dr bipul borthakur

1. DEPOSITION ARTHROPATHIES
DR BIPUL BORTHAKUR
PROF OF ORTHOPAEDICS,SILCHAR,ASSAM,INDIA

2. INTRODUCTION
• DEPOSITION DISORDERS INCLUDE THE
FOLLOWING
– GOUT
– CALCIUM PYROPHOSPHATE CRYSTAL ASSOCIATED
ARTHROPATHY (CPPD)
– BASIC CALCIUM PHOSPHATE CRYSTAL DEPOSITION
DISEASE

3. GOUT
• DEPOSITS OF MONOSODIUM URATE CRYSTALS
IN JOINTS AND OTHER TISSUES
• SECONDARY TO HYPERURICEMIA
• CLASSIFIED INTO
– PRIMARY (95%) – WITHOUT ANY OBVIOUS CAUSE
– SECONDARY – RARE HEREDITARY CONDITIONS OR
ACQUIRED DISORDERS
• M/C INFLAMMATORY JOINT DISEASE IN MEN
• PEAK – 5TH DECADE

4. • RISK FACTORS
– FAMILY HISTORY (30-40%)
– ALCOHOL (50%)
– RENAL IMPAIREMENT
– OBESITY
– DIURETICS USE
• ONSET IN MEN PRIOR TO ADULTHOOD OR IN
WOMEN BEFORE MENOPAUSE – POSSIBILITY
OF INHERITED DISORDER

5. • HEREDITARY DISORDERS CAUSING
HYPERURICEMIA
– HGPRT DEFICIENCY
– LESCH-NYHAN SYNDROME
– KELLEY-SEEGMILLER SYNDROME

6. • PATHOPHYSIOLOGY
– URIC ACID PRODUCED IN LIVER
– END PRODUCT OF PURINE METABOLISM
– PRODUCED FROM HYPOXANTHINE AND
XANTHINE
– BY XANTHINE OXIDASE
• HYPERURICEMIA ALONG WITH pH,
TEMPERATURE ARE PRE-REQUISITES FOR
CRYSTAL FORMATION

7. • CLINICAL FEATURES
– SEVERE PAIN –
• BEGINNING AT NIGHT
• WITHIN FEW HOURS THE JOIN BECOMES RED, HOT AND
SWOLLEN
• 70% IN 1ST METATARSOPHALLANGEAL JOINT
(PODAGRA)
– FEVER
– MALAISE
– DESQUAMATION OF SKIN OVER AFFECTED JOINT

9. • CORMORBIDITIES
– METABOLIC SYNDROME
– CARDIOVASCULAR DISEASE
– HYPERTENSION
– DIABETES

10. • INVESTIGATIONS
– S. URIC ACID LEVELS
– XRAYS –
• NOT HELPFUL IN ACUTE ATTACK, MAY SHOW ONLY
SOFT TISSUE SWELLING
• IN CHRONIC- EROSIONS, AWAY FROM JOINT MARGIN,
PUNCHED OUT MAY BE SEEN
– SYNOVIAL FLUID ANALYSIS – URATE CRYSTALS,
NEEDLE SHAPED, STRONGLY NEGATIVE
BIREFRINGENCE

12. TREATMENT
• ACUTE
– NSAIDS- DOC FROM ACUTE EPISODES (IN PTS
WITHOUT COMORBIDITIES)
– STEROIDS – IN PTS WITH COMORBIDITIES
– COLCHICINE – ALSO EFFECTIVE IN ACUTE PHASE
• CHRONIC
– URATE LOWERING THERAPY

13. • URATE LOWERING THERAPY
– ALLOPURINOL – DOC
– TRIGGERS PARADOXICAL FLARE OF GOUT
– THUS STARTED AFTER AT LEAST 4 WEEKS AFTER
THE LAST ACUTE ATTACK
– FEBUXOSTAT – AN ALTERNATIVE FOR
ALLOPURINOL
– URICOSURIC DRUGS – PROBENECID,
SULPHINPYRAZONE

14. CALCIUM PYROPHPOSPHATE CRYSTAL
ASSOCIATED ARTHROPATHY (CPPD)
• CONSEQUENCE OF CARTILAGE CHANGES DUE
TO
– AGEING
– DEGENERATION
– ENZYMATIC DEGRADATION
– TRAUMA
• RESULTS IN DEPOSITION OF CALCIUM
PYROPHOSPHATE CRYSTALS

15. • 4 TYPES OF PRESENTATION
– CARTILAGE CALCIFICATION (CC)
– ACUTE CPP ARTHRITIS (PSEUDOGOUT)
– OSTEOARTHRITIS WITH CPPD
– CHRONIC CPP CRYSTAL INFLAMATORY ARTHRITIS

16. CARTILAGE CALCIFICATION (CC)
• AKA CHONDROCALCINOSIS
• RADIOLOGICAL DIAGNOSIS
• DEPOSITION GENERALLY SEEN IN THE CARTILAGE
• OFTEN BILATERAL AND SYMMETRICAL
• MORE IN THE ELDERLY
• DIABETES, HYPOTHYROIDISM, UREMIA MAY
PREDISPOSE
• HEMOCHROMATOSIS, HYPOMAGNESEMIA,
HYPOPHOSPHATASIA, WILSON’S DISEASE MAY
ALSO BE ASSOCIATED

18. ACUTE CPP ARTHRITIS
• AKA PSEUDOGOUT
• CPP CRYSTALS TRIGGER INFLAMMATORY
REACTION WITHIN THE JOINT
• TRIGGERS
– TRAUMA
– INTERCURRENT MEDICAL ILLNESS
– SURGERY
– BLOOD TRANSFUSION
• M/C CAUSE OF MONOARTHRITIS IN ELDERLY

19. • COMMON JOINTS
– KNEE
– WRIST
– SHOULDER
– ANKLE
• CLINICAL FGEATURES
– PAIN & SWELLING WORSENING OVER 6-24HRS
– FEVER

20. • DIFFERNTIATION FROM GOUT
– LESS ACUTE IN ONSET
– TENDS TO LAST LONGER (7-10DAYS)
– PAIN LESS SEVERE THAN IN GOUT
– CRYSTALS – POSITIVE BIREFRINGENT, RHOMBOID
SHAPED
• JOINT ASPIRATION AND ANALYSIS IS
MANDATORY FOR DIAGNOSIS

21. • TREATMENT
– REST
– ANALGESIA
– ASPIORATION
– INJECTION WITH STEROID, NSAIDs
– COLCHICINE MAY ALSO BE EFFECTIVE

22. CPP CRYSTALS IN POLARIZED LIGHT

23. OSTEOARTHRITIS WITH CPPD
• CRYSTALS MODULATE THE DEVELOPEMENMT OF
OSTEOARTHRITIS
• HYPERTROPHIC REACTION
• MARKED OSTEOPHYTE FORJMATION
• COMMON IN OLDER WOMEN
• C/F – PAIN, SWELLING, STIFFNESS, JOIUNT
CREPITUS, LOSS OF MOVEMENT
• SYNOVITIS IS MORE OBVIOUS THAN OA
WITHOUT CPPD

24. • AFFECTS MAINLY THE KNEES
• XRAY
– COMBINATION OF INTRAARTICULAR &
PERIARTICULAR CALCIFICATION
– JOINT DESTRUCTION IN ADVANCED CASES MAY BE
SEEN
– FORMATION OF LOOSE BODIES
• HEMOCHROMATOSIS ALSO MAY BE
ASSOCCIATED

25. CHRONIC CPP CRYSTAL
INFLAMMAYTORY ARTHRITIS
• CHRONIC OLIGO OR POLIARTGHRITIS
• INFLAMMATORY SYMPTOMS
• O0FTEN RAISED ESR/CRP SEEN
• DIFFERENTIAL DIAGNOSIS WITH RA
• COMMON JOINTS AFFECTED ARE
– KNEE
– RADIOCARPEL
– GLENOHUMERAL

26. BASIC CALCIUM PHOSPHATE CRYSTAL
DEPOSITION DISEASE
• BCP IS A NORMAL COMPONENT OF BONE
• DEPOSITION MAY OCCUR IN AND AROUND
JOINTS DUE TO LOCAL TISSUE DAMAGE
• COMMON WITH INCREASING AGE
• USUALLY ASYMPTOMATIC
• M/C AROUND SHOULDER & KNEE
• EVENTUALLY THEY MAY BE SEEN IN AN XRAY

27. CLINICAL FEATURES
• 2 SYNDROMES ARE ASSOCIATED WITH BCP
– ACUTE OR SUBACUTE PERIARTHRITIS
– CHRONIC DESTRUCTIVE ARTHRITIS

28. ACUTE PERIARTHRITIS
• M/C FORM
• M/C IN ROTATOR CUFF
• M/C IN FEMALES
• C/F – PAIN (AFTER MINOR TRAUMA),
SWELLING, WARMTH, TENDERNESS
• XRAY – CALCIFICATION AROUND JOINT

29. • Rx –
– REST, NSAIDs, INJ. CORTICOSTEROIDS (RESISTANT
CASES)
– OPERATIVE DECOMPRESSION IF PAIN &
TENDERNESS PERSISTS

30. CHRONIC DESWTRUCTIVE ARTHRITIS
• M/C SHOULDER, HIP (KNEE RARE)
• M/C ELDERLY FEMALE
• JOINT DESTRUCTION WITH AGGREGATES OF
BCP IN THE FLUID
• C/F – PAIN, SWELLING, LOSS OF FUNCTION
(70%)

31. • O/E –
– LARGE EFFUSION SEEN
– OCCASIONALLY CAPSULE MAY RUPTURE
– FLUID THEN EXTRAVASATES INTO THE SURROUNDING
SOFT TISSUE
• XRAYS-
– LOSS OF ARTICULAR SPACE
– LITTLE OR NO SCLEROSIS OR OSTEOPHYTES
– EROSIONS OF SUBCHONDRAL BONE MAY BE PRESENT

32. • Rx –
– ASPIRATION & STEROID INJECTIONS MAY BE TRIED
BUT RECURRENCE IS COMMON
– MASSIVE ROTATOR CUFF TEARS MAKE SURGERY
DIFFICULT

33. अच्छेद्योऽयमदाह्योऽयमक्लेद्योऽशोष्य एव च एव एव|
नित्य: सचवगत: स्थाणुर लोऽयं एवसिाति: || 24||
achchhedyo ’yam adāhyo ’yam akledyo ’śhoṣhya
eva cha
nityaḥ sarva-gataḥ sthāṇur achalo ’yaṁ
sanātanaḥ
meaning-The soul is unbreakable and
incombustible; it can neither be dampened nor
dried. It is everlasting, in all places, unalterable,
immutable, and primordial.