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Wheeless' Textbook of Orthopaedics
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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;
    - differential diagnosis:
           - trauma:
                  - perhaps the majority of cases of chondrocalcinosis occur from trauma;
                  - ref: Localized chondrocalcinosis in traumatized joints.   EE De Lange and TE Keats.  Skeletal Radiology. Vol 14. 1985. p 249-256.
           - 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;
           - hemochromatosis;
           - hyperparathyroidism (most common);
                  - up to 30% of hyperparathyroid pts have chondrocalcinosis;
           - hypothyroidism;
           - gout:
           - hyperparathyroidism
           - hypothyroidism
           - hemochromatosis
           - ochronosis
           - acromegaly
           - Paget's disease;


- 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 the involved joint and steroid injection, once diagnosis of infection has been excluded, will usually control symptoms;
    - indomethacin;
    - colchicine: not as useful for pseudogout;







A histological study of calcium pyrophosphate dihydrate crystal-deposition disease.

Clinical features of pseudogout attack. A survey of 50 cases.

Arthroscopy and chondrocalcinosis. A Fisseler-Eckhoff and KM Muller.  Arthroscopy. Vol 8. 1992. p 98-104.

Pseudogout After Total Knee Arthroplasty.

Calcium Pyrophosphate Dihydrate Deposition Disease (Pseudogout) after Total Knee Arthroplasty. 

Pseudogout after total knee arthroplasty.
















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