The Hip: Preservation, Replacement and Revision

Pseudogout and Chondrocalcinosis

- Discussion:
    - acute arthritis caused by CPPD crystal-induced inflammation;
    - almost as common as gout & may perfectly mimic gout during acute flare;
    - pseudogout attacks occurring before age 50 are uncommon;
    - see: pseudogout occurence after joint replacement:
    - references:
           - A histological study of calcium pyrophosphate dihydrate crystal-deposition disease.
           - Clinical features of pseudogout attack. A survey of 50 cases.
    - differential diagnosis:
           - pseudogout occurence after joint replacement:
           - septic arthritis:
                  - pseudogout may be confused with septic arthritis;
                  - chondrocalcinosis of the meniscus occurs not only in otherwise healthy individuals in older age groups but also in definite
                           association w/ several distinct metabolic disorders;
                  - references:
                           - Monoarticular pseudogout of the hip presenting as septic arthritis: a case report.
                           - Presence of crystals is not an evidence of absence of infection.
           - trauma:
                  - perhaps the majority of cases of chondrocalcinosis occur from trauma;
                  - ref: Localized chondrocalcinosis in traumatized joints.   
           - hemochromatosis;
           - hyperparathyroidism (most common);
                  - up to 30% of hyperparathyroid pts have chondrocalcinosis;
           - hypothyroidism;
           - gout:
                   - ref: Gout and coexisting pseudogout in the knee joint.
           - hyperparathyroidism
           - hypothyroidism
           - hemochromatosis
           - ochronosis
                  - ochronosis is a hereditary enzyme deficiency (homogentisic acid oxidase) resulting in deposition of homogentisic
                             acid polymers in articular cartilage
           - acromegaly
           - Paget's disease
           - hypomagnesemia
                   - references:
                          - Hypomagnesemia associated with chondrocalcinosis: a cross-sectional study
                          - Images in clinical medicine. Chondrocalcinosis and hypomagnesemia.

- Clinical Features:
    - most often affects the knee and the wrists;

- CPPD Crystal Exam:
      - Crystal Examination of Synovial Fluid:
      - Calcium pyrophosphate dihydrate crystals are visualized under compensated polarized light microscopy
               - crystals may be more difficult to detect than MSU crystals because of their smaller size, more intraphagolysosomal
                          location, & less brilliant colors;
               - in contrast to MSU crystals, CPPD crystals show weak positive birefringency and have squared or rhomboidal shaped ends;
               - aggregates do not show birefringence (or are weakly birefringent) under polarized light;
               - alizarin red stain, can confirm that these clumps are masses of calcium crystals;

- Radiographic Analysis:
    - punctate and linear densities in hyaline or fibrocartilage, which are found in knee menisci, acetabular labrum, & TFCC;


- Therapeutic Principles:
    - aspiration of joint and steroid injection, once diagnosis of infection has been excluded, will usually control symptoms;
           - references:
                - Rapidly destructive tibiofemoral knee osteoarthritis: presentation and outcome after global medical treatment including non-arthroscopic joint lavage plus corticosteroid injection. A single center retrolective study.

    - indomethacin;
    - colchicine? may be useful for pseudogout;
    - magnesium on an as needed basis
    - arthroscopic lavage:
Joint lavage and pseudogout

Treating difficult crystal pyrophosphate dihydrate deposition disease
Arthroscopy and chondrocalcinosis.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, February 10, 2014 10:22 am