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Flashcards in Arthritic conditions Deck (37):

Define pseudogout?

  • A metabolic disease resulting from desposition of CALCIUM PYROPHOSPHATE DIHDRATE (CPPD) crystals within the joint space
  • Characterised by recurrent monoarticular arthritis


What is the epidemiology of pseudogout?

  • Commonly affects the elderly
  • rarely affects the young


Name associated conditions?

  • Haemochromatosis
  • Hyperparathyroidism
  • SLE
  • Gout
  • RA
  • Wilson's disease
  • Haemophilia
  • Long term haemodialysis
  • Chondrocalcinosis present in 7%


How is it different form gout?

  • Affects older patient >60 yrs
  • Affects more proximal joints
  • weakly Positive befringement crystals


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Describe the symptoms and signs?


  • Acute onset joint tenderness
  • warm , erythermatous joint
  • Commonly on knee and wrist joint


  • Erythermatous, monoarticular arthritis
  • Joint tenderness to palpation
  • May observe superficial mineral deposits under skin at affected joints


What is seen on xrays?

  • Chondrocalcinosis- calcification of fibroartilage structures
  • TFCC in wrist
  • Mensicus in knee

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How is pseudogout dx?

  • Weakly POSTIVE BIFEFRINGENT RHOMBOID shaped crystals


What is the tx of acute gout?

  • Acute
    • NSAIDS
    • Splints for comfort
  • Chronic
    • Non operative
    • Intra-articular yttrium-90 injection
    • cochicine- 0.6mg PO for recurrent cases
      • prophylatic cochicine can help to prevent recurrence


Complications of pseudogout?

  • Can result in permanent damage to joints and renal disease



  • postive birefringent rhombpid crystals
  • calcium Pyrophosphate dihydrate


What is the epidemiology of ankle arthritis?

Describe the pathophysiology of ankle arthritis?

  • Less common than OA of knee/hip


  • Post traumatic arthritis
    • Greater than 2/3 ankle arthritis
  • Primary OA- Less than 10% 
  • RA
  • Osteonecrosis
  • Septic arthritis
  • Gout


What is the pathoanatomy of ankle arthritis?

  • Nonanatomic fracture healing alters the joint reaction forces of the ankle and changes the load bearing mechanics of the ankle joint
  • Loss of cartilage on the talus and tibial plafound-> joint space naarowing, sunchondral sclerosis and Eburnation


Decribe the anatomy of the ankle joint?

  • Ginglymus joint- HINGE
  • Talar dome is biconcave with a central sulcus
  • Dorsiflexion 20o
  • Plantarflexion 50o


What are the signs and symptoms of ankle arthritis?


  • Pain on weight bearing
  • Reduction in motion


  • Joint effusion
  • reduced ROM cf contralateral side
  • Angular deformity if hx of trauma


What investigations are useful?


  • AP standing, lateral standing, oblique
  • Loss of joint space, subchondrial sclerosis, Eburnation, possible angular deformity


What is the tx for ankle arthritis?

  • Nonoperative
    • activity modification, bracing to immobilise ankle,NSAIDS
    • single rocker can improve things
  • Surgery
  • Debridement with anterior tibial/dortsal talectomy
    • Mild disease/ pai onpush off
  • Distraction arthroplasty
  • Supramalleolar osteotomy
    • ​medial focused ankle pain
  • Arthrodesis
    • eldery less active patient
  • ​Arthroplasty
    • Post-traumatic/ inflammatory arthritis/ eldery pt
    • Pt selection is key

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What are the Ci for ankle arthroplasty

  • Uncorrectable deformity
  • Severe osteporosis
  • talus ostenecrosis
  • Charot joint
  • ankle instablity
  • obesity
  • Young labourer
  • Increased reisk of failure and revision


What are the outcomes and complcations of ankle arthrodesis? 

  • Outcome- relief in pain and return to ADL
  • Complications
    • by 10 yrs - 50% subtalar arthritis
    • Non union
      • RF= Smoking
      • Adjacent joint fusion
      • Hx of failed arthrodesis
      • Avascular necrosis


What are the outomes and complications of ankle arthroplasty?

  • Recent 5-10 yr fu showed 90% good- excellent results
  • Long term studies results still pending


  • complications
    • syndesmosis nonunion
    • Wound infection
    • Deep infection
    • Osteolysis


How wpud you tx metatarsal prominence-> ulcers?


Double Rocker

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What is the consx tx of toe tip ulceration?

Severe angled rocker

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What consx tx is available for fixed angle dorsiflexion deformities?

Negative heel rocker

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Define midfoot arthritis?

Arthritis in 

  • Naviculocuneiform
  • Intercuneiform
  • Metatarsal cuneiform




What is the aetiology of midfoot arthritis?

  • Idiopathic- primary osteoarthritis
  • Posttraumatic
  • Inflammatory


What is the pathology of midfoot arthritis?

  • Large forces seen by joints that have limited motion
  • Soft tissues that support joints abnormally high forces over time
  • Results in midfoot collapse


What are the symptoms and signs of midfoot arthritis?


  • Midfoot pain adn in arch with push off


  • Longitudinal arch collapse- Meary's angle normally =O- but in this negative with collapse
  • Midfoot collapse- Looks like PTTI
  • Forefoot abduction
  • Hindfoot valgus
  • Equinnus contracture of achilles tendon
  • Halux valgus
  • palpation of arch/midfoot-> pain

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What do you see on xrays of midfoot arthritis?

  • Lateral- loss of co-linerity between talus and 1st MT= Meary's line
    • Apex of deformity is at level of midfoot
    • may shows collapse of LONGITUDINAL ARCH
  • ​AP
    • Arthritic signs in midfoot
    • Abduction of forefoot

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What is the ddx of this

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  • Post  tibial tendon insufficiency
  • Midfoot arthritis
  • Post traumatic LIs- Franc injury
  • Lateral ankle instability



What is the TX of midfoot arthritis?

  • Non operative
    • NSAIDS, Activity modification, orthotic/bracing
    • first line tx
    • steriods injections under radiographic guidance
    • orthotics
      • cushioned heel
      • longitudinal arch supports
      • stiff sole with rocker bottom
  • Operative
      • ​failure of non op tx
      • Outcomes= midfoot joints are non essential joints
      • arthrodesis results in close to normal foot function
      • Achilles tendon lengthening/ hindfoot relaignment
        • may need to be done concomitantly


Decribe the technique of midfoot arhrodesis?

  • Realignment arthrodesis
    • Fusion of 1st RAY via the TARSO-METATARSAL joint
    • Fusion of the 2/3rd rays via the NAVICULOCUNEIFORM/INTERCUNEIFROM joint
    • Don't fuse 4/5 TMT joints
      • ​lateral ray facilitates foot accomdation during stance
      • Interpositional arthroplasties of 4/5 Tarsometatarsal joints 
        • for select cases
        • will maintain length of lateral column
        • can assist with gait accomodation
    • can use screws. staples and plates for midfoot fusions


What is the cause of tibiotalar impingment?

  • Osteophyte impingment in anterior tibiotalar joint
  • Excessive anterolateral soft tissues or posterior soft tissue or osseous abnormalities

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What is the epidemiology of tibiotalar impingment?

  • Common in athletes who play on turf or on grass including
    • Rugby
    • football
    • dancers


What is the mechanism of tibiotalar impingment?

  • Repetitive overuse injuries
  • Trauma
  • Degenerative sequlae


What are the symptoms and signs of tibiotalar impingment?

  • Symptoms
    • Pain in anterior ankle
  • Signs
    • Pain with forced dorsiflexion
    • limited dorsiflexion
    • Soft tissue swelling and effusion may be evident
    • subtalar joint is pain free


What imaging is useful in tibiotalar impingment?

  • xrays
    • Ap, lateral standing and oblique
    • spurs seen anterior disatl tibia or dorsal aspect of talus
  • CT
    • delinates extent of bony osteophytes
  • MRI
    • Shows spurring and fluid in joint

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What is the tx of talotibial impingement?

  • Non operative
    • Therapy, lifestyle modficiations, NSAIDS
    • first line tx
  • Operative
    • Arthroscopic excision


What are the complications of ankle arthroscopy?

  • Superifical peroneal nerve injury to anterolateral portal creation
  • Saphenous vein injury during anteromedial portal creation
  • Dorsal neurovascular bundle during tibiotalar spur removal