arthritis and inflammatory foot imaging

1. ARTHRITIS and FOOT
Catherine Cyteval
Montpellier
Montpellier

2. 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

3. 2nd metatarsal bone neck erosion
X rays

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

5. Inflammatory joint
+
Normal joint space
+
Soft tissu bulke
Gout

6. 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

7. • 10! / 1 "
• primitive forms (genetic): 90 %
• secondary forms: hyperuricemic patients
• Metatarsophalangeal joint of the hallux +++

8. • No joint narowing
• Erosions and
metaphyseal notches on
cookie cutter
• Marginal osteophytes
gives an aspect bristling
• Periosteal reaction
• High density of the
bulck++++

10. MTP
Fin hyperechoïc border at the
surface of cartilage
(refractive micro crystals)
SA Wright Ann Rheum Dis 2007

11. T2
T1
T1 gado
Non specific MRI

13. Ct scan

14. Spectral CT
Urique Ac
(HAP)
HAP (urique
Ac )
Ca (urique
Ac)
FusionUrique Ac
(Ca)
Two beams of different energy (80 et 140kV) , a difference in
attenuation is characteristic of a given element (attenuation
profile)

15. gouty tophus with
gouty arthropathy of
the 2nd MTP
No biopsy
Favorable evolution
with drug treatment

17. Mr C 78 years old
Mr C 73 years old
Painful inflammatory joints for less than 1 year

18. chondrocalcinosis
• Quick severe destruction
• Non-bearing joint
• Few osteophytosis
• Subchondral sclerosis with clear
limit
• many souschondrale erosions
• Crenellated meshed articular
surfaces

19. Chondrocalcinosis
• Extremely common condition
• 5% in adults
• 27.6% for elderly
• Ca pyrophosphate crystal deposition ++
• articular structures
• cartilages
• fibro-cartilage

20. Cartilage cell
Pseudo osteo arthritis (70 %) Gouty like (24 %)
Arthritis like (6 %)
Ca++
PYROPHOSPHATE CRYSTALS

21. Calcic deposition
- within cartilages
- tendons
- Se 96,4% ; Sp 86,7%
- PPV 92% ; NPV 93%
G Filippou Ann Rheum Dis 2007

23. Nrl
Gout
CCA

24. Mr H 48 years old
Acute Painful hallux
Hydroxyapatite

25. Take Home Message
microcristals arthritis
Apatitis
Periarticular
Chondrocalcinosis
Sharpe dense bone
surface
Gout
Para articular dense bulk

26. 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

27. 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

28. 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

29. FOUR FEATURES TO BE SEEK FOR
ENTHESITIS
ARTHRITIS
TENOSYNOVITIS
PERIOSTITIS Modalities
X Rays
MRI
Ultra Sonography

30. ENTHESITIS
1)ARTHRITIS
TENOSYNOVITIS
PERIOSTITIS

31. 1) Inflammatory Arthritis
Synovitis
Synovium is the first inflammatory location in the joint
Bone edema
Erosions
Joint space narrowing

32. US and synovitis
Normal=0
2
1
3
MTP
3
2
1
Doppler activity differentiates
active from inactive synovium 0

34. T1
TIRM
T2 fat sat
T1 gado fat sat
IRM et Synovite
Epaissisement synovial
Hypersignal T2 et réhaussement après injection de gadolinium

35. 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

36. 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

37. 1) Inflammatory arthritis
• Synovitis
• Bone edema
• Erosions

38. 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.

39. MRI - Erosions
Early RA – 6 month prevalence
X Ray : 8 to 40 %
MRI : 45 to 72 %

40. ENTHESITIS
ARTHRITIS
TENOSYNOVITIS
PERIOSTITIS Localisation in
• Rheumatoid arthritis
• Spondylarthropathy
(Psoriatic arthritis)

41. Christian Buchbender Rheumatol Int 2013

42. 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

43. Rheumatoid arthritis
Forefoot
The lateral aspect of the fifth MTP is a very early
and important finding of the disease

44. Bone edema
Demineralisation
Erosion

45. 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

46. 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

47. ©van der Heijde
Erosions
Narrowing
Score 7
Simple Erosion Narrowing Score (SENS)

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

49. Rheumatoid arthritis
midfoot
Osseous fusion
can occasionally be seen
In later evolution

50. 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

51. PSORIATIC ARTHRITIS
forefoot
Joint widening (pencil and cup)
Joint ankylosis

53. ENTHESITIS
1) ARTHRITIS
TENOSYNOVITIS
2) PERIOSTITIS and bone shaft edema
In addition to arthritis, spondylarthopathies show adjacent
osseous abnormalities

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

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

56. Psoriatic arthritis
forefoot : later evolution
• Deformations with asymetric lesion associating joint
fusions and widening

57. FOUR FEATURES TO BE SEEK FOR
ENTHESITIS
1) ARTHRITIS
3) TENOSYNOVITIS
2) PERIOSTITIS

58. 3) Tenosynovitis

59. rupture of an inflammed tendon (posterior
tibialis) can lead to
flat feet with talonavicular malalignment

60. 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…

61. 4) Enthesitis
• 1rst phase : Inflammation
thickening of the tendon,
Plantar apeunevrosis Normal Enthesopathy< 4,4 mm
< 6,1 mm
Achilles tendon
Normal Enthesopathy

62. Doppler or MR T2 hypersignal

63. 4) Enthesitis
• 2nd phase : Destruction =Erosions

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

65. ENTHESITIS
ARTHRITIS
TENOSYNOVITIS
PERIOSTITIS
RA
Bilateral symetric
Destruction
MTP
Spondylarthropathies
Bilateral Asymetric
Destruction and construction
IP
Take home message

66. 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