[Approach to joint effusion]. / Vorgehen bei Gelenkerguss.

The fundamental components of the differential diagnostics of joint effusions are the patient history and clinical examination. In the case of unclear findings, arthrosonography can provide information for the distinction between intra-articular and extra-articular pathologies. In atraumatic joint effusions inflammatory parameters in blood are determined in order to differentiate between systemic inflammatory and local inflammatory joint effusions. In the case of normal values further diagnostics are carried out using imaging. With elevated inflammatory parameters the main differential diagnoses are gouty arthritis, autoimmune joint processes and septic arthritis. When in doubt, a joint aspiration and synovial fluid analysis should be performed to rule out septic arthritis or if necessary confirmation of gouty arthritis.

A case of unilateral shoulder joint hydrarthrosis with wild-type amyloidogenic transthyretin amyloidosis.

Wild-type amyloidogenic transthyretin (ATTR) amyloidosis, known as systemic senile amyloidosis (SSA), is an age-related nonhereditary amyloidosis, which is known to cause cardiomyopathy and carpal tunnel syndrome (CTS). Herein, we report a case of unilateral hydrarthrosis with arthritis of the right shoulder joint in an 82-year-old Japanese housewife who has a seven year history of polyneuropathy due to an unknown aetiology. At first, her joint pain was thought to be caused by overuse of her right upper arm. Despite treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and repeated arthrocentesis, her symptoms did not improve. She then visited our hospital, where magnetic resonance imaging (MRI) of her right shoulder suggested synovitis and hydrarthrosis. She also had an arthroscopic synovectomy of the right shoulder joint. The pathological testing revealed a diagnosis of non-specific arthritis with amyloidosis. After further pathological examination, wild-type ATTR was identified and she was diagnosed with senile amyloidosis.

Palindromic rheumatism and other relapsing arthritis.

Patients with recurrent or relapsing arthritis are frequently seen in rheumatological practice. Besides crystal arthritis, the most frequent cause of recurrent arthritis, there are several diseases that may present clinically as intermittent mono- or polyarthritis. Palindromic rheumatism is the paradigm of this type of condition, but other diseases such as systemic autoinflammatory disorders (periodic fever syndromes), Whipple's disease, arthritis associated with hyperlipidemia, intermittent hydrarthrosis and other diseases should be taken into account in the differential diagnosis of patients with recurrent arthritis. In this chapter, we discuss recent developments in these diseases with special emphasis on palindromic rheumatism, a common condition whose close relationship with rheumatoid arthritis remains intriguing.

Chondroblastoma of the femoral neck as a cause of hip synovitis.

Chondroblastoma is a rare benign chondroid bone tumor, which typically arises from the epiphysis of a long tubular bone. We present a 13-year-old girl with persistent hip synovitis caused by a chondroblastoma that arose from the femoral neck (metaphysis) and uniquely extended extraosseously into the hip joint. Computed tomography scan clearly demonstrated a tumoral lesion of the left femoral neck and a periosteal reaction along the anterior cortex of the femur, distal to the legion. Magnetic resonance imaging showed reactive synovitis with marked joint effusion of the hip and an extensive edema in the proximal femur and the surrounding soft tissues. Aneurysmal bone cysts formation secondary to chondroblastoma was confirmed by histologic examinations of the excised specimens. Complete relief of pain and an improvement in the range of movement of the hip joint was obtained after surgical resection of the tumor.

Chylous hip joint effusion and bone absorption after total hip arthroplasty in a patient with chylocolporrhoea: a case of Gorham's disease.

Chyle is a sterile, milky fluid consisting of lymph and emulsified fats that is formed in the small intestines and taken up by lymph vessels. Chylous effusions usually occur after destruction or obstruction of lymphatic channels, and chylous joint effusions have been reported in association with rheumatoid and/or septic arthritis, and as the result of penetrating trauma to subsynovial fatty tissue and the intra-articular fat pad. We report a case of bone absorption and lytic change in the femur associated with a chylous hip joint effusion after a total hip arthroplasty (THA) in a patient with chylocolporrhoea and a history of chylous ascites.

Pigmented villonodular synovitis: a retrospective single-center study of 122 cases and review of the literature.

OBJECTIVES: Pigmented villonodular synovitis (PVNS) is a rare but disabling disease. The objective was to describe the clinical presentation and outcomes of PVNS according to its localization. METHODS: Retrospective, systematic study of all cases of biopsy-proven PVNS followed in 1 tertiary-care center specialized in isotopic synoviorthesis. Cases were selected by keyword. Collected data included disease localization, therapeutic modalities, and outcomes. RESULTS: A total of 122 cases (mean age 33.0 ± 13.1 years, 58% female, 89% diffuse form) of histologically confirmed PVNS were analyzed with a mean follow-up of 5.8 ± 4.3 years (707 patient-years total). The main localizations were the knee (75%) and ankle (16%). Clinical presentation included joint pain (80%) and joint effusion (79%) with hemarthrosis (75% of analyzed articular fluid). The mean delay before diagnosis was 2.9 ± 3.7 years. Magnetic resonance imaging was helpful for diagnosis in 83%. Surgical synovectomy was initially performed in 98% of cases and was often associated with isotopic synoviorthesis (knee: 57%; other localizations: 74%). In patients with a diffuse form treated at first line by surgery followed by isotopic synoviorthesis, the relapse rate was 30% (knee) and 9% (other localizations), respectively, with a mean delay before relapse of 2.6 ± 2.4 and 2.4 ± 0.9 years, respectively. CONCLUSIONS: PVNS occurs in young adults, mainly in the knee joint; joint pain and effusion with hemarthrosis are the most frequent signs. Relapse is frequent, in particular, for diffuse knee PVNS; the usefulness of isotopic synoviorthesis remains to be confirmed.

Does running cause metatarsophalangeal joint effusions? A comparison of synovial fluid volumes on MRI in athletes before and after running.

OBJECTIVE: The metatarsophalangeal joints (MTPJ) are the only joints that bear weight directly through synovium. The purpose of this study was to determine whether there is an association between synovial stresses during running and increases in volume of joint fluid. MATERIALS AND METHODS: This was a prospective case controlled study (nine healthy athlete volunteers acting as own controls). High-resolution coronal 3D T2W magnetic resonance imaging of the MTPJs were obtained following 24 h rest and after a 30-min run. The volume of joint fluid in each MTPJ (n = 90) was measured by two independent observers using an automated propagating segmentation tool. RESULTS: The median volume of synovial fluid in the MTPJs at rest was 0.018 ml (inter-quartile range (IQ) range 0.005-0.04) and after running 0.019 ml (IQ range 0.005-0.04, p = 0.34, 99% confidence interval (CI), 0.330.35). The volume of fluid in the MTPJs of the great toes was substantially larger than other toes (0.152 ml at rest, 0.154 ml after exercise, p = 0.903). Median volumes decrease from second to fifth MTPJs (0.032-0.007 ml at rest and 0.035-0.004 ml after exercise). Subset analysis for each toe revealed no significant difference in volumes before and after running (p = 0.39 to p = 0.9). The inter-rater reliability for observer measurements was good with an intra-class correlation of 0.70 (95% CI, 0.60 to 0.78). CONCLUSION: It appears to be normal to find synovial fluid, particularly in the MTPJs of the great toes, of athletes at rest and after running. There does not appear to be an association between moderate distance running and an increase in the volume of synovial fluid.

Arthrosonography: gray-scale ultrasound evaluation of the shoulder.

Gray-scale ultrasound images of the shoulders of 6 rhesus monkeys were obtained before and after fluid instillation to assess the ability of ultrasound to diagnose joint disorders. The normal bony landmarks and muscular structures were shown. After the fluid was introduced, fluid collections were identified in the axillary pouch and subscapular bursa. Ultrasound is a promising new method of detecting intra-articular effusions of the shoulder.

MR anatomy of the subcoracoid bursa and the association of subcoracoid effusion with tears of the anterior rotator cuff and the rotator interval.

OBJECTIVE: We describe the MR anatomy of the subcoracoid bursa and findings associated with subcoracoid effusion. CONCLUSION: Fluid in the subcoracoid space, revealed on MR imaging of the shoulder, may lie in the subcoracoid bursa or the subscapularis recess (both structures can be distinguished with MR imaging). In our patients, subcoracoid effusions were often associated with anterior rotator cuff tears, including tears of the rotator interval.

Effusion criteria and clinical importance of glenohumeral joint fluid: MR imaging evaluation.

PURPOSE: To investigate the clinical importance of glenohumeral joint (GHJ) fluid. MATERIALS AND METHODS: The amount of GHJ fluid in 17 volunteers and 208 consecutive patients was graded at magnetic resonance imaging with T2-weighted fat-suppressed coronal oblique images by two blinded observers. Thorough historical data and physical examination results were available for 108 patients. Presence and grade of GHJ fluid were correlated with age, sex, presence of osteophytes activity scale, supraspinatus tenderness, clinical impingement, prior subacromial injections, rotator cuff tears (RCTs), joint tenderness, joint pain, and history of trauma. RESULTS: GHJ fluid was seen in 40% (n = 83) of patients and in only 6% (n = 1) of volunteers. The volume of fluid correlated with osteophytes (P = .04), increasing age (P = .0001), and RCTs (P = .005). No correlation was found with activity rating, focal tenderness, joint pain, diagnosis of impingement, impingement grade, supraspinatus insertional tenderness, subacromial injection, prior trauma, or sex. CONCLUSION: The presence of GHJ fluid appears to be abnormal and in most cases is related to RCTs and osteoarthritis. It seems to be unrelated to activity, tenderness, or impingement.

Quantification of articular cartilage in the knee with pulsed saturation transfer subtraction and fat-suppressed MR imaging: optimization and validation.

PURPOSE: To assess the reproducibility and accuracy of volumetric quantifications of articular cartilage in the knee determined with three-dimensional (3D) magnetic resonance (MR) imaging combined with pulsed saturation transfer subtraction (STS) or T1-weighted fat suppression (FS) imaging. MATERIALS AND METHODS: Eight osteoarthritic knees were imaged repeatedly with optimized STS and FS sequences. Cartilage volumes were determined from 3D reconstructions of FS and STS images and by means of water displacement of surgically retrieved tissue. RESULTS: Mean over- or underestimation of cartilage volume at STS and FS imaging was 0.40 mL +/- 0.11 (standard deviation) (8.2%) and 0.31 mL +/- 0.08 (5.9%), respectively. Intraobserver reproducibility error was 0.20-0.65 mL (3.6%-6.4%) for STS and 0.21-0.58 mL (4.2%-6.4%) for FS imaging. Interobserver error was less than 0.62 mL and 7.8%. CONCLUSION: Three-dimensional data analysis of MR images acquired with STS or FS allows accurate and reproducible volumetric quantification of articular cartilage in the knee.

Acromioclavicular joint fluid: determination of clinical significance with MR imaging.

PURPOSE: To determine the clinical significance of fluid in the acromioclavicular (AC) joint. MATERIALS AND METHODS: A total of 108 patients with clinical shoulder problems and 16 volunteers underwent MR imaging with a 1.5-T unit. Coronal T1- and T2-weighted images were evaluated for the presence of AC joint fluid, glenohumeral joint fluid, and AC joint osteophytes. Medical records were reviewed for the presence of clinical signs and symptoms. RESULTS: AC joint fluid was commonly seen in the patients (67%) but was rare in the volunteers (12%). The presence of AC joint fluid was associated with advancing patient age, presence of osteophytes, and fluid in the glenohumeral joint. AC joint fluid was not associated with focal tenderness, prior corticosteroid injections, history of trauma, findings of impingement, evidence of rotator cuff tear on MR images, or gender. CONCLUSION: AC joint fluid appears to be an asymptomatic manifestation of osteoarthritis.

Fluid in normal and abnormal ankle joints: amount and distribution as seen on MR images.

OBJECTIVE: The appearance of fluid in tendon sheaths of the ankle joint and in ankle articulations seems to vary. To determine the degree of this variability and to see if fluid occurs in normal ankles, we evaluated the presence, amount, and distribution of joint fluid as seen on MR images of normal and abnormal ankles. MATERIALS AND METHODS: The study included 40 normal ankles of volunteers, 15 ankles of patients with disorders of the posterior tibial tendon, 73 ankles of patients with disorders not involving tendons studied (occult fractures, osteochondritis dissecans, and Achilles tendon disorders), and 46 asymptomatic ankles of patients with disorders of the opposite ankle. We analyzed the MR images of these ankles to determine the volume of fluid in the ankle and subtalar joints. We also analyzed the relative volumes of fluid in tendon sheaths. We then compared the results in patients who had symptoms with those in asymptomatic subjects and developed an algorithm of fluid interrelationships. RESULTS: Most patients had fluid in the ankle (77%) and subtalar joints (72%). Fluid was common around all tendons except the extensor tendons. Large amounts of fluid were particularly common around the flexor hallucis longus tendon (14%). No statistically significant difference in the prevalence or relative volumes of fluid in the subtalar or ankle joints or tendon sheaths was found between normal and abnormal ankles. A close relationship was found between volumes of fluid between tendons, usually those in close proximity to each other. We found no correlation between fluid in the subtalar and ankle joints. CONCLUSION: Our results show that fluid in the articulations and tendon sheaths of the ankle is common in asymptomatic patients, and the amounts of fluid are not significantly different from the amounts in patients with symptoms. There also appear to be complex interrelationships between fluid seen in the joint and in tendon sheaths.