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Synovial Fluid ( Joint
Fluid ) Analysis
Dr.Sandeep Agrawal
Consultant Orthopedic Surgeon
MS,DNB
Agrasen Hospital
Gondia
Ma...
2
Synovial Fluid
 Synovial
 syn(like) + ovia (egg)
 “Joint Fluid”
3
GENERATION AND CLEARANCE OF SYNOVIAL
FLUID
• The Starling equation reads as follows:
• J = K ([Pc − Pi] − σ[πc − πi])
• ...
4
• According to Starling's equation, the
movement of fluid depends on six variables:
• Capillary hydrostatic pressure ( P...
5
• Synovial fluid is a mixture of a protein-rich
ultrafiltrate of plasma and hyaluronan
synthesized by synoviocytes.
• Ge...
6
Synovial Fluid
 Viscous fluid found in the
cavities of movable joints
 Synovial membrane
 Inner membrane of
synovial ...
Synovial fluid….Dialysate of plasma
Normal synovial fluid..clear pale or straw
coloured , viscous & does not clot
Contains...
8
• In normal joints, intra-articular pressures are
slightly subatmospheric at rest (0 to -5 )
• During exercise, hydrosta...
Bulge test
The Bulge test is used to determine if there is an
abnormal amount of fluid surrounding a joint
Bulge test of j...
Synovial fluid
Physical : viscosity,clarity,
colour.
Cytology: WBC count, smear for
Gram stain, AFB stain,
Bacteriology: c...
11
Specimen Collection
 Arthrocentesis
Placement of needle in arthrocentesis of (A) elbow and
(B) knee joints.
12
13
CollectionThree samples are collected.
Note
If the specimen cannot be examined immediately, fluid should be frozen and...
14
Macroscopic Laboratory Testing
 Volume
 Color and Clarity
 Inclusions
 Viscosity
 Clotting
 Mucin Clot
15
Macroscopic Analysis: Inclusions
 Rice bodies.
 Free-floating aggregates of tissue appear as rice
bodies.
 rheumatoi...
viscosity
Non- inflammatory conditions : Normal
vis.
Inflammatory : low viscosity due to
reduced content of hyaluronan & r...
Colour & clarity
Deep yellow
In active R.A. slight greenish
tinge
Uniformly blood stained : PVNS
Loss of clarity : crystal...
WBC COUNT
T.C. INFLAMMATORY >2000 x
106/L
D.C.polymorphs, lymphocytosis,
synoviocytes, chondrocytes
Clumping of cells can ...
Synovial fluid – table I
feature Non-inflam inflammato
ry
infective
example O.A. R.A. Septic
arthritis
viscosity high low ...
Synovial fluid – table II
O.A. R.A./CRYST
ALS
SEPTIC
WBC
(x106/L)
50 - 500 1,500 –
30,000
>50,000
polymorphs occasional 30...
eosinophils
Occasionally seen in normal
syn.fluid
Increased in haemarthrosis
Following arthrography –
contrast induced
Par...
24
Microscopic Analysis: Differential
 LE cells
 Neutrophils that have
engulfed a nucleus of a
lymphocyte
 Tart cells
...
25
Microscopic Analysis: Differential
 Reiter cells
 Vacuolated macrophages
with ingested neutrophils
 RA cells
 “Rago...
26
Microscopic Analysis: Differential
 Hemosiderin
 Seen in Pigmented
Villonodular Synovitis
 Inclusions within cluster...
27
Laboratory Testing: Microbiology
 Staining
 Smears prepared by centrifugation or
cytocentrifugation
 Saline dilution...
28
• Proteins are present in synovial fluid at
concentrations inversely proportional to
molecular size, with synovial flui...
29
Chemical Analysis: Protein
 All proteins found in plasma
 Exception: various high–molecular weight proteins which
may...
Synovial fluid analysis
Recommended as a routine procedure in
the diagnosis of joint disorders by Ropes &
Bauer
Hollander ...
Synovial fluid analysis
Shmerling (1994) concluded :
Two major uses of synovial fluid
analysis were to identify or rule
ou...
Infective arthritis
Difficult to differentiate infective
arthritis from acute crystal synovitis
on clinical examination al...
Crystal induced arthritis
Important cause of acute mono arthritis
Gout affects peripheral joints mostly and
pseudo-gout or...
35
These fluid collections which serve as good samples of cloudy but translucent
inflammatory synovial fluid were taken fr...
Traumatic arthritis
Following meniscal tears,
ligament injuries,
haemarthrosis, osteochondral
fractures, acute or episodic...
Normal synovial fluid: Do not
clot
Clotting of synovial fluid =
fibrinogen
1.Damaged synovial
membrane
2.Traumatic tap
Mac...
Osteoarthritis
Acute on chronic monoarticular swelling is
quite common in degenerative arthritis
due to cartilage debris ,...
Infective arthritis
In a large study(n=242) Weston
etal reported that SF Gram
staining was +ve in 50% of
cases only
SF cul...
Syn.fluid analysis
Shmerling studied sensitivity and specificity of SF
analysis critically
He concluded that SF analysis w...
Infective arthritis
Freemont etal concluded that when
parameters like increased polymorph
cellcount >2000/cc and usage of ...
Crystals in Syn.fluid
Absence of crystals in SF does not ruleout
crystal induced arthritis
Monosodium monourate crystals a...
44
 Monosodium urate (MSU)
 Calcium pyrophosphate (CPPD)
Crystal Identification
45
 Corticosteroid
 Cholesterol
Crystal Identification
Intercritical gout
Pascual and Jovani studied 101
samples of syn.fluid from
asymptomatic gout
Results showed 43 out of 43
...
Crystals in Syn.fluid
CPPD crystals : these are
associated with pseudogout
Rhomboid in shape and +vely
bi-refrengent
They ...
Crystals in SF
Hydroxyapatite crystals are
found in syn. Fluid in Milwakee
arthritis
These cannot be seen under
polarising...
Crystals in SF
Crystals of other substances like
steroids injected can be seen in
SF
Beclomethasone crystals are
needle sh...
Rheumatoid arthritis
Rheumatoid factor titres in
syn.fluid raise much before
seropositivity
In the presence of inflammator...
51
Laboratory Testing: Rheumatoid Factor
 RF is an antibody to immunoglobulins.
 Present in rheumatoid arthritis:
 Seru...
Synovial fluid analysis
Mucin clot test: reflects de-polymarization
Of hyaluronic acid and can be
demonstrated by precipit...
53
Macroscopic Analysis: Viscosity
 “Ropes” or “Mucin Clot
Test”
 Normal = 4-6 cm
 When 2-5% acetic acid is
added, norm...
Mucin clot test
grade clot solution
good Tight ropy
mass
clear
fair Softer,shreddy Clear/hazy
poor shreddy turbid
55
 “Ropes test”
 Estimation of hyaluronic acid–
protein complex integrity
 The adding of acetic acid to
normal synovia...
String test
Syn.fluid is allowed to fall from
the pippette
Length of string is noted
Normal: 4 – 6 cm. String (5cm.
averag...
SF analysis vs Syn.biopsy
Johnson and Freemont (2000) published
a 10 year retrospective study of the
diagnostic usefulness...
SF analysis vs syn.biopsy
In cases where SF analysis was
more informative, than syn.
Biopsy, 86% were inflammatory
and 14%...
Tuberculous arthritis
Wallace etal showed that
AFB +ve rate depended
upon the stage of disease.
20% of SF in Tuberculous
j...
Recent advances
Biochemical analysis of SF for glucose,
proteins and chloride is of little relevance
MMP3 levels in Syn.fl...
Rheumatoid arthritis
IL-1 stimulates production of MMP3
MMP3 levels in SF correlate well with SF
IL1 levels aswell as with...
Rheumatoid arthritis
Measurement of IL6 remains difficult
because of its short half life, presence of
blocking factors , a...
69
Classification of Joint Disorders
70
71
To have a fulfilling life, you should
find your life purpose and follow it
faithfully. Find what
matters to you and build ...
73
This presentation is for doctors and students in general.
. Graphics,Images and jpeg files are taken from Google and ya...
Clinical applications of Synovial (joint ) fluid analysis  Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
Clinical applications of Synovial (joint ) fluid analysis  Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
Clinical applications of Synovial (joint ) fluid analysis  Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
Clinical applications of Synovial (joint ) fluid analysis  Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
Clinical applications of Synovial (joint ) fluid analysis  Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
Clinical applications of Synovial (joint ) fluid analysis  Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
Clinical applications of Synovial (joint ) fluid analysis  Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
Clinical applications of Synovial (joint ) fluid analysis  Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
Clinical applications of Synovial (joint ) fluid analysis  Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
Clinical applications of Synovial (joint ) fluid analysis  Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
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Clinical applications of Synovial (joint ) fluid analysis Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

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Clinical applications of Synovial (joint ) fluid analysis Dr.Sandeep C Agrawal Agrasen Hospital Gondia India
Osteoarthritis,Rheumatoid Arthritis,Joint Tuberculosis,Crystal Induced Arthropathy,Periarticula Malignancy,SLE,Autoimmune diseases

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Clinical applications of Synovial (joint ) fluid analysis Dr.Sandeep C Agrawal Agrasen Hospital Gondia India

  1. 1. Synovial Fluid ( Joint Fluid ) Analysis Dr.Sandeep Agrawal Consultant Orthopedic Surgeon MS,DNB Agrasen Hospital Gondia Maharashtra India www.agrasenortho.com drsandeep123@gmail.com 09960122234
  2. 2. 2 Synovial Fluid  Synovial  syn(like) + ovia (egg)  “Joint Fluid”
  3. 3. 3 GENERATION AND CLEARANCE OF SYNOVIAL FLUID • The Starling equation reads as follows: • J = K ([Pc − Pi] − σ[πc − πi]) • ([Pc − Pi] − σ[πc − πi]) is the net driving force, • Kf is the proportionality constant, and • Jv is the net fluid movement between compartments.
  4. 4. 4 • According to Starling's equation, the movement of fluid depends on six variables: • Capillary hydrostatic pressure ( Pc ) • Interstitial hydrostatic pressure ( Pi ) • Capillary oncotic pressure ( πc ) • Interstitial oncotic pressure ( πi ) • Filtration coefficient ( Kf ) • Reflection coefficient ( σ )
  5. 5. 5 • Synovial fluid is a mixture of a protein-rich ultrafiltrate of plasma and hyaluronan synthesized by synoviocytes. • Generation of this ultrafiltrate depends on the difference between intracapillary and intra- articular hydrostatic pressures and between colloid osmotic pressures of capillary plasma and synovial tissue fluid
  6. 6. 6 Synovial Fluid  Viscous fluid found in the cavities of movable joints  Synovial membrane  Inner membrane of synovial joints  Secretes synovial fluid into the joint cavity  Contain specialized cells (synoviocytes)
  7. 7. Synovial fluid….Dialysate of plasma Normal synovial fluid..clear pale or straw coloured , viscous & does not clot Contains 0.2 – 0.5% Hyluronan synthesised by type-B synoviocytes It polymerises to form large molecular weight complexes causing high viscosity Relatively acellular & has a WBC content of <100x106/L :70% mono cytes; 30% lymphocytes SYNOVIAL FLUID
  8. 8. 8 • In normal joints, intra-articular pressures are slightly subatmospheric at rest (0 to -5 ) • During exercise, hydrostatic pressure in the normal joint may decrease further • Resting intra-articular pressures in rheumatoid joints are around 20 mm Hg, whereas during isometric exercise, they may increase to greater than 100 mm Hg, well above capillary perfusion pressure and, at times, above arterial pressure
  9. 9. Bulge test The Bulge test is used to determine if there is an abnormal amount of fluid surrounding a joint Bulge test of joint for the detection of synovial effusion
  10. 10. Synovial fluid Physical : viscosity,clarity, colour. Cytology: WBC count, smear for Gram stain, AFB stain, Bacteriology: culture & sensitivity Immunology: immune profile , R.A.  Laboratory Testing  Macroscopic Evaluation  Chemical Examination  Microscopic Examination
  11. 11. 11 Specimen Collection  Arthrocentesis Placement of needle in arthrocentesis of (A) elbow and (B) knee joints.
  12. 12. 12
  13. 13. 13 CollectionThree samples are collected. Note If the specimen cannot be examined immediately, fluid should be frozen and stored at -70°C until examined
  14. 14. 14 Macroscopic Laboratory Testing  Volume  Color and Clarity  Inclusions  Viscosity  Clotting  Mucin Clot
  15. 15. 15 Macroscopic Analysis: Inclusions  Rice bodies.  Free-floating aggregates of tissue appear as rice bodies.  rheumatoid arthritis (RA)  Degenarated synovium enriched with fibrin  Ochronotic shards  debris from joint prosthesis  look like ground pepper A =ochronotic shards B =rice bodies
  16. 16. viscosity Non- inflammatory conditions : Normal vis. Inflammatory : low viscosity due to reduced content of hyaluronan & reduced polymerisation (low molecular wt.) String test: synovial fluid dripping from pippette in the form of long string(10- 15cm) Inflammatory : fluid falling as free droplets
  17. 17. Colour & clarity Deep yellow In active R.A. slight greenish tinge Uniformly blood stained : PVNS Loss of clarity : crystals, increased cellularity, infective, cartilage debris Corporae oryzae ( rice bodies):T.B., R.A.
  18. 18. WBC COUNT T.C. INFLAMMATORY >2000 x 106/L D.C.polymorphs, lymphocytosis, synoviocytes, chondrocytes Clumping of cells can be prevented by collecting in EDTA bottles, or heparin
  19. 19. Synovial fluid – table I feature Non-inflam inflammato ry infective example O.A. R.A. Septic arthritis viscosity high low low colour Light straw Yellow- greenish Cream/ yellow clarity clear Mild turbid opaque
  20. 20. Synovial fluid – table II O.A. R.A./CRYST ALS SEPTIC WBC (x106/L) 50 - 500 1,500 – 30,000 >50,000 polymorphs occasional 30 – 70% >95% smear normal Ragocytes, macrophag es,crystals Polys, bacteria centrifugat e Cartilage & fibrin debris Fibrindebris /crystals Fibrin debris, bacteria R.A. -ve +ve -ve
  21. 21. eosinophils Occasionally seen in normal syn.fluid Increased in haemarthrosis Following arthrography – contrast induced Parasytic – Lyme arthritis
  22. 22. 24 Microscopic Analysis: Differential  LE cells  Neutrophils that have engulfed a nucleus of a lymphocyte  Tart cells  Monocytes that have engulfed nuclear material
  23. 23. 25 Microscopic Analysis: Differential  Reiter cells  Vacuolated macrophages with ingested neutrophils  RA cells  “Ragocytes”  Neutrophils with small, dark, cytoplasmic granules that consist of precipitated rheumatoid factor
  24. 24. 26 Microscopic Analysis: Differential  Hemosiderin  Seen in Pigmented Villonodular Synovitis  Inclusions within clusters of synovial cells  Rice bodies  Macroscopically resemble polished rice  Microscopically show collagen and fibrin
  25. 25. 27 Laboratory Testing: Microbiology  Staining  Smears prepared by centrifugation or cytocentrifugation  Saline dilution reduces clustering of cells  Gram’s stain most common  Culture  Set up with positive or negative stain results  Aerobic  anaerobic
  26. 26. 28 • Proteins are present in synovial fluid at concentrations inversely proportional to molecular size, with synovial fluid albumin concentrations being about 45% of those in plasma • Synovial fluid is cleared through lymphatics in the synovium, assisted by joint movement
  27. 27. 29 Chemical Analysis: Protein  All proteins found in plasma  Exception: various high–molecular weight proteins which may be present in very small amount  Fibrinogen  beta 2 macroglobulin  alpha 2 macroglobulin  Use common serum protein procedures
  28. 28. Synovial fluid analysis Recommended as a routine procedure in the diagnosis of joint disorders by Ropes & Bauer Hollander introduced the term synovianalysis Hollander & McCarty introduced polarised light microscopy of synovial fluid for identification of crystals of monosodium monourate & calcium pyrophosphate Biochemical analysis for glucose,protein,or lactic acid are not useful
  29. 29. Synovial fluid analysis Shmerling (1994) concluded : Two major uses of synovial fluid analysis were to identify or rule out bacterial infection or identification of crystals A total of 6,556 papers were published during 1980 – 2001 on synovial fluid analysis
  30. 30. Infective arthritis Difficult to differentiate infective arthritis from acute crystal synovitis on clinical examination alone in monoarticular disease Infection can co-exist with crystal induced or rheumatoid inflammatory arthritis also Synovial fluid analysis...Extremely useful to identify crystals & bacteria and culture studies
  31. 31. Crystal induced arthritis Important cause of acute mono arthritis Gout affects peripheral joints mostly and pseudo-gout or CPPD mainly affects knee joint The converse is also true Pain, swelling redness, sudden onset, and fever mimic infective arthritis Identification of crystals in syn.fluid is diagnostic
  32. 32. 35 These fluid collections which serve as good samples of cloudy but translucent inflammatory synovial fluid were taken from a patient with rheumatoid arthritis (left) and gout (right) respectively
  33. 33. Traumatic arthritis Following meniscal tears, ligament injuries, haemarthrosis, osteochondral fractures, acute or episodic synovitis of monoarticular nature is common. Syn. Fluid analysis along with arthroscopy can establish the diagnosis and help in treatment
  34. 34. Normal synovial fluid: Do not clot Clotting of synovial fluid = fibrinogen 1.Damaged synovial membrane 2.Traumatic tap Macroscopic Analysis: Clotting
  35. 35. Osteoarthritis Acute on chronic monoarticular swelling is quite common in degenerative arthritis due to cartilage debris , avascular necrosis, steroid usage, haemoglobinopathies, sickle cell disease , alcoholism and diabetes Tumour associated monoarthritis can present without any evidence of underlying pathology . SF analysis helps
  36. 36. Infective arthritis In a large study(n=242) Weston etal reported that SF Gram staining was +ve in 50% of cases only SF culture was +ve in 67% of cases Blood culture was +ve when SF gram staining & SF culture were -ve
  37. 37. Syn.fluid analysis Shmerling studied sensitivity and specificity of SF analysis critically He concluded that SF analysis was specific in 90% of infective arthritis and sensitivity of gram staining was 50 – 75% and that of SF culture 75 – 95% Freemont etal estimated that in patients on antibiotic therapy SF cultures were +ve in 30 – 80% only and that usage of blood culture bottles for SF culture and using large amount of Syn.fluid improved pick-up rate
  38. 38. Infective arthritis Freemont etal concluded that when parameters like increased polymorph cellcount >2000/cc and usage of special culture media (BACTEC plus Anaerobic /F medium) improved diagnostic sensitivity In granulomatous lesions with little aspiratable Syn.fluid, syn . tissue can be used for culture purpose
  39. 39. Crystals in Syn.fluid Absence of crystals in SF does not ruleout crystal induced arthritis Monosodium monourate crystals are needle shaped, negatively bi-refrengent and soluble in water Crystals must be intra cellular (phagocytosed) to diagnose gout Extracellular cellular crystals in SF donot produce gout
  40. 40. 44  Monosodium urate (MSU)  Calcium pyrophosphate (CPPD) Crystal Identification
  41. 41. 45  Corticosteroid  Cholesterol Crystal Identification
  42. 42. Intercritical gout Pascual and Jovani studied 101 samples of syn.fluid from asymptomatic gout Results showed 43 out of 43 patients not on treatment for gout had SF +ve for uric acid crystals 34 out of 48 patients receiving treatment for gout had uric acid crystals in SF
  43. 43. Crystals in Syn.fluid CPPD crystals : these are associated with pseudogout Rhomboid in shape and +vely bi-refrengent They also must be intra-cellular to produce pseudo gout Mere presence of these crystals in SF is not diagnostic
  44. 44. Crystals in SF Hydroxyapatite crystals are found in syn. Fluid in Milwakee arthritis These cannot be seen under polarising light microscopy Only electron microscopy can demonstrate these crystals(TEM) These crystals stain with Alizarin
  45. 45. Crystals in SF Crystals of other substances like steroids injected can be seen in SF Beclomethasone crystals are needle shaped, but vary in size and shape Calcium oxalate crystals are particularly seen in SF in renal failure patients Cholesterol crystals can be seen
  46. 46. Rheumatoid arthritis Rheumatoid factor titres in syn.fluid raise much before seropositivity In the presence of inflammatory SF presence of RAF in SF is diagnostic even if blood RAF is – ve RAF in SF is not only derived from blood but also produced by synoviocytes in joint
  47. 47. 51 Laboratory Testing: Rheumatoid Factor  RF is an antibody to immunoglobulins.  Present in rheumatoid arthritis:  Serum – most cases  Synovial fluid - 50%  Rarely elevated only in synovial fluid and not serum  False positives in other chronic inflammatory diseases.
  48. 48. Synovial fluid analysis Mucin clot test: reflects de-polymarization Of hyaluronic acid and can be demonstrated by precipitation of hyaluronate with acetic acid to form a clot of mucin. One part of syn.fluid is added to 4 parts of 2% acetic acid and briskly stirred. Its quality is interpreted
  49. 49. 53 Macroscopic Analysis: Viscosity  “Ropes” or “Mucin Clot Test”  Normal = 4-6 cm  When 2-5% acetic acid is added, normal synovial fluid will form a clot surrounded by clear fluid
  50. 50. Mucin clot test grade clot solution good Tight ropy mass clear fair Softer,shreddy Clear/hazy poor shreddy turbid
  51. 51. 55  “Ropes test”  Estimation of hyaluronic acid– protein complex integrity  The adding of acetic acid to normal synovial fluid, which causes clot formation.  Criteria:  Compactness of the clot  Clarity of the supernatant fluid Macroscopic Analysis: Mucin Clot
  52. 52. String test Syn.fluid is allowed to fall from the pippette Length of string is noted Normal: 4 – 6 cm. String (5cm. average) Abnormal : less than 3 cm. String indicates low viscosity or inflammatory effusion
  53. 53. SF analysis vs Syn.biopsy Johnson and Freemont (2000) published a 10 year retrospective study of the diagnostic usefulness of SF analysis and syn. Biopsy 103 cases in which both SF analysis and Syn.biopsy were performed were studied Biopsy gave more information in 29% of cases and SF analysis provided more information in 18% of cases In cases where syn. Biopsy was more informative, than syn. Fluid analysis 65% were inflammatory arthropathies and 35% were non-inflammatory
  54. 54. SF analysis vs syn.biopsy In cases where SF analysis was more informative, than syn. Biopsy, 86% were inflammatory and 14% were non- inflammatory
  55. 55. Tuberculous arthritis Wallace etal showed that AFB +ve rate depended upon the stage of disease. 20% of SF in Tuberculous joints showed AFB +ve on smear 80% of SF cultures for AFB were positive in tuberculous joints
  56. 56. Recent advances Biochemical analysis of SF for glucose, proteins and chloride is of little relevance MMP3 levels in Syn.fluid reflect the degree of inflammation of a joint and it also correlates with TNF alpha which is a potent inducer of of MMP-3 (matrix metallo protease –3) in synovial fibroblasts, but also of IL- 6 which in turn increases levels of IL -1
  57. 57. Rheumatoid arthritis IL-1 stimulates production of MMP3 MMP3 levels in SF correlate well with SF IL1 levels aswell as with those of its receptors sTNF-RI and sTNF-RII thus corresponding to erosive rheumatoid disease conversely low SF levels of MMP3 correlate with non-erosive rheumatoid disease Detection of MMP3 thus indicates local inflammatory reaction in the joint and it is easy to detect because its concentration is 1000times higher than that of IL-6
  58. 58. Rheumatoid arthritis Measurement of IL6 remains difficult because of its short half life, presence of blocking factors , and its circadian rhythm Though MMP3 is a synovium derived indicator of inflammatory process, it can also be measured in serum and correlate well with levels of IL-6 and erosive rheumatoid disease – positive predictive value
  59. 59. 69 Classification of Joint Disorders
  60. 60. 70
  61. 61. 71
  62. 62. To have a fulfilling life, you should find your life purpose and follow it faithfully. Find what matters to you and build the courage to follow it. Having a one- liner will help you internalize and communicate with your mission. Happiness will never come to those who fail to appreciate what they already have. - Unknown The more passions and desires one has, the more ways one has of being happy. -Charlotte-Catherine
  63. 63. 73 This presentation is for doctors and students in general. . Graphics,Images and jpeg files are taken from Google and yahoo Image to heighten the specific points in this presentation. • If there is any objection/or copyright violation, please inform drsandeep123@gmail.com for prompt deletion. • It is intended for use only by the doctors of orthopaedic surgery. . Views expressed in this presentation are personal. • .For any confusion please contact the sole author for clarification. • Every body is allowed to copy or download and use the material best suited to him. There is no financial involvement. • For any correction or suggestion please contact drsandeep123@gmail.com.

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