I. Bertoldi

Extent and distribution of CPP deposits in patients affected by calcium pyrophosphate dihydrate deposition disease: an ultrasonographic study

Objective To assess the extent of calcium pyrophosphate dihydrate (CPP) crystal deposition and the distribution of affected sites, using ultrasonography (US), in patients affected by CPP deposition disease (CPPD). Patients and methods 42 consecutive patients affected by definite CPPD according to the McCarty criteria were enrolled in the study. All patients underwent an US examination of metacarpophalangeal joints of II, III, IV and V fingers of both hands, wrists and knees, Achilles’ tendons and plantar fascia looking for CPP deposits. A dichotomous score for presence/absence of CPP and a semiquantitative score for extent of deposits (0–3: 0, absent; 1, 1–2 spots; 2, more than two spots covering <50% of the structure; 3, deposits covering >50% of the structure) were assigned to each site examined. A site distribution score (total number of affected sites) was then calculated as well as an extent score equal to the sum of the extent scores of all sites. Results The mean involvement in our patients was 4.7 sites (SD±1.7, range 2–8 sites). The knee was the most affected, site (41 of 42) followed by the wrist (at least one in 37 patients) the Achilles’ tendons (23 patients), plantar fascia (11 patients) and metacarpophalangeal joints (four patients). The highest mean values of the extent score were in the menisci, followed by the hyaline cartilage of the femoral condyles and the entheses. Conclusions The deposition of CPP crystals involves at least two sites with a mean of four sites involved in most patients affected by CPPD and is therefore an oligoarticular or polyarticular disease.

Ultrasound detection of calcium pyrophosphate dihydrate crystal deposits in menisci: a pilot in vivo and ex vivo study

Over the last decade, ultrasonography (US) has been demonstrated to be an excellent technique for detecting calcium pyrophosphate dihydrate (CPP)crystal deposits in joints and periarticular tissues.1,–,8 The main difficulty in performing sensitivity and specificity studies for CPP crystal deposition disease is the definition of the gold standard for the diagnosis. The objective of our study was to define the sensitivity and specificity of US in detecting CPP crystal deposits in human menisci using polarised light microscopy as the gold standard. In our study we enrolled all patients waiting to undergo knee replacement surgery due to severe osteoarthritis for two consecutive weeks. All patients underwent US examination of the knee on the day before surgery. Only the knee to be subjected to surgery was examined by an expert ultrasonographer. US scans were performed at the level of the medial and lateral meniscus with the knee completely extended, …

Ultrasound in the diagnosis of calcium pyrophosphate dihydrate deposition disease. A systematic literature review and a meta-analysis

OBJECTIVE Ultrasonography (US) demonstrated to be a promising tool for the diagnosis of calcium pyrophosphate dihydrate deposition disease (CPPD). The aim of this systematic literature review (SLR) was to collect the definitions for the US elementary lesions and to summarize the available data about US diagnostic accuracy in CPPD. METHODS We systematically reviewed all the studies that considered US as the index test for CPPD diagnosis without restrictions about the reference test or that provided definitions about US identification of CPPD. Sensitivity and specificity were calculated for each study and definitions were extrapolated. Subgroup analyses were planned by anatomical site included in the index text and different reference standards. RESULTS Thirty-seven studies were included in this review. All the studies were eligible for the collection of US findings and all definitions were summarized. US description of elementary lesions appeared heterogeneous among the studies. Regarding US accuracy, 13 articles entered in the meta-analysis. Considering each joint structure, the sensitivity ranged between 0.77 (0.63-0.87) and 0.34 (0.16-0.58) while the specificity varies between 1.00 (0.89-1.00) and 0.92 (0.16-1.00). Considering the reference standards used, the sensibility ranged between 0.34 (0.02-0.65) and 0.87 (0.76-0.99) while specificity ranged between 0.84 (0.52-1.00) and 1.00 (0.99-1.00). CONCLUSION US is potentially a useful tool for the diagnosis of CPPD but universally accepted definitions and further testing are necessary in order to assess the role of the technique in the diagnostic process.

Tendon involvement in patients with ochronosis: an ultrasonographic study

Ochronosis is the musculoskeletal manifestation of alcaptonuria, a rare autosomal recessive disorder with an estimated prevalence of below 1:250 000.1 Alcaptonuria is associated with deficient homogentisate 1,2-dioxygenase (HGO) activity in the liver,2 causing production of large quantities of homogentisic acid (HGA). In urine and tissues, HGA oxidises to benzoquinones, which in turn form melanin-like polymers. Tendons are sites of ochronotic pigment deposition because of their high collagen content.3 Several cases of tendon and ligament ruptures in alcaptonuria have been reported.1 4 5 To our knowledge, no studies have been carried out regarding tendon pathology in ochronosis. Ultrasonography (US) is an inexpensive, repeatable, non-invasive exam that permits accurate visualisation of tendons and ligaments. Our …

Prevalence of Baker’s cyst in patients with knee pain: an ultrasonographic study

The objectives of this study are to investigate the prevalence of Bakers cyst (BC) in patients with knee pain, and to assess the correlation between BC and severity of osteophytes and joint effusion. A retrospective study was conducted on a group of patients with knee pain referred to our outpatient clinic for ultrasonography of the knee between January 2010 and February 2011. Patients underwent an ultrasonographic exam of the knees to assess the presence of marginal femorotibial osteophytosis, joint effusion and BC. A dichotomous score was assigned to each item (1 present, 0 absent) and severity of US signs of osteoarthritis and joint effusion were also graded semiquantitatively. Collected data were processed using logistic regression analysis to evaluate the correlation between degree of osteophytosis and joint effusion and BC. Patients affected by inflammatory joint conditions or with history of joint surgery or recent trauma were excluded. A total of 399 patients with knee pain were studied (299 women), in the age range 18-89 years (mean 56.2, SD 16.3 years). 293 patients (73.4%) showed sonographic features of osteoarthritis and 251 (62.9%) joint effusion. BC was found in 102 patients (25.8%) together with a positive association with sonographic features of osteoarthritis and joint effusion. Our data show a prevalence of BC of 25.8% in a population of patients with knee pain, and suggest that BC is positively related to osteoarthritis and joint effusion. Ultrasonographic examination of knee is worthwhile in patients with painful osteoarthritis or evidence of effusion.

Do Not Hallow until You Are out of the Wood! Ultrasonographic Detection of CPP Crystal Deposits in Menisci: Facts and Pitfalls

Purpose. Ultrasonography (US) has been demonstrated to be an important tool in the diagnosis of calcium pyrophosphate (CPP) crystal deposition disease. The aim of our study was to individuate and describe possible pitfalls in US detection of such deposits in menisci. Patients and Methods. We enrolled all patients waiting to undergo knee replacement surgery due to osteoarthritis, for one-month period. Each patient underwent US examination of the knee, focusing on the menisci. After surgery, the menisci were examined by US, macroscopically and microscopically, using the microscopic analysis as the gold standard for CPP deposition. Results. 11 menisci of 6 patients have been studied. Ex vivo examination of menisci performed better in CPP identification than in vivo examination. The possible reasons of misinterpretation or misdiagnosis of the in vivo exam were identified and are extensively described in the paper. Also a new sign of CPP crystal deposits was found. Conclusions. This study permitted to highlight some difficulties in CPP crystal detection by US in menisci. Further studies are needed to define completely US CPP crystal aspect and to improve the sensibility and specificity of US in CPP deposition diagnosis.

Disease Activity and Bone Mineral Density of MCP Joints in Patients with Rheumatoid and Psoriatic Arthritis: Is There a Correlation?—A Study in Patients Treated with Methotrexate and an Anti-TNFα Agent

Background. Bone damage in rheumatoid arthritis (RA) and in psoriatic arthritis (PsA) includes an accelerated bone mineral density (BMD) reduction. The objective was to evaluate BMD variations of the metacarpophalangeal joints (MCPs) in patients starting treatment with methotrexate (MTX) or etanercept. Methods. Patients affected by RA or PsA with hand joints involvement and with moderate or high disease activity, were enrolled in this study. All patients underwent clinical examination, laboratory exams, and a DXA scan of the most affected hand, as assessed with an ultrasound examination at the baseline, at the time of enrolment and after 1, 3, 6, and 12 months. Patients non-responders to MTX received combination therapy, while patients with no previous treatment initiated MTX. Results. 22 patients were enrolled. In both RA and PsA groups, BMD increased independently of the treatment. However, in the patients affected by RA, a slight BMD decrease was observed at the last checkup. Globally, the BMD variations of the MCPs were strongly correlated with the disease activity. At the reduction of DAS28, the scores corresponded an increase of BMD. Conclusions. MCPs BMD is inversely correlated to disease activity. BMD increase seems to be correlated with the response to treatment and not with the drug itself.

Change perspective to increase diagnostic accuracy of ultrasonography in calcium pyrophosphate dehydrate deposition disease! A new approach: the axial scan of the meniscus.

Ultrasonography (US) is a relevant tool in the study of calcium pyrophosphate dihydrate (CPP) deposition disease. However, differential diagnosis of hyperechoic deposits within the fibrocartilage can be difficult; moreover, US study is limited by the need of an adequate acoustic window. We describe a US scanning technique that offers a new viewpoint in the study of knee meniscal structure: a longitudinal scan performed according to the long axis of meniscus. This technique proves to be particularly useful for the identification of CPP deposition, but could also improve the US diagnostic utility and accuracy in other meniscal pathologies.

No enthesis should be overlooked when psoriatic arthritis is suspected: enthesitis of the extensor digitorum tendons.

A common and well-documented feature of spondyloarthropathies is inflammation of the peripheral enthesis1. Ultrasound (US) imaging is useful when assessing enthesitis, and many investigators have described its features2,3. A 50-year-old man with psoriasis developed morning stiffness, tenderness, and swelling of small joints in the hands asymmetrically during the last month. Clinical examination revealed tenderness and swelling of the proximal interphalangeal joints (PIP) of the second, third, and fourth fingers …

Histology of the synovial membrane of patients affected by osteoarthritis and calcium pyrophosphate dihydrate crystal deposition disease vs. osteoarthritis alone: a pilot study.

Osteoarthritis (OA) is often associated with calcium pyrophosphate dihydrate (CPP) crystal deposition disease (CPPD) but neither the pathogenetic link nor the influence on the clinical outcome of the two diseases has yet been clarified (1). The aim of this pilot study was to investigate the morphological aspects of the synovial membrane of patients affected by OA alone or OA with CPPD. In this study we enrolled all consecutive patients who underwent total knee replacement surgery for late-stage OA during March 2015 by our reference orthopaedic surgeon. The synovial membrane, menisci, and hyaline cartilage of the femoral condyles were retrieved and used for the diagnosis of CPPD as described previously (2). According to our previous studies (2, 3) and literature data (4), and considering a histological examination as the reference test for diagnosis, a prevalence of CPPD in these patients of approximately 50% was expected. All the synovial membrane specimens were fixed in 10% neutral buffered formalin for 12 h, routinely processed, embedded in paraffin, cut into 4-μm-thick sections, and stained with haematoxylin and eosin. An expert pathologist observed all slides by transmitted light microscopy and also under polarized light microscopy to assess the presence of crystals in the membrane. All the procedures followed in the study were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 1983.