feet(
( (F(erythema(of(palms(or(soles(
( (F(cutaneous(desquamation((2F3(wk)(
((((F(transverse(nail(grooves((2F3(mo)(

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AP view (left) looks almost normal except for the absence of j

space, which could be due to arthritis (but the rest of the j is
normal, so no) or posterior dislocation
This is why the axillary view is key to dxing post. Dislocations
note the abnormal appearance in the top right pic vs the normal
bottom pic. The reason axillary view is unpopular (esp for a pt
w/ joint pain) is that it requires keeping the arm abducted for the
pic, c/ the resident may need to do himself

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Acute or reccurent dislocation will p/w apprehension sign, where

holding the pt in the shown position will make them stressed
(because theyve learned that the abducted extended arm is
likely to dislocate), You then put your hand on the head of the
humerus to keep it in place and ask them if that makes them less
worried, and they say yes
Global instability often p/w Sulcus sign a sulcus is visible
under the acromion when the arm is adducted

84

MR arthrogram shows a reduced dislocation with a +ve Bankart

lesion (small arrows pointing to a torn ant-inf labrum) and a
Hill-Sachs lesion (big arrow)

85

Typical fracture is middle 3rd of clavicle, which can get displaced

(top right)

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Operative = surgical decompression (acromioplasty) to shave the

acromion and make it flat -> get more space for the rotator cuff.
This can be done arthroscopically

89

Hx is much more acute pt developed limited ROM within a

few days

90

Right side shows massive rotator cuff tear 2/2 chronic rotator
cuff tear and arthropathy
Note muscle atrophy on MRI w/ fatty infiltration. This occurs bc
the joint is not movable w/ the slowly progressing limitation of
ROM

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3/25/14

Radiographic Evaluation of Arthritis

Douglas Goodwin, MD
Department of Radiology

Radiographic Signs
1
2
3
4

soft tissue swelling

mineralization
joint space narrowing
erosions

5
6
7
8

subluxation
bone production
calcification
distribution of disease

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1. Soft Tissue Swelling

A. Centered at the joint
B. Asymmetric (mass-like)
C. Fusiform (sausage digit)

Rheumatoid Arthritis: soft tissue swelling at joint!

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Gout: asymmetric mass-like swelling

Psoriatic arthritis: sausage digits

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2. Mineralization

Normal
Juxta-articular decrease
diffusely decreased
increased

Hyperemia: septic joint

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Rheumatoid Arthritis: demineralization

WARNING: This sign is of very limited usefulness

Increased density: psoriatic arthritis

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3. Joint space narrowing

Reflects the width of
articular cartilage
difficult to assess due
to the irregular
contour of joint
surfaces
weight bearing films
may help

Joint space narrowing

Reflects the width of
articular cartilage
difficult to assess due
to the irregular
contour of joint
surfaces
weight bearing films
may help

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Joint Space Narrowing

UNIFORM
reflects diffuse and uniform loss of articular
cartilage
RA
septic arthritis
seronegative
THINK INFLAMMATION

Uniform Joint Space Narrowing

cartilage
capsule
synovium

INFLAMMATION

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Rheumatoid arthritis: uniform joint space narrowing

Joint Space Narrowing

NONUNIFORM
reflects regional loss of articular cartilage
Osteoarthrosis
Pyrophosphate arthropathy (CPPD)

DEGENERATIVE

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Nonuniform Joint Space Narrowing

cartilage
capsule
synovium

weight bearing

OA: nonuniform joint space narrowing

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OA: medial compartment narrowing

OA: single compartment narrowing

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Joint space narrowing

Rheumatoid arthritis

Osteoarthritis

Joint Space Narrowing

PRESERVED
reflects very focal damage to cartilage
Gout
Pigmented Villonodular Synovitis
early OA

SMALL OR FOCAL DEFECTS

11

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Gout: joint space preservation

Gout: joint space preservation

12

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OA: joint space preservation

Small chondral lesion

4. Marginal Erosions
destruction of bone by inflammatory
pannus
occur first at uncovered bone at the
margin of the joint
inflammatory arthritis
RA, Psoriatic arthritis, Reactive arthritis

13

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Marginal Erosions

cartilage
capsule
synovium

destruction of bone
by inflammatory
pannus
occur first at
uncovered bone at
the margin of the
joint

MARGINAL EROSION
destruction of bone by
inflammatory pannus
occur first at uncovered
bone at the margin of
the joint

14

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Rheumatoid Arthritis: marginal erosions

Gout: erosions
May be remote from
joint
well-defined
overhanging edge of
bone

15

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5. Subluxation
incomplete or partial dislocation
Due to laxity or disruption of ligamentous
support
with erosions: Rheumatoid arthritis
without erosions: SLE

Swan neck deformity

Boutonnire deformity

16

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Subluxation with erosions: Rheumatoid arthritis

Alignment: Rheumatoid arthritis

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Lupus: subluxation without erosions

Lupus: subluxation without erosions

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6. Bone Production

Osteophytes
Subchondral bone
Periosteal new bone
Ankylosis
Overhanging edge

OSTEOARTHRITIS
SERONEGATIVE

GOUT

Osteophytes
enchondral bone
formation
extension of the
articular surface

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Osteoarthritis: DIP osteophytes

Subchondral bone
dense eburnation on Xray
thickening of bone, possibly
healing of trabecular injury

20

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Periosteal new bone

Seronegative
Spondyloarthropathies
sign of inflammation

at the enthesis
joint margins
shafts of small tubular
bones
spine

Nature Medicine Volume:18, 10691076: (2012)

Entheseal inflammation
Seronegative
Spondyloarthropathies
sign of inflammation

CT

at the enthesis
joint margins
shafts of small tubular
bones
spine

PET-CT
FDG PET

ucdmc.ucdavis.edu

21

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Increased density: enthesopathy

Seronegative
Spondyloarthropathies
sign of inflammation

at the enthesis
joint margins
shafts of small tubular
bones
spine

Psoriatic arthritis: proliferative bone

22

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Proliferative bone formation

Reiters syndrome / Reactive Arthritis

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Ankylosis
fusion of bone due to joint destruction
and inflammation
Seronegative Spondylitis
Rheumatoid arthritis (only carpal and
tarsal bones)
Inflammatory OA (IP joints)

Psoriatic arthritis: ankylosis

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Ankylosing spondylitis

Ankylosing
Spondylitis

25

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Ankylosing Spondylitis vs. DISH

Ankylosing spondylitis

DISH

Ankylosing Spondylitis vs. DISH

Ankylosing spondylitis

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Ankylosing Spondylitis vs. DISH

DISH

Ankylosing Spondylitis vs. DISH

Ankylosing spondylitis

DISH

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Overhanging edge
Sign of Gout
excresence of bone
extending beyond the
margin of the bone
reactive bone
adjacent to tophus

Overhanging edge
Sign of Gout
excresence of bone
extending beyond the
margin of the bone
reactive bone
adjacent to tophus

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7. Calcification
mass calcification
chondrocalcification
tendon and soft tissue calcification

Calcification: Scleroderma

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Calcification: pyrophosphate arthropathy

Chondrocalcinosis

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Calcification: calcific tendonitis

Gout 7/11 1/13

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Gout

8. Distribution
distribution may be characteristic of a
specific disease
Gout: 1st MTP
OA: DIP, 1st CMC,
Rheumatoid arthritis: MCP and MTP
joints

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Distribution: Gout

Radiographic signs
Soft tissue swelling -- inflammation
Demineralization -- vascularity / bone
resorption
Joint space narrowing -- loss of cartilage
Erosions -- bone destruction

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Radiographic signs
Alignment -- breakdown of supporting
structures or asymmetric joint narrowing
Bone formation -- inflamed or healing
bone
Calcification -- clue to specific diagnosis
Distribution

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preserved bone
density
soft tissue swelling
marginal erosions
periostitis

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