Imaging approach to

inflammatory arthritis
PRESENTER: DR. ADIT KAMODIA (PG2)
SR: DR. ANKITA KANWAR
MODERATOR: DR. DHARMENDRA KUMAR SINGH (ASSOCIATE PROFESSOR)
 Preview

History and
Clinical
examination

Imaging Laboratory
data

Macropattern Micropattern Results

Diagnosis
 Objectives
 Understanding of basic pathogenesis of arthritis (Micro-pattern)
 Distribution of joints in arthritis (Macro-pattern)
 Imaging: (Radiograph, US, MRI)
: To confirm
: To know progression
: To know response to therapy
: To rule out mimickers
: For guidance of interventions
 Quantitative / Holistic Consensus : Scoring systems.
Classification
Synovial arthropathy Chondropathic Mixed arthropathy
arthropathy (Syn + Chon)

Synovium is the Articular cartilage is the Primarily cartilage-

primary target. primary target. secondarily synovium

 Inflammatory  Osteoarthritis Primary synovium-

arthropathy  CPPD (Calcium secondarily cartilage
Pyrophosphate
 Infective Deposition Disease)  Gout
arthropathy  Hemarthrosis  Burnt out infective
arthritis
 PVNS (Pigmented  Inflammatory
Villonodular osteoarthritis
Synovitis)
 Arthritis
Abnormality of joint

Synovial joint-
1 Periosteum
2 Outer fibrous layer of the capsule
3 Internal synovial layer of the capsule
4 Fat and loose soft tissue
5 Articular space
6 Cartilage
7 Bone
8 Bare area.

Sommer OJ, Kladosek A, Weiler V, Czembirek H, Boeck M et al. Rheumatoid arthritis: a practical guide to state-of-the-art imaging, image interpretation,
and clinical implications. Radiographics. 2005 Mar-Apr;25(2):381-98. doi: 10.1148/rg.252045111.
 Synovial / Inflammatory
Arthropathy- (Micropattern)

1. Synovitis and joint effusion, joint space widening

2. Periarticular hyperaemia and osteopenia
3. Pannus formation and marginal erosion at synovial attachment site
4. Cartilage destruction and concentric joint space narrowing, DJD and ankylosis
Approach to Inflammatory arthritis

 Clinical: Acute vs. Subacute Vs. Chronic

 Lab investigations: CBC, ESR, CRP, RF, HLAB27 and Anti

CCP (depending upon clinical presentation)
 Inflammatory
arthritis

Monoarticular Polyarticular

RA factor+ HLAB27+
Infectious Distal with
Proximal + no
bony proliferation bony
proliferation

Rhematoid Spondyloarthritis
arthritis (seronegative)
Acute Subacute/Chronic
↑CRP, ESR ↑lymphocytes, ESR

Ankylosing Reactive/ Enteropathy undifferent

Psoriatic
spondylitis Reiter’s associated iated
Pyogenic Tubercular

Jacobson JA, Girish G, Jiang Y, Resnick D. Radiographic evaluation of arthritis: inflammatory conditions. Radiology. 2008 Aug;248(2):378-89. doi:
10.1148/radiol.2482062110. PMID: 18641245.
Inflammatory arthritis
 Synovial hypertrophy / synovitis.

 Joint effusion.

 Initial joint space widening, later on Concentric / Uniform joint space

narrowing. (cf. eccentric joint space narrowing in Chondropathic arthritis).

 Bare area / marginal bone erosion. (cf. marginal osteophytes in

chondropathic arthropathy).

 Periarticular osteopenia (cf. subchondral sclerosis in chondropathic

arthropathy).

 Soft tissue swelling.

1. Infectious arthritis
Causes:
 Bacterial – S. aureus, E. coli, proteus, streptococcus.
 Viral
 Mycobacterial
 Fungal

Risk factors:
Immunocompromised state, DM, RA, IV drug users, old age>80yr

Route of spread:
1. Hematogenous (m/c)
2. Direct inoculation (via trauma or iatrogenic )
Pathogenesis
Pyogenic Arthritis


Clinical features: Monoarticular, acute onset fever,
severe pain, tenderness and swelling of joint, limited
mobility.

 Lab investigations: Raised ESR, CRP

 M/C site: Knee, ankle, hip joints

Radiographs
 First radiological investigation sought in clinical and lab
supported pyogenic arthritis.
Findings:
 Joint capsule distention - Waldenstrom sign,

 Loss of subarticular white line (earliest skeletal

radiographic sign)
 Cartilage and bony articular edges destruction f/b
complete loss of joint space within few weeks.
Ultrasonography
 Joint effusion
 Synovial inflammation
 Guided aspirations for isolating organism (Diagnosis and culture
sensitivity for guiding treatment)
MRI
 If patient is not responding to conservative treatment.
 To assess extra-articular involvement – myositis, myo-abscess (thick and
nodular rims and ill-defined external margins)
 If patient has indeterminate / normal radiograph and only joint effusion
in USG: Transient synovitis
 Monoarticular
Acute onset pain, stiffness
↑CRP, ESR

Radiographs

+ve -ve

USG for joint

USG for joint effusion &
effusion
guided aspiration-
diagnosis , C/S

MRI
Treatment
If not responding

To R/o transient
MRI synovitis
For myoabscess
Tubercular

Clinical features:
 Insidious onset
 Mild pain with stiffness and focal tenderness and decreased range if motion.
 Previous history

Laboratory evaluation:
Raised ESR,CRP, Lymphocytes

M/C site:
 Spine> hip> knee, ankle, SI joint
Radiographic features
Spinal
 Loss of joint space
 Lytic destruction in anterior endplate of
vertebral body
 Vertebral body collapse-wedging
 Gibbus deformity
Radiographic features
 Extraspinal
Phemister’s triad:
 Juxta- articular osteopenia
 Periphery located osseous erosions
 Gradual decrease in joint space
MRI

To assess
 Extent of lesion (osseous +
articular+ soft tissue)
 Degree of destruction
 Activity of lesion
 Extra-articular lesions –
relatively well-defined smooth
margin. Abscesses show thin
rim and are smooth internally
with sharply defined outer
margin.
USG AND CT
 USG: Primarily used for guided aspirations from extra-spinal
joints and collections.
 CT : Primarily used for guided biopsies from spondylodiscitis.
 Sample is sent for
- AFB staining
- gram staining
- AFB culture and sensitivity.
-GeneXpert (CBNAAT)

To differentiate among mycobacterium tuberculosis, atypical

mycobacteria or superadded infections. In known case the biopsy /
aspiration is done to know the response to treatment.
 Monoarticular
Subacute - chronic
presentation
↑CRP, ↑lymphocyte ↑ESR

Spinal Extraspinal

Xray
Xray

+/-
MR
I
MR
I
US / CT guided
biopsy / aspiration
CT guided
biopsy / Treatment
aspiration
Pigmented Villo-nodular Synovitis (PVNS) /
Tenosynovial Giant cell tumor
Radiographs:
 Nonspecific (mainly joint effusion).
 Bone density and joint space are preserved
until the late stages.
 No calcification is seen.
 Extrinsic marginal pressure erosions may be
present. (D/d: Synovial chondromatosis)

MRI: Lobulated T2 hypointense synovium,

Gradient blooming (Hemosiderin)
Rheumatoid arthritis
Clinical features:
 Chronic autoimmune multisystem inflammatory disease,
mainly affect synovial tissues & joints
 30-60 Years( F>M, after 40 years M=F)
 B/L symmetrical & progressive joint involvement.

Laboratory evaluations:
• Raised ESR, CRP, anti-CCP Ab, ACPA.
• RA factor +ve in 70% cases.
 Rheumatoid factor (IgG / IgM) present in
synovial fluid: Combine with antigen: Ag-Ab
Reaction: Synovitis and cascade.
 High titre of RF in synovial fluid: RA
 High titre of RF in synovial fluid in early RA than
it becomes positive in serum.
 Recent RA : RF in serum may be negative, later on
become positive.
 If in recent onset RF is positive: Severe disease.
Pathology of Rheumatoid
arthritis (Micropattern)

B.Initial C. Bone and

D. Ankylosis-
A. Normal Joint Changes joint
Fibrous/bony
(Arrows: Bare (Synovial destruction
area) proliferation)
 Rheumatoid Arthritis: Macropattern
Hands :
 MCP, PIP, mid-carpal, radiocarpal, distal radioulnar joints
 Ulnar styloid process
 Tendon sheath

Feet:
 MTP, proximal IP
 First site of erosion : lateral aspect of 5 th metatarsal head
 Tendon sheaths
 Retrocalcaneal bursa

Spine:
 Odontoid process erosion
 Widened atlanto-dens interval (>3mm)
 Imaging
 Diagnosis in most cases is clinical.

Uses of imaging
-when diagnosis is less than certain
- undifferentiated type
- prognosis
-disease progression
- response to treatment
-better demonstration of synovitis when clinical evidence is absent.
General Radiologic Features
RADIOLOGIC FEATURES PATHOLOGIC BASIS

 Bilateral Symmetry

 Periarticular Soft Tissue Swelling Synovial edema and effusion

(1st radiological sign)
 Juxta-Articular Osteoporosis Inflammatory hyperemia

 Uniform Loss of Joint Space Cartilage destruction by pannus

 Marginal Erosions (Rat Bite Erosions). Pannus eroding bare area

(earliest articular change on radiograph)
 Large Pseudo-Cysts Intraosseus pannus and synovial fluid
intrusions

 Juxta-Articular Periostitis

 Deformity. Capsule and ligamentous laxity, tendon rupture

 2010 ACR/EULAR Classification Criteria for RA
 Target population: Newly presenting patients who have both of the following two criteria:
1. At least one joint with definite clinical synovitis (swelling)
2. Synovitis not better explained by another disease

≥6 of 10 : classified as definite RA
 Imaging in early RA
 Diagnosis of RA is Clinical + Serological + Biochemical (ACR/EULAR)

 Role of imaging:
1. Demonstration of synovitis when clinical evidence is absent.
2. Seronegative RA: Demonstration of synovitis.
3. Disease progression / Response to treatment (??).- DAS 28
ULTRASONOGRAPHY

 High resolution linear transducers (7.5 MHz and higher)

 Initial diagnosis and treatment follow up, sometimes for guided aspirations and therapeutic injections.

 Can evaluate both osseous and soft tissue abnormalities

 Early synovial inflammation - synovial thickening and joint effusion.
 Increased synovial vascularity (Power Doppler).
 Early erosions(>>sensitive than radiographs)
 Integrity of tendons

 High yield locations: Metatarsophalangeal joints- earliest and most commonly affected
Joints assessed- MTPII,V; MCPII,III; PIPII,III; wrist joint and symptomatic joints; tendon sheaths, carpal tunnel
 EULAR-OMMERACT-PDUS SCORE OF SYNOVITIS (GS+PD)
Grade GS PD
0 (No synovitis) 0 0
1 (Mild synovitis) 1 0,1
2 (Moderate synovitis) 2 0, 1, 2
1 2
3 (Severe synovitis) 3 0,1,2,3
1/2 3
PDUS

 To detect low velocity flow in RA

 Used to assess
 Better marker of synovitis
 Flare ups
 Response to treatment
Semiquantitative grading:
 Grade 0: no signal
 Grade 1 one single or several vessels visualized
 Grade 2: < 50% of ROI having signals
 Grade 3: > 50% of ROI having signals
US-7 joint (EULAR-OMMERACT-PDUS Score):
 Role of MRI in early RA
 Clinical evidence + and US indeterminate regarding synovitis:
 MRI (Palm to palm prayer position)
 Synovial enhancement, bone marrow edema and tenosynovitis are s/o active
disease.
 Gold standard for synovial imaging.
 At least two planes (axial and coronal),
 T1 W images (pre and post contrast)
 Fat saturated T2W or STIR sequence.
Radiographs

 For bone erosions

 To assess extent of disease and progression
 Erosive disease criteria: erosion at 3 separate joint on X-ray
of both hands and feet at PIP,MCP, wrist or MTP joints.
 Poor sensitivity for early disease-Unable to detect synovial
inflammation

Jacobson JA, Girish G, Jiang Y, Resnick D. Radiographic evaluation of arthritis: inflammatory conditions. Radiology. 2008
Aug;248(2):378-89. doi: 10.1148/radiol.2482062110. PMID: 18641245.
Norgaard view or Ball- catcher’s
view

To better assess marginal erosions with poorly defined irregular non

sclerotic borders (initially at radial margins of 2 nd & 3rd metacarpal heads
and radial margins of distal and proximal ends of proximal phalanges.
Frontal radiograph of the right hand shows soft- Boutonniere deformity (Yellow) & Hitch-
tissue swelling and progression of erosions hiker thumb deformity (Red)
(arrows) at the second through fourth proximal
interphalangeal joints and at the ulnar styloid
process.
Jacobson JA, Girish G, Jiang Y, Resnick D. Radiographic evaluation of arthritis: inflammatory conditions. Radiology. 2008 Aug;248(2):378-
89.
Rheumatoid Arthritis involving Cervical spine (in 50 % cases)

Pseudo-basilar Eroded dens & increased

invagination ADI
Narváez JA, Narváez J, De Lama E, De Albert M. MR imaging of early rheumatoid arthritis. Radiographics. 2010 Jan;30(1):143-63;
discussion 163-5. doi: 10.1148/rg.301095089. PMID: 20083591.
CT

 Limited role
 Inferior to MRI and USG to detect early disease
 Main role - assess cervical spine (atlantoaxial subluxation) & lung
involvement.
 CT guided aspiration from Atlantoaxial joint to differentiate
between RA and TB.
 Polyarticular
RF+,
ACPA +

USG Treatment

- Synovitis
- Tenosynovitis
- Erosion
- PD Follow up
X
Ray
- erosions
- Disease
Lab USG
progression
- Disease activity
- *In case of flare up in 1 joint - USG guided intraarticular steroid injections
- * If pt. not responding to Anti RA drugs - Synovial biopsy for superadded infections
 Seronegative Polyarticular Inflammatory
Arthropathy: Spondyloarthropathy
Seronegative
Spondyloarthropathy
(HLA B27 +, RF -)
Micropattern Synovial arthropathy with bony
proliferation
Seropositive arthropathy
(Rheumatoid Arthritis)
(RF +, HLAB27-)
Synovial arthropathy with bony
erosion

Macropattern SI joint, DL Spine, LS Spine, Hip SI joint, DL spine: No

joint Hip joint: Rare
Hand: Distal predilection Hand: Proximal predilection

Juxta-articular osteoporosis No Yes

Bony Proliferation:
Enthesitis Yes No
Fluffy periostitis
SERONEGATIVE SPONDYLOARTHROPATHIES

 Chronic inflammatory arthropathies

 Highly heritable
 ASUS classified them into 2 types:

 Axial:
 Clinical features: chronic lower back pain which improves with physical activity.
 Lab: HLA- B27 positive

 Peripheral
 Clinical features: pain and stiffness in peripheral joints.
 Lab: HLA B27 positive
 Axial Spondyloarthropathy
Chronic low back pain > 3 months at age of onset < 45 years

Sacroilitis on Imaging HLA-B27 Positive

or
> 1 SpA features > 2 other SpA features

Spondylarthritis features (SPINEACHE):

• Sausage digit (dactylitis)
• Psoriasis
• Positive family history of spondyloarthritis
• Inflammatory back pain
• NSAID therapy: good response
• Enthesitis (heel)
• Crohn disease or colitis
• C-reactive protein level elevation
• HLA-B27
• Eye (uveitis)
 Peripheral Spondyloarthropathy
Arthritis / Enthesitis / Dactylitis without back pain
(If back pain is present then axial SpA criteria should be applied)

> 1 SpA: > 2 SpA:

• Psoriasis • Peripheral arthritis,
• Crohn disease or colitis • enthesitis,
• Preceding infection • dactylitis,
• HLA-B27 or • Inflammatory back pain in the
• Uveitis past
• Sacroilitis on radiographs or • Family history of
MR images spondyloarthritis
AXIAL SPONDYLOARTHRITIS
Imaging in early Axial SpA
 MRI can visualize active sacroiliitis and enthesitis in spine in very early disease.

ASAS/OMERACT imaging group definition for the definitive diagnosis

Sacroiliitis: (Slice x lesion =2)
Minimum amount of bone marrow edema (one lesion at least two
adjacent slices or more than one lesion at least one slice)
ANKYLOSING SPONDYLITIS

 Radiographs
 First line
 Erect AP view of pelvis – SI joint and hip joints
 AP and lateral spine – for presence and progression of structural changes.
 Insensitive in early stages.

SACROILIAC JOINTS:
• Bilateral and symmetrical involvement.
• Initially involves lower half of joints (synovial portion).
• Iliac side more extensively involved.
Chang EY, Chen KC, Huang BK, Kavanaugh A. Adult Inflammatory Arthritides: What the Radiologist Should Know. Radiographics. 2016 Oct;36(6):1849-1870.
doi: 10.1148/rg.2016160011.
 SPINE
 Locations : thoracolumbar, lumbosacral, atlantoaxial
 Discovertebral junction, apophyseal and costovertebral joint involvement
is seen and spinous process enthesopathy occurs.

Spine involvement is characterized by:

• Ostitis
• Syndesmophytes formation
• Facet inflammation
• Facet joint and vertebral body fusion

Squaring of vertebral bodies
One of the early radiographic signs.
Caused by loss of the normal concave contour
of the anterior surface of vertebral body.
Romanus lesion
There is a focal destruction of vertebral body
rim at the outer annulus enthesis, resulting in
discrete radiolucent corner erosion
shiny corner sign
Healing of corner erosions- transient reactive
sclerosis in subadjacent bone
 Syndesmophytes
Inflammatory ossification of spinal ligamentous tissue.
Marginal type of syndesmophytes are seen.
Fine, vertical bridging ossification at the outer disc limit,
originating from the adjacent vertebral body margins.
Bamboo spine
When multiple segments are ankylosed by symmetric,
marginal syndesmophytes, the continuous undulating
spinal contour is termed as bamboo spine.
 Trolly – track sign- Ossification of the joint capsule,
Dagger sign- Ossification of interspinous and supraspinous ligaments
ligamentum flavum and interspinous ligaments
produces a single radiodense vertical stripe connecting the lumbar spinous
produces three parallel linear densities .
processes.
 Peripheral joints

• Commonly involved : hips, shoulders and heel

• Bilateral symmetrical manner
• In approximately 50% of patients

• Hip: small osteophytes, subchondral cysts, enthesopathy, uniform loss

of joint space with axial migration of femoral head and eventually
ankylosis of joint.

• Shoulder: erosive lesions at lateral aspect of humerus and distal

clavicle and enthesopathy

• Calcaneum: erosions, localized osteoporosis and periostitis

 Early Peripheral changes in Axial SpA
 Hip

 Shoulder . Heel . Dactylitis

 Complications
 Carrot-Stick Fractures- A fracture caused by the brittle nature of the ankylosed
vertebral column
 Andersson’s Lesion - In advanced cases in which a single level becomes mobile,
resulting in instability and adjacent destruction that simulates infection or
neuropathy

Arachnoid
Diverticula
MRI

 Assess the disease activity during treatment

 To differentiate from TB of SI joint when HLAB27 is negative -collection in TB
 To differentiate from gout
• Later in the course of the disease, inflammation usually decreases and subchondral
edema is progressively replaced by post inflammatory fatty bone marrow, which
appears hyperintense on T1-weighted sequences.
CT
 Joint erosions, subchondral sclerosis and bony ankylosis are better
visualized on CT.
 Low Back Pain
HLAB 27+

Radiograph of SI joint &DL

spine

S/o AS Not s/o AS

To assess extend of disease MRI

MRI>>CT
PERIPHERAL
SPONDYLOARTHRITIS
 Imaging in early Peripheral Spondyloarthropathy

1. Peripheral arthritis / Dactylitis: DIP of hands and feet.

 Radiograph:
 Asymmetric DIP joint involvement
 Erosion and fluffy periostitis
(mouse ear sign)
 Soft tissue swelling
(SAUSAGE DIGIT)
 Normal Bone Density
 Sometimes dense phalanx
(Ivory phalanx)
2. Enthesitis:
PSORIATIC ARTHRITIS

• Etiology -combination of environmental and hereditary factors.

• Approximately 30% of patients with psoriasis develop inflammatory arthritis.
• Age of onset: 20-50 years of age , no sex predilection.

CASPAR Classification criteria

Clinical scenarios

Moll and Wright described five clinical scenarios:

 Distal arthritis, DIP joints involvement
 Asymmetric oligoarthritis: < five small and/or large joints are affected in an
asymmetric distribution.
 Symmetric polyarthritis.
 Arthritis mutilans
 Spondyloarthritis, including sacroiliitis.
Radiographic features

• Most common location: DIP of hands and feet

• Other target sites: PIP, hips, knees,ankles.

 General radiologic features:

• Asymmetric involvement
• Soft tissue swelling- SAUSAGE DIGIT
• Normal bone density
• Marginal erosions and tapered bone ends
• Fluffy juxta-articular periostitis (mouse ear sign)
• Widened joint space
• Pencil in cup
• Ivory phalynx
Crespo-Rodríguez AM, Sanz Sanz J, Freites D, Rosales Z, Abasolo L, et al. Role of diagnostic imaging in psoriatic arthritis: how, when, and why. Insights Imaging. 2021 Aug 25;12(1):121. doi:
10.1186/s13244-021-01035-0
Sacroiliac joint:
• Involved in 30-50 % of psoriatic arthritis patients.
• Bilateral asymmetrical sacroiliitis.
• Erosions, hazy joint margin and sclerosis, predominantly along the
entire iliac surface.

Spine:
• Involved in approximately 60 % of individuals with skin disease.
• Coarse, asymmetric non-marginal syndesmophytes, atlanto-axial
subluxation and discovertebral erosions with sparing of apophyseal
joints.
Achilles tendon is among the most frequent sites of enthesopathic involvement in PsA.

Crespo-Rodríguez AM, Sanz Sanz J, Freites D, Rosales Z, Abasolo L, et al. Role of diagnostic imaging in psoriatic arthritis: how, when, and why. Insights Imaging. 2021 Aug
25;12(1):121. doi: 10.1186/s13244-021-01035-0.
 Spinal Changes in PSpA (Asymmetry is the rule)

PSpA ASpA
Sacroilitis Unilateral Bilateral symmetrical
Bilateral (Asymmetrical)
Syndesmophytes Asymmetrical, Non-marginal, Symmetrical, marginal, thin
bulky
 Reiters
 Clinical features: Triad: urethritis,
conjunctivitis and polyarthritis.
 HLA B 27 positive
 Target site: forefoot, calcaneus, ankle
 Radiographs:
Asymmetric arthritis(lower limb
predilection)
Psoriasis
 Clinical features: pain and stiffness in
joints with nail pathologies.
 HLA B 27 positive
 Target sites: DIP of hands and feet
 Radiographs:
Asymmetric arthritis (DIP of hands)
Fluffy periostitis
ENTEROPATHIC ANKYLOSING
ARTHROPATHIES SPONDYLITIS

 C/F: predominantly peripheral joint  C/F: lower back pain, peripheral

complaints complaints less common
 a/w inflammatory intestinal diseases
– UC, Crohn’s, whipple disease.
 HLAB27 positive  HLAB27 positive
 Radiographs: Bilateral symmetrical  Bilateral symmetrical sacroiliitis
sacroiliitis
Non erosive lesions

Usually self resolving attacks with no

permanent peripheral joint damage.
UNDIFFERENTIATED

 Clinical features s/o spondyloarthropathies

 RF and HLAB27 negative
 Early phase of definite forms of spondyloarthritis
 Abortive and self limiting forms that do not develop into stablished entity
 Overlap syndrome
Erosive osteoarthritis
 C/F: Peripheral joint involvement-
swelling, erythema, tenderness,
warmth
 Middle aged women
 LAB:↑MPO, CRP ,RF negative
Radiographic features:
 symmetrical
 Gull wing sign-central erosions with
marginal bone proliferation
 Loss of joint space (non uniform)
 Sclerosis
Psoriatic arthritis
 C/F: Peripheral joint involvement
with nail abnormalities.(DIP)
 20-50yrs
 Lab: HLA B27 positive, RF negative
Radiographic features
 Asymmetric
 Fluffy juxta-articular periostitis
(mouse ear sign)
 Widened joint space
 Normal bone density
 Marginal erosions
Asymmetric random (Mono/Poly) Synovial
Arthropathy: Gout
 Deposition of monourate crystals on synovium,
on cartilage and in soft tissue. (Micropattern)
 MC affected joint: Great toe (1st MTP), Others:
Ankle, Knee, elbow, wrist. (Macropattern)
Stage Symptoms Condition
A Asymptomatic Hyperuricemia without crystal
deposition.
B Crystals deposition in joint but without
symptoms.
C Symptomatic Crystal deposition with acute
inflammation (Acute Gouty arthritis)
D Advanced Gout (Chronic gouty
arthritis / chronic tophaceous arthritis)
 Imaging in early Gout (Acute Gouty arthritis)
Ultrasound (OMERACT criteria)
Inflammatory changes (Non-specific) Structural changes (Specific)
1. Double contour sign
1. Synovial hypertrophy.
2. Color doppler. 2. MSU aggregates.
3. Tenosynovitis.
a. Joint fluid: Snow-storm
4. Erosions.
b. Synovium: Cloudy / cotton images

3. Tophi
 Imaging in Chronic tophaceous gout
Its rare to see radiographic changes as the radiographic changes take approx. 6-8
years to develop.

Classical pentad of Erosion (Hands and feet)

 Periarticular then intra-articular: Overhanging
margin.
 Erosion having sclerotic margin.
 Juxta-articular osteoporosis absent.
 Joint space / part of joint space is preserved.
 Soft tissue swelling (Tophi): Periarticular, Patellar
tendon, Achilles, Triceps, quadriceps.
MRI
 Useful in spinal tophaceous gout
 Tophi- low signal intensity on T1 and T2
 Dual Energy CT
 DECT imaging is useful in identifying urate burden.
 Limitations:
1. May miss small deposits.
2. May miss large deposits if not dense.
3. Imaging protocol dependent.
Thus, Aspiration of urate crystals, collection in NS and visualization in polaroid
microscopy still GOLD STANDARD
Take Home Message
 Clinical and Serology / biochemistry defines the type of most of the arthropathies.

 Role of Radiology:
 To confirm the diagnosis
 To assess the extent of damage
 Response to treatment
 To know the disease activity
 For guided interventions.

 The state of art imaging utilizes the resources for early diagnosis and to monitor the
treatment.

 State of art imaging will justify:

 What
 When
 Where
 How
THANK YOU