RHEUMATOID ARTHRITIS

& OSTEOARTHRITIS

dr. John Kurniawan

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Arthritis or not? An arthritis is a disease that affects a joint and usually the bones on either side
of the joint, almost always accompanied by joint space narrowing. A, This disease meets those
specifications. There is narrowing of the hip joint, and both the femoral head and the
acetabulum are abnormal (solid white arrow). This is osteoarthritis of the hip. B, There is an
abnormality of the femoral head (sclerosis) but the joint space is normal as is the acetabulum
(solid black arrow). This is avascular necrosis of the femoral head.
 CLASSIFICATION OF ARTHRITIS
Category Hallmarks Types Remarks

Hypertrophic Bone formation Primary osteoarthritis Most common; mechanical stress; hands, hips, and knees most common
arthritis Osteophytes

Secondary osteoarthritis Degenerative joint disease (DJD) secondary to prior trauma, or avascular necrosis

Charcot arthropathy Fragmentation; joint destruction; sclerosis; most often secondary to diabetes

CPPD Chondrocalcinosis; DJD in unusual sites

Erosive Erosions Rheumatoid Carpals, metacarpal-phalangeal joints, proximal interphalangeal joints of hands;
arthritis osteoporosis; soft-tissue swelling

Gout Juxtaarticular erosions with overhanging edges; long-latency; metatarsal-phalangeal

joint of big toe; no osteoporosis

Psoriatic Juxtaarticular erosions of distal interphalangeal joints of hands; pencil-in-cup

deformity; enthesophytes

Hemophilia Remodeling from hemarthroses and hyperemia; same changes in knee in female-
think of juvenile rheumatoid arthritis

Ankylosing spondylitis HLA-B27+; bilateral sacroiliac (SI) joints; syndesmophytes

Seronegative Rheumatoid factor negative; HLA-B27+; SI joints; syndesmophytes reactive arthritis,

spondyloarthropathies psoriasis

Infectious Osteopenia and soft tissue swelling; early and Pyogenic Early destruction of articular cortex; osteoporosis
arthritis marked destruction of most or all of the TB Gradual and late destruction of articular cortex; marked osteoporosis
articular cortex
The imaging hallmarks of the three major categories of arthritis. A, Hypertrophic arthritis
features subchondral sclerosis (solid black arrow) and marginal osteophyte production (solid
white arrow). B, Erosive (inflammatory) arthritis features characteristic marginal lytic erosions
(solid white and black arrows). C, Infectious arthritis features destruction of the articular cortex
(dotted white arrow).
Osteoarthritis. The hallmarks of
osteoarthritis are demonstrated in this
patient's right hip. There is marginal
osteophyte formation (solid white arrow), a
process by which osseous transformation of
cartilaginous excrescences and metaplasia of
synovial lining cells leads to the production of
bony protrusions at or near the joint. There is
also subchondral sclerosis (solid black
arrows), representing reaction of the bone to
the mechanical stress to which it is subjected
when its protective cartilage has been
destroyed. Subchondral cyst formation is also
present (dotted black arrow)
Osteoarthritis of hip (A) and knee (B). In osteoarthritis, destruction of the cartilaginous buffer
between the apposing bones of a joint leads to narrowing of the joint space most often on the
weight-bearing side of the joint. In the hip (A), the superior and lateral surface is most affected
(solid white arrow) while in the knee (B), the medial compartment is more affected (solid black
arrow)
Osteoarthritis of the hands (A and B). In the hands, osteoarthritis affects primarily the distal
and then proximal interphalangeal joints. There are osteophytes at the distal and proximal
phalangeal joints (solid white arrows) and the joint spaces are narrowed. There is also
subchondral sclerosis present at the carpal-metacarpal joint of the thumb (solid black arrow).
Osteoarthritis of the hands occurs most often in older women.
 Some Causes of Secondary
Osteoarthritis
• Trauma
• Infection
• Avascular necrosis
• Calcium pyrophosphate deposition disease
• Rheumatoid arthritis
Secondary osteoarthritis, right hip. Notice the marked discrepancy between the two hips
with severe and advanced osteoarthritis of the right hip (solid black arrow) and a normal left
hip (solid white arrow). The radiographic findings of secondary osteoarthritis are the same as
those for the primary form except it occurs at an atypical age for primary osteoarthritis, it has
an atypical appearance for primary osteoarthritis, and it may appear in an unusual location
for primary osteoarthritis. This patient had a slipped capital femoral epiphysis on the right,
and it was never attended to medically
Erosive osteoarthritis. A type of primary osteoarthritis characterized by more severe
inflammation and by the development of erosive changes, erosive osteoarthritis may feature
bilaterally symmetrical changes like the osteophytes of DJD but with marked inflammation
(swelling and tenderness). The erosions are typically centrally located within the joint (solid
black arrows) and, combined with the small osteophytes associated with the disease (solid white
arrows), produce what has been called the gull-wing deformity.
Charcot arthropathy of knees. As a hypertrophic arthritis, a Charcot joint will demonstrate
extensive subchondral sclerosis. The hallmark findings of a Charcot joint, however, are
fragmentation of the bones surrounding the joint, which produces numerous small, bony
densities within the joint capsule (solid white arrows) as well as joint space destruction (solid
black arrows). The most common cause of a Charcot joint of the knee is diabetes
Charcot arthropathy of foot. This patient had previously undergone an amputation of the
phalanges of the second toe (solid white arrow) for diabetic gangrene but the destruction and
marked fragmentation of the great toe are manifestations of Charcot neuropathy (solid black
arrows). Charcot neuropathy can produce some of the most dramatic examples of total joint
destruction of any arthritis
Chondrocalcinosis. Chondrocalcinosis refers only to calcification of the articular cartilage (solid
white arrows) or fibrocartilage and is seen in about 50% of adults over the age of 85, most of
whom are asymptomatic. If this patient had acute pain, redness, swelling, and limitation of
motion, the combination would be called pseudogout.
Calcium pyrophosphate deposition disease (CPPD). CPPD arthropathy produces changes similar
to osteoarthritis but differs from it in that CPPD affects joints not usually affected by primary
osteoarthritis. A, Hook-shaped bony excrescences along the 2nd and 3rd metacarpal heads are a
common finding in CPPD (solid white arrows). The radiocarpal joint is narrowed (solid black
arrow). B, In the wrist, characteristic findings include calcification of the triangular fibrocartilage
(solid white arrow), separation of the scaphoid (S) and the lunate (L) (scapholunate dissociation)
and collapse of the capitate (C) toward the radius (solid black arrow) called scapholunate
 Some Causes of Erosive Arthritis

 Rheumatoid arthritis
 Gout
 Psoriatic arthritis
 Ankylosing spondylitis (spine)
Box 23-2 Some Causes of Erosive Arthritis

 Rheumatoid variants
 Reactive arthritis (formerly known as Reiter syndrome)
 Sarcoid
 Hemophilia
Rheumatoid arthritis, hand (A) and wrist (B). A, In the hand, the erosions of RA tend to involve
the proximal joints: the carpal-metacarpal joints, metacarpal-phalangeal (solid white arrows),
and proximal interphalangeal joints. Late findings in the hands include deformities such as
ulnar deviation of the fingers at the MCP joints, subluxation of the MCP joints, and ligamentous
laxity leading to deformities of the fingers, which are also present in this hand. B, In the wrist,
erosions of the carpals (dotted white arrow), ulnar styloid (solid white arrow), and narrowing of
the radiocarpal joint space (solid black arrow) are commonly seen.
Rheumatoid arthritis of the hip. The larger joints (hips and knees) usually show no erosions, but
there may be marked uniform narrowing of the joint space with little or no subchondral
sclerosis (solid black arrow). If this were primary osteoarthritis, you would expect far more
subchondral sclerosis and osteophyte production for this degree of joint space narrowing
Rheumatoid arthritis of the cervical spine. RA tends to involve the cervical spine by producing
ligamentous laxity, which can lead to forward subluxation of C1 on C2 (atlantoaxial
subluxation). The distance between the anterior border of the dens (D) and the posterior
border of the anterior tubercle of C1 (T) is called the predentate space and is normally no more
than 3 mm. This patient's predentate space measured 8 mm (solid black arrow). RA may also
cause fusion of the facet joints (solid white arrow).
Gout. Gout most commonly affects the metatarsal-phalangeal joint of the great toe, as in this
patient. As an erosive arthritis, the hallmark of gout is the sharply marginated, juxtaarticular
erosion which may have a sclerotic border (solid white arrows). The overhanging edges of gouty
erosions have been called rat bites. The metatarsal-phalangeal joint space is not particularly
narrowed, and there is no periarticular osteoporosis.
Olecranon bursitis in gout. Olecranon bursitis is a common manifestation of gout (large soft
tissue mass around elbow shown by solid white arrows) and its presence alone should alert you
to the possibility of underlying gout. This patient also displays erosions adjacent to the elbow
joint (solid black arrow).
Psoriatic arthritis, hand (A) and foot (B). A, Psoriatic arthritis typically involves the small joints
of the hands, especially the distal interphalangeal (DIP) joints (solid white arrows) leading to
telescoping of one phalanx into another (pencil-in-cup deformity). B, In the foot of another
patient with psoriasis, there is ankylosis of the 2nd toe (solid black arrow) and more pencil-in-cup
deformities (dotted white arrows).
Ankylosing spondylitis. Ankylosing spondylitis is an enthesopathy, a process that produces
inflammation with subsequent calcification and ossification at and around the entheses, which
are the insertion sites of tendons, ligaments, and joint capsules (solid white arrow points to
bony overgrowth at the ischial tuberosity). Bilaterally symmetrical sacroiliitis is the hallmark of
ankylosing spondylitis. This eventually leads to bony fusion or ankylosis of the SI joints until they
disappear as joints altogether (solid black arrows). The symphysis pubis is also ankylosed (dotted
black arrow).
Ankylosing spondylitis, frontal (A) and lateral (B) spine. In the spine, there is ossification of the
outer fibers of the annulus fibrosus producing thin, bony bridges joining the corners of adjacent
vertebrae called syndesmophytes (solid white arrows). Progressive ossification connecting
adjacent vertebral bodies produces the bamboo-spine appearance seen in this case, which is
characteristic of ankylosing spondylitis
Septic arthritis and osteomyelitis, middle finger. The
hallmark of infectious arthritis, especially the pyogenic
form, is destruction of the articular cartilage and long
contiguous segments of the adjacent articular cortex
from proteolytic enzymes released by the inflamed
synovium. This patient has septic arthritis (the distal
interphalangeal joint is destroyed) which has extended
to the subjacent bone as osteomyelitis and destroyed
either side of the joint space as well (solid and dotted
white arrows). The time course of septic arthritis, unlike
other arthritides, is usually quite rapid. This infection
was the result of a human bite