DECEMBER, 1971

PERIARTICULAR CALCIFICATIONS IN
PYOGENIC ARTHRITIS*
B THOMAS H. SHAWKER, M.D., and JOHN M. DENNIS, M.D.
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BALTIMORE, MARYLAND

IN PYOGENIC arthritis the usual roent- peared to be within the joint capsule (Fig. 2).

genographic changes are joint effusion The patient has not been seen since that time.
and bone destruction. The development of
pen articular calcification has occasionally
CASE III. M.M., a 38 year old Negro female,
was admitted on August 7, 1970, with pain of
been noted but has not been commented
2 weeks’ duration in the right shoulder and
upon by recent authors.4 The roentgeno-
both knees. Pneumococci were cultured from
grams of 38 cases of pyogenic arthritis all of the involved joints. She was treated with
were reviewed and 3 of these revealed the intravenous penicillin and multiple arthrot-
presence of periarticular soft tissue cal- omies.
cification. These 3 cases are reported. Roentgenographic studies on admission re-
vealed effusion in the suprapatellar bursa of the
REPORT OF CASES right knee (Fig. 3). Small areas of soft tissue
CASE I. E.M., a 49 year old Negro male, was calcification were also present in the region of
admitted on December 12, 3968, with a painful the acromioclavicular joint and coracoclavicu-
right knee of days’ duration. Group A strepto-
cocci were cultured from this joint.
The initial roentgenographic study revealed
only soft tissue swelling. Five weeks following
intravenous penicillin therapy and an arthrot-
omy, an ill-defined linear calcification was
noted in the soft tissues adjacent to the medial
femoral condyle (Fig. i).

The patient was discharged after 8 weeks

with residual pain and limitation of motion of
the right knee.

CASE II. S.P., a 39 year old Negro male, was

admitted on May , 1970, with a painful left
knee and right shoulder of 3 days’ duration.
Pneumococci were cultured from the left knee
and the patient was treated with intramuscular
inlections of penicillin.
The initial roentgenographic studies on ad-
mission revealed an old mild acromioclavicular
separation of the right shoulder. Minimal soft
tissue calcification was noted in the left knee
approximately 4 weeks after the onset of his
illness.
The patient was discharged after 2 months.
Three months later he continued to have pain Fio. . Case I. January i#{243}.
1969. Linear soft tissue
and limitation of motion in his right shoulder calcification along the medial aspect of the distal
and roentgenographic studies at this time re- shaft of the right femur (arrow), 6 weeks after onset
vealed a large soft tissue calcification which ap- of symptoms.

*From the Department of Radiology, University of Maryland School of Medicine and University of Maryland Hospital, Baltimore,
Maryland.

6o
 VOL. 113, No. Periarticular Calcifications in Pvogenic Arthritis 6 i

lar ligament of the right shoulder, the result of

previous injury (Fig. 7M.
Two months after onset of symptoms exten-
sive calcifications were noted roentgenograph-
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ically in the suprapatellar bursa and in the soft

tissues of both knees, apparently both within
and outside the joint capsule (Fig. 4, A and B).
At this time soft tissue calcifications were also
present in the right shoulder about the head of
the humerus and below the clavicle (Fig. 7B).
The patient was discharged 2 months after
admission to a chronic care facility where physi-
cal therapy was started.
Roentgenographic studies of the right knee
on February 10, 197 I,revealed partial reabsorp-
tion of the soft tissue calcification (Fig. , A
and B). An arthrographic study was performed
at this time with 4 cc. of opaque contrast ma-
terial and 20 cc. of air and carbon dioxide. The
normal joint volume is 50 to 6o cc.,2 but due
to joint space contraction the lesser amount of
contrast material and air were injected only
with great difficulty. The suprapatellar bursa
was decreased in volume also, with calcifica-
tion in its upper portion, apparently the supe-
rior limits of the original bursa. The other soft FIG. 3. Case III. August 7, 1970. Effusion in
suprapatellar bursa of right knee on admission.
tissue calcifications remained within the wall of
Linear calcification in the soft tissues posteriorly
the original joint capsule, as the contrast ma- was probably in the popliteal artery.
terial was medial to and did not extend beyond
these calcifications (Fig. 6, A and B). DISCUSSION
When last seen on March 18, I97I, the pa-
tient was much improved clinically and roent-
The actual incidence of periarticular soft
genographic studies at that time revealed tissue calcification in the 38 cases of pyo-
moderate resorption of the soft tissue calcifica- genic arthritis studied could not be deter-
tion in the right shoulder (Fig. 7C). mined, as most of the patients had only
initial roen tgenographic studies because of
their short clinical courses and rapid re-
sponses to treatment. Periarticular calci-
fication, which occurred approximately 4
to 12 weeks after the onset of symptoms,
appeared in those cases with more severe
and lengthy illnesses. The 3 cases presented
were notable for their long and serious
illnesses.
Dystrophic soft tissue calcifications in
patients with pyogenic arthritis probably
occur as the result of rupture of the joint
capsule with extension of the infection and
pus into the soft tissues.8 The periarticular
soft tissues then become necrotic with a
decrease in the metabolic rate and the car-
tion of the capsule of the right shoulder (arrow), bon dioxide concentration in these devital-
months after admission. ized tissues. This results in local alkalinity.7
 652 Thomas H. Shawker and John M. Dennis DECEMBER, 3971
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110. 4. Case 111. (A and B) September 30, 1970. Extensive soft tissue calcifications laterally, medially
and posteriorly and in the suprapatellar bursa, 2 months after onset of symptoms.

Calcium and phosphorus salts are less sol- tions that irregular periosteal calcification
uble in an alkaline medium and therefore may also be seen in the bones adjacent to
percipitate out as flaky amorphous cal- the joint, as was noted along the lateral as-
cifications.6 pect of the humerus in Case III (Fig. 7B).
In addition to the periarticular calcifica- Dystrophic pen articular calcifications
tions in pyogenic arthritis, Ferguson5 men- have been noted experimentally. Barden-

FIG. . Case 113. (A and B) February JO, 1971. Moderate resorption of soft tissue
calcifications in the right knee, 7 months after onset of illness.
 VOL. 113, No. Periarticular Calcifications in Pvogenic Arthritis 653
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did not extend beyond these calcifications.

heier et al.’ injected rabbit knees with Pen articular calcifications indicate ex-
staphylococci and found that periarticular tensive disruption of the soft tissues about
calcifications occurred by the twelfth week. the joint. Calcifications are laid down in
Parenteral penicillin, arthrotomies and in- the remnant of the original joint capsule
terarticular injections of penicillin were with consequent shrink of the volume
 654 Thomas H. Shawker and John M. Dennis DECEMBER, 3973

ture the articular cartilage and to lubricate demonstrated the presence of dystrophic
the joint. Anastomotic plexuses of blood periarticular calcifications.
vessels are normally found in the margins These soft tissue calcifications, which are
of the joint capsule, terminating in the indicative of severe soft tissue disruption,
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synovial membrane and aiding in the ex- occurred several weeks after the onset of the
change of metabolytes between the blood illness in those patients with severe and pro-
and synovial fluid.3 This exchange is there- longed illnesses.
fore compromised by obliteration of the John M. Dennis, M.D.
margins of the articular cartilage, resulting Department of Radiology
in deranged metabolism within the joint. University of Maryland Hospital
Of equal importance clinically is the Baltimore, Maryland 21201

painful mechanical effect of the calcifica-

REFERENCES
tions about the joint. All 3 of the patients
1. BARDENHEIER, J. A., MORGAN, H. C., and
reported had residual pain in the affected
STAMP, W. G. Treatment and sequelae of ex-
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Surg.,arthritis.
ritative effects of the calcium deposits may Gynec. & Obst., 1966, 122, 249-254.
be partially responsible for this discomfort 2. Burr, W. P., and MCINTYRE, J. L. Double con-
and, as observed in Case III, the suprapatel- trast arthrography of knee. Radiology, 1969, 92,
487-499.
lar bursa was partially obliterated and the
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Pyogenic arthritis should be one of the
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Three of the 38 cases reviewed in this edition. The Macmillan Company, New York,
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