15- Calcium Pyrophosphate Dihydrate Disease (CPPD)

Question 1

What is the general features of CPPD?
ph 1092
28-reader

Answer 1

• is an articular disease characterised by the production of gout-like symptoms in the prescence of these crystals
• anything that can result in calcification in the cartilage, synovium, tendons and ligaments
• tendinous deposits common in Achillies, triceps, quadriceps and supraspinatus tendons.

− Onset after 30 years, peak incidence at 60 − Terminology
− “Pseudo gout”- clinical diagnosis-gout like symptoms
− Chondrocalcinosis- radiographic finding
− Pyrophosphate arthropathy (joint destruction)
− Simulates gout, RA, DJD, Charcot’s joint − Affects peripheral joints predominately
− Labs: CPPD crystals on aspiration

Question 2

What are the radiographic signs of CPPD
1093
28 reader

Answer 2

-Cartilage (chondrocalcinosis)-involves hayline or fibrocartilage
-hyaline calcification is thin, linear, continuous or interrupted calcification.
-fibrocartilage calcification has thick, irregular have shaggy poorly defined margin.
CPPD crystal deposition disease may be distinguished from DJD, by 5 recognisable features.
-cartilage calcification is most common in knees, wrist, symphysis pubis, elbow and hips
-fibrocartilage is shaggy and irregular (knee menisci, wrist triangular cartilage, symphysis pubis)
-hayline is thin linear and parallel to and separated from adjacent subchondral bone (wrist, shoulder, elbow, knee and hip.
-pyrophosphate arthropathy most common in knee, wrist and metacarpophalangeal joints.
-chondrocalcinosis of menisci. -intraarticular and osseous bodies common
-wrist–> condrocalcinosis of triangular cartilage
-scaphoid move proximal and lunate distal
-Spine (ligamentous calcification of outer annulus fibres resembeks syndesmophyes of ankylosing spondylitis
- -ligamentum flavum may calcify but not nucleus pulpous
-Hip and shoulders show hyaline chondrocalcinosis and signs of DJD

1) Unusual articular distribution–> features of DJD without history of previous trauma or surgery present e.g. wrist, elbow and glenohumeral joints.
2) Unusual intra-articular distribution–> Involvment of selective joint compartments within a joint. most common sites are did changes in the radio carpal, patellofemoral and talocalcaneal joints.
3) Prominent subchondral cysts- intraosseus synovial fluid extrusion result in numerous large subchondral cysts.
4) Severe, destructive subchondral bone changes–> lousy body formation
5) Visible osteophyte formation –>they may be large or absent despite sever joint space changes.

Question 3

Targeted sites of Involvment:

Knee pg 1096

Answer 3

− Most frequent joint for clinical and radiographic changes
− Chondrocalcinosis in menisci-calcification of cartilage
− Medial joint then patellofemoral, then lateral joint space
− Isolated patellofemoral joint, stress CPPD
as cause
− Sclerosis, cysts, fragmentation
-intra articular osseus and calcified bodies’-diagnosis is strongly suggested if patellofemoral joint is selectively involved.

Question 4

Targeted sites of involvement
Wrist
1096

Answer 4

− Very common location
− Calcification of triangle cartilage (The Triangular fibrocartilage complex (TFCC) is formed by the triangular fibrocartilage discus (TFC), the radioulnar ligaments (RUL’s) and the ulnocarpal ligaments (UCL’s).) (ulnar
meniscal triquetral joint)
− See in radiocarpal joint, big cysts in radius
− See “Terry Thomas sign”-pg 1097 bottom left pic
− Scapholunate advanced collapse (SLAC wrist) − MCP joint involvement can also be seen