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.

[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.

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.

Mujer joven con artritis intermitente / Young woman with relapsing arthritis

Mujer de 28 años con episodios autolimitados de artritis intermitente de rodilla de 48 a 72h de duración, los cuales se repetían cada 2 semanas de forma periódica. El estudio inmunológico fue negativo así como el estudio radiológico. Posteriormente se realizó artroscopia de rodilla sin llegar a un diagnóstico definitivo. Se discuten, a continuación, las diferentes causas de reumatismos intermitentes(AU)

A 28-years old lady complains of self-limited episodes of relapsing knee arthritis of 48–72h of duration every 2 weeks. Immunological profile was all negative. At the same time, radiological images did not reveal any abnormality. She underwent to knee arthroscopy, however, a definite diagnosis was not reached. We discuss the differential diagnosis of relapsing arthritis(AU)

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.

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.

Accuracy of plain films, and the effect of experience, in the assessment of ankle effusions.

OBJECTIVE: To investigate the accuracy of plain radiographs, and the effect of observer experience, in the assessment of ankle effusions compared with an MRI gold standard. DESIGN AND PATIENTS: Anteroposterior (AP) and lateral radiographs of the ankle of 39 patients were evaluated by four observers, ranging from first-year radiology resident to an attending musculoskeletal radiologist. Observers independently graded the lateral films from 0 to 5 at one sitting, and the AP films at a second sitting. All patients had an MRI scan performed within 48 h of the ankle radiographs, on which distention of the anterior recess was used as the gold standard for an effusion. RESULTS: Lateral radiographs had variable sensitivity (range 17-63%), but specificity (81-94%) was usually high. AP radiographs similarly had variable sensitivity (15-55%), but their specificity (63-75%) was surprisingly good. Overall, sensitivity and specificity were inversely proportional and more related to individual variability than experience (observer 1, 53% and 81%; observer 2, 17% and 94%; observer 3, 63% and 88%; observer 4, 21% and 94%); however, individual sensitivity and specificity were consistent between AP and lateral radiographs (observer 1, 53% and 81%, 50% and 65%; observer 2, 17% and 94%, 15% and 75%), observer 3, 63% and 88%, 55% and 63%; observer 4, 21% and 94%, 25% and 70%). Positive predictive value was reasonably good for lateral radiographs (range 75-86%); however, it was fairly low for AP radiographs (38-61%). Negative predictive value was low for both lateral (50-67%) and AP (47-58%) radiographs. Accuracy was low for both AP (45-59%) and lateral (53-74%) radiographs. As expected, individual accuracy was consistently higher for lateral radiographs than for AP radiographs (observer 1, 65% and 58%; observer 2, 53% and 45%; observer 3, 74% and 59%; observer 4, 54% and 48%). CONCLUSIONS: For the diagnosis of ankle effusions the overall accuracy of radiographs was surprisingly low. Quite surprisingly, the diagnosis of effusions on AP radiographs was not much poorer than on lateral films. Results, however, varied little with experience and training.

Magnetic resonance imaging of synovial proliferation in temporomandibular disorders with pain.

OBJECTIVE: The objective of this study was to assess the clinical significance of synovial proliferation in patients with painful temporomandibular disorders based on magnetic resonance imaging findings. METHODS: The current study was conducted in 100 joints of 100 patients with unilateral painful temporomandibular disorders. One hundred joints on the contralateral side of patients with unilateral disease were used as nonpain group. Areas in the articular space that showed a low signal intensity on T1-weighted imaging, a high signal intensity on T2-weighted imaging, and high signal intensity on gadolinium-enhanced fat-suppressed T1-weighted imaging were judged to be regions of synovial proliferation. RESULTS: Synovial proliferation alone was observed in 8.0% of the pain group, but in none of the nonpain group. Synovial proliferation + effusion was observed in 33.0% of the pain group and in 7.0% of the nonpain group. Effusion alone was observed in 7.0% of the pain group and in 3.0% of the nonpain group. The mean visual analog scale value of pain was in the order of synovial proliferation alone > synovial proliferation + effusion > effusion alone. The incidence rates of anterior displacement of the disk were 100% for synovial proliferation alone, 93.9% for synovial proliferation + effusion, 57.1% for effusion alone, and 57.7% for "without synovial proliferation/effusion." CONCLUSIONS: Strong correlations were observed between synovial proliferation, pain, and disk displacement. It is considered that evaluating effusion alone provides only limited information on the disease state in painful temporomandibular disorders. Thus, it is essential to include enhanced T1-weighted imaging as a means to judge the disease state as well as to assess disease progression.

MR imaging of bone marrow edema and joint effusion in patients with osteonecrosis of the femoral head: relationship to pain.

OBJECTIVE: Our aim was to determine the occurrence of bone marrow edema and joint effusion and their relationship to pain in patients with osteonecrosis of the femoral head on the basis of MR imaging. MATERIALS AND METHODS: There were 71 patients with osteonecrosis of the femoral head based on characteristic radiographic and MR imaging findings. All patients had surgical confirmation of the disease. Both hips were affected with osteonecrosis in 39 patients, whereas only one hip was involved in 31 patients. The last patient underwent an arthroplasty of one hip during the study and had only one hip imaged. We evaluated a total of 110 hips in this study, of which 98 were painful. We staged osteonecrosis of the femoral head, using the classification of Steinberg et al. The 31 unaffected hips served as controls. Bone marrow edema and joint fluid were evaluated on MR images. Bone marrow edema was defined as an ill-defined area of low signal intensity on T1-weighted images with corresponding high signal intensity on T2-weighted or inversion recovery images localizing to the femoral head, neck, and intertrochanteric region. The amount of joint fluid was graded from 0 to 3. RESULTS: The peak of bone marrow edema occurred in stage III disease (72%); its odds ratio was seven times greater than that for stage I osteonecrotic hips. Effusions of a grade greater than or equal to 2 were seen most often in stage III disease (92%), compared with 10% in the control hips. With an effusion, bone marrow edema was 12.6 times greater when the hip was painful than when it was not. CONCLUSION: Both bone marrow edema and joint effusions existed with a peak occurrence in stage III disease. Bone marrow edema seems to have a stronger association with pain than does joint effusion in osteonecrosis of the femoral head.

Utility of frequency-selective fat saturation T2-weighted MR images for the detection of joint effusion in the temporomandibular joint.

OBJECTIVES: To evaluate joint effusion in the temporomandibular joint (TMJ) using frequency-selective fat saturation (FS) T2-weighted images and assess this technique. To investigate whether bone marrow abnormalities and magnetic resonance imaging (MRI) findings of internal derangement may be linked to joint effusion in the TMJ in patients with pain. METHODS: TMJ effusion was sought on FS T2-weighted images and conventional T2-weighted images in 400 joints from 200 patients with TMJ-related pain. Self-reported pain records were obtained from patients immediately before MRI and images assessed by the amount of TMJ fluid graded bilaterally using reference films by two radiologists. Other parameters recorded included disk displacement categories and condyle marrow abnormalities. The association between the recorded parameters and TMJ effusion judged by FS-sequences or conventional sequences was analysed using chi-square and Kappa tests. RESULTS: The detection rate of TMJ effusion by FS-sequences was significantly greater than by conventional methods, and the results showed a significant relationship between MRI interpretation of TMJ effusion using FS-sequences or conventional methods and the presence of pain. The correlation between TMJ effusion on FS-sequences and pain was significantly stronger than the conventional method. Kappa test indicated good agreement between pain and MRI TMJ effusion by FS-sequences (kappa = 0.66), but not by conventional sequences (kappa = 0.56). The other parameters showed a similar trend for TMJ-related pain. CONCLUSIONS: FS T2-weighted imaging is useful for detection of TMJ effusion, without known causes and confirms the importance of TMJ effusion as an indicator in patients with TMJ-related pain, bone abnormalities, and disk displacement.

MRI abnormalities of foot and ankle in asymptomatic, physically active individuals.

OBJECTIVE: To assess MRI changes in the ankle and foot after physical exercise. DESIGN AND PATIENTS: Nineteen non-professional marathon runners and 19 age- and sex-matched controls volunteered for the study. All had ankle and foot MR images (1.5 T) taken in three perpendicular planes (STIR, T2F and T1FS sequences) within 3 h of running a full-length marathon (42.125 km). Three radiologists independently analysed the groups on a masked basis using a predefined form. RESULTS: Severe bone marrow oedema was seen in one and slight bone marrow oedema in three marathon runners. Slight bone marrow oedema was found in three control subjects. Signal alteration within the soleus muscle, consistent with a grade 1 strain, was found in one marathon runner. Small punctate hyperintensities within the Achilles tendon were seen in 26% of the marathon runners and in 63% of controls (P = 0.016). An increased amount of fluid in the retrocalcaneal bursa was found in one control and in none of the marathon runners. Small amounts of fluid in the retrocalcaneal bursa were seen in 68% of marathon runners and in 53% of controls. Grade 1 or 2 peritendinous joint fluid was found around 22% of tendons, among both marathon runners and controls, most often involving the tendon sheath of the flexor hallucis longus muscle. An increased amount of joint fluid was noted in 34% of the joints of the marathon runners, and in 18% of the controls. CONCLUSION: MRI shows several abnormalities in the ankle and foot both after marathon races and in asymptomatic physically active individuals without any preceding extraordinary strain. Recreational sports may lead to a number of positive MRI findings without correlation with clinical findings.

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.

Joint fluid enhancement at MRI of the glenohumeral joint with intravenous injection of gadodiamide in standard and triple dose: a prospective comparative study of stable and unstable shoulders.

OBJECTIVE: To investigate the joint fluid enhancement at MRI of unstable and stable glenohumeral joints after intravenous administration of different doses of gadodiamide. DESIGN AND PATIENTS: Fourteen patients with unilateral anterior shoulder instability and six healthy controls had both shoulders examined on two occasions using either a standard dose (0.1 mmol/kg) or a triple dose (0.3 mmol/kg) of gadodiamide in an open MRI magnet (0.2 T). RESULTS AND CONCLUSIONS: The joint fluid enhancement in the unstable shoulders was on average 134% following the lower dose and 182% for the triple dose, whereas corresponding values in the stable shoulder in the same individuals were 69% and 142%, and (65% and 159%) in the healthy controls. Enhancement of the joint fluid was higher after the triple dose than after the standard dose in both the unstable shoulders (P < 0.0001) and the controls (P < 0.0005). Compared with the stable controls enhancement in the unstable shoulders was higher for the lower dose (P < 0.0001) while there was no significant difference between the groups following the higher dose. The improved enhancement following the higher dose was especially evident in stable shoulders, while the lower dose was found satisfactory for unstable shoulders.