Peh, WCG

Cheung, KMC

W C Peh

K M Cheung

P, Hodgson S.

A, Enarson D.

T, Davidson P.

A, Selwyn P.

Martini, M.

Rathakrishnan, V.

Resnick, D.

B, Phemister D.

Coppola, J.

Araki, Y.

de Roos A

P, Ormerod L.

KimY, Y.

Crossref

Progressive shoulder arthropathy.

Frías, José Antonio

Name not available

El catálogo de fichas y la opinión de los usuarios: selección bibliográfica.

HKU Scholars Hub

Title Progressive shoulder arthropathyAuthor(s) Peh, WCG; Cheung, KMCCitation Annals Of The Rheumatic Diseases, 1995, v. 54 n. 3, p. 168-173Issued Date 1995URL http://hdl.handle.net/10722/53442Rights Creative Commons: Attribution 3.0 Hong Kong LicenseAnnals of the Rheumatic Diseases 1995; 54: 168-173CASE STUDIES IN DIAGNOSTIC IMAGING Series editor: VN Cassar-Pullicino*Progressive shoulder arthropathyW C G Peh, KM C CheungDepartment ofDiagnostic Radiology,The University ofHong Kong,Queen Mary Hospital,Hong KongW C G PehDepartment ofOrthopaedic SurgeryKM C CheungCorrespondence to:Dr Wilfred C G Peh,Departmnent ofDiagnostic Radiology,The University ofHong Kong,Queen Mary Hospital,Hong Kong.*Department ofDiagnostic Imaging,The Robert Jones and AgnesHunt Orthopaedic Hospital,Oswestry,Shropshire SYlO 7AG,United Kingdom.Accepted for publication17 November 1994Clinical historyAn 84 year old Chinese woman presented witha one year history of increasingly severe rightshoulder pain, associated with joint stiffness.There were no symptoms related to the rest ofthe upper limb or neck. On examination, a softtissue mass was palpable over the anterior aspectof the right shoulder. The mass measuredabout 6 cm in diameter, was generally ill-defined, soft in consistency, non-tender andcold to touch. Right shoulder movements wereseverely restricted in all directions because ofsevere pain. The other peripheral joints hadsatisfactory ranges of motion. Her generalcondition was otherwise satisfactory, with noother systemic abnormality evident.Imaging findings and clinical coursePlain radiograph of the right shoulder showedpatchy periarticular osteoporosis. There was alytic area in the lower humeral head, suggestiveof a large erosion or cyst. Small bony densitieswere present in the soft tissues just inferior tothe glenohumeral joint (fig 1). As the initialworking diagnosis was osteoarthritis of theshoulder, the patient was managed with physio-therapy and mobilisation. Aspiration was notperformed at this time. No steroids wereadministered. However, her shoulder painbecame progressively worse despite this con-servative treatment. Repeat radiograph twomonths later demonstrated further destructiveFigure 1 Right shoulder radiograph shows a lytic area in the humeral head (arrowheads).J7oint space is preserved, with collection of bony densities inferior to the joint (arrows). Thereis patchy periarticular osteoporosis.changes of the humeral head, with involvementof the bony glenoid. There was increase inthe amount of bony debris surrounding theshoulder joint (fig 2). Her erythrocyte sedi-mentation rate was increased (1 15 mm/Ist h).Computed tomography (CT) confirmeddestruction of the articulating surfaces of theglenohumeral joint, with erosions of theadjacent humeral head and lateral scapula.Multiple bony fragments were present withinthe joint space. The deltoid and subscapularismuscles were enlarged and swollen. Theycontained hypodense areas which showedperipheral ring like enhancement after contrastinjection. The space within the remnant gleno-humeral joint was occupied by similarlyenhancing soft tissue and fluid (fig 3).Differential diagnosisUntil proven otherwise, any monoarticularlesion should be regarded to be of infectiveorigin and investigated appropriately. Causesof monoarthritis such as trauma, gout andother crystal induced arthritis, and rheumatoidarthritis (rare) could be excluded on the basisof the clinical features, particularly with lack ofsystemic involvement. Osteoporosis is mild orabsent in gout. In calcium pyrophosphatedeposition disease (CPPD), there is degenerativerather than active destruction of the joint, andarticular cartilage calcification may be seen.Apatite associated joint destruction, alsoknown as the Milwaukee shoulder, producesglenohumeral changes similar to those ofCPPD and additionally occurs in combinationwith complete rotator cuff tear, which may giverise to proximal humeral head migration.Diagnosis of both CPPD and apatite associatedarthritis depends upon analysis of aspiratedsynovial fluid.Besides typically having a bilateral andsymmetrical distribution, rheumatoid arthritismanifests with early and significant jointspace loss. Radiographic features of osteo-arthritis are joint space narrowing, subchondralsclerosis and osteophytes. Synovial osteo-chondromatosis characteristically producescalcified loose bodies and well defined pressureerosions on plain radiographs, while in pig-mented villonodular synovitis there is absenceof osteoporosis, joint space preservation, andintra-articular nodular soft tissue causingextrinsic bony erosions on radiography andCT.An atrophic type of neuropathic (orCharcot) joint may present with a large,168Progressive shoulder arthropathyFigure 2 Repeat radiograph after two months shows marked destruction of the articulatinghumeral head and glenoidfossa. The amount of intra-articular debris has increased(arrows).clinically 'cool' effusion and rapid develop-ment of instability. However, in the shoulder,neuroarthropathy is almost always indicative ofunderlying syringomyelia. Radiographically,fragmentation and resorption resulting indestruction are often confined to the humeralhead, with sparing of the glenoid. There isusually no associated osteopenia or articularerosion. In osteonecrosis, careful clinicalassessment is required to elicit a possiblepredisposing cause. While poorly definedincreased density or 'snowcapping' of thehumeral head may be encountered, featuressuch as subchondral lucencies, meniscus sign,humeral head collapse and joint destructionoccur less frequently, compared with the hipjoint. Although the clinical and radiographicfeatures could fit those of a synovioma, the CTfindings did not support this diagnosis.Progressive destructive joint changes makeseptic arthritis the most likely diagnosis,particularly with CT demonstration of intra-muscular abscesses and intra-articular inflam-matory mass and effusion. The lack of bothlocal inflammatory signs and systemic toxicity,despite the florid imaging abnormalities, isagainst a pyogenic organism as the cause ofseptic arthritis. Moreover, pyogenic arthritistypically results in early joint space loss andpreservation of bone density before bonydestruction. The table summarises principalcauses of destructive large joint monoarthritis.Figure 3 Axial CT images (bone window), at the levels of (A) the base of the coracoid process and (B) the mid-glenoidfossa, show marked destruction ofthe glenohumeraljoint with multiple small bonyfragments (arrows). Enhanced CT images (soft tissue window) at corresponding levels (C and D), showmultiple ring shaped enhancing lesions within the swollen deltoid and subscapularis muscles (arrowheads). An inflammatory mass is seen in theglenohumeral joint.169Peh, CheungPrincipal causes ofprogressive destructive large jointmonoarthritis1 Septic arthritis(a) Tuberculosis(b) Pyogenic2. Apatite associated destructive arthritis(or Milwaukee shoulder)3. Calcium pyrophosphate deposition disease4. Synovioma5. Atrophic neuropathic (or Charcot) joint6. Osteonecrosis (±pre-existing osteoarthritis)7. Gout (rare)8. Rheumatoid arthritis (rare)DiagnosisThe diagnosis was tuberculous arthritis.Aspiration of the right shoulder joint yieldedblood stained fluid, culture of which sub-sequently grew Mycobacterium tuberculosis. Thepatient was started on antituberculosis therapyconsisting of isoniazid, pyrazinamide, ofloxacinand ethambutol. However, the patient developeda persistent discharging sinus over the antero-lateral aspect of the right shoulder (fig 4A). Atoperation, this was found to communicate withan abscess within the deltoid muscle and withthe shoulder joint, which contained greyishcaseous necrotic material (fig 4B). Excision ofthe sinus tract and abscess drainage was per-formed. Magnetic resonance imaging (MRI)subsequently demonstrated that the deltoidmuscle abscesses had largely resolved but thereremained active inflammatory tissue within theshoulder joint and subdeltoid space (fig 5).The patient continued to receive anti-tuberculous drugs for a total of six months. Atlast follow up, eight months after presentation,she had regained a moderate range of rightshoulder motion.DiscussionThe incidence of bone and joint tuberculosis(TB) in the United Kingdom and NorthAmerica is low and has been declining forseveral decades.' 2 Compared with other extra-pulmonary sites, articular involvement israre, occurring in fewer than 1% of patientswith active tuberculosis.3 Since the onset ofthe human immunodeficiency virus (HIV)epidemic, there has been much interest andconcern over possible TB-HIV interaction.4There is evidence to suggest that up to 30% ofpeople with previous TB, if infected with HIV,will develop active disease as a result ofreactivation of latent infection.5Tuberculous arthritis is a potentiallydisabling condition which, if untreated, maylead to complete destruction of the joint. DelayFigure 4 A: Clinical photograph showing a discharging sinus over the right shoulder. B: Operative photograph showing caseous necrotic material (arrows)within the shoulderjoint.Figure 5 Coronal MRI through the mid-remnant humeral head. A: Tl weighted image showing that the glenohumeral and subdeltoid spaces contain alargely isointense mass (arrowheads), with small hypointense areas within. B: Post-gadolinium DTPA Tl weighted image showing marked contrastenhancement, mainly located peripherally, indicating active inflammatory tissue (arrowheads).170Progressive shoulder arthropathyFigure 6 Mechanism and routes of tuberculous arthritis. A: Primary involvement ofsynovium. B: Fistula from adjacent organ or soft tissue. C: Spreadfrom osteomyelitic focus:= cartilage surface spread; ii = mushrooming through cartilage; iii = subchondral spread.in diagnosis is frequent, as the clinical mani-festations are often mild. Patients typicallypresent with insidious onset of joint pain andswelling, with minimal signs of inflammation.Monoarticular disease predominates, althougholigoarticular involvement is not uncommon.Weight bearing joints, such as the hip and knee,are most frequently affected. Physical findingswhich may be present are joint deformity,swelling and discharging sinus. Predisposingfactors include trauma, intra-articular cortico-steroid injection, narcotic addiction and,possibly, systemic illnesses.2 9 In the UnitedKingdom, the incidence of bone and joint TBin immigrants from the Indian subcontinent ismuch greater than that in the indigenouspopulation; however, probably because ofreduced clinical suspicion, the diagnoses inlatter group are invariably delayed in com-parison with the Indian group.' Absence ofpulmonary TB in more than 50% of patientswith articular infection adds to the difficulty indiagnosis.238In most subjects, tuberculous arthritisdevelops through spread from adjacent osteo-myelitis. Alternatively, primary synovial involve-ment may occur, especially in the knee. Thecommon pathway remains haematogenousspread of disease, presumably from a pulmonaryfocus. There may be reactivation of a quiescentfocus following decreased local resistance, as aresult of causes such as trauma or debilitation;the hip joint is one such recognised site.2Another pathway for articular contamination isfistula formation from tuberculous infection oforgans such as the bowel and bladder, or fromsoft tissue abscesses. Conversely, tuberculousarthritis may spread to involve adjacentstructures. Intra-articular tissue responds tothe presence of tuberculosis bacilli by pro-ducing a well vascularised granulomatouslesion, which microscopically contains necroticand fibrin like material, collections of leuco-cytes and mononuclear phagocytes, and areasof caseation. Epithelioid cells and tuberclesmay be seen in the caseated areas. Thegranulation tissue may extend along the freecartilaginous surface, spread between cartilageand subchondral bone (particularly in closefitting articulating joints such as the hip andankle), and occasionally, mushroom from asubchondral site, through gaps in the cartilage,into the joint cavity.9 Figure 6 illustratesvarious mechanisms of articular infection.In early disease, radiographs may be normal.Areas of decalcification of bone away fromthe joint surfaces and corner erosions thendevelop, especially in weight bearing jointssuch as the hip, knee, and ankle. This com-bination of periarticular osteoporosis, marginalerosions and relative joint space preservation,also known as Phemister's triad, is highlysuggestive of tuberculous arthritis.'0 Theincidence and degree of bony proliferation,periostitis and intra-articular bony ankylosisare less than with pyogenic arthritis. Later,bone loss may occur as a result of destructionby granulation tissue. Sequestra may form andare seen as collections of dense bone frag-ments, adjacent to the articular edges.9 Largeareas of necrosis may occur in the subchondralbone on opposing sides of a weight bearingjoint, resulting in gradual bony sequestration,forming so-called 'kissing sequestra'.10 Inadvanced disease, massive destruction, sub-luxation, deformity and eventually, fibrousankylosis, may result.9CT is a useful tool in the evaluation ofmusculoskeletal TB, demonstrating moreextensive involvement than could be seen onplain radiographs. Tuberculous lesions areseen as areas of osseous destruction, associatedwith adjacent soft tissue masses showingcharacteristic rim enhancement. It is postulatedthat this appearance occurs from developingvascularity of the tuberculous mass." Theapplication of scintigraphy, being sensitive butnon-specific, is probably quite limited in thiscondition. The vascularised granulomatoustuberculous mass may produce increaseduptake during dynamic and blood pool phases,with adjacent bony involvement demonstratedon delayed static images (fig 7). The appear-ance of tuberculous arthritis on MRI hasrecently been described.'2 13 The involvedsynovium and granulation tissue may be seenas a lobulated inhomogenous mass, of mixedhypo- and isointensities on TI weighted, andmixed hypo-, iso- and hyperintensities on T2weighted images (fig 8). Besides the inflam-matory mass which is largely of low to inter-mediate Ti and high T2 signal, joint fluid (lowTl and high T2 signal), haemosiderin, andloose cartilaginous bodies (both producinglow signal on Tl and T2 weighted images)also contribute to the inhomogenous MRIappearance.'2 13 As demonstrated in our firstpatient (fig 5), the utilisation of intravenousgadolinium-DTPA is helpful in delineating theextent of viable inflammatory tissue intuberculous infection.'4 Obviously, conditionssuch as pigmented villonodular synovitis,haemophilia, synovial osteochondromatosis,pyogenic arthritis and post-traumatic loosebodies with associated joint effusion could171Peh, CheungFigure 7 Tuberculous arthritis of the right hip in a 68yearEA old woman. A: Initial radiograph showing long standingfemoral headflattening and deformity, consistent withK osteonecrosis. B: Radiograph taken four weeks later,* showing destruction of thefemoro acetabular articulation.* Technetium MDP scintigram shows (C) increased bloodpool uptake over the right hip on early static images,corresponding to the inflammatory mass (arrows), withlinear areas representing iliac andfemoral vessels(arrowheads); and (D) increased uptake at the acetabulumand remnantfemoral neck on delayed (three hour) images,corresponding to infected bony margins.produce similar MRI appearances."1 However,an attempt at the diagnosis should only bemade after careful review of the clinical andplain radiographic features. If this basicprinciple of MRI interpretation is observed,B many of the differential diagnoses can beexcluded.The definitive diagnosis of tuberculousarthritis is based on identification of Myco-bacterium tuberculosis organism from either thesynovial fluid or the synovium itself, or onhistological evidence of granulomas on synovialbiopsy,9 all of which give good diagnosticyields. Chemotherapy is the treatment ofchoice for all cases of tuberculous arthritis,being effective in arresting the disease pro-gression. The British Thoracic Society hasrecommended that the drug treatment of adultpatients with extrapulmonary TB should beshared with a chest physician and that ofchildren shared with a paediatrician.'5 Surgery,including arthroplasty, may be indicatedin selected patients to correct persistingdeformnities or provide relief to disablingC arthropathy. In these cases, the importance ofappropriate and adequate preoperative anti-tuberculous chemotherapy is emphasised.7 11 Hodgson S P, Ormerod L P. Ten-year experience of boneand joint tuberculosis in Blackburn 1978 1987. J7 R CoillSurgEdin 1990; 35: 259-62.2 Enarson D A, Fujii M, Nakielna E M, Grzybowski S. Boneand joint tuberculosis: a continuing problem. Can MedAssocJ 1979; 120: 139-45.3 Davidson P T, Horowitz I. Skeletal tuberculosis-a reviewwith patient presentations and discussions. Am J Med1970; 48: 77-84.4 Subcommittee of the Joint Tuberculosis Committee of theBritish Thoracic Society. Guidelines on the managementof tuberculosis and HIV infection in the United Kingdom.BMJ 1992; 304: 123 1-3.5 Selwyn P A, Hartel D, Lewis V A, et al. A prospective studyof the risk of tuberculosis among intravenous drug userswith human immunodeficiency virus infection. N EngiYMed 1989; 320: 545 50.D 6 Berey S, Goldstein M, Bishko F. Clinical and diagnosticfeatures of tuberculous arthritis. Am J Med 1972; 53:36-42.7 Martini M, Ouahes M. Bone and joint tuberculosis: a reviewof 652 cases. Orthopedics 1988; 11: 861 6.8 Rathakrishnan V, Mohd T H. Osteo-articular tuberculosis.A radiological study in a Malaysian hospital. SkeletalRadiol 1989; 18: 267-72.9 Resnick D, Niwayama G. Tuberculous arthritis. In:Resnick D, Niwayama G, eds. Diagnosis of bone and jointdisorders, 2nd edn. Philadelphia: W B Saunders, 1988:A 132678-85.10 Phemister D B, Hatcher C H. Correlation of pathologicaland roentgenological findings in the diagnosis oftuberculous arthritis. AmJRoentgenol 1933; 29: 736-52.11 Coppola J, Muller N L, Connell D G. Computedtomography of musculoskeletal tuberculosis. J Can Assoc1 Radiol 1987; 38: 199-203.12 Schultz E, Richterman I, Dorfman H D. Case report 739.Tuberculous arthritis of knee. Skeletal Radiol 1992; 21:330-4.13 Araki Y, Tsukaguchi I, Shino K, Nakamura H. Tuberculousarthritis ofthe knee: MR findings [letter]. Am J Roentgenol1993; 160: 664.172Progressive shoulder arthropathy14 de Roos A, van Meerten E L P, Bloem J L, Bluemm R G.MRI of tuberculous spondylitis. Am Jf Roentgenol 1986;146: 79-82.15 Ormerod L P for the Joint Tuberculosis Committee.Chemotherapy and management of tuberculosis inthe United Kingdom: recommendations of the JointTuberculosis Committee of the British Thoracic Society.Thorax 1990; 45: 403-8.16 KimY Y, Ko C U, Ahn J Y, Yoon Y S, Kwak B M. Charnleylow friction arthroplasty in tuberculosis of the hip. Aneight to 13-year follow-up. J7 Bonejoint Surg Br 1988; 70:756-60.Figure 8 MRI of the same patient as in figure 7. Coronal(A) Tl and (B) T2 weighted images of the pelvisdemonstrate the tuberculous granulomatous lesion as a largemass ofmixed heterogenicity occupying and eroding themargins of the right hipjoint (arrows). Leftfemoral head isnormal (arrowheads). Axial (C) Tl (upper) and T2weighted (lower) images at the level of the intact leftfemoralhead (arrowheads) show extent of the large right sidedinflammatoty mass (arrows).173

Annals of the Rheumatic Diseases

Progressive shoulder arthropathy

This article describes and analyses the main conclusions of research carried out imto the use of card catalogues by library users. Three main aspects are concentrated on: user preference for certain types of catalogue, search strategies used and the results of these searches. It is concluded that, contrary to the present tendency to give less value to the capacity of card catalogues as instruments of information recovery, these, nevertheless, continue to be valid tools for satisfying the information requirements of the majority of library users. | Se exponen y analizan las principales conclusiones de las investigaciones que se han llevado a cabo sobre la utilización de los catálogos de fichas por parte de los usuarios de la biblioteca, centrándose en tres aspectos principales: la preferencia de los usuarios por determinados tipos de catálogos, las estrategias de búsqueda que utilizan y los resultados de estas búsquedas. Se concluye que, frente a la actual tendencia a infravalorar las capacidades del catálogo de fichas corno instrumento de recuperación de la información, éste continúa siendo una herramienta válida para satisfacer las necesidades informativas de la mayorparte de los usuarios de la biblioteca

Temaria - Revistas digitales de biblioteconomía y documentación

El catálogo de fichas y la opinión de los usuarios : selección bibliográfica

[ES]Se exponen y analizan las principales conclusiones de las investigaciones que se han llevado a cabo sobre la utilización de los catálogos de fichas por parte de los usuarios de la biblioteca, centrándose en tres aspectos principales: la preferencia de los usuarios por determinados tipos de catálogos, las estrategias de búsqueda que utilizan y los resultados de estas búsquedas. Se concluye que, frente a la actual tendencia a infravalorar las capacidades del catálogo de fichas como instrumento de recuperación de la información, éste continúa siendo una herramienta válida para satisfacer las necesidades informativas de la mayor parte de los usuarios de la biblioteca

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Gestion del Repositorio Documental de la Universidad de Salamanca

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El catálogo de fichas y la opinión de los usuarios: selección bibliográfica

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Progressive shoulder arthropathy

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