0:02

Hello and welcome to Noon Conference hosted by MRI Online

0:06

Noon Conference connects the global radiology community

0:09

through free live educational webinars that are accessible

0:12

for all and is an opportunity

0:14

to learn alongside top radiologists from around the world.

0:18

We encourage you to ask questions

0:20

and share ideas to help the community learn and grow.

0:23

You can access a recording of today's conference

0:25

and previous noom conferences

0:27

by creating a free MRI online account.

0:31

Today we're honored to welcome Dr. Dennis Bki

0:34

for a lecture entitled Introduction to Arthritis.

0:37

Dr. Bki is an academic diagnostic radiologist

0:40

with over 30 years of experience in bone

0:43

and joint joint radiology.

0:45

He's a senior MSK specialist radiologist at King's College

0:48

Hospital, as well as a senior lecturer in imaging sciences

0:52

at King's College London.

0:54

He's also a member of the Arthritis Subcommittee

0:56

of the European Skeletal Society, a member

0:59

of the Polish Medical Radiology Society, an honorary member

1:02

of the Ukrainian Association of Radiologists

1:05

and the editor-in-chief of Radiology Online Journal.

1:08

As part of his training, he was a research fellow at UCSD

1:12

working under the tutelage of Donald Resnick

1:14

and was involved in the publication

1:16

of six peer reviewed research papers.

1:19

He's published over 50 papers and educational exhibits

1:22

and teaches radiology residents worldwide in uk, Poland,

1:26

Ukraine, and Israel.

1:27

We're grateful to Dr. Beki for being here

1:29

to share his expertise with us.

1:32

At the end of the lecture, please join him in a q

1:34

and A session while he'll address questions you

1:36

may have on today's topic.

1:38

Please remember to use the q

1:39

and a feature to submit your questions so we can get to

1:42

as many as we can before our time is up.

1:44

With that, we're ready to begin today's lecture. Dr.

1:47

Beki, please take it from here.

1:49

Thank you very much, Ashley.

1:51

It's a great honor for me to be here

1:53

and to lectured for MRI Online.

1:57

I am going to do a lecture called Introduction

2:02

to Arthritis, which is the first

2:04

of three lectures which we hope

2:06

to schedule in the near future.

2:09

In the next approximately 50 minutes,

2:12

I will cover general considerations

2:15

regarding the radiographic presentation of arthritis.

2:19

I will spend a lot of time discussing the differences

2:22

between non-inflammatory arthritis using the example

2:26

of osteoarthritis

2:28

and inflammatory arthritis using rheumatoid

2:32

arthritis as the example.

2:35

We will learn an approach to systematically evaluate joints

2:39

of the hands and feet

2:40

and other joints for the presence of arthritis.

2:43

We will use the target area approach to diagnose

2:47

and to pinpoint the most likely type of arthritis present.

2:52

We will learn in detail the presence of osteoarthrosis

2:55

and rheumatoid arthritis in parts two

2:59

and three of this series.

3:00

We will continue our discussion including all the important

3:05

arthritic entities.

3:11

I have nothing to disclose.

3:14

The target audience for this talk are medical students,

3:17

radiology, rheumatology, and orthopedic residents,

3:21

and practicing radiologists

3:23

who would like a review of the subject.

3:26

Our learning objectives are to become familiar

3:28

with the radiographic findings in the common Arth disease

3:33

learning detail, the index diseases, osteoarthrosis

3:37

and rheumatoid arthritis better understand the target area

3:41

approach to diagnosis

3:43

of arthritis in the most common conditions

3:46

that are clinically seen

3:48

and become more confident in the radiographic

3:52

diagnosis of arthritis.

3:54

So let's begin. This talk will provide an overview

3:59

of the various imaging findings of common joint diseases.

4:03

Arthritis is a challenging topic.

4:06

A long list of diagnoses must be considered when looking at

4:10

radiographs of the hands

4:11

and feet each with its own extensive set of findings.

4:16

Sometimes the abnormalities are pathognomonic

4:19

for a specific disease,

4:21

but more than often the findings are nonspecific

4:25

because there is significant overlap

4:27

between different joint diseases.

4:30

When one starts looking at arthritis

4:32

cases, remember the following.

4:36

If it is the patient's initial examination, try

4:40

to make a differential diagnosis based on imaging findings

4:44

as well as patient information and lab findings.

4:48

Master the radiographic findings of osteoarthrosis

4:52

and rheumatoid arthritis

4:54

and remember the distinct features

4:57

between these two entities.

5:00

If it is not typical osteoarthritis

5:03

or rheumatoid arthritis, then use the systemic approach

5:06

in the first paragraph.

5:09

If it is a follow-up case, then check disease progression

5:13

and look for new findings and progression.

5:17

Remember that secondary osteoarthrosis can develop

5:21

secondary osteoarthrosis can also be a sign

5:24

of low grade progression of the original disease.

5:29

This flow chart shows the approach

5:31

to radiographic evaluation of arthritis in the presence

5:36

of joint space narrowing.

5:38

It is important to differentiate degenerative from

5:41

inflammatory conditions.

5:44

It looks complicated, but don't let it scare you.

5:47

We will first cover general concepts

5:50

and later specifically address the findings in

5:53

osteoarthrosis and rheumatoid arthritis.

5:57

In both RA and oa, we begin with joint space narrowing,

6:01

but in oa, the joint space narrowing is

6:04

usually asymmetric.

6:06

There may be osteophytosis

6:09

and there may be sclerosis in ra.

6:12

On the other hand, we see symmetric joint space narrowing,

6:17

erosions and soft tissue swelling.

6:20

Degenerative joint disease is characterized by osteophytes

6:24

and subc chondral sclerosis with an asymmetric distribution,

6:29

both when you compare left to right as as well

6:32

as within the joint itself.

6:36

Usually it is typical osteoarthrosis

6:39

when findings are atypical, including an unusual combination

6:44

of patient age affected joint and severity.

6:48

Think of post-traumatic arthritis

6:51

or calcium pyrophosphate dehydrate crystal deposition

6:55

disease, neuropathic disease

6:58

or rare diseases such as hemophilia,

7:02

inflammatory joint disease is characterized by bone erosions

7:08

osteopenia, soft tissue swelling

7:11

and symmetric joint space loss.

7:15

Inflammation of a single joint should raise concern

7:18

for infection multiple symmetric joint inflammation

7:23

in a proximal distribution in the hands

7:26

or feet without bone proliferation

7:29

suggests rheumatoid arthritis

7:33

when the inflammation is more in a distal distribution in

7:36

the hands or feet with bone proliferation,

7:39

it suggests a seronegative spondyloarthropathy.

7:45

Spondyloarthropathy is a group

7:46

of chronic inflammatory diseases associated

7:50

with the HL a B 27 antigen.

7:55

Axial spondyloarthropathy.

7:58

Most commonly ankylosing spondylitis

8:01

is located more in the axial skeleton, peripheral

8:07

spondyloarthropathy like psoriatic reactive

8:11

and inflammatory bowel disease.

8:13

Associated arthritis is located more in

8:16

the peripheral skeleton.

8:20

Joint diseases have variable manifestations

8:23

with often an overlap of radiologic features.

8:28

The A-B-C-D-E-S mnemonic is a helpful tool

8:33

for a systemic and complete

8:36

radiologic interpretation and reporting.

8:40

We use this tool which stands for articular findings,

8:45

bone changes, cartilage findings, distribution,

8:50

extra findings, and soft tissue findings.

8:53

There are also variants of this mnemonic.

8:57

Some use A B, CDE for alignment, bone

9:02

cartilage distribution and joint effusion.

9:08

Here we see a typical synovial joint.

9:10

On the left, we see two bones separated by a joint space

9:16

with the bone ends covered in articular cartilage,

9:18

which is demonstrated in blue.

9:21

We see the joint capsule in red surrounding the joint.

9:26

Notice the bay areas indicated in the left diagram.

9:30

This region is not covered with articular cartilage and

9:34

therefore hypertrophic synovium

9:37

can cause erosions in this area.

9:40

When we look at the disease, rheumatoid arthritis

9:44

D diagrammed in the middle image, we see those

9:48

marginal erosions located at the bare areas of bone.

9:53

Marginal erosions are typically seen in rheumatoid arthritis

9:56

at the metacarpophalangeal joints

9:59

and in psoriatic arthritis,

10:01

but not at the metacarpophalangeal joints.

10:04

Instead, psoriatic is seen at the distal

10:07

interphalangeal joints.

10:10

If we look at the right hand diagram,

10:12

we see subc chondral erosions in the cartilage,

10:16

which are typical features of osteoarthrosis

10:20

in severe osteoarthrosis.

10:22

The bones may even interdigitate.

10:25

I will show you images of this later.

10:29

Here we see more example of articular erosions.

10:34

In erosive osteoarthrosis, we see osteophyte formation

10:38

and a central erosion,

10:39

which can be termed the gull wing deformity

10:42

like a flying bird.

10:44

In psoriatic arthritis, we see a combination

10:48

of erosive changes

10:49

and bone proliferation as seen in the middle diagram.

10:54

These changes occur because psoriatic arthritis,

10:57

although inflammatory has a much slower progression than

11:01

rheumatoid arthritis,

11:03

thus can begin bone forming at the margins

11:06

of the distal bone.

11:08

As we see in this diagram in psoriatic arthritis,

11:13

this picture is called the pencil and cup deformity.

11:18

When we look at the right hand diagram,

11:19

we see a marginal erosion that is eccentric, juxta articular

11:25

and has an overhanging edge.

11:28

This is characteristic of the disease gout.

11:34

Rheumatoid arthritis in image number one shows typical

11:38

marginal erosions in the metacarpophalangeal joints.

11:42

In image two, erosive osteoarthritis is present

11:47

showing subc chondral erosions in the distal interphalangeal

11:51

joints and proximal interphalangeal joints.

11:54

The current, the concurrent formation of osteophytes

11:57

and joint space narrowing results in a gull wing deformity.

12:02

There also may be interation of the bones.

12:06

This is indicated by the white arrow.

12:09

The distal interphalangeal joint

12:11

to the left is a classic gull wing deformity.

12:16

Gout is shown in image number three.

12:19

Here we see eccentric erosion with an overhanging edge.

12:23

The sclerotic margin in this case indicates chronic

12:27

and indolent disease.

12:31

Infection is noted in image number four,

12:35

demonstrates destructive changes

12:37

with a permeated appearance, cartilage loss erosions,

12:42

and sometimes soft tissue swelling as seen here,

12:47

psoriatic arthritis shows boney erosions

12:50

and the narrowed end of the proximal flinx as a pencil,

12:55

which rests in the cup formed by the expanded base

12:59

of the distal fink.

13:02

Scleroderma and other multisystem disorders can produce

13:06

erosions at the distal tts, which is called

13:10

acro osteolysis.

13:12

You will see more examples

13:14

and we will cover these disorders, these disease processes.

13:18

As we move forward

13:19

and in further talks,

13:23

let's now look at alignment with rheumatoid arthritis.

13:28

Ulnar deviation of the dis digits may occur

13:30

as a late finding.

13:32

Notice the joint space narrowing

13:34

and erosions as well in erosive arthritis,

13:39

malalignment may occur as an end stage finding,

13:42

but the erosions and inner digitation give away the disease.

13:47

Here's a nice example of subluxation,

13:50

perhaps frank dislocation, soft tissue swelling

13:54

and increased soft tissue density in gout.

14:00

Bone formation is also an important finding in

14:03

osteoarthrosis CPPD, crystal deposition disease

14:06

and psoriatic arthritis.

14:09

Bone formation or proliferation is seen in many joint

14:13

diseases, especially in osteoarthrosis,

14:17

diffuse idiopathic skeletal, hyperos, ptosis,

14:20

and the spondyloarthropathies like ankylosing spondylitis

14:25

and psoriatic arthritis.

14:28

It is not present in the active phase

14:31

of rheumatoid arthritis.

14:34

Osteophytes and osteoarthrosis are marginal bony

14:38

proliferations that develop at the margins

14:40

of a synovial joint secondary

14:44

to articular cartilage damage osteophytes.

14:48

In patients with CPPD as we see in the image,

14:52

notice the soft tissue calcifications indicated

14:56

by the circle bony proliferations in psoriatic

15:00

arthritis sometimes described as fluffy peros titis

15:06

indicated by the arrowhead

15:11

osteophytes in the spine.

15:13

Spondylosis degenerative disease are seen in their typical

15:17

orientation, horizontal

15:20

and perpendicular to the spine.

15:24

CDEs aytes, on the other hand, are ossifications

15:27

of the anterior fibers of the annulus fibrosis

15:32

with a typical orientation is vertical

15:35

or parallel orientation to the spine.

15:39

This is a hallmark of ankylosing spondylitis,

15:43

diffuse idiopathic skeletal hypers.

15:45

Ptosis is seen as ossification

15:49

and deep to the anterior longitudinal ligament.

15:53

These ossifications are bulkier compared to ossifications.

15:57

In ankylosing spondylitis.

16:02

Changes in bone density presented as either osteopenia

16:06

or as osteosclerosis.

16:09

Perticular osteopenia is typically seen in rheumatoid

16:14

arthritis and not seen in osteoarthrosis.

16:19

Perticular demineralization develops

16:21

because of hyperemia of the inflamed synovium

16:24

and soft tissues.

16:26

Increased blood flow washes out the bone about the joints.

16:32

Subc chondral sclerosis is typically seen in osteoarthrosis.

16:37

It can be also found in patients

16:39

with neuropathic arthritis in later stages.

16:43

Here are two examples of perticular osteopenia.

16:47

In patients with rheumatoid arthritis,

16:50

the osteopenia can be very subtle.

16:53

It may help to play with the window settings on your monitor

16:56

or squint your eyes to see the osteopenia brother.

17:00

In the first image on the left,

17:02

the light blue box demonstrates subtle

17:05

perticular osteopenia at the metacarpophalangeal joints.

17:10

In the yellow box, in the middle image

17:12

and the circle, we can see the characteristic

17:16

perticular osteopenia.

17:18

This is also clearly seen in the image on your right.

17:24

In these diagrams which demonstrate degenerative changes on

17:28

the left and inflammatory changes on the right, we can see

17:33

that degenerative diseases affect the cartilage in a

17:37

non-uniform matter

17:39

because of the mechanical load,

17:40

which is not evenly distributed throughout the joint

17:45

in inflammatory diseases.

17:47

On the other hand, hand, the cartilage is affected mostly

17:51

uniformly since the synovitis is present across

17:55

the entire joint.

17:59

Here's a nice example of typical osteoarthrosis

18:02

with cartilage loss on the medial side,

18:05

subc chondral sclerosis

18:08

and osteophytes in image number one.

18:11

This also demonstrates mild medial femoral tibial shift,

18:15

which occurs because of laxity in the medial

18:18

and lateral collateral ligaments.

18:22

In image two, there is uniform cartilage loss,

18:25

no osteophytes,

18:26

and in such a case,

18:28

your first thought should be inflammatory joint disease.

18:35

The distribution of joints involved in various disorders

18:38

will be discussed throughout this talk.

18:41

Understanding the distribution patterns is a very powerful

18:45

tool since the most common diseases such as osteoarthrosis,

18:50

rheumatoid arthritis

18:51

and psoriatic arthritis have distinctive patterns.

18:55

As we see here, as I move through this series

19:00

of lectures about the various joint diseases,

19:03

I will start each section with an illustration

19:06

of distribution.

19:08

The classic distribution

19:10

for osteoarthrosis is seen in the left image

19:14

osteoarthrosis most commonly affects the trife joint

19:17

and the base of the thumb in the wrist

19:20

and the distal interphalangeal joints of the hand.

19:24

Occasionally, as seen in yellow,

19:27

the proximal interphalangeal joints may be affected.

19:32

Rheumatoid arthritis has a totally different distribution

19:35

as seen in the middle image.

19:37

Rheumatoid affects the entire wrist as we see here,

19:41

the metacarpal phal joints

19:43

and the proximal interphalangeal joints.

19:47

This is an important pattern to learn

19:50

in psoriatic arthritis.

19:52

Changes are noted in the distal interphalangeal joints,

19:56

the proximal interphalangeal joints with sparing

20:00

of the metacarpophalangeal joints,

20:02

but in the wrist, the trife joint

20:05

and the triquetral hamate

20:07

and pisiform joints may be involved.

20:12

Please also remember

20:13

that serologic tests can be helpful if rheumatoid

20:16

disease are suspected.

20:18

A positive rheumatoid factor

20:20

or anti citral related peptide, also known

20:24

as CCP antibody test

20:26

can support when rheumatoid arthritis is suspected.

20:32

A positive hhl a V 27 antigen test can aid in establishing

20:36

the diagnosis of ankylosing spondylitis,

20:40

which we will look at in detail much later.

20:45

Also, non-specific inflammatory markers,

20:47

including the erythrocyte sedimentation rate

20:50

and C-reactive protein are often

20:54

elevated in any inflammatory disease.

20:57

Please do remember

20:58

that immunologic tests are not always helpful

21:01

because they have limited specificity

21:04

for the type of disease.

21:09

It is important to look at the soft tissue as well.

21:12

When evaluating the joints for arthritis,

21:16

soft tissue swelling

21:17

and calcification are frequently seen in arthritis

21:20

and can help to narrow the differential diagnosis.

21:24

Here are three different images

21:26

that demonstrate the importance of soft tissue changes

21:30

and calcification.

21:32

In the first image of an AP wrist radiograph

21:36

with calcium pyrophosphate dehydrate crystal deposition

21:39

disease, we see several findings that suggest this disease.

21:46

Chondrocalcinosis is a descriptive term for the presence

21:50

of calcifications within the joint.

21:53

Although nonspecific CPPD is very likely when

21:57

chondrocalcinosis is located

21:59

around the tri triangular fibrocartilage complex

22:04

radiocarpal joint

22:06

or within the knee joints as well as the synthesis pubis.

22:10

Another finding that we see on imaging number one is

22:14

SIC dissociation,

22:16

which may be an end stage often seen in CPPD crystal

22:20

deposition disease.

22:23

In the middle image, we see chondrocalcinosis in the

22:26

meniscus of the knee.

22:28

Chondro calcinosis in the knee can be quite

22:31

bizarre and extensive.

22:34

Finally, in the third image which represents gout,

22:37

the arrow indicates a soft tissue swelling

22:41

that is denser than the adjacent soft tissues.

22:45

This soft tissue mass

22:46

with increased density is almost pathognomonic for gout.

22:51

Other typical locations are tendon insertions

22:54

around the knee, for example, the populous tendon

22:57

or flexor tendons around the ankle joint.

23:03

In the left image, we see fusiform perticular soft tissue

23:07

swelling, which is a common finding in psoriatic arthritis

23:11

and may involve the entire digit resulting in dactylitis.

23:17

Did you notice the pencil

23:18

and cup deformity

23:19

of the distal inner FLA interphalangeal joint of the thumb?

23:24

In the middle image, we see coarse calcifications in the

23:28

subcutaneous tissues at the medial side of the thumb.

23:32

This type of calcification seen in the fingers

23:35

and toes is very likely secondary to scleroderma.

23:40

Scleroderma is also noted in the right image.

23:46

Here we have more soft tissue findings.

23:49

In the specimen photograph, we see an arrow porting

23:52

to a heberden's nodule seen commonly in osteoarthrosis.

23:58

In the middle image, we see masses

24:00

that we might think look like gout.

24:03

However, the patient has a normal serum uric acid

24:08

and high rheumatoid factor titer,

24:11

so these are most likely rheumatoid nodules.

24:15

Additionally, they are too large for he nodules

24:19

and no osteophytes or other degenerative changes

24:22

or present adjacent to them.

24:25

Finally, in the right image,

24:27

we see an AP projection of the wrist.

24:30

Multiple findings consistent

24:32

with CPPD crystal deposition disease arthropathy in its end

24:36

stage are present, including severe narrowing

24:39

of the radiocarpal joint,

24:41

particularly the radio scaphoid joint winding widening

24:46

of the scapholunate joint, marked narrowing

24:50

of the mid carpal joint, large subc chondral

24:53

and intraosseous cysts,

24:55

and finally chondrocalcinosis in the triangular

24:59

fibrocartilage complex.

25:02

This pattern is referred to as a slack wrist, which stands

25:06

for scaffold lunate advanced collapse.

25:10

Remember, if you see this pattern in the wrist,

25:12

without the presence of chondrocalcinosis,

25:15

you can still confidently make the diagnosis

25:18

of CPBD crystal deposition disease arthropathy.

25:25

Now we're going to move on

25:26

to our first index disease osteoarthrosis.

25:31

Many people refer

25:32

to this in this fashion rather than osteoarthritis

25:35

because in osteoarthrosis there is little

25:38

to no inflammation.

25:41

In the diagram, you can see the most common areas affected

25:44

by this disease, including the cervical spine,

25:48

the acromioclavicular joint, the lumbosacral spine, the hip

25:53

and the knee in the hand.

25:56

Osteoarthrosis effects the trica joint

25:59

and the base of the thumb along

26:01

with the distal interphalangeal joints

26:03

and rarely the proximal interphalangeal joints in the foot.

26:09

The most common location is the metacarpophalangeal

26:12

joint of the great toe.

26:15

Osteoarthrosis is the most common joint

26:17

disease in the world.

26:19

Its incidents increases with age.

26:22

It is characteristic characterized by nine non-inflammatory

26:27

destruction of cartilage, which is usually

26:31

somewhat asymmetric.

26:33

There are two forms, primary idiopathic and secondary.

26:39

Secondary occurs because of changes post-trauma

26:43

or in obese patients.

26:47

The radiographic findings include using our A, B, C, D,

26:52

E and S criterion articular changes.

26:56

There are no erosions noted in this disease bone changes.

27:02

There is no osteopenia.

27:04

However, productive changes like osteophyte formation

27:08

and subc chondral sclerosis are common.

27:12

Cartilage demonstrates non-uniform joint space narrowing,

27:17

subc chondral, cyst formation,

27:19

and sometimes marginal sclerosis.

27:23

The distribution is, as we see in the illustration,

27:27

extra findings include subluxations associated

27:31

with such findings as hax valgus or hax rigidus in the foot.

27:37

Finally, soft tissue changes include Hebert heberden's nodes

27:41

in the distal interphalangeal joint

27:43

or BOUCHARD'S nodes in the proximal interphalangeal joint.

27:48

An important pearl to remember is that in many arthropathy,

27:53

secondary osteoarthrosis can be seen in the later stages.

28:00

If we think about osteoarthrosis in the knee,

28:03

it can be classified by the calgren

28:05

and Lawrence classification.

28:07

Also, it can be characterized by the degree

28:10

of joint space narrowing, which I find

28:12

to be somewhat easier.

28:14

The degenerative pattern in the knee is one

28:17

of predominantly medial com compartmental knee joint space

28:20

narrowing with usually a normal lateral compartment

28:24

or a minimally narrowed lateral compartment.

28:28

This is because the vector of body weight travels

28:31

through the medial compartment.

28:34

I will move on and discuss degenerative changes in the knee

28:38

using the recently developed top five tips in the diagnosis

28:42

of osteoarthrosis,

28:44

which has been published on the ESSR

28:47

musculoskeletal website.

28:50

We will only discuss the first

28:52

and second tip which applies to conventional radiography.

29:00

I will discuss several of the tips in the diagnosis

29:03

of osteoarthrosis.

29:06

Tip number one has to do with the imaging modalities

29:09

that we use in osteoarthrosis.

29:13

Radiography really is the imaging modality of choice

29:16

for the diagnosis of this disease.

29:19

This method allows the diagnosis

29:22

and enables the grading of its severity,

29:25

which we discussed is done using the Calgren Lawrence system

29:30

or by using a consistent system,

29:32

which demonstrates the variable findings of mild, moderate,

29:37

and severe osteoarthrosis.

29:40

Cross-sectional imaging methods are usually not needed.

29:44

They are used for the assessment of focal cartilage lesions

29:48

and for the preoperative setting if a

29:50

prosthesis is to be placed.

29:53

MRI techniques are mainly used in research

29:56

and currently have no routine clinical application.

29:59

In the diagnosis of osteoarthrosis

30:05

standing weight-bearing images of the knee are important

30:08

to quantify the degree of joint space narrowing.

30:12

Here we can see two different

30:13

radiographs of the same patient.

30:15

A non-weight-bearing AP view on the left

30:19

and a standing PA view on the right.

30:23

Notice the difference in joint space narrowing

30:27

in the right radiograph.

30:28

This really looks like moderate joint space narrowing.

30:31

However, looking at the standing PA weightbearing view

30:35

of the knee, we realize

30:38

that the joint space narrowing is

30:40

of the medial knee joint compartment

30:43

and is severe at our institution.

30:46

We do pa bilateral weightbearing knees

30:49

and then the lateral view of the knee in question.

30:52

This allows us to compare both knees,

30:55

which helps in deciding whether the joint space narrowing is

30:59

mild, moderate, or severe.

31:02

Also, on both radiographs, we see squaring of the lateral

31:07

and medial aspects of the tibial plateau,

31:10

which represents early osteophyte formation

31:13

seen commonly in osteoarthrosis.

31:17

Also, please note in the right radiograph

31:19

that the arrowheads indicate subc chondral sclerosis,

31:23

which is a common finding as well.

31:27

Subc chondral cysts are also a common finding

31:30

in osteoarthrosis.

31:32

The pathogenesis is not clearly known,

31:34

but there are two theories.

31:37

The bone contusion theory states that high loads

31:40

or multiple microtrauma lead to trabecular microfractures

31:45

necrotic bone and focal bone resorption resulting in the

31:49

development of cysts.

31:51

The synovial fluid intrusion theory states

31:55

that alterations of the cal calcified barrier

31:58

between cartilage

32:00

and subc chondral bone allow the entrance

32:03

of fluid into the subc chondral bone region causing a fluid

32:07

filled cystic lesion.

32:10

Here we can see a sub chondral cyst indicated

32:13

by the arrowhead in plain radiography

32:16

and in magnetic resonance imaging.

32:20

Now it's time to look at multiple examples of joints

32:23

with osteoarthrosis.

32:26

Looking at the radiograph labeled a joint space narrowing is

32:30

seen at the fourth distal interphalangeal joint indicated

32:34

by the arrow with osteophyte formation

32:37

and subc chondral sclerosis in the image designated B

32:42

asymmetric joint space narrowing of the second

32:45

through fifth distal interphalangeal joints

32:48

with osteophyte formation, subc chondral sclerosis,

32:52

and slight ulnar deviation

32:54

of the third distal interphalangeal joint is indicated

32:58

by the black arrow.

33:01

The proximal interphalangeal joints are also affected,

33:04

but to a lesser degree.

33:08

Here are images of the hip and the shoulder.

33:12

When we look at the image of the hip, we see severe

33:14

and non-uniform narrowing of the hip joint

33:18

with osteophyte formation, subc chondral sclerosis,

33:22

and large cyst formation.

33:24

In the shoulder, we see severe narrowing

33:27

of the glenohumeral joint space with osteophyte formation

33:31

and subc chondral sclerosis.

33:33

This would be incidentally designated a Calgren Lawrence

33:37

classification grade four.

33:42

Here we have two terrific examples of osteoarthrosis.

33:46

In the image of the hip, we see severe non-uniform narrowing

33:50

of the hip joint with osteophyte formation,

33:53

subc chondral sclerosis, and a large cyst.

33:58

In these later stages, joint deformity with broadening

34:02

and flattening of the femoral head can occur.

34:06

Looking at the knee joint, we see classic evidence

34:09

of moderate to severe asymmetric narrowing

34:12

of the medial compartment of the femoral tibial joint space

34:17

with osteophyte formation and subc chondral sclerosis.

34:21

This would be a Calgren Lawrence

34:23

classification grade three hyphen four.

34:27

In my practice, I would report the knee image

34:29

by saying severe near bone on bone joint space narrowing is

34:33

noted at the medial knee joint compartment

34:36

with subc chondral sclerosis, subc chondral cyst formation,

34:40

and small medial osteophyte production.

34:44

Squaring and sharpening

34:45

of the lateral tibial margin is also noted.

34:48

This would be consistent with moderate

34:50

to severe medial compartment osteo art.

34:56

Here we see two classic examples

34:58

of osteoarthrosis in the wrist.

35:01

On the left, we see base

35:03

of the thumb carpal metacarpal osteoarthrosis

35:06

with non-uniform joint space narrowing, osteophyte formation

35:10

and subc chondral sclerosis.

35:13

There is a large subc chondral cent in the base

35:16

of the first metacarpal indicated by the white arrow

35:21

Tris Osteoarthrosis is present in the right hand image.

35:26

This image shows non-uniform joint space narrowing

35:29

of the tris scfe joint with osteophyte formation

35:33

and subc chondral sclerosis.

35:36

These two areas are the target areas

35:38

for osteoarthrosis in the wrist.

35:43

Now we turn our attention to the second index disease

35:47

that you should know well, rheumatoid arthritis.

35:51

The distribution of rheumatoid arthritis,

35:53

as you can see in the diagram, is different than that seen

35:57

with osteoarthrosis.

35:59

Rheumatoid involves the wrist

36:01

and midfoot as well as the metacarpophalangeal joint

36:05

and the proximal interphalangeal joints

36:08

of both the hand and the foot.

36:11

Additionally, rheumatoid arthritis has a hyper proclivity

36:14

for the cervical spine without affecting the rest

36:18

of the spine, the shoulder,

36:20

the elbow, the hip, and the knee.

36:22

However, this disorder is diagnosed most frequently

36:26

by changes in the hands

36:28

and feet in rheumatoid arthritis.

36:32

Synovial hyperplasia causes cartilage damage

36:36

with marginal erosions at the bare areas of bone,

36:40

predominantly in the metacarpophalangeal joints, the wrist

36:44

and proximal interphalangeal joints.

36:48

The distal interphalangeal joints are usually not affected.

36:53

Remember that no bony proliferation is noted clinically,

36:58

rheumatoid arthritis usually starts to develop

37:01

between the ages of 40 and 50.

37:04

Rheumatoid factor and anti CCP are most often positive

37:10

because this is a systemic disease,

37:13

it has a symmetrical pattern

37:15

and usually begins in the appendicular skeleton

37:20

using our A-B-C-D-S mnemonic.

37:24

Articular changes consist

37:26

of erosions typically at the bare area of joints,

37:30

which are not covered with articular cartilages.

37:34

In later cases, we will see bony deformity.

37:38

The bones demonstrate perticular osteopenia.

37:42

This is because synovial inflammation causes hyperemia at

37:46

the affected joints

37:48

and this hyperemia washes out the

37:51

bone adjacent to the joint.

37:53

There is no bone production

37:55

or proliferation in rheumatoid arthritis.

37:57

During the active phase.

38:00

The cartilage demonstrates uniform

38:03

cartilaginous destruction.

38:05

The distribution is bilaterally symmetric

38:09

as seen in the diagram.

38:12

The extra findings are that

38:14

of systemic autoimmune inflammatory disease

38:17

that affects many organs such as the lungs,

38:20

skin, eyes, or heart.

38:23

Soft tissue swelling also will be seen demonstrated by

38:28

M soft tissue, swelling about the joints, the presence

38:32

of rheumatoid nodules and deform.

38:35

We will see these changes as we move forward.

38:41

I will now show you multiple examples

38:43

of the findings noted in rheumatoid arthritis.

38:47

In this radiograph, we see typical marginal erosions

38:50

and joint space narrowing of the

38:52

metacarpophalangeal joints three through five.

38:56

Also note the uniform joint space narrowing

38:59

of the metacarpophalangeal joints.

39:02

The proximal interphalangeal joints only show minimal joint

39:06

space narrowing.

39:10

These are images of the hands in end stage rheumatoid.

39:14

We can see severe erosive changes, ligamentous laxity

39:18

and destruction causing dislocation

39:21

of the metacarpophalangeal joints.

39:25

Ate dissociation indicated

39:27

by the white arrow is a common finding.

39:30

Due diffuse carpal inflammation, both the dissociation

39:34

and inflammation can cause joint space narrowing in

39:38

the radiocarpal joint.

39:40

Rheumatoid is one of the two diseases that causes

39:43

that change that causes changes in the radiocarpal joint.

39:47

In rheumatoid, we see joint space narrowing

39:50

without sclerosis or osteophytosis.

39:54

In CPPD crystal deposition disease,

39:57

the radiocarpal joint shows degenerative changes

40:01

with joint space narrowing, sclerosis,

40:04

subc chondral cyst formation,

40:06

and the presence of osteophytes.

40:09

These changes are not seen in rheumatoid arthritis.

40:15

Erosions of the distal ulnar syl can occur in

40:18

rheumatoid arthritis.

40:20

This is indicated by the light blue arrow.

40:23

These erosions are important

40:25

and may be one of the first signs we see in early

40:28

rheumatoid arthritis.

40:32

Here's a nice example in the feet.

40:35

Erosions in rheumatoid may occur in the feet at the fifth

40:39

metatarsal phal joint As we see here, remember

40:43

that when you look at the hands and feet

40:45

and you are thinking about rheumatoid arthritis as the cause

40:48

of the disease, check the ulnar OID

40:52

and the head of the fifth metatarsal.

40:54

First.

40:59

Soft tissue changes in rheumatoid arthritis are often seen

41:02

in various joints.

41:04

Rheumatoid nodules are firm masses

41:07

that appear subcutaneously in up to 20% of patients

41:11

with rheumatoid arthritis.

41:14

These nodules usually occur adjacent to joints

41:17

that are overexposed to trauma

41:20

or pressure such as the finger joints and elbows.

41:24

Here we see a lateral elbow radiograph on the left

41:27

of a patient with a large rheumatoid nodule.

41:30

On the croon, notice

41:33

that it is the same radio density as muscle.

41:37

The right image is of a different patient

41:40

with zero positive gout.

41:42

That demonstrates a much denser interior structure,

41:47

and that's one of the ways to tell them apart.

41:50

Gouty tophi tend

41:52

to be more dense than the surrounding soft tissues.

41:58

Atlantoaxial subluxation in the cervical spine is an

42:01

important finding in rheumatoid arthritis.

42:05

The cervical spine is a frequently affected area

42:07

for rheumatoid arthritis

42:09

and can present as atlantoaxial sub subluxation

42:13

or basilar invagination with cranial settling.

42:17

Cranial settling occurs when the dens extends into

42:20

the Formin Magnum.

42:22

Atlanta Axial subluxation is an important

42:25

and potentially life-threatening complication.

42:29

It is defined when the space between the dens of C two

42:33

and the arch of the atlas exceeds more than three

42:36

millimeters in width.

42:38

It is caused by inflammatory ligament. DYS laxity.

42:43

Instability of this joint may result in numerous neurologic

42:46

symptoms because of the compression of the spinal cord.

42:51

Here we see two lateral images of the cervical spine,

42:55

the left image in extension

42:57

and the right image is inflection.

43:00

Notice that in extension,

43:02

the anterior arch dens distance is difficult to measure,

43:07

however, inflection the distance increases markedly

43:11

to 14 millimeters

43:14

and with the norm in adults being about three millimeters.

43:20

Here is the lateral view taken from a computer tomography

43:23

image of the cervical spine demonstrating basal

43:27

invagination, also called cranial settling.

43:31

This finding occurs in five to 10% of patients

43:34

with cervical rheumatoid arthritis in basler invagination.

43:40

The odontoid process projects into the Formin Magnum

43:44

limiting the space for the spinal cord.

43:46

As we see in this image,

43:49

clinical presentations range from chronic headaches,

43:53

limited neck motion to acute neurologic deteriorations

43:57

because of spinal cord

44:00

and brain stem compression, which can lead to paralysis

44:04

or even death if the neck is moved in certain positions.

44:10

We have come to the end of part one

44:11

of a three part lecture series

44:13

concerning introduction to arthritis.

44:16

In this lecture, I have outlined

44:18

and discussed the target approach to the diagnosis

44:20

of osteoarthrosis and rheumatoid arthritis.

44:24

I have shared an overview of the bone

44:26

and soft tissue findings in both these disorders

44:29

and have compared them showing examples

44:32

of typical findings seen in these entities.

44:36

In part two of this series,

44:38

I will discuss the target approach to the diagnosis

44:41

of many types of arthritis including juvenile,

44:45

rheumatoid arthritis, erosive osteoarthritis,

44:50

septic arthritis, and the spondyloarthropathies

44:53

dish and gout.

44:55

Part three will deal with CPPD, crystal deposition disease,

45:00

scleroderma, systemic lupus, erythema ptosis, sarid,

45:06

neuropathic arthritis, hemophilia, and CRMO

45:10

and SFO syndrome.

45:12

Thank you so much for your time and attention.

45:18

Thank you so much for sharing your lecture with us, Dr.

45:20

Beki. At this time, we'll open the floor

45:22

for any questions from our audience

45:24

and remember you can submit those through that Q

45:27

and A feature so we can get to as many as we can

45:31

before our time is up.

45:34

Dr. B, are you able to open the The q&a? Yeah.

45:37

Awesome, and I think people, someone wrote in cases

45:40

of severe osteoarthritis with femoral head deformity,

45:45

is it okay to use the term A VN, which stands

45:49

for avascular necrosis?

45:52

No, because avascular necrosis is a different mechanism.

45:56

This is bony destruction just secondary

45:59

to all the all the things, the cyst formation,

46:03

the mechanical breakdown or the femoral head,

46:06

and it completely changes its shape.

46:11

Okay. Someone said great talk with great diagrams.

46:14

Do you have any experience using AI

46:16

to detect subtle erosion, subtle joint space narrowing

46:19

and subtle osteopenia in hand films?

46:22

I wish I did. I would be grateful to have an AI system

46:26

that would help me do this.

46:28

Working for the National Health, uh, service in, in London,

46:32

we basically deal with what we are given

46:35

and we work using our eyes.

46:37

There are programs that have AI in in the United Kingdom,

46:41

but I don't have access to

46:43

to it at this time and let's see.

46:46

Great talk with great diagrams.

46:47

Okay, that one, that one I answered. Alright.

46:51

Thank you very much.

46:56

Findings of osteoarthrosis of the sacroiliac joints.

47:00

I will discuss later in a later lecture

47:05

in rheumatoid arthritis.

47:06

This is okay to give a differential

47:08

of gout in case the patient is not known for weather.

47:14

Uh, the presentation

47:17

of gout is usually much different than

47:21

than rheumatoid arthritis,

47:23

and I would not put the two together in my mind.

47:27

They're separate entities with a separate distribution,

47:31

as you'll see when I discuss gout later on.

47:35

How does the rheumatoid nodules appear in ultrasound?

47:38

Unfortunately, I'm not an ultrasound expert

47:41

and I'm not sure how they, how they appear.

47:44

Dual energy CT for gout?

47:46

Yes, we do, and that will be part

47:48

of the lecture when we discuss gout,

47:54

DDD

47:59

sometimes in later stages of rheumatoid arthritis, uh,

48:03

osteoarthritis does occur.

48:06

Uh, someone asks, with RA

48:08

or the spine is a common to have existing oa.

48:11

The OA tends to come secondary to the rheumatoid arthritis

48:16

in most cases, in the cervical spine.

48:19

Degenerative changes begin in the forties in some patients,

48:24

and rheumatoid also begins in the forties and fifties.

48:37

If you are, oh boy, they're jumping.

48:39

If you're not convinced what it is,

48:41

can you give a differential diagnosis

48:43

and use the term arthropathy or is this incorrect?

48:47

Well, I had hoped that I showed you how to be convinced

48:51

for at least these two diseases

48:53

and will learn the differentials

48:56

and the distributions of every disease that I'll discuss.

49:01

So if you study these patterns

49:03

and just burn them into your mind, you'll look at a case

49:08

and you'll see the changes and you'll recognize the disease.

49:15

I don't use the term accelerated oa.

49:18

I've, in fact, I've never heard that,

49:20

but I don't and I don't use it.

49:23

How did I end up in the uk? That's a personal question.

49:30

How do we differentiate primary from secondary CPPD?

49:34

That's also fo coming in the, in the next, that's an also,

49:37

that's a lecture to itself in itself.

49:43

I've enjoyed doing the, uh, the talk today

49:46

and I'm, you've had some really good questions. Guess

49:51

That's About all of them so far.

49:53

Yeah. Thank you so much for answering all those questions

49:55

and thank you so much for the lecture.

49:57

We really appreciate it. Dr.

49:59

Bii, thank you all

50:00

for participating in our noon conference lecture today

50:04

and for asking such great questions.

50:06

You'll be able to access the recording

50:07

of the noon conference

50:09

by creating a free MRI online account,

50:11

and you'll receive an email shortly with the replay.

50:14

Be sure to join us next week on Thursday,

50:16

February 8th at 12:00 PM Eastern

50:18

for a noon conference featuring Dr.

50:21

SSH McCury for a lecture entitled SCCA of the Larynx,

50:25

what Radiologists Need to Know.

50:27

You can register for this free lecture@mrionline.com

50:30

and follow us on social media

50:32

for updates on future lectures.

50:34

Thanks again and have a great day.