A case of unilateral shoulder joint hydrarthrosis with wild-type amyloidogenic transthyretin amyloidosis.

Wild-type amyloidogenic transthyretin (ATTR) amyloidosis, known as systemic senile amyloidosis (SSA), is an age-related nonhereditary amyloidosis, which is known to cause cardiomyopathy and carpal tunnel syndrome (CTS). Herein, we report a case of unilateral hydrarthrosis with arthritis of the right shoulder joint in an 82-year-old Japanese housewife who has a seven year history of polyneuropathy due to an unknown aetiology. At first, her joint pain was thought to be caused by overuse of her right upper arm. Despite treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and repeated arthrocentesis, her symptoms did not improve. She then visited our hospital, where magnetic resonance imaging (MRI) of her right shoulder suggested synovitis and hydrarthrosis. She also had an arthroscopic synovectomy of the right shoulder joint. The pathological testing revealed a diagnosis of non-specific arthritis with amyloidosis. After further pathological examination, wild-type ATTR was identified and she was diagnosed with senile amyloidosis.

The Role of Clinical Examination in Predicting Relevant MRI Findings in Acute Knee Injuries: A Retrospective Study.

The objective of this study was to delineate the usefulness of clinical examination and magnetic resonance imaging (MRI) in acute knee injuries. We aim to establish whether the time period post acute knee injury is related to the diagnostic accuracy of clinical examination and to investigate the strength of specific clinical examination findings in predicting a clinically relevant MRI abnormality. Seventy patients were referred to fracture clinic with an acute knee injury who subsequently went on to be investigated with MRI over 12 months. These patients were retrospectively analyzed looking at the time period they were reviewed, the components that were assessed at physical examination, and the results of their eventual MRI scan looking for any correlation. A greater proportion of patients who were examined at 2 weeks had relevant positive findings on MRI scan, p = 0.03. Range of movement and lateral joint line tenderness were not associated with a positive MRI scan at any period after injury. The presence of a moderate to large effusion was not associated with an MRI abnormality if the examination was within 2 weeks of injury but was if present 2 weeks after injury, p = 0.0001. Range of movement should not form part of the decision making on whether an injury should be investigated with MRI. Joint effusion in isolation within 2 weeks after injury should not be an indication for MRI but a repeat clinical examination in 2 weeks, where if still present, should be investigated with MRI.

Parotid Lymphadenopathy Is Associated With Joint Effusion in Non-Neoplastic Temporomandibular Disorders.

PURPOSE: Lymphadenopathy often occurs in the setting of inflammation, with or without infection. We sought to elucidate any association of parotid lymphadenopathy with joint effusion in temporomandibular joint (TMJ) disorders. MATERIALS AND METHODS: We performed a retrospective cohort study. We analyzed the magnetic resonance imaging studies of patients with suspected TMJ disorders performed from April 2006 to March 2007. The degree of joint effusion was graded on sagittal T2-weighted spin echo images according to a commonly used system. On axial short T1-weighted short inversion recovery images, the number and short-axis diameter of the parotid lymph nodes were recorded. We performed analyses of the cluster-correlated data using the Mann-Whitney U test and Spearman's correlation coefficients. P < .05 was considered to indicate significance. To assess the possible predictive value of certain variables, a generalized linear model (generalized estimation equation) was constructed, considering the multiple measurements. RESULTS: A total of 402 TMJ disorders were analyzed from 201 patients during the study period. The number and size of the parotid lymph nodes identified was significantly greater in the patients with TMJ effusion (P < .01) than in those without effusion. CONCLUSION: In the present study, we found an association between parotid lymphadenopathy and joint effusion in TMJ disorders. These findings indicate that lymphadenopathy should be considered as an inflammation condition commonly associated with joint effusion in TMJ disorders.

Negative magnetic resonance imaging in femoral neck stress fracture with joint effusion: a case report.

Femoral neck stress fracture (FNSF) is well documented in the orthopedic literature and is generally associated with strenuous activities such as long-distance running and military training. The diagnostic yield of magnetic resonance imaging (MRI) for FNSF was reported to be 100 %, and early MRI is recommended when this fracture is suspected. We encountered a 16-year-old male long-distance runner with FNSF in whom the left femoral neck showed no signal changes on MRI although an effusion was detected in the left hip joint. One month later, roentgenograms revealed periosteal callus and oblique consolidation of the left femoral neck, confirming the diagnosis of compression FNSF. Because FNSF with a normal bone marrow signal on MRI is very rare, this patient is presented here.

Association of hip joint effusion volume with early osteonecrosis of the femoral head.

This study aimed to examine the association between hip joint effusion volume and osteonecrosis of the femoral head (ONFH) using the Association Research Circulation Osseous (ARCO) classification. Patients (n = 403) who were diagnosed with ONFH were enrolled between February 2005 and December 2008. Only patients (n = 109) with complete clinical and imaging data and at early to mid ARCO stage (I - III) were eligible for further analysis, including 94 males and 15 females. All the included patients had hip joint radiographic examinations (anteroposterior and frog-leg views) and magnetic resonance imaging scans (axial and coronal views). Out of 109 patients included in this study, 185 hip joints were involved (unilateral disease in 33 patients and bilateral diseases in 76 patients). The patients had a mean age of 39 ± 11 years (range, 13-70). All the affected hip joints exhibited effusion, classified as grade 1 (n = 70, 37.8%), grade 2 (n = 62, 33.5%), and grade 3 (n = 53, 28.7%). The volume of joint effusion varied significantly among stage I, II, and III (X2 = 29.210, P < 0.05). The effusion volume did not differ significantly among stage IIA, IIB, and IIC (X2 = 0.103, P > 0.05), whereas it differed significantly among stage IIIA, IIIB, and IIIC (X2 =11.556, P < 0.05). The volume of hip joint effusion was associated with the ARCO stage, and increased over the staging.

Chondroblastoma of the femoral neck as a cause of hip synovitis.

Chondroblastoma is a rare benign chondroid bone tumor, which typically arises from the epiphysis of a long tubular bone. We present a 13-year-old girl with persistent hip synovitis caused by a chondroblastoma that arose from the femoral neck (metaphysis) and uniquely extended extraosseously into the hip joint. Computed tomography scan clearly demonstrated a tumoral lesion of the left femoral neck and a periosteal reaction along the anterior cortex of the femur, distal to the legion. Magnetic resonance imaging showed reactive synovitis with marked joint effusion of the hip and an extensive edema in the proximal femur and the surrounding soft tissues. Aneurysmal bone cysts formation secondary to chondroblastoma was confirmed by histologic examinations of the excised specimens. Complete relief of pain and an improvement in the range of movement of the hip joint was obtained after surgical resection of the tumor.

Pigmented villonodular synovitis: extrasynovial recurrence.

A 32-year-old female athlete underwent arthroscopy for a second recurrence of pigmented villonodular synovitis (PVNS), which was extrasynovial, seen on magnetic resonance imaging. It was noted on arthroscopy that (1) the nodules moved medially with joint insufflation, (2) the nodules were less prominent than on magnetic resonance imaging, and (3) more than 95% of the recurrent tumor was hidden by neosynovium. We believe that the extrasynovial location is because of the more rapid proliferation of the neosynovium relative to the growth of the remaining tumor cells after the previous resection. In resecting pigmented villonodular synovitis with a high risk of recurrence, a layer of periarticular fat should be removed and the surgeon should be wary of change in position with insufflation.

Chylous hip joint effusion and bone absorption after total hip arthroplasty in a patient with chylocolporrhoea: a case of Gorham's disease.

Chyle is a sterile, milky fluid consisting of lymph and emulsified fats that is formed in the small intestines and taken up by lymph vessels. Chylous effusions usually occur after destruction or obstruction of lymphatic channels, and chylous joint effusions have been reported in association with rheumatoid and/or septic arthritis, and as the result of penetrating trauma to subsynovial fatty tissue and the intra-articular fat pad. We report a case of bone absorption and lytic change in the femur associated with a chylous hip joint effusion after a total hip arthroplasty (THA) in a patient with chylocolporrhoea and a history of chylous ascites.

Pigmented villonodular synovitis: a retrospective single-center study of 122 cases and review of the literature.

OBJECTIVES: Pigmented villonodular synovitis (PVNS) is a rare but disabling disease. The objective was to describe the clinical presentation and outcomes of PVNS according to its localization. METHODS: Retrospective, systematic study of all cases of biopsy-proven PVNS followed in 1 tertiary-care center specialized in isotopic synoviorthesis. Cases were selected by keyword. Collected data included disease localization, therapeutic modalities, and outcomes. RESULTS: A total of 122 cases (mean age 33.0 ± 13.1 years, 58% female, 89% diffuse form) of histologically confirmed PVNS were analyzed with a mean follow-up of 5.8 ± 4.3 years (707 patient-years total). The main localizations were the knee (75%) and ankle (16%). Clinical presentation included joint pain (80%) and joint effusion (79%) with hemarthrosis (75% of analyzed articular fluid). The mean delay before diagnosis was 2.9 ± 3.7 years. Magnetic resonance imaging was helpful for diagnosis in 83%. Surgical synovectomy was initially performed in 98% of cases and was often associated with isotopic synoviorthesis (knee: 57%; other localizations: 74%). In patients with a diffuse form treated at first line by surgery followed by isotopic synoviorthesis, the relapse rate was 30% (knee) and 9% (other localizations), respectively, with a mean delay before relapse of 2.6 ± 2.4 and 2.4 ± 0.9 years, respectively. CONCLUSIONS: PVNS occurs in young adults, mainly in the knee joint; joint pain and effusion with hemarthrosis are the most frequent signs. Relapse is frequent, in particular, for diffuse knee PVNS; the usefulness of isotopic synoviorthesis remains to be confirmed.

Knee joint effusion following ipsilateral hip surgery.

PURPOSE: To correlate patellar reflex inhibition with sympathetic knee joint effusion. METHODS: 65 women and 40 men aged 45 to 75 (mean, 65) years underwent hip surgery. The surgery entailed dynamic hip screw fixation using the lateral approach with reflection of the vastus lateralis for pertrochantric fractures (n = 49), and hip hemiarthroplasty or total hip replacement using the Watson-Jones approach (n = 38) or hip hemiarthroplasty using the posterior approach (n = 18) for subcapital femoral fractures (n = 28) or osteoarthritis (n = 28). Knee joint effusion, patellar reflex, and thigh circumference were assessed in both legs before and after surgery (at day 0.5, 2, 7, 14, 30, and 45). Time-sequence plots were used for chronological analysis, and correlation between patellar reflex inhibition and knee joint effusion was tested. RESULTS: In the time-sequence plot, the peak frequency of patellar reflex inhibition (on day 0.5) preceded that of the knee joint effusion and the thigh circumference increase (on day 2). Patellar reflex inhibition correlated positively with the knee joint effusion (r = 0.843, p = 0.035). These 2 factors correlated significantly for all 3 surgical approaches (p < 0.0005). All 3 approaches were associated with patellar reflex inhibition on day 0.5 (p = 0.033) and knee joint effusion on day 2 (p = 0.051). CONCLUSION: Surgical trauma of the thigh may cause patellar reflex inhibition and subsequently knee joint effusion.

Rehabilitation results following anterior cruciate ligament reconstruction using a hard brace compared to a fluid-filled soft brace.

The purpose of this study was to compare the clinical outcomes of rehabilitation after ACL reconstruction using a water-filled soft brace to those using a hard brace. The method used in this study was a prospective randomised clinical trial including 36 patients wearing a hard brace and 37 patients wearing a water-filled soft brace for 6 weeks after surgery. Preoperative and postoperative (seven examinations) clinical evaluation within a follow-up period of 1 year including effusion status, swelling and range of motion (ROM), IKDC 2000, KT1000 Arthrometer, Lysholm knee scoring scale and Tegner activity score. Mean values are presented with standard deviations. Data was analysed using descriptive statistics and Student's t-test for unpaired samples. Significantly less effusion was found in the soft brace group from 5 days (p=0.002) to 12 weeks (p<0.024) postoperative. Hard brace patients presented with significantly more extension deficit from 5 days (p=0.036) to 12 months (p=0.014) postoperative but no significant difference was detected in complete ROM, laxity or thigh atrophy at any follow-up examination. Patients treated with a soft brace had significantly higher IKDC subjective ratings at 6 weeks (p=0.02) up to 12 months after operation (p=0.002) and rated significantly higher in Tegner activity score (p=0.004) and Lysholm knee scoring scale (p=0.006) 6 and 12 months (p<0.001 for both scores) postoperatively. The water-filled soft brace was superior regarding effusion, swelling, extension deficit and patient-measured midterm outcome. The soft brace presents a safe, easy-to-use and effective alternative to the hard brace.

Does running cause metatarsophalangeal joint effusions? A comparison of synovial fluid volumes on MRI in athletes before and after running.

OBJECTIVE: The metatarsophalangeal joints (MTPJ) are the only joints that bear weight directly through synovium. The purpose of this study was to determine whether there is an association between synovial stresses during running and increases in volume of joint fluid. MATERIALS AND METHODS: This was a prospective case controlled study (nine healthy athlete volunteers acting as own controls). High-resolution coronal 3D T2W magnetic resonance imaging of the MTPJs were obtained following 24 h rest and after a 30-min run. The volume of joint fluid in each MTPJ (n = 90) was measured by two independent observers using an automated propagating segmentation tool. RESULTS: The median volume of synovial fluid in the MTPJs at rest was 0.018 ml (inter-quartile range (IQ) range 0.005-0.04) and after running 0.019 ml (IQ range 0.005-0.04, p = 0.34, 99% confidence interval (CI), 0.330.35). The volume of fluid in the MTPJs of the great toes was substantially larger than other toes (0.152 ml at rest, 0.154 ml after exercise, p = 0.903). Median volumes decrease from second to fifth MTPJs (0.032-0.007 ml at rest and 0.035-0.004 ml after exercise). Subset analysis for each toe revealed no significant difference in volumes before and after running (p = 0.39 to p = 0.9). The inter-rater reliability for observer measurements was good with an intra-class correlation of 0.70 (95% CI, 0.60 to 0.78). CONCLUSION: It appears to be normal to find synovial fluid, particularly in the MTPJs of the great toes, of athletes at rest and after running. There does not appear to be an association between moderate distance running and an increase in the volume of synovial fluid.

Sonographic-detected joint effusion compared with physical examination in the assessment of sacroiliac joints in spondyloarthritis.

OBJECTIVE: An observational case-control study was designed to analyse the discriminative value of ultrasound (US)-detected joint effusion compared with physical examination in the assessment of sacroiliac joints (SIJ) in patients with spondyloarthropathy (SpA) with or without inflammatory back pain (IBP). METHODS: 45 patients with SpA, classified according to European Spondylarthropathy Study Group criteria, and 30 healthy volunteers were studied. All patients had clinical evaluation of the SIJ, Bath ankylosing spondylitis (AS) metrology index, Bath AS disease activity index, Bath AS functional index, health assessment questionnaire, patient's and physician's visual analogue scale on global disease activity. RESULTS: Ultrasound showed joint effusion in 38.9% of SIJ of patients with SpA and in 1.7% of SIJ of controls (p<0.001). The presence of IBP was significantly associated with SIJ effusion assessed by US alone or plus at least one SIJ test. SIJ effusion assessed by US alone or plus at least one SIJ test had a positive likelihood ratio (LR) (2.67 and 4.04, respectively) for the presence of IBP higher than LR of single clinical tests. Positive sacral sulcus test, iliac gapping and midline sacral thrust test were associated with SIJ effusion assessed by US, but all clinical tests, singly and in various combinations, had a low LR for the presence of SIJ effusion assessed by US. CONCLUSIONS: The study suggests that high resolution sonography is useful in the assessment of SIJ involvement in SpA, resulting in images that are fast and inexpensive and may locate, complementing the physical examination, the origin of IBP.

Bone bruise in magnetic resonance imaging strongly correlates with the production of joint effusion and with knee osteoarthritis.

BACKGROUND: The findings of magnetic resonance imaging (MRI) have not been studied systematically in patients with osteoarthritis (OA). The objective here was to compare MRI findings with radiological findings in patients with knee pain and to identify factors that influence the progression of OA of the knee. METHODS: Of 212 patients with knee pain and MRI of the knee joint, 161 patients were selected for the study after exclusion of cases of trauma and other arthritides. MRI was used to evaluate the presence and degree of bone bruise, hydrarthrosis, and injuries to the cruciate ligament and meniscus. Bone bruise was classified into four types, and hydrarthrosis into four grades. Radiologically, OA progression in the femorotibial and patellofemoral joints was analyzed according to the Kellgren-Lawrence classification. Age was divided into four groups based on distribution quartiles. Logistic regression analysis and a generalized linear model with Poisson regression were used to analyze correlations among these factors. RESULTS: Bone bruise was present in 87 cases, hydrarthrosis in 100, cruciate ligament injury in 20, and meniscus injury in 98. The presence of bone bruise was not related to age, cruciate ligament injury, meniscus injury, nor to OA of the patellofemoral joint, but was related to hydrarthrosis and to OA of the femorotibial joint. Femorotibial OA was much more strongly associated with bone bruise than with hydrarthrosis. Furthermore, analyzing the relation between the types of bone bruise and the degree of hydrarthrosis using a generalized linear model with Poisson regression, there was a positive correlation between the grade of bone bruise and the amount of hydrarthrosis. CONCLUSIONS: A factor associated with the degree of osteoarthritis of the knee is bone bruise observed on MRI. The degree of hydrarthrosis is related to the grade of bone bruise, but is not linked to the degree of osteoarthritis.

Ultrasound and clinical evaluation of quadricipital tendon enthesitis in patients with psoriatic arthritis and rheumatoid arthritis.

Enthesitis is an inflammatory lesion of the tendon, ligament and capsular insertions into the bone, and it is a fundamental element in the diagnosis of spondyloarthropathies. Sonography is the method of choice for studying periarticular soft tissues because it is capable of detecting both the early (oedema, thickening) and late alterations (erosions and enthesophytes); it is also an inexpensive, biologically harmless and easily repeatable technique. The aim of this study was to compare the prevalence of quadricipital enthesitis in psoriatic arthritis (PsA) and rheumatoid arthritis (RA) patients, and to document any clinical and echostructural differences in this lesion between the two diseases. The results show that enthesitis is more frequent in PsA patients, more than half of whom are asymptomatic. Knee inflammation was found in the PsA patients with enthesitis regardless of the concomitant presence of joint effusion; none of the RA patients suffered from enthesitis alone. Quadricipital enthesitis is more frequent in male patients. There was no significant correlation between the presence of peripatellar psoriatic lesions and enthesitis. Sonographic examinations of patients with enthesitis revealed that those with RA had predominantly inflammatory lesions, whereas PsA patients also showed major new bone deposition.