Degenerative Joint Diseases

Osteoarthritis Degenerative joint diseases include osteoarthritis, osteoarthrosis, osteochondrosis and others, and are the most common joint disorders that gradually disable patients. These recently receive greater attention because of the unprecedented prolongation of life expectancy and the availability of efficient prosthetic therapy. The terms describing "degenerative joint diseases" are many and used more or less loosely and even interchangeably. Osteoarthritis and osteoarthosis designate degraded states of a synovial joint with and without significant inflammation, respectively. Osteoarthritis is classified into primary or idiopathic and secondary, and inflammatory when there is significant synovial involvement with effusion.

A number of factors have been implicated as causative, but mechanical wearing down of the articular cartilages and supportive structures due to aging and obesity appears most important. According to Mitchel and Cruess (1977), osteoarthritis results from an abnormal concentration of stress across a normal joint or conversely a normal concentration of stress across an abnormal joint with an altered cartilage or subchondral bone. On the other hand, a hereditable element of osteoarthritis has been demonstrated in 50% to 65% in a twin epidemiological study (Cicuttini and Spector 1997) and one most recent study has indicated the existence of vertical transmission of primary osteoarthritis (Spencer et al. 2005).

Pathology Osteoarthritis is initiated by either the enzymatic disruption of the cartilaginous matrix or microfractures in the subchon-dral bone trabeculae that are rendered vulnerable due to the thinning of the covering

Manifestations Osteoarthritis

Fig. 9.1 Radiographic manifestations of osteoarthritis. Oblique radiograph of the right knee in a 51-year-old woman shows marked narrowing of the medial femoro-tibial compartment (open arrow) with subchondral ebur-nation (arrowheads) and a marginal osteophyte at the posterior tibial edge (curved arrow)

Fig. 9.1 Radiographic manifestations of osteoarthritis. Oblique radiograph of the right knee in a 51-year-old woman shows marked narrowing of the medial femoro-tibial compartment (open arrow) with subchondral ebur-nation (arrowheads) and a marginal osteophyte at the posterior tibial edge (curved arrow)

articular cartilage (Radin et al. 1977). Mild synovitis may develop after the appearance of his-tological alterations in the cartilage and bone as a result of the removal of the cartilage breakdown products through the synovial intersti-tium (Howell et al. 1976). Occasional cases show significant inflammation with effusion.

Radiographic Manifestations The radiographic features include: (a) narrowing of the joint space, (b) bone erosion, (c) eburnation in

Subchondral Bone Osteoarthritis

Fig. 9.2A, B Osteoarthritis with local synovitis. A Anteroposterior radiograph of the right knee in an 85-year-old female shows a narrowed medial articular compartment with a thickened capsule and collateral ligament (arrow) and sclerosis in the medial tibial plateau (arrowhead). B Anterior pinhole scan shows subchondral bone uptake with a narrowed joint space denoting synovitis with local bone reaction (arrow). Note focal sclerosis (arrowhead)

Degenerative Bone Disease

Fig. 9.3 Asymmetrical, discrete, periarticular segmental and spotty tracer uptake with articular narrowing in osteoarthritis in the knee. Anterior pinhole scan of the right knee in the same patient as in Fig. 9.1 shows irregular, asymmetrical, segmental intense tracer uptake in the medial femorotibial compartment and the distal femoral bone end with narrowed articular space (arrow)

Fig. 9.2A, B Osteoarthritis with local synovitis. A Anteroposterior radiograph of the right knee in an 85-year-old female shows a narrowed medial articular compartment with a thickened capsule and collateral ligament (arrow) and sclerosis in the medial tibial plateau (arrowhead). B Anterior pinhole scan shows subchondral bone uptake with a narrowed joint space denoting synovitis with local bone reaction (arrow). Note focal sclerosis (arrowhead)

Fig. 9.3 Asymmetrical, discrete, periarticular segmental and spotty tracer uptake with articular narrowing in osteoarthritis in the knee. Anterior pinhole scan of the right knee in the same patient as in Fig. 9.1 shows irregular, asymmetrical, segmental intense tracer uptake in the medial femorotibial compartment and the distal femoral bone end with narrowed articular space (arrow)

the contact area, (d) osteophytosis in the non-contact area, and (e) cyst in the subarticular bone (Fig. 9.1). When osteoarthritis is attended by local synovitis that part of the joint becomes blurred with effusion, para-articular soft-tissue thickening, and bulging (Fig. 9.2A). An important differential diagnostic feature of osteoar-thritis is that changes are asymmetrical and focal, and occur most typically in the area under stress and pressure. Such areas are in the lateral or medial aspect of the acetabular roof in the hip and in the medial, patellofemoral, or less frequently the lateral compartment, in the knee. Degeneration may occur both in the synovial and nonsynovial joints. The knee, the hip, the acromioclavicular joint, and the pha-langeal joints belong to the former and the dis-kovertebral joints, the manubriosternal joints, and the symphysis pubis belong to the latter. The apophyseal and costovertebral joints of the spine are well-known seats of osteoarthritis.

Symphysis Pubis Osteoarthritis

Fig. 9.4A, B Intense intraosseous tracer uptake in the cystic change of osteoarthritis. A Minimally rotated anterior pinhole scan of the right knee in a 74-year-old woman shows an extremely intense, triangular tracer uptake deep in the trabecular bone of the medial tibial condyle surrounded by less intense uptake (arrow). The joint is preserved and other asymmetrical, patchy tracer uptake can be seen in the femoral condyles. B Anteroposterior radiograph shows a small subcortical cyst and sclerosis in the medial tibial condyle (arrow)

Fig. 9.4A, B Intense intraosseous tracer uptake in the cystic change of osteoarthritis. A Minimally rotated anterior pinhole scan of the right knee in a 74-year-old woman shows an extremely intense, triangular tracer uptake deep in the trabecular bone of the medial tibial condyle surrounded by less intense uptake (arrow). The joint is preserved and other asymmetrical, patchy tracer uptake can be seen in the femoral condyles. B Anteroposterior radiograph shows a small subcortical cyst and sclerosis in the medial tibial condyle (arrow)

Subcortical Cyst Knee

Fig. 9.5A, B Osteophytes in nonstress, marginal areas with little tracer uptake. A Anterior pinhole scintigraph of the right knee in a 72-year-old man shows insignificant tracer uptake in the osteophytes in the medial aspects (arrowheads). In contrast very intense uptake is seen in the articular surfaces of femoral condyles, medial plateau and tibial tubercle, all of which are radiographically unremarkable (arrows). These denote preradiographic change. B Anteroposterior radiograph shows mature osteophytes in medial aspect of the knee (arrows). Note that periar-ticular bones are normal despite very intense tracer uptake

Fig. 9.5A, B Osteophytes in nonstress, marginal areas with little tracer uptake. A Anterior pinhole scintigraph of the right knee in a 72-year-old man shows insignificant tracer uptake in the osteophytes in the medial aspects (arrowheads). In contrast very intense uptake is seen in the articular surfaces of femoral condyles, medial plateau and tibial tubercle, all of which are radiographically unremarkable (arrows). These denote preradiographic change. B Anteroposterior radiograph shows mature osteophytes in medial aspect of the knee (arrows). Note that periar-ticular bones are normal despite very intense tracer uptake

Incipient Diabetes Mellitus

Fig. 9.6A, B Preradiographic manifestation of osteoarthritis and incipient osteophyte. A Slightly rotated pinhole scintigraph of the right knee in a 61-year-old woman with pain shows indeed subtle tracer uptake in the lateral aspect of the medial femoral condyle (arrowhead) and also in the lateral tibial tubercle (arrow). The medial fem-orotibial compartment is narrowed. B Anteroposterior radiograph appears normal, except for questionable pointing of the tip of the lateral tibial tubercle (arrowhead). The pointing may not have drawn enough attention if it had not been for the scan abnormality

Fig. 9.6A, B Preradiographic manifestation of osteoarthritis and incipient osteophyte. A Slightly rotated pinhole scintigraph of the right knee in a 61-year-old woman with pain shows indeed subtle tracer uptake in the lateral aspect of the medial femoral condyle (arrowhead) and also in the lateral tibial tubercle (arrow). The medial fem-orotibial compartment is narrowed. B Anteroposterior radiograph appears normal, except for questionable pointing of the tip of the lateral tibial tubercle (arrowhead). The pointing may not have drawn enough attention if it had not been for the scan abnormality

Fig. 9.7A, B Osteoarthritis in the sacroiliac joint. A Anteroposterior radiograph of the left sacroiliac joint in a 33-year-old male shows paraarticular sclerosis in the lower compartment (arrow). Note that sclerosis is more prominent on the iliac side than on the sacral side. B Anterior pinhole scan shows tracer uptake to be more intense in the iliac bone (arrow)

Sacroiliac Joints Sclerosis Iliac

Fig. 9.8A-C Osteoarthritis in the sacroiliac joint with osteophytosis. A Anteroposterior radiograph of the left sacroiliac joint in a 49-year-old female shows sclerosis and articular obliteration in the lower articular compartment (arrow). B CT demonstrates anteriorly protruding hyperostosis with more prominent change occurring in the ilium (arrow). C Anterior pinhole scan shows tracer uptake in osteophytosis (arrow)

Fig. 9.8A-C Osteoarthritis in the sacroiliac joint with osteophytosis. A Anteroposterior radiograph of the left sacroiliac joint in a 49-year-old female shows sclerosis and articular obliteration in the lower articular compartment (arrow). B CT demonstrates anteriorly protruding hyperostosis with more prominent change occurring in the ilium (arrow). C Anterior pinhole scan shows tracer uptake in osteophytosis (arrow)

Costotransverse Joint Degeneration

Pinhole Scintigraphic Manifestations Pinhole scan features include focal articular narrowing, segmental or patchy uptake, and malalignment or deformity (Fig. 9.3). Tracer uptake appears to closely correlate with cortical erosion, eburnation, and subchondral cystic change. It is to be noted that the cystic change in the cancellous bone beneath the cortex accumulates tracer more intensely than in eburnation or mature osteophytes (Fig. 9.4). On the other hand, the mature osteophytes found in the marginal, nonstress area of a joint accumulate tracer only minimally, indicating that they are metabolically inert (Fig. 9.5). Pinhole scintigraphy can often show area(s) of very subtle uptake in a painful yet radiographi-cally normal joint (Fig. 9.6). Many such lesions are not visualized on ordinary scintigraphs.

Hip Joint Narrowing
Fig. 9.9 Advanced osteoarthritis in the hip joint. Antero posterior radiograph of the right hip in a 73-year-old female with longstanding arthritis shows articular narrowing, sclerosis, osteophytosis, subchondral cystic change, and osseous ankylosis (same patient as in Fig. 9.11)
Patient Tracers

Fig. 9.10 Eccentric tracer uptake in the uppermost aspect of the femoral head in osteoarthritis. Anterior pinhole scintigraph of the right hip in a 62-year-old woman with advanced osteoarthritis shows intense tracer uptake localized eccentrically in the uppermost part of the femoral head (arrows) with narrowed joint. Modest tracer uptake can be seen also in the medial aspect of the neck, denoting buttress (arrowheads). The acetabulum shows little alteration. All these findings were validated by radiography (not shown here)

Fig. 9.11 Anterior pinhole scan of the right hip joint shows diffusely increased tracer uptake with dominant uptake involving the femoral head with extinct joint space due to ankylosis (same patient as in Fig. 9.9).

Fig. 9.10 Eccentric tracer uptake in the uppermost aspect of the femoral head in osteoarthritis. Anterior pinhole scintigraph of the right hip in a 62-year-old woman with advanced osteoarthritis shows intense tracer uptake localized eccentrically in the uppermost part of the femoral head (arrows) with narrowed joint. Modest tracer uptake can be seen also in the medial aspect of the neck, denoting buttress (arrowheads). The acetabulum shows little alteration. All these findings were validated by radiography (not shown here)

Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

Get My Free Ebook


Post a comment