EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
Ali et al
DIAGNOSTIC UTILITY OF SYNOVIAL FLUID ANALYSIS AND
MUSCULOSKELETAL ULTRASONOGRAPHY IN CRYSTALS
INDUCED ARTHRITIS
By
Rasha Ali*, Abdou Ellaban*, Ashraf El-Shereef**,
Shreen Refaat**** and Hanaa Ahmed****
Departments of *Rheumatology and Rehablitation; **Diagnostic Radiology (A)
Minia Faculty of Medicine.
ABSTRACT:
The types of crystals associated with joint disease include monosodium urate
(MSU), calcium pyrophosphate dihydrate crystals (CPPD) and basic calcium
phosphate crystals (BCP), including hydroxyapatite (HA). Aim; the aim of the current
study was to detect the rule of synovial fluid analysis (using polarized light
microscopy) and musculoskeletal ultrasonography for the diagnosis of crystals
induced arthritis.
Patients and methods: sixty patients with knee effusion available for aspiration.
There were 34 male (56.7%), and 26 female (43.3%), the age of the patients ranged
from 25 to 70 years with a mean of 49±9.3 years. All patients had; imaging technique
(plain radiography and musculoskeletal ultrasonography), and synovial fluid analysis.
Patients were classified according to presence of CPPD crystals into 2 groups group I
(+ve CPPD, 38 patients) and group II (-ve CPPD, 22 patients).
Results; calcification characteristic of CPPD were found in knee joint in 32 (84.2%)
patients, wrist joint in 18 (47.4%) patients, Achilles tendon in 22 (57.9%) patients,
and plantar fascia in 6 (15.8%) patients in group I, calcification characteristic of MSU
(double contour sign) was found in 4 (18.2%) patients in group II, and calcification
characteristic of HA was found in 2 (5.3%) patients in group I and 2 (9%) in group II.
Conclusion: the most reliable method of diagnosis of crystal deposition in articular
and extra-articular tissue is invasive needle aspiration for synovial fluid analysis and
identification of crystals on polarizing microscopy. Ultrasonography is a useful
indirect sign for the presence of CPPD crystal deposition disease.
KEY WORDS:
Synovial Fluid
Musculoskeletal
Arthritis
crystals (CPPD and BCP) are common
components of osteoar-thritic synovial
fluids 3-5.
INTRODUCTION:
Crystal deposition pathology is
one of the most frequent situations that
rheumatologist is confronted with in
their practice. The types of crystals
associated with joint disease include
monosodium urate (MSU), calcium
pyrophosphate
dihydrate
crystals
(CPPD) and basic calcium phosphate
crystals (BCP), including hydroxyapatite (HA). The attacks of acute
arthritis are the characteristic clinical
manifestations1,2. Calcium-containing
The most reliable method of
diagnosis of crystal deposition
pathology is invasive needle aspiration
for synovial fluid analysis and
identification of crystals on polarizing
microscopy6-8.
McCarty and colleagues9, were
the first to discover non-urate crystals,
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EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
identified by X-ray diffraction as
CPPD, in knee synovial fluid from
patients with acute synovitis and
cartilage calcification visualized on
standard radiographs. Studies identified CPPD as the most common cause
of radiographic articular calcification at
the knee (Chondrocalcinosis’ (CC))10.
Ali et al
with a mean of 49±9.3 years, and the
disease duration ranged from 0.1-12
years with a mean of 3.4±3.5 years.
Patients with known auto-immune
disease or patients younger than 20
years or older than 70 years were
excluded from the study.
All patients had; full history,
clinical
examination,
laboratory
investigations, imaging technique, and
synovial fluid analysis.
Detection of typical calcifications on plain radiographs; usually
of the knees, the wrists and the pelvis,
allows the diagnosis of CC. However,
radiographs are relatively insensitive
and detect only sizeable CPPD
deposits11. High frequency US has
proved to be an excellent technique for
accurate evaluation of articular and
juxta-articular alterations in crystal
related diseases2,8,12. Ultrasonography
(US) is an emerging technique that
could be used for detection of the
CPPD deposits (hyperechoic deposits),
particularly those that are too small to
be visible on plain radiographs13. US
demonstrate a high specificity and
good sensitivity for detection of the
CPPD crystals induced calcification,
using microscopic analysis as the
positive standard8,13. Also studies
confirms the usefulness of US in
revealing signs of CPPD deposits in
peri-articular
structures
(Achilles
tendon) that show no calcification on
plain radiographs14.
Musculoskeletal ultrasonography:
Conventional grey-scale ultrasound
(US) and power Doppler (PDS) examinations were carried out using 7-12.5
linear transducers.
Musculoskeletal ultrasonography and
power Doppler US were done for:
Joints (Shoulder, elbow, wrist, MCP,
knee, MTP joints), tendons (rotator
cuff tendons, triceps tendon, achilles
tendon, quadriceps tendon and plantar
fascia), bursa (subacromial bursa,
olecranon, prepatellar , pes-anserine,
retrocalcaenal bursa and Backer's cyst),
heels (cortical bone of posterior and
inferior aspects of the heel), and sites
of enthesis, and the patellar surface.
Ultrasonographic Examination
was carried out bilaterally and symmetrically, with both longitudinal and
transverse scans.
Examinations of joints for (effusion,
calcification, erosion, and tophi)
AIM OF THE WORK:
The aim of the current study
was to detect the rule of synovial fluid
analysis (using polarized light microscopy) and musculoskeletal ultrasonography for the diagnosis of
crystals induced arthritis.
Examination of the heels
(cortical bone of posterior and inferior
aspects of the heel) for (Enthesophytosis (hyperechoic bony spur
interrupting the cortical profile), determining the characteristic shadowing
and erosions of the posterior and
inferior aspects of the heel).
PATIENTS AND METHODS:
This study included 60 patients
with knee effusion available for aspiration. There were 34 male (56.7%),
and 26 female (43.3%), the age of the
patients ranged from 25 to 70 years
Examination of the Achilles
tendon for (Calcifications, entheso-
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EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
pathy (thickening of the insertional
tract of the tendon), pretendtious
edema, and Power Doppler sonography
(PDS) was performed for the presence
of intratendinous color activity was
attributed to vascularization).
Ali et al
Using SPSS for windows
version 17.015, two-tailed tests were
used throughout and statistical signifycance was set at the conventional 0.05
level.
The following statistics were carried
out:
Descriptive statistics (the range,
means and standard deviation were
calculated for interval and ordinary
variables
and
frequencies
and
percentages for categorical variables16,
group comparisons (Student's t-test and
the chi-squared (²) test)17, correlations
(Bivariate Correlations procedure computes Pearson’s correlation coefficient
with its significance levels)16, and
Sensitivity and specificity.
Examination other tendons for
calcification. Plantar fascia examination for (calcifications, plantar
fasciitis (thickening of the insertional
tract of the fascia, measured where it
crosses the antero-inferior border of
the calcaneus), perifascial edema,
Power Doppler sonography (PDS) for
the presence of color activity of the
plantar fascia was attributed to
vasculari-zation). Examination of bursa
for (bursal involvement, Power
Doppler sonography (PDS) for the
presence of intrabursal color activity
was attributed to vascularization).
Backer's cyst (comma shaped fluid
accumulation between the medial head
of gastrocnemius and semimembranosus tendon).
RESULTS:
Microscopic
examination
(using polarized light microscopy) for
identification of crystals in the studied
patients showed that; 44(73.3%)
patients were positive for crystals and
16(26.7%) patients were negative for
crystals, they were distributed as
follows; calcium pyrophosphate deposition disease (CPPD) crystals in 38
(63.3%) patients, Monosodium urate
(MSU) crystals in 7(11.7%) patients
and hydroxyappatite (HA) crystals in
26(43.3%) patients. There was overlap
between types of crystals.
Enthesis (Around the patella (in
the superior part, at the quadriceps
tendon insertion and in the inferior
part, at the patellar tendon insertion)
and around the calcaneus (at Achilles
tendon and plantar fascia insertion)).
Patella (for the irregularity of the
anterior surface of the patella).
Synovial Fluid Analysis:
1- Gross (macroscopic) examination
(viscosity, colour, clarity).
2- Microscopic examination (using
polarised light microscopy) (wet film
preparation, for cell count and
birefringent crystals determination,
stained film examination (for nonbirefringent crystals examination using
Alezarin red stain and cytological
examination for differential leucocytic
count using Wright's Stain).
According to the results of
synovial fluid analysis for identification of CPPD crystals we divided
the patients into two groups; Group I:
Patients positive for CPPD crystals,
including 38(63.3%) patients and
Group II: Patients negative for CPPD
crystals, including 22(36.7%) patients.
Table (1) shows the demographic data
of patients in the two groups.
Table (2) represents the comparison
between synovial fluid analysis in
Statistical analysis:
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EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
patients with +ve CPPD and patients
with –ve CPPD.
Plain radiography identify calcification
in knee joint (chondrocalcinosis)
5(13.2%) patients and 33(86.8%)
patients show no calcification, while in
group II; no calcify-cation was found,
with no statistically significant differrence between the 2 groups. No
radiological findings of calcification
were found at other sites (wrist, spines,
and pelvis, AT or PF).
Ali et al
For MSU crystals there were 7
patients (11.7%) had MSU crystals, 3
patients of them had MSU crystals in
association with CPPD crystals and 4
of them had MSU crystals alone; those
4 patients with MSU crystals alone
showed
the
knee
calcification
characteristic of MSU (double contour
sign), first metatarsophalyngeal joint
calcification characteristic of MSU
(double contour sign) and erosion, and
metacarpophalyngeal
joints
calcifications characteristic of MSU
(double contour sign) and erosion.
Ultrasonographic findings of
calcification (knee, shoulder, wrist, 1st
MTP joints, MCP joints, Achilles
tendon (AT), and plantar fascia (PF))
was present in 32 patients (84.2%) in
group I and in 6 patients (27.3%) in
group II, this difference was statisticcally significant (p=0.0001) (Figure 1).
For hydroxyappatite (HA)
crystals; there were 26 patients
(43.3%) had hydroxyappatite (HA)
crystals, 24 patients of them had
hydroxyappatite (HA) crystals in
association with CPPD crystals and 2
of them had hydroxyappatite (HA)
crystals alone. Those 2 patients who
had hydroxyappatite (HA) crystals
alone and 2 of the patients who had
hydroxyappatite (HA) crystals in
association with CPPD crystals had
shoulder calcification characteristic of
HA deposition (hypoechoic deposits).
Difference
between
plain
radiography and ultrasonography in
the identification of calcification
(Figure 2).
Table (3) show the comparison
between ultrasonographic findings of
joint in patients with +ve CPPD and
patients with –ve CPPD.
The
sensitivity
of
ultrasonography for detection of
calcification was 86.4% in all patients
while the sensitivity of plain
radiography was 11.4%, the specificity
of both ultrasonography and plain
radiography
for
detection
of
calcification was 100% in all patients
with positive predictive value 1 for
both ultrasonography and plain
radiography, negative predictive value
was 0.73 for ultrasonography and 0.29
for plain radiography.
Table (4) represents the comparison between ultrasonographic
findings of Achilles tendon in patients
with +ve CPPD and patients with –ve
CPPD.
Table (5) represents the comparison between ultrasonographic findings of plantar fascia in patients with
+ve CPPD and patients with –ve
CPPD.
Table (6) shows the ultrasonographic examination for frequency of
calcification characteristic of CPPD in
patients with +ve CPPD crystals.
The
sensitivity
of
ultrasonography for detection of
calcification (knee, wrist) in patients
with +ve CPPD crystals was 84.2%
while that of plain radiography was
13.2%, the specificity of both
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EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
ultrasonography and plain radiography
for detection of calcification was
100%.
The sensitivity of ultrasonography for detection of calcification in
Ali et al
Achilles tendon was 57.9% and the
specificity was 100%.
For plantar fascia the sensitivity of
ultrasonography for detection of
calcification was 15.8% and the specificity was 100%.
Tables and Figures:
Table (1): Demographic and clinical data of patients with +ve CPPD and those with
–ve CPPD crystals.
Sex
Age (years)
Male
Group I
+ve CPPD
(n = 38)
23 (60.5%)
Group II
-ve CPPD
(n=22)
11 (50%)
Female
15 (39.5%)
11 (50%)
Range
27-65
25-70
51.1±8.7
45.4±12.2
0.2-10
0.1-12
3.9±3.2
2.5±4
10-45
15-45
Mean±SD
23.3±10.4
23.9±12.2
NO. (%)
35 (92.1%)
9 (40.9%)
5-15
5-10
Mean±SD
8.1±3.1
7±2.6
NO. (%)
31 (81.6%)
9 (40.9%)
2-9
5-9
7.2±1.5
7.1±1.2
Mean±SD
Disease duration (years) Range
Mean±SD
Morning stiffness
duration (min)
Inactivity stiffness
duration (min)
Range
Range
Numerical rating scale Range
Mean±SD
By (x2) test and student's t-test
*Significant P-value <0.05.
**Significant P-value <0.01.
***Significant P-value <0.001.
312
p-value
x²/t
0.629
0.5
2.135
0.03*
1.378
0.1
-0.150
18.675
0.8
0.0001***
0.986
8.403
0.3
0.008**
0.299
0.7
EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
Ali et al
Table (2): Comparison between synovial fluid analysis in patients with +ve CPPD
and patients with –ve CPPD crystals.
Viscosity
Aspect
Birifringient
MSU
Hydroxyapatite
(HA)
Leucocytic count
Group I
+ve CPPD
(n = 38)
Group II
-ve CPPD
(n=22)
Normal
10 (26.3%)
16 (72.7%)
Decreased
28 (73.7%)
6 (27.3%)
Clear
37 (97.4%)
0 (0%)
1 (2.6%)
0 (0%)
Birifrigient
38 (100%)
4 (18.2%)
Non
Birifrigient
Positive
24 (0%)
2 (9.1%)
3 (7.9%)
4 (18.2%)
Negative
35 (92.1%)
18 (81.8%)
Positive
24 (63.2%)
2 (9.1%)
Negative
14 (36.8%)
20 (90.1%)
Range
4000-30000
300-30000
Mean±SD
16197±5372
4918±8341
90%-94%
28%-93%
91.9%±1.3%
49.3%±26
Turbid
Range
PMN cells
Mean±SD
By student's t- test and (x2) test
**Significant P-value <0.01.
***Significant P-value <0.001.
MSU: Monosodium urate
HA: Hydroxyappatite
PMN: Polymorphonuclear neutrophil
313
p-value
x²/t
12.222
0.001**
0.598
1.000
44.416
0.0001***
1.431
0.4
16.587
0.0001***
6.376
0.0001***
10.127
0.0001***
EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
Ali et al
Table (3): Comparison between ultrasonographic findings of joints in patients with
+ve CPPD and patients with –ve CPPD crystals.
Calcification (For MSU
Double contour sign)
Calcification (For CPPD
hyperechoic deposits )
Backer cyst
Calcification (For MSU
1st MTP joint Double contour sign)
Erosion
Effusion
Shoulder joint Calcification (For CPPD
hyperechoic deposits )
Calcification (For HA
hypoechoic deposits)
Calcification (For CPPD
Wrist joint
hyperechoic deposits )
Calcification (For MSU
MCP
Double contour sign)
Erosion
Effusion
By (x2) test
*Significant P-value <0.05.
***Significant P-value <0.001.
Group I
+ve CPPD
(n = 38)
0 (0%)
Group II
-ve CPPD
(n=22)
4 (18.2%)
x²
Pvalue
7.403
0.02*
32 (84.2%)
0 (0%)
39.699 0.0001***
24 (63.2%)
0 (0%)
3 (13.6%)
4 (18.2%)
13.806 0.0001***
7.403
0.02*
0 (0%)
2 (5.3%)
0 (0%)
4 (18.2%)
4 (18.2%)
0 (0%)
7.403
2.584
-
0.02*
0.2
-
2 (5.3%)
2 (9%)
0.328
0.6
18(47.4%)
0 (0%)
14.887 0.0001***
0 (0%)
2 (9%)
3.574
0.1
0 (0%)
1 (2.6%)
2 (9%)
2 (9%)
3.574
1.224
0.1
0.5
Knee joint
MCP: Metacrpophalyngeal joints
HA: Hydroxyappatite
1 st MTP: First metatarsophalyngeal joint
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EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
Ali et al
Table (4): Comparison between ultrasonographic findings of Achilles tendon in
patients with +ve CPPD and patients with –ve CPPD crystals.
Group I
+ve CPPD
(n = 38)
22 (57.9%)
Calcification
Pattern of Pattern I 16 (42.1%)
calcification Pattern II
4 (10.5%)
2 (5.3%)
Pattern III
4 (10.5%)
Cortical bone surface
irregularity
Group II
-ve CPPD
(n=22)
0 (0%)
0 (0%)
20.111 0.0001*** 6 (15.8%)
0 (0%)
4 (10.5%)
2 (5.3%)
2.481
0.4
0 (0%)
16 (42.1%)
16 (42.1%)
0 (0%)
0 (0%)
4 (10.5%)
22 (57.9%)
Enthesophytosis
9 (23.7%)
Entheseopathy
8 (21%)
Vascular sign
5 (13.2%)
Bursitis
By (x2) test
*Significant P-value <0.05.
***Significant P-value <0.01.
9 (40.9%)
0 (0%)
0 (0%)
0 (0%)
1.610
6.130
5.344
3.158
22 (57.9%)
3 (7.9%)
2 (5.3%)
2 (5.3%)
x²
Unilaeral
Bilateral
p-value (for group I) (for group I)
0.3
0.02*
0.02*
0.1
0 (0%)
6 (15.8%)
6 (15.8%)
3 (7.9%)
Patterns of calcification in Achilles tendon:
Pattern I: Multiple thin linear bands
Pattern II: Single fine linear bands.
Pattern III: Thick solid bands.
Table (5): Comparison between ultrasonographic findings of plantar fascia in patients
with +ve CPPD and patients with –ve CPPD crystals.
Group I
+ve CPPD
(n = 38)
6 (15.8%)
Calcification
Pattern of Pattern I 6 (15.8%)
calcification Pattern II 0 (0%)
Pattern III 0 (0%)
Cortical bone surface 30 (78.9%)
irregularity
Group II
-veCPPD
(n=22)
0 (0%)
7 (31.8%)
23 (60.5%) 10 (45.5%)
Enthesophytosis
16 (42.1%) 4 (18.2%)
Plantar fasciitis
By (x2) test
**Significant P-value <0.01.
Patterns of calcification in plantar fascia:
Pattern I: Multiple thin linear bands
Pattern II: Single fine linear bands.
Pattern III: Thick solid bands.
315
pUnilaeral
x²
value
(for
group I)
3.860
0.08
0 (0%)
0 (0%)
0 (0%)
0 (0%)
13.092 0.001** 0 (0%)
Bilateral
(for
group I)
6 (15.8%)
6 (15.8%)
0 (0%)
0 (0%)
30 (78.9%)
1.279
3.589
23 (60.5%)
16 (42.1%)
0.3
0.09
0 (0%)
0 (0%)
EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
Ali et al
Table (6): Ultrasonographic examination for frequency of calcification characteristic
of CPPD in patients with +ve CPPD crystals.
Number Frequency % Unilateral Bilateral
Knee calcification
32
84.2%
8 (21.1%)
24 (63.2%)
Pattern of
calcification
Pattern I
0
0%
-
-
Pattern II
Pattern III
Pattern I&II
Pattern I&II&III
Site of
Articular surface
calcification
Fibrous cartilage
Tendons
Joint recesses
Wrist calcification
21
2
8
1
9
30
0
3
18
55.3%
5.3%
21.1%
2.6%
23.7%
78.9%
0%
7.9%
47.4%
0 (0%)
18 (47.4%)
Pattern of
calcification
Pattern I
Pattern II
Pattern III
Articular surface
Fibrous cartilage
Tendons
0
18
0
0
18
0
0
0%
47.4%
0%
0%
47.4%
0%
0%
-
-
22
6
0
57.9%
15.8%
0%
6 (15.8%)
0 (0%)
-
16 (42.1)
6 (15.8%)
-
Site of
calcification
Joint recesses
Achilles tendon calcification
Plantar fascia calcification
Shoulder calcification
Patterns of calcification in the knee joint:
Pattern I: Hyperechoic band.
Pattern II: Several thin hyperechoic spots (Punctate pattern).
Pattern III: Homogenous hyperechoic nodular or oval deposits.
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EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
Ali et al
Figure (1): Frequency of ultrasonographic findings of calcification in patients
with +ve CPPD and patients with –ve CPPD crystals.
Frequency of US findings of calcification in
patients in group I and group II
35
30
25
32
(84.2%)
20
15
10
6
(27.3%)
5
0
Group I
Group II
Figure (2): Plain radiography and ultrasonography findings of calcification in
patients with +ve CPPD crystals.
Plain radiograhy and US findings of calcification
in patients in group I
35
30
25
20
32
(84.2%)
33
(86.8%)
15
10
5
6
(15.8%)
5
(13.2%)
0
Plain rad
Calcification
Plain rad No
calcification
US
Calcification
317
US No
calcification
EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
Ali et al
that calcification (chondrocalcinosis)
was found in 5 (8%) patients. In
agreement with our results; Richette et
al.,23, reported a crude prevelance of
radiographic calcification (CC) in 7%
of patients with no difference between
men and women. Also Neame et al.,24,
reported a crude prevelance of
radiographic calcification (CC) is 7%.
However, in the study of Malavia et
al.,25, the prevelance of chondrocalcinosis was lower; it was 2% of the
adult Kuwaiti and other MiddleEastern Arab patients. In the current
study,
there
were
statistically
significant difference between patients
in group I and group II concerning
patients' age (p=0.03) being older in
patients in group I. Although there
were patients with old age in group II
that may be the cause of the presence
of other types of crystals in such
patients (MSU and HA). In agreement
with our results; Doherty,26, who
proved that age is a risk factor for both
crystal arthropathies, MSU preferentially deposits in OA joints Roddy et
al., 27, and OA predisposes to CPPD
Neame et al.,24 deposition.
DISCUSSION:
In our study, synovial fluid analysis
for the identification of crystals
showed that; 38(63.3%) patients CPPD
crystals, 7(11.7%) patients had MSU
crystals, and 26 (43.3%) patients had
hydroxyappatite (HA) crystals, in with
the note that there were patients with
more than one type of crystals. Patients
who had CPPD and/ or hydroxyappatite crystals or both represent
70% of patients. In agreement with our
results, Derfus et al.,18, they found that
60% of osteoarthritic patients had
CPPD, hydroxyappatite crystals or
both in their synovial fluid. The
frequency of association of CPPD
crystals deposits may result from the
biological effects of CPPD as they
interact with fibroblasts or mononuclear cells. In a study by
Viriyavejkul et al.,19, the presence of
CPPD crystals was identified in 52.9%
of patients with osteoarthritis. Also in
the study of Nalbant et al.,20, they
found the prevalence of hydroxylappatite crystals in synovial fluid from
patients with knee OA is between 30%
and 60%. The same finding was
proved by O'shea and McCarthy,21,
who found that the incidence of
hydroxyappatite crystals in the
synovial fluid from patients with osteoarthritis is at least 30% to 60%. Jaccard
et al.,22, found that; calcium pyrophosphate dehydrate was in 55.7% and
monosodium urate in 42% of patients.
They reported that both types of
crystals
(calcium
pyrophosphate
dihydrate and monosodium urate
crystals) may coexist and they were
found in (2%) of patients, usually in
specimens obtained from the knee.
Among the patients with a mixed
crystal composition, these patients had
a higher age.
In the current study, the ultrasonographic examination of patients
with +ve CPPD versus patients with –
ve CPPD for the detection of
calcification characteristic of CPPD
(hyperechoic deposits; bands, spots or
nodules) showed that; calcification was
found 32(84.2%) patients; knee
calcification was present in 32(84.2%)
patients, wrist calcification was present
in 18(47.4%) patients in group I and no
patient in group II, these difference
was statistically significant (P= 0.0001
for both of them). No patient in either
group had shoulder calcification
characteristic of CPPD deposition. In
agreement with our results; Foldes,28,
in his study for detection of calcification in the knee joint he found that
ultrasonically, detectable calcification
In the current study, plain
radiography findings of calcification in
knee joint (chondrocalcinosis) showed
318
EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
in the knee was present in 17 of 21
patients (81%). However, in the study
of Frediani et al.,6, they found that
ultrasonically defined CPPD calcifycations were found in all the 11
patients with CPPD crystals (100%).
Knee calcification was present in 10 of
11 patients (90.9%), shoulder calcifycation was present in 4 of 11 patients
(36%) of patients, and wrist calcifycation was present in 5 of 11 patients
(45.5%). The differences from our
study that; the calcification in our
study was 84.4% while in Frediani et
al.,6 it was 100% this may be due to
that, the mean age of patients is higher
in Frediani et al., 6 than in our current
study, racial and genetic factors.
Ali et al
patients, it was present in all patients
who had calcification in this study, it
was found in 30(78.9%) patients in the
knee (fibrous cartilag, and in 18
(47.4%) patients in the wrist (fibrous
cartilage). In agreement with our
results Frediani et al.,6 found that;
pattern II was the most common
pattern of calcification found in the
study (found in at least one site in all
patients). It was present in all patients
who had wrist calcification (5 of 11
(45.5%)) and in the knee in either
alone (6 of 11 patients (54.5%)) or in
association with pattern I (4 of 11
patients (36.4%)). Also Filippou et
al.,13, pattern II (at the minsci) was the
most common pattern found and it was
present in all the patients who had
calcification (14 patients of 14) and
pattern I at the articular cartilage in 4
of 14 patients.
In the current study, shoulder
calcification that was found in 2
patients in group I and also 2 patients
in group II who were –ve for CPPD
crystals calcifications was characterized by hypoechoic appearance that
was characteristic of hydroxyappatite
depositon (CPPD calcification characterized by hyperechoic deposits), and
synovial fluid of these 4 patients
showed hat the 2 patients in group I
had hydroxyappatite (HA) crystals in
association with CPPD crystals and in
the 2 patients in group 2 had also
hydroxyappatite (HA) crystals alone.
In agreement with our result; Frediani
et al.,6, found that calcifications that
presented a hypoechoic appearance
with posterior shadowing were considered as crystalline deposits of another
nature than CPPD, probably due to
hydroxyapatite (HA) crystal deposition
disease deposits. These calcifications
were found in four control group
patients and none of patients in the
group of patients with positive CPPD
crystals.
In the current study it was found
that, all patients who had calcification
had CPPD crystals in their synovial
fluis and no patient without CPPD
crystals in the synovial fluid analysis
had either radiographic chondrocalcinosis or ultrasonographic finding
of calcification characteristic of CPPD.
In agreement with our results Frediani
et al.,6, who found that in all patients
with ultrasonographically defined
CPPD deposits, CPPD crystals were
found in the synovial fluid, however,
standard radiographic examination did
not show evidence of the calcific
deposits that were identified by ultrasonography in all cases, and CPPD
crystals were not found in the synovial
fluid of controls without ultrasonographically defined CPPD deposits or
radiographic chondrocalcinosis.
However in the study of Filippou et
al.,13, they found the presence of CPPD
calcifications without the presence of
CPPD crystals in synovial fluid.
In the current study, patten II of
calcification was the most common
pattern of calcification found among
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EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
In the current study, the sensitivity
of ultrasonography for detection of
calcification was 84.2% patients in
group I (+ve CPPD = 38) while that of
plain radiography it was 13.2%, and
the specificity of both ultrasonography
and plain radiography for detection of
calcification was 100%. In agreement
with our results, Foldes,28, found that
the sensitivity and specificity of ultrasonography for the diagnosis of
chondrocalcinosis were 80% and 100%
respectively. Also Filippou et al.,13,
who proved that, ultrasonography
demonstrated good sensitivity (equal to
86.7%) and a high specificity (equal to
96.4%) in the diagnosis of chondrocalcinosis.
Ali et al
calcification in only 25% of Achilles
tendons of patients with CC. Also
Gerster et al.,30, described fine linear
calcifications in 13% of the Achilles
tendons in patients with articular CC,
concluding that this radiographic
pattern was a useful indirect sign of
CPPD crystal deposition disease.
Gerster et al.,30, described 3 cases of
Achilles tendinitis associated with
linear calcification of CPPD as a rare
presentation of extraarticular CC.
In the current study; the sensitivity
of ultrasonography for detection of
calcification in Achilles tendon was
57.9% and the specificity was 100%.
In agreement with our results, Falsetti
et
al.,14,
who
found
that
ultrasonography was found to be
57.9% sensitive, and 100% specific for
detection
of
Achilles
tendon
calcifications which was a useful
indirect sign for the presence of CPPD
crystal deposition disease.
In the current study, Achilles
tendon calcification was present in 22
(57.9%) patients in group I and no
patient in group II (p= 0.0001),
calcification of the Achilles tendon
was charactarized by hyperechoic
deposits within the fibrillar tendon
structure not in continuity with the
bone profile. The pattern of calcifycation was pattern I (multiple thin
linear bands) in 16 (84.2%) patients
who were bilateral in all of them,
pattern II (single fine linear bands) in 4
(10.5%) patients who were unilatreal in
all of them, and pattern III (thick solid
bands) in 2 (5.3%) patients who were
unilateal in all of them. In agreement
with our results, Falsetti et al.,14, who
found that US examination showed
Achilles tendon calcifications in 57.9%
(33/57 patients) of CC and no patient
in the control group (OA without
CPPD) had calcification (p= 0.0001) it
was bilateral in 25 of 57 cases (43.8%).
The sonographic patterns of these
calcifications were multiple thin linear
bands in 72.4% of cases, single fine
linear bands in 17.2%, and thick solid
bands in 10.3%. However, in disagreement with our results, Pereira et al.,29,
they described thin linear bands of
In the current study, plantar fascia
calcification was present in 6 (15.7%)
patients in group I (who were bilateral
in all of them) and no patient in group
II, with no statistically significant
difference between the 2 groups, and
the pattern of calcification was pattern
I (multiple thin linear bands) in all of
them. Calcifications of the plantar
fascia insertional tract were charactarized by hyperechoic deposits in the
superficial region of the insertional
tract of the fascia, not in continuity
with the bone profile. In agreement
with our results, Falsetti et al.,14, who
found that; plantar fascia calcifications
was present in 15.8% (9/57 patients) of
CC (it was bilateral in all cases); but
they found plantar fascia calcifications
in 2% (1/50 patients) of OA (control
group) (p not significant). Falsetti et
al.,14, found that calcifications of the
plantar fascia appeared in all cases as a
single fine linear echoic band located
320
EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009
Ali et al
in the superficial region of the
insertional tract of the fascia,
apparently not in continuity with the
cortical bone. In disagreement with our
results, Gerster et al.,30, they described
fine linear calcifications in 0.5% of the
plantar fascia in patients with articular
CC, concluding that this radiographic
pattern was a useful indirect sign of
CPPD crystal deposition disease.
finding of calcification characteristic of
CPPD.
In the current study; the sensitivity
of ultrasonography for detection of
calcification in plantar fascia was
15.8% and the specificity was 100%.
In agreement with our results, Falsetti
et al.,14, found that ultrasonography
was found to be 15.8% sensitive, and
100% specific for detection of plantar
fascia calcifications which was a useful
indirect sign for the presence of CPPD
crystal deposition disease.
Ultrasonography is a useful indirect
sign for the presence of CPPD crystal
deposition disease, it has high
specificity in all the examined sites,
good sensitivity for joint calcification;
however the low sensitivity in Achilles
tendon and plantar fascia calcifycations, suggests a moderate accuracy
for using the ultrasonographic finding
of Achilles tendon and plantar fascia
calcifications alone as a method for
diagnosing CPPD crystal deposition
disease without searching for other
sites of calcification characteristic of
CPPD.
So we can conclude that; the most
reliable method of diagnosis of crystal
deposition in articular and extraarticular tissue is invasive needle
aspiration for synovial fluid analysis
and identification of crystals on
polarizing microscopy.
Conclusion and Recommendation
From the result of the current study
it was found that ultrasonography (US)
has proved to be an excellent technique
for accurate detection of calcification
in articular and juxta-articular in
crystal induced arthritis. Ultrasonography was found to be more sensetive
for identification of calcification in
articular and extra-articular tissues than
plain radiography.
It is recommended to do
ultrasonographic examination for any
patient presented with joint effusion in
cases suspected to have crystals
induced pathology prior to proceeding
to needle aspiration for synovial fluid
analysis and identification of crystals
on polarizing microscopy, and to keep
needle aspiration for cases with high
suspicion of crystals induced arthritis
and in whom no characteristic findings
of calcification was found in ultrasonographic examination or in patients
in need for therapeutic injection .
In the current study it was found
that, all patients who had either
radiographic chondrocalcinosis or
ultrasonographic finding of calcification characteristic of CPPD had
CPPD crystals in their synovial fluid
and no patient without CPPD crystals
in the synovial fluid analysis had either
radiographic chondrocalcinosis or
ultrasonographic
finding
of
calcification characteristic of CPPD,
however there are patients with CPPD
crystals in their synovial fluid but they
had
not
either
radiographic
chondrocalcinosis or ultrasonographic
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‫الملخـــص العربــــى‬
‫تعدداإللتهتباتددامإللهية ددناتإللهعاتتددتإلاددلإلتراددفإللهتننددلرلمإلأددرإللهيةا دد إليددلإل ددرإلل يددرل إل‬
‫لهرلياتازياتإلإلشالااً‪.‬‬
‫ليلإل شبرإلهذهإللهتننلرلمإلتننلرلمإلتارلألاةامإلله اهادال إل عدا رإللهبادارلتاللإلتنندلرلمإلل داا إل‬
‫الرلمإلله لاال إللإلتننلرلمإلألاةامإلله اهاال إللهقااااتلإللترافإلهذهإللهتننلرلمإلأرإللهيةا إللإل‬
‫ل عاتتإل ل إلإللهيةا لإللهذهإللهتنندلرلمإليلتدلابإلت دربإلأدرإللهادا إللهاداعلأرإلهنيريدرإللهدذالإل‬
‫اعاعللإليلإلخشلعتإلإللهيةا ‪ .‬إل‬
‫لاعاإللهة صإللهيا رلا لترإلهناا إللهااعلأرإلهلإللهطراقتإللهيؤ ابإلهنتشخاصلإللهلإلاااااإل اياإلً‬
‫أرإلت اااإلعشاطإللهير ‪ .‬إل‬
‫لهقدداإل ددت إل إاددتخال إللهيلتددامإلأددلتإلله ددلتاتإلهنتبازلهعيددنرإلله ر ددرإلأددرإلتشددخاصإللا د إل‬
‫ل يرل إللهرلياتازياتإلذلإليتا إلللاعإللههإليزلااإلاااابإلالإلغارهإليلإللهطرتإلل خر إل ا شدعتإل‬
‫لهااعاتإللل شعتإللهيقطعاتإلللهرعالإللهيغعاطاار‪ .‬إل‬
‫لتاددتخا إللهيلتددامإلأددلتإلله ددلتاتإلهنتبازلهعيددنرإلله ر ددرإلأددرإلتشددخاصإللتهتباتددامإللهية ددناتإل‬
‫لهعاتتتإلالإلترافإللهتننلرلمإللت اااإلتأ ارهاإلانرإللهيةا إللإلل عاتتإل ل إلإللهيةا د لإللاي دلإل‬
‫الإلطراقإلإاتخاليباإللهتةرقهإلتالإللتهتبافإلله ااإلللهيزيلإلهنيةا د لإللإلااداااإل ايداًإلأدرإلت ااداإل‬
‫عشاطإللهير إلليا إلتأ ارإللترافإلهذهإللهتنندلرلمإلاندرإللهيةا د إليدلإلتشدلهامإللتا و د ‪.‬إللتتيادزإل‬
‫لهيلتامإلألتإلله لتاتإلهنتبازلهعينرإلله ر رإلتقارتباإلانرإلت اااإللهت ناامإلأدرإللهيةا د إلادلإل‬
‫ل شعتإللهااعات‪ .‬إل‬
‫لااتخا إللهة صإلتيلتامإللهالتنرإلأرإلت اااإللهايلاتإلأرإلل عاتتإل ل إلإللهيةا إلليلإل إلت ااداإل‬
‫عشاطإللهير ‪ .‬إل‬
‫‪323‬‬
‫‪Ali et al‬‬
‫‪EL-MINIA MED. BULL. VOL. 20, NO. 2, JUNE, 2009‬‬
‫تننددلرلمإلتارلألاددةامإلله اهاددال إل عددا رإللهباددارلتالإلاعددت إلاعبدداإلتددأ ارإلللي د إلانددرإللهيةا د إل‬
‫لتترافإلهذهإللهتننلرلمإلأرإللهيةا إللإلل عادتتإل دل إلإللهيةا د إليؤاادتإلإهدرإللهت ناداملإللادزالاإل‬
‫يعدا إلإعتشددارهاإلتزاداابإل ايددارإللهيريدر‪.‬إلل هد إلطراقدتإلهنتشددخاصإلهدرإللهة ددصإللهيا رلاد لترإل‬
‫هناا إللهااعلأرإلللهتعرفإلانرإلهذهإللهتننلرلمإلللتلاإللهت نادامإلأدرإللهيةا د إللإلل عادتتإل دل إلإل‬
‫لهيةا ‪ .‬إل‬
‫لتعاإللهيلتامإلألتإلله لتاتإلهنتبازلهعينرإلله ر رإليلإللهطرتإللهبايدتإلأدرإلتشدخاصإللهت نادامإل‬
‫لإل ايداًإلأددرإللتددلاإلإرتشددافإلأددرإللهيةا د لإلتا و د إلأددرإللهع ددا لإللتددلاإلإهتبددافإلتا اددا إللهز هاددتإل‬
‫لل غشاتإللهااعلأات‪ .‬إل‬
‫اعاإلير إللهعقر إليلإل رإلل يرل إلشالااًإللهترإلتدؤا إلإهدرإلإهتبدافإللهيةا د إللهدرإلتعدت إلادلإل‬
‫ترافإلتننلرلمإلل اا إلالرلمإلله لاال إلأرإللهيةا د إلللهتدرإلا دعفإلت ااداهاإلتا شدعتإللهاداعاتإل‬
‫لل شعتإللهيقطعاتإلللهرعالإللهيغعاطاار‪ .‬إل‬
‫تا و إللهع ا إلأرإلل شعتإللهااعاتإلإلأرإلير إللهعقر إل إلا برإلإ إلتعداإليدرلرإليدلإل‪٦‬إلإهدرإل‪١٢‬إلادعتإل‬
‫تعاإللت اتتإلتاهير ‪ .‬إل‬
‫لاعتترإللهة صإللهيا رلا لترإلهناا إللهااعلأرإلللهتعرفإلانرإللتلاإللهتننلرلمإليلإل ه إللهطدرتإل‬
‫هنتشخاصلإلل اياًإلتعتترإللهيلتامإلألتإلله لتاتإلهنتبازلهعينرإلله ر رإليلإللهطدرتإللهبايدتإلأدرإل‬
‫تشخاصإلير إللهعقر ‪ .‬إل‬
‫ً‬
‫هعاكإلعلعإللٓخرإليلإللهتننلرلمإللهلإلتننلرلمإلألاةامإلله اهاال إللهقااااتإللهذ إلادؤا إل ايداإلإهدرإل‬
‫لتلاإللهت نا امإللخا تإل دل إلية د إلله تدفلإللإلاعداإللهة دصإللهيا رلاد لترإلهنادا إللهاداعلأرإل‬
‫للهتعرفإلانرإللتلاإللهتننلرلمإللإلإاتخال إللهيلتامإلألتإلله دلتاتإلهنتبازلهعيدنرإلله ر درإليدلإل‬
‫لهطرتإللهبايتإلأرإلتشخاصإلترافإلهذهإللهتننلرلم‪ .‬إل‬
‫الهدف من الدراسة‪:‬‬
‫تبافإلهذهإللهارلاهإلإهرإلتليا إلالرإلإاتخال إلأ صإللهاا إللهااعلأرإللإللهيلتامإللهةلتإل لتات إل‬
‫هنتبازلهعينرإلله ر رإلأرإلتشخاصإل يرل إللهيةا إللهعاتتتإلالإلترافإلتننلر ‪ .‬إل‬
‫المرضى وطرق البحث‪:‬‬
‫تييعمإلهذهإللهارلاتإلادتللإليرايداإلهدااب إلإرتشدافإلتية د إللهر تدتلإللتد إلتقادا إلتيادعإللهيريدرإل‬
‫إ ناعا ااًإللإلتاهة ل دامإللهيعينادتكإل يداإلتد إللهة دصإلتا شدعتإللهاداعاتإللإللهيلتدامإللهةدلتإل دلتات إل‬
‫هنتبازلهعينرإلله ر رإللإللهة صإللهيا رلا لترإلهناا إللهااعلأر‪ .‬إل‬
‫وقد أظهرت النتائج ما يلي‪:‬‬
‫برمإلل شعتإللهااعات إللتلاإللهت ناامإلأرإلاااإليلإللهيريرإل ق إليلإللهترإل برتباإللهيلتامإل‬
‫لهةلتإل لتات إلهنتبازلهعينرإلله ر رإلأرإلية إللهر تتإللية إللهراغإلللترإل خانا إللتطاعتإل‬
‫لهقايال إلييازب إلهتراف إلتننلرلم إلتارلألاةام إلله اهاال إل عا ر إللهباارلتال إلللتلا إلت ناام إلأرإل‬
‫ية إلله تف إلييازب إلهتراف إلتننلرلم إلألاةام إلله اهاال إللهقاااات إللتلا إللهت ناام إلأر إلية إل‬
‫لهر تتإلللهيةا إلله غاربإلهنااالإلللهقايال‪ .‬إل‬
‫لقا إل لي م إللهارلات إل اااااات إللهيلتام إللهةلت إل لتات إلهنتبازلهعينر إلله ر ر إل ر إليلإل‬
‫ل شعتإللهااعاتإلأرإلإ بارإللهت ناام‪ .‬إل‬
‫ومن ذلك أمكن إستنتاج اآلتى‪:‬‬
‫ال رإلتعي إللهيلتامإللهةلتإل لتات إلهنتبازلهعينرإل إليرا إلهااهإلإرتشافإلتية إللهر تتإل‬
‫قت إللها فإللاي إللهة صإللهيا رلا لترإلهناا إللهااعلأر‪.‬‬
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