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| CPPD Crystal Deposition Disease of the Wrist:
Trapezioscaphoid Joint Abnormality
Alisara Suptuesat, Nittaya Lektrakul, Charles C. Liu, Daphne J. Theodorou, Yousuke Kakitsubata, and Donald Resnick
Key Indexing Terms: Calcium Pyrophosphate Dihydrate ( CPPD ) Crystal Deposition Disease, Wrist Joint, Trapezium, Scaphoid, Radiography From the Department of Radiology, University of California, San Diego, Veterans Affairs Medical Center, 3350 La Jolla Village Drive, San Diego, CA 92161. *Support by VA grant SA-360. A. Suptuesat, MD, Research fellow; N. Lektrakul, MD, Research Fellow; C.C. Liu, MD, Third year resident; D.J. Theodorou, MD, Research Fellow; Y. Kakitsubata, MD, Research Fellow; D. Resnick, MD, Professor of Radiology. Correspondence and reprint requests to: Donald Resnick, MD; Department of Radiology (114); Veterans Affairs Medical Center; 3350 La Jolla Village Drive; San Diego, CA 92161 Tel: (619)-552-8585 EXT. 3343; FAX: (619)- 552-7565 CPPD Crystal Deposition Disease of the Wrist: Trapezioscaphoid Joint Abnormality
ABSTRACT Objective. To determine whether trapezioscaphoid (TS) joint alterations are associated with CPPD disease and, if so, to determine the nature of these alterations. Methods. 160 wrists radiographs with evidence of chondrocalcinosis were evaluated with regard to TS joint abnormalities, and findings were compared with a similar number of radiographs in an age - and sex - matched control population in whom no evidence of chondrocalcinosis or other calcification in the wrist was seen. Two radiologists in consensus recorded radiographic findings in both groups, and a third radiologist blinded to the presence or absence of chondrocalcinosis reviewed wrist radiographs in both groups in a random order. Correlation of TS joint abnormalities with other changes in the wrist was also accomplished. Results. TS arthropathy was found in 43.7 % of CPPD wrists and in 14.4 % of control wrists in the consensus evaluation. In the blind evaluation, 30 % of CPPD wrists and 12.5 % of control wrists had TS arthropathy. The degree of arthropathy was more extensive in the CPPD group than in the control group. Features associated with TS arthropathy in the patient population were first carpometacarpal arthropathy and subchondral cysts in the scaphoid or trapezium, or both bones. Conclusions. CPPD patients, when compared to a control population, reveal frequent and significant radiographic abnormalities of the TS joint that maybe suggestive of the diagnosis, even in patients in whom chondrocalcinosis is obscured or absent. The features associated with TS arthropathy are first carpometacarpal arthropathy and subchondral cysts in the scaphoid and trapezium.
INTRODUCTION Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease is a common articular disorder, first recognized by Zitnan and Sitaj in 1958 (1). This disease is widespread in elderly persons and characterized by acute, subacute, or chronic joint inflammation and deposition of CPPD crystals in hyaline cartilage, fibrocartilage, and other soft tissue structures (2). Radiographically, CPPD crystal deposition disease is characterized by calcification in and around joints, most commonly in cartilage, known as chondrocalcinosis, and structural joint changes known as pyrophosphate arthropathy (2, 3). Many studies about this disorder have been reported, and clues to radiological diagnosis continue to be revealed. There is often associated radiocarpal joint space narrowing, which occurs most frequently at the radioscaphoid space (2). A scapholunate advanced collapsed (SLAC) pattern of arthritis is the most common form of structural joint damage in the wrist in patients with CPPD crystal deposition disease (4, 5, 6). Other findings found in the wrist and hand in this disease include narrowing of the capitolunate and metacarpophalangeal joint spaces (especially the second and third) (2). Sclerosis, cyst formation, and subchondral collapse also may be found. It has been reported that CPPD crystal deposition disease may affect the trapezioscaphoid (TS) joint, leading to TS arthropathy (7, 8). In some studies (3, 9), however, no significant association between TS joint arthropathy and CPPD crystal deposition disease was found. The correlation between TS joint arthropathy and other changes in the wrist also has not been reported. The objectives of this study were to determine whether TS joint arthropathy is associated with CPPD crystal deposition disease, and whether there is an association between TS joint arthropathy and other changes in the wrist of patients with this disease.
MATERIALS AND METHODS A retrospective review of frontal (i.e., posteroanterior) wrist radiographs was performed in two groups of patients. The first group (CPPD group) was comprised of 160 wrist radiographs that had evidence of chondrocalcinosis (probable or definite diagnosis of CPPD crystal deposition disease by McCarty criteria) (10) obtained from the teaching file of a university - affiliated hospital. These 160 radiographs were from 105 patients, 72 men and 33 women; age range 40-99 years, with a mean age of 73.3 years. In all wrists chrondrocalcinosis involving the triangular fibrocartilage with or without additional sites of calcification in the wrist was seen. The second group consisted of similar wrist radiographs derived from a randomly chosen age- and sex - matched control population from the computer - based patient files of the same hospital, in which no evidence of chondrocalcinosis or other wrist calcifications were seen (control group). All patients who had evidence of gout, rheumatoid arthritis, or neuropathic disease on the basis of clinical, laboratory and/ or radiographic data were excluded from the study. Two radiologists in consensus graded the degree of TS joint abnormalities for all radiographs in both groups. Other changes including first carpometacarpal, midcarpal, radiocarpal, and inferior radioulnar joint abnormalities, the precise location of the calcifications, and the presence or absence of cystic lesions in the wrist, were also evaluated. The degree of joint space loss in the TS, first carpometacarpal, and capitolunate joints was graded from 0 to 3 as follows: 0 = gross normal joint space, 1 = mild joint space narrowing, 2 = moderate joint space narrowing, 3 = marked loss of joint space. The degree of joint space loss at other sites was graded from 0 to 2 as follows: 0 = gross normal joint space, 1 = mild to moderate joint space narrowing, 2 = marked joint space narrowing. The findings in the CPPD group were then compared with those in the control group. The Mann - Whitney (U) test was used in determining whether TS arthropathy was associated with CPPD crystal deposition. The association of TS joint arthropathy with other changes in the wrists with CPPD deposition was also accomplished using Chi - square test. To reduce bias, a third radiologist blinded to the presence or absence of chondrocalcinosis or other patterns of calcification about the distal portion of the ulna, which was accomplished by using an opaque marker over the triangular fibrocartilage (TFC) region, again evaluated the degree of TS joint abnormalities in both groups in random order. The correlation between the findings observed by the third radiologist and the findings obtained from consensus reading by two radiologists was determined using Spearman's correlation.
RESULTS TS Joint: The frequency and degree of TS joint arthropathy in the wrists of CPPD patients and of the control population as determined in the consensus reading are shown in Table 1. An example of TS joint arthropathy compared to normal TS joint in patients with CPPD crystal deposition disease are shown in Figure 1. Forty - three percent (70 of 160) of the wrists in the CPPD group had TS arthropathy, while only 15% (23 of 160) of the wrists in the control group had TS arthropathy. Among those wrists that had TS arthropathy, the wrists in the CPPD group showed mild involvement in 42 of 70 (60 %), moderate involvement in 25 (35.7%), and marked involvement in 3 (4.3%); the wrists in the control group showed mild involvement in 14 of 23 (60.9%) and moderate involvement in 9 (39.1%). No cases of marked involvement were found in the control group (Table 1). The differences in the frequency and severity of TS arthropathy between these two groups were statistically significant (Table 1). The results obtained from blind evaluation of the TS joint in both groups of patients by the third radiologist, compared to the results obtained from consensus evaluation by two radiologists, are presented in Table 2. From the blind evaluation, 30 % (48 of 160 wrists) of the wrists in the CPPD group, and 12.5 % (20 of 160 wrists) of the wrists in the control group had TS arthropathy. A greater number of wrists in both the CPPD and control groups were read as normal. However, among the patients who had TS arthropathy, the record from the third radiologist showed a higher degree of severity than that of the consensus reading. In the CPPD group, the third radiologist recorded mild involvement in 14 of 48 (29.2%) compared to 60% in the consensus reading, moderate involvement in 23 of 48 (47.9%) compared to 35.7% in the consensus reading, and marked involvement in 11 of 48 (22.9%) compared to 4.3% in the consensus reading. In the control group, the third radiologist recorded mild involvement in 7 of 20 (35%) compared to 60.9% in the consensus reading, and moderate involvement in 13 out of 20 (65%) compared to 39.1% in the consensus reading, and no severe involvement was found in either the evaluation of the third radiologist or the consensus evaluation. In addition, the third radiologist recorded a greater frequency of TS arthropathy in the CPPD group (30%) than in the control group (22.5%) and also a higher degree of TS arthropathy. These findings were in agreement with the results from the consensus reading. The test of correlation between the blind records from the third radiologist and the records from the consensus reading showed highly significant correlation in both groups of patients (correlation coefficient = 0.813, p < .001) Thus, the consensus record was used as a data base for further statistical analysis. Other Locations : The pattern of joints involvement in each location in CPPD wrists compared to the control wrists and tests of the differences between these two groups are presented in Table 1. The test of association between TS arthropathy and other changes in CPPD wrists are summarized in Table 3. First CMC joint arthropathy was found in 40.6 % (65 of 160) of the CPPD wrists, and in 23.8 % (38 of 160) of the control wrists. Among those that had first CMC arthropathy, the wrists in the CPPD group showed mild involvement in 45 of 65 (69.2 %), moderate involvement in 15 (23.1 %), and severe involvement in 5 (7.7 %); the wrists in the control group showed mild involvement in 27 of 38 (71.1 %), moderate involvement in 7 (18.4 %), and severe involvement in 4 (10.5 %). The frequency and severity of the first CMC arthropathy in patients with CPPD crystal deposition disease when compared to controls were statistically significant (Table 1). The tests of association between TS arthropathy and first CMC arthropathy in the CPPD group of patients also showed statistical significance (Table 3). On the contrary, this correlation was not statistically significant in the control population (p > .05). Figure 2 shows TS arthropathy with first CMC arthropathy in CPPD patient. Five other joints or spaces were evaluated, including the lunate - capitate (capitolunate), scaphoid - trapezoid, scaphoid - capitate, lunate- hamate, and triquetrum - hamate articulations, with emphasis on the capitolunate space owing to its recognized involvement in CPPD crystal deposition disease (2). 1 ) Capitolunate arthropathy : In our series, 20.6 % (33 of 160) of the CPPD wrists and 4.4 % (7 of 160) of the control wrists had arthropathy at the capitolunate articulation. The degree of involvement is shown in Table 1. Among those that had capitolunate arthropathy, mild involvement was found in 18 of 33 wrists (54.5%), moderate involvement in 11 (33.3%), and marked involvement in 4 (12.1%). In the CPPD group; mild involvement was found in 3 out of 7 (42.9%) and moderate involvement was found in 4 of 7 (57.1%) control wrists. These differences between the two groups were statistically significant (Table 1). The test of association between TS arthropathy and capitolunate arthropathy showed no significant correlation (Table 3). 2 ) Scaphoid - trapezoid arthropathy : Only 2.5 % (4 of 160) of the CPPD wrists had arthropathy of this joint, and none of the control wrists had such abnormality. The differences between these two groups were statistically significant (Table 1). The test of association between TS arthropathy and scaphoid - trapezoid arthropathy showed no significant correlation (Table 3). 3 ) Scaphoid - capitate arthropathy : 15 % (24 of 160) of the CPPD wrists and 0.6 % (1 of 160) of the control wrists had arthropathy of this joint. The differences between these two groups were statistically significant (Table 1). The test of association between TS arthropathy and scaphoid - capitate arthropathy showed no significant correlation (Table 3). 4 ) Lunate - hamate arthropathy : 7.5 % (12 of 160) of the CPPD wrists and 1.2 % (2 of 160) of the control wrists had arthropathy of this joint. The differences between these two groups were statistically significant (Table 1). The test of association between TS arthropathy and lunate - hamate arthropathy showed no significant correlation (Table 3). 5 ) Triquetrum - hamate arthropathy: 3.1 % (5 of 160) of the CPPD wrists and 0.6 % (1 of 160) of the control wrists had arthropathy of this joint. The difference between these two groups was not statistically significant (Table 1). The test of association between TS arthropathy and triquetrum - hamate arthropathy showed no significant correlation (Table 3). Radioscaphoid arthropathy was found in 28.8 % (46 of 160) of the CPPD wrists, and 10.6 % (17 of 160) of the control wrists had arthropathy of this joint. In the CPPD group, 31 of 46 (67.4%) showed mild to moderate involvement and 15 of 46 (32.6%) showed marked involvement (Table 1). In the control group, 16 of 17 (94.1%) showed mild to moderate involvement and 1 of 17 (5.9%) showed marked involvement (Table 1). The differences in the two groups regarding the frequency and severity of radioscaphoid arthropathy were statistically significant (Table 1). The test of association between TS arthropathy and radioscaphoid arthropathy showed no significant correlation (Table 3). Radiolunate arthropathy was found in 18.8 % (30 of 160) of the CPPD wrists, and 6.2 % (10 of 160) of the control wrists had arthropathy of this joint. This difference between these two groups was statistically significant (Table 1). The test of association between TS arthropathy and radiolunate arthropathy showed no significant correlation (Table 3). Arthropathy of the inferior radioulnar joint was found in 5 % (8 of 160) of the CPPD wrists and 2.5 % (4 of 160) of the control wrists. The difference between these two groups was not statistically significant (Table 1). The test of association between TS arthropathy and inferior radioulnar arthropathy showed no significant correlation (Table 3). Scapholunate advanced collapse (SLAC) was noted in 5.6 % (9 of 160) of the CPPD wrists in our series. This lesion was not found in the control group. The pattern of wrist calcifications in the CPPD patients (160 wrists) is summarized in Table 4. The most frequent site of calcification was the triangular fibrocartilage (TFC), found in 92.5% of the CPPD wrists. The second most common site was the lunate - triquetrum area seen in 54.4%. Other common sites of calcifications were the radiocarpal joint (31.9 %), synovium and capsule (28.8%), and scaphoid – capitate (15.6 %), scaphoid - lunate (14.4%), and trapezioscaphoid (13.1%) spaces. The test of association between TS arthropathy and calcification in the trapezioscaphoid area showed no significant correlation (Table 3). Many cystic lesions were seen in the CPPD wrists in our series, varying in size and location. The prevalence of cysts found in each location are summarized in Table 5. The three most common sites of cysts in our series were the capitate (22.5%), scaphoid (17.5%), and lunate (16.3%). The test of association between TS arthropathy and cystic lesions in the scaphoid or trapezium, or both, showed statistical significance (Table 3). Figure 3 and Figure 4 show TS arthropathy with cystic lesions in both scaphoid and trapezium in patients with CPPD crystal deposition disease.
DISCUSSION This study was undertaken to determine the frequency and pattern of TS joint involvement in CPPD crystal deposition disease and to correlate such involvement with other changes in the wrist. As previous reports had indicated that structural joint alterations in CPPD crystal deposition disease resemble osteoarthritis (11, 12, 13), we included an age - and sex - matched control group in our study. In addition, patients who had rheumatoid arthritis, gout, or neuropathic joint were excluded from the study. This study contained a disproportionately high number of men because it was carried out at a Veterans Affairs Medical Center. Resnick et al. (3) found that 34 % of CPPD wrists had TS alterations. This occurred in 43 % of such wrists in our series. The main findings of our study was a strong and significant association between TS arthropathy and CPPD crystal deposition disease. Our results are in agreement with those of Bensasson et al. (7) who described an association of isolated TS arthropathy with CPPD crystal deposition disease in 40 women and 10 men. Our study is also in agreement with a study of Stucki et al.(8), which had a high proportion of female patients and revealed an association between TS arthropathy and CPPD crystal deposition. Our results are in contrast to those reported by Bourqui et al. (9), who found a lack of a significant association between TS arthropathy and CPPD crystal deposition disease. No data on the severity of TS arthropathy found in that study were presented. In our series, patients with CPPD crystal deposition disease had a significantly higher incidence of structural alterations in most of the articulations studied, when compared to those in the control population. This difference was greatest in the TS joint, and capitolunate, scaphoid - capitate, and radioscaphoid spaces. First CMC joint arthropathy usually occurs in degenerative disease, but it can also be seen in patients with CPPD crystal deposition. Resnick et al.(3) found that 35 % of the CPPD patients had first CMC alterations; this was found in 40 % of the CPPD wrists in our series. From our study, we also found a significant association between first CMC joint arthropathy and TS arthropathy in patients with CPPD crystal deposition. Midcarpal compartment abnormalities were found in 29 % of CPPD wrists in our series with the capitolunate articulation being the most commonly afftected site. No significant association between midcarpal joint alteration and TS arthropathy was found in our study, however. In pyrophosphate arthropathy, a peculiar predilection for the radiocarpal compartment of the wrists is well known (14, 15, 16) and was shown in 37 % in our patients. We found no significant association between radioscaphoid or radiolunate arthropathy and TS joint abnormalities. The association between inferior radioulnar joint arthropathy and TS arthropathy in CPPD patients also was insignificant. In patients with CPPD crystal deposition in the wrist, calcification has been reported to occur most frequently in the TFC, although the interosseous ligaments of the scapholunate and lunotriquetral areas and the hyaline cartilage of the midcarpal and carpometacarpal regions may also be affected (3, 13, 15, 17 - 25). However, Yang et al.(26) reported that the lunotriquetral ligament was a more common site of calcification than the TFC. In our series, we found the TFC to be the most common site of calcification, followed by the lunotriquetral area. Synovial and capsular calcifications also occurred commonly in our study. In addition, we found a significant association between calcification about the TS joint and TS arthropathy in the CPPD population. Subchondral cysts are one of the hallmarks of pyrophosphate arthropathy (2). Cysts may form before cartilage loss is evident (2). We found that cystic lesions either of the scaphoid or trapezium, or both bones, had a significant association with TS arthropathy. There are a few weaknesses related to this study. First, there was no proof that the nature of calcification seen in the study was caused by CPPD crystal deposition disease. Second, the distal ulnar region was obscured in the blind analysis but other calcifications could be seen in the blinded reading. Third, other joints were not surveyed to determine if chondrocalcinosis was present. Finally, we did not study patients with other diseases such as rheumatoid arthritis or gout to determine if similar patterns of wrist disease may be seen. In conclusion, CPPD crystal deposition disease revealed frequent and significant radiographic abnormalities of the TS joint that may allow accurate diagnosis of this disease, even in those patients in whom chondrocalcinosis or other types of calcification is obscure or absent. Furthermore, first CMC, radiocarpal, and midcarpal joint alterations also were significant findings associated with CPPD crystal deposition disease. The features that had a significant association with TS arthropathy in CPPD patients were first CMC arthropathy and subchondral cysts of the scaphoid and trapezium.
Acknowledgment: The authors wish to thank Paul Clopton, M.S., for his assistance in statistical analysis of our data.
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Table1. The prevalence and degree of joint involvement in CPPD group compared to control group and test of the difference between these two groups in each
location.
Table 2. The degree of TS joint involvement in CPPD group and control group from consensus reading and blind reading.
Table 3. Changes in CPPD wrist and their association with TS arthropathy.
Table 4. Patterns of calcification in 160 CPPD wrists.
Table 5. Prevalence of subchondral cysts in each location in 160 CPPD wrists.
FIGURE LEGENDS Figure 1. (a) Posteroanterior radiograph of a CPPD wrist shows marked narrowing of the TS joint with sclerosis (open arrows). Small cysts in the scaphoid, lunate, triquetrum, and pisiform are also seen (black arrows).
Figure 3. Posteroanterior radiograph of a CPPD wrist shows mild TS arthropathy with multiple cysts in the scaphoid and trapezium (arrows). Calcifications are seen in the TFC, lunotriquetral space, and TS joint. Mild radioscaphoid joint narrowing is also noted. Figure 4. Posteroanterior radiograph of a CPPD wrist shows moderate TS joint and first CMC arthropathy with multile cysts in the scaphoid, trapezium, base of the first metacarpal bone, and hamate (arrows).
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