Knees – AP – early signs of chondrocalcinosis, fine linear shadow in the central part of the tibiofemoral joint space in both knees, calcification of hyaline cartilage (red arrow) and speckled shadow medially; on the right side, calcification of the right medial meniscus (green arrow)
Right knee – LL – calcification of hyaline cartilage lining the contour of epiphyses (yellow arrows), hyperplastic patellofemoral OA of the knee (blue arrow)
The first changes appear usually in the third age decade in the form of discrete calcifications. In case of polyarticular involvement, the changes come slightly earlier. Calcifications get more pronounced and are gradually accompanied by signs of secondary knee osteoarthritis (Fig. 18.3) that is already well developed in the fifth age decade.
Knees – AP – advanced chondrocalcinosis; dense granular or flowing shadows in the joint space (yellow arrow) are accompanied by marked osteoplastic changes along the edges of articular surfaces and intercondylar eminences in bilateral secondary OA of the knee (blue arrows)
In addition to calcifications, skiagraphs show also narrowing of the joint space, sclerotised articular surfaces, subchondral geodes and marginal osteophytes. In the advanced stage (Fig. 18.4), the changes are more intensive, with a massive hyperplastic osteophyte lining, which may sometimes result even in bone ankylosis.
Right knee – AP – severe destructive changes and varus deformity in secondary OA of the knee with impression of the medial condyle; calcification in the joint space is less pronounced
Oligoarticular involvement is characterised by calcifications in the meniscus, especially the lateral one, gradual development of secondary OA of the knee, often also isolated patellofemoral, calcified cruciate ligaments and the quadriceps tendon, intra-articular loose bodies and “Charcot knee” .
One of the most frequently affected sites in the early stage of chondrocalcinosis, both its hereditary and solitary form, is the fibrocartilaginous disc (lamina interpubica) of symphysis. Calcifications are shown as granular shadows, the density of which and subchondral sclerosis of the edges of the symphysis get more intensive with the progress of the disease [4, 5].
Involvement of sacroiliac synchondrosis is also quite common and is presented in the skiagraphs by discrete granular shadows in the joint space and subchondral sclerosis of the bone. Some patients exhibit late reactive hyperplastic changes of SI joints, most frequently unilateral ankylosis [4, 5].
In the polyarticular form of chondrocalcinosis, skiagraphs show approximately from the fourth age decade calcifications of the hyaline cartilage of hip joints (Fig. 18.5) that are by their nature similar to those in shoulders. Calcifications get gradually more intensive and are accompanied by development of secondary hip osteoarthritis that reaches after about 10 years of the disease its advanced stage and is characterised mainly by central narrowing of the joint space, subchondral geodes and osteophytic lining along edges of articular surfaces [2, 3].
Pelvis – AP – linear fine shadow in the central part of the joint space of both hip joints, calcifications of hyaline cartilage (yellow arrow); on the right side also para-articular calcification in the joint capsule (violet arrow)
Late onset of hip joint involvement (approximately in the sixth age decade) has skiagraphic signs of the initial stage of early polyarticular form with a slow progress. Sometimes hip joint involvement may be associated with extra-articular calcification of tendons and their insertions mainly in the region of the ischial tuberosity. Rare cases of “coxa profunda” as a secondary response to capsular calcification deposits were also reported .
18.3 Ankles and Feet
The initial lesions of talocrural and tarsal joints in polyarticular chondrocalcinosis can be noted as a rule in the fourth age decade and is usually associated with gradual development of secondary arthritic changes.
Approximately in the fourth decade, skiagraphy of the polyarticular form of chondrocalcinosis may confirm intra-articular calcifications shown as linear shadows in both the central parts of the joint space and the metatarsophalangeal joints (Figs. 18.6 and 18.7). In the early stage, they are accompanied also by para-articular calcification deposits in joint capsules and early onset of secondary osteoarthritis, with later severe deformities, mainly valgus deviations of great toes [4, 5].
Figs. 18.6 and 18.7
Feet and fourth and fifth MTPs on the right side – AP – calcification of hyaline cartilage in all tarsal joints, thin linear shadow in the middle part of the joint space of both the fourth and fifth MTP joints of the right foot (yellow arrow), extra-articular calcification in the joint capsule of the fifth MTP joint in the region of fibula (green arrow)
Intra-articular calcifications in the proximal and distal joints of toes are extremely sporadic.
In some patients there dominates extra-articular involvement – progressive calcification of the Achilles tendon and plantar fascia .
18.4 Shoulders, Elbows and Sternoclavicular Joints
The first signs of calcification of the hyaline cartilage of the shoulder joint may be proved in case of polyarticular hereditary chondrocalcinosis as early as in the third decade. It is manifested as a narrow dense striped shadow along the humeral head (Fig. 18.8) which doubles at the site of its contact with the glenoid fossa. During the following 10 years, the cartilage becomes completely calcified. Later there develop also signs of para-articular calcification at the site of rotator cuff tendon insertions, mainly the tendon of the supraspinatus and subdeltoid bursa [4, 5].