ARTHRITIS and FOOT Catherine Cyteval

Montpellier

Montpellier

Mr L 54 years old

Bulk centered on the head of the second metatarsal bone and inter osseous space of metatarsus of the left foot Synovial sarcoma?

Patient referred for biopsy under US

2nd metatarsal bone neck erosion

X rays

US

Toute lésion para articulaire est d’origine articulaire jusqu’à preuve histologique du contraire

Inflammatory joint +

Normal joint space +

Soft tissu bulke

Gout

Diagnostic issues with Gout Differential diagnosis: Arthritis Tumor Puncture-aspiration Negative in 25% of the cases -Thick content, challenging Suction -Fast routing in the laboratory: change of environment crystals of monosodium urate => solubilization of the crystals, risk of false negatives

Swan  A,  Amer  H,  Dieppe  P.  The  value  of  synovial  fluid  assays  in  the  diagnosis  of  joint  disease:  a  literature  survey.  Ann  Rheum  Dis  2002  

Crystals of sodium urate negatively birefringent. polarizing Microscope

•  10! / 1 "

•  primitive forms (genetic): 90 %

•  secondary forms: hyperuricemic patients •  Metatarsophalangeal joint of the hallux +++

•  No joint narowing •  Erosions and

metaphyseal notches on cookie cutter

•  Marginal osteophytes gives an aspect bristling

•  Periosteal reaction

•  High density of the bulck++++

MTP

Fin hyperechoïc border at the surface of cartilage (refractive micro crystals)

SA Wright Ann Rheum Dis 2007

T2 T1

T1 gado

Non specific MRI

Ct scan

Spectral CT

Urique Ac (HAP)

HAP (urique Ac )

Ca (urique Ac)

Fusion Urique Ac (Ca)

Two beams of different energy (80 et 140kV) , a difference in attenuation is characteristic of a given element (attenuation profile)

gouty tophus with gouty arthropathy of the 2nd MTP

No biopsy Favorable evolution with drug treatment

Mr C 78 years old

Mr C 73 years old

Painful inflammatory joints for less than 1 year

chondrocalcinosis •  Quick severe destruction •  Non-bearing joint •  Few osteophytosis

•  Subchondral sclerosis with clear limit

•  many souschondrale erosions •  Crenellated meshed articular

surfaces

Chondrocalcinosis

•  Extremely common condition •  5% in adults •  27.6% for elderly

•  Ca pyrophosphate crystal deposition ++ •  articular structures •  cartilages •  fibro-cartilage

Cartilage cell

Pseudo osteo arthritis (70 %)

Gouty like (24 %) Arthritis like (6 %)

Ca++

PYROPHOSPHATE CRYSTALS

Calcic deposition - within cartilages

- tendons -  Se 96,4% ; Sp 86,7% -  PPV 92% ; NPV 93%

G Filippou Ann Rheum Dis 2007

Nrl

Gout

CCA

Mr H 48 years old

Acute Painful hallux

Hydroxyapatite

Take Home Message microcristals arthritis

Apatitis Periarticular

Chondrocalcinosis Sharpe dense bone surface

Gout Para articular dense bulk

Rheumatoid Arthritis (RA) •  Affects appendicular skeleton particularly the small joints

of hands and feet

Spondylarthropathies

•  Asymetric oligoarthritis •  Abnormalities in cartilaginous joints (Spine discs,

sacroiliac joints) •  HLA-B27 often present

Rheumatoid Arthritis 0.5% in the population - Foot involvement 90%

Spondylarthropathies •  Ankylosing spondylitis : mainly affects axial skeleton

0.2% in the population – 40% joint and 30% foot involvement

•  Psoriatic arthritis : skin involvement 0.2% in the population -70% joint and 60% foot involvement

•  Reiter’s syndrome :urethritis, conjontivitis and arthritis

<0.1% in the population - 70% joint and foot involvement

INFLAMMATORY JOINT DISEASES have many characteristics in common

•  They lead to inflammation in –  Synovium-lined joints –  Bursae and tendon sheaths –  Tendinous attachment to bones –  Soft tissues –  Bones.

•  However the distribution and extent of abnormalities at specific target vary among the disorder

FOUR FEATURES TO BE SEEK FOR

ENTHESITIS

ARTHRITIS

TENOSYNOVITIS

PERIOSTITIS Modalities X Rays MRI Ultra Sonography

ENTHESITIS

1)ARTHRITIS

TENOSYNOVITIS

PERIOSTITIS

1) Inflammatory Arthritis Synovitis

Synovium is the first inflammatory location in the joint

Bone edema Erosions

Joint space narrowing

US and synovitis

Normal=0

2

1

3

MTP

3

2

1

Doppler activity differentiates active from inactive synovium 0

T1 TIRM T2 fat sat

T1 gado fat sat

IRM et Synovite Epaissisement synovial

Hypersignal T2 et réhaussement après injection de gadolinium

MRI and Synovitis Dynamic MRI directly reflects the synovial inflammation

Dec

Feb April

The straight line of early enhancement rate reflects the increase of the vx number and of their permeability

Allows to follow the evolution of inflammation

1)Inflammatory arthritis •  Synovitis

•  Bone edema

•  Erosions •  Space joint narrowing

Lesion of high signal intensity on T2 images has ill defined margins Reversible bone lesion before the irreversible erosion Only seen with MRI

1) Inflammatory arthritis

•  Synovitis

•  Bone edema

•  Erosions

US-Erosions

Sagittal Axial

MTP

US allows to see the erosions 2 years before XRay but doesn’t allow an exhaustive approach

Sharply marginated bone lesion with juxta articular localisation Visible in two planes with a cortical break seen in at least one plane.

MRI - Erosions Early RA – 6 month prevalence

X Ray : 8 to 40 % MRI : 45 to 72 %

ENTHESITIS

ARTHRITIS

TENOSYNOVITIS

PERIOSTITIS Localisation in • Rheumatoid arthritis • Spondylarthropathy

(Psoriatic arthritis)

Christian Buchbender Rheumatol Int 2013

Rheumatoid Arthritis Forefoot 90% of the patients will have a foot involvment during the disease Commonly an initial manifestation of RA Lesions predominate :

on the medial aspect of metatarsal head except for that in the fifth (lateral)

on the proximal and plantar aspect of the MTP joints

Bilateral and symetric lesions

Rheumatoid arthritis Forefoot

The lateral aspect of the fifth MTP is a very early and important finding of the disease

Bone edema Demineralisation

Erosion

Rheumatoid arthritis Forefoot

•  With progression the MTP are affected in a relatively symetric fashion in both feet.

– Osteopenia – Erosion at the lateral aspect of joints

–  Joint narrowing

Rheumatoid arthritis forefoot : later evolution

•  Joints narrowing •  Deformations : hallux valgus, spraid of MTP joints

with fibular deviation of the toes (except the fifth) Due to destruction of tendons and ligaments

©van der Heijde

Erosions

Narrowing

Score 7

Simple Erosion Narrowing Score (SENS)

Rheumatoid arthritis midfoot •  Diffuse joint space loss, focal sclerosis and osteophytosis. •  Erosions are infrequent and small

Rheumatoid arthritis midfoot

Osseous fusion can occasionally be seen In later evolution

PSORIATIC ARTHRITIS forefoot (up to 60 %)

•  Bilateral, asymetric changes •  predominating at MTP and IP (50%) •  Extensive destruction of the IP great toe is characteristic

2/3 with skin psoriasis prior to joint lesions

PSORIATIC ARTHRITIS forefoot

Joint widening (pencil and cup)

Joint ankylosis

ENTHESITIS

1) ARTHRITIS

TENOSYNOVITIS

2) PERIOSTITIS and bone shaft edema

In addition to arthritis, spondylarthopathies show adjacent osseous abnormalities

2) PERIOSTITIS in Psoriatic arthritis •  In phalangeal tufts and diaphysis

2) PERIOSTITIS in Psoriatic arthritis •  Bone construction in phalangeal tufts and diaphysis

Psoriatic arthritis forefoot : later evolution

•  Deformations with asymetric lesion associating joint fusions and widening

FOUR FEATURES TO BE SEEK FOR

ENTHESITIS

1) ARTHRITIS

3) TENOSYNOVITIS

2) PERIOSTITIS

3) Tenosynovitis

rupture of an inflammed tendon (posterior tibialis) can lead to

flat feet with talonavicular malalignment

4) ENTHESITIS

1) ARTHRITIS

3) TENOSYNOVITIS

2) PERIOSTITIS

RA 38%

Spondylarthropathies 45% (Genc 2005)

Location on the heels ++

Can appear at any point of osseous attachment of a tendon, ligament…

4) Enthesitis •  1rst phase : Inflammation

thickening of the tendon,

Plantar apeunevrosis Normal Enthesopathy < 4,4 mm

< 6,1 mm

Achilles tendon

Normal Enthesopathy

Doppler or MR T2 hypersignal

4) Enthesitis •  2nd phase : Destruction =Erosions

4) Enthesitis •  3rd phase : Bony construction = enthesophyte formation

ENTHESITIS

ARTHRITIS

TENOSYNOVITIS

PERIOSTITIS

RA

Bilateral symetric Destruction MTP

Spondylarthropathies

Bilateral Asymetric Destruction and construction IP

Take home message

ENTHESITIS

ARTHRITIS

TENOSYNOVITIS

PERIOSTITIS RA

MTP 90% Midfoot

Sporiatic A

A spondyl

Reiter syndrome

Forefoot Heel

15%

70%

30%

50% MTP –IP-tufts 60%

Take home message