Difference between revisions of "Joints"

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[[Image:907 Synovial Joints.jpg|thumb|right|Schematic of a synovial joint. (WC/OpenStax College)]]
'''Joints''' are important for locomotion. This article collects tidbits about their [[pathology]].
'''Joints''' are important for locomotion. This article collects tidbits about their [[pathology]].
A general differential diagnosis for joints is dealt with in the ''[[cartilage]]'' article.
==Septic arthritis==
:''Septic joint'' redirects here.
===General===
*Uncommon.
*May be treated in a one-stage ''or'' two-stage procedure.<ref name=pmid17483946>{{cite journal |author=Chen CE, Wang JW, Juhn RJ |title=Total hip arthroplasty for primary septic arthritis of the hip in adults |journal=Int Orthop |volume=32 |issue=5 |pages=573–80 |year=2008 |month=October |pmid=17483946 |pmc=2551720 |doi=10.1007/s00264-007-0366-1 |url=}}</ref>
===Microscopic===
Features:
*Microorganisms - '''key feature'''.
*Inflammatory cells, esp. [[neutrophils]]. ‡
*+/-[[Osteomyelitis]].
Note:
*‡ There are several criteria for the number of neurophils in the context of prosthetic joints - see ''[[prosthetic joint infection]]''.
===Sign out===
<pre>
RIGHT FEMORAL HEAD AND SURROUNDING TISSUE, REMOVAL:
- OSTEOMYELITIS, ACUTE.
- OSTEONECROSIS, FOCAL.
- DEGENERATIVE JOINT DISEASE.
- SOFT TISSUE WITH FOCAL NECROSIS AND COCCI MICROORGANISMS, CORRELATION
  WITH MICROBIOLOGY SUGGESTED.
- NEGATIVE FOR MALIGNANCY.
</pre>


==Prosthetic joint infection==
==Prosthetic joint infection==
Line 12: Line 41:
Notes:
Notes:
*Various criteria for the number of neutrophils exist (see below).<ref name=pmid17545426>{{Cite journal  | last1 = Bori | first1 = G. | last2 = Soriano | first2 = A. | last3 = García | first3 = S. | last4 = Mallofré | first4 = C. | last5 = Riba | first5 = J. | last6 = Mensa | first6 = J. | title = Usefulness of histological analysis for predicting the presence of microorganisms at the time of reimplantation after hip resection arthroplasty for the treatment of infection. | journal = J Bone Joint Surg Am | volume = 89 | issue = 6 | pages = 1232-7 | month = Jun | year = 2007 | doi = 10.2106/JBJS.F.00741 | PMID = 17545426 }}</ref>
*Various criteria for the number of neutrophils exist (see below).<ref name=pmid17545426>{{Cite journal  | last1 = Bori | first1 = G. | last2 = Soriano | first2 = A. | last3 = García | first3 = S. | last4 = Mallofré | first4 = C. | last5 = Riba | first5 = J. | last6 = Mensa | first6 = J. | title = Usefulness of histological analysis for predicting the presence of microorganisms at the time of reimplantation after hip resection arthroplasty for the treatment of infection. | journal = J Bone Joint Surg Am | volume = 89 | issue = 6 | pages = 1232-7 | month = Jun | year = 2007 | doi = 10.2106/JBJS.F.00741 | PMID = 17545426 }}</ref>
**The definitions suffer from [[HPFitis]].
**The definitions (with the exception of Morawietz ''et al.''<ref name=pmid19635104>{{Cite journal  | last1 = Morawietz | first1 = L. | last2 = Tiddens | first2 = O. | last3 = Mueller | first3 = M. | last4 = Tohtz | first4 = S. | last5 = Gansukh | first5 = T. | last6 = Schroeder | first6 = JH. | last7 = Perka | first7 = C. | last8 = Krenn | first8 = V. | title = Twenty-three neutrophil granulocytes in 10 high-power fields is the best histopathological threshold to differentiate between aseptic and septic endoprosthesis loosening. | journal = Histopathology | volume = 54 | issue = 7 | pages = 847-53 | month = Jun | year = 2009 | doi = 10.1111/j.1365-2559.2009.03313.x | PMID = 19635104 }}</ref>) suffer from [[HPFitis]].
*Finding of plasma cells and lymphocytes is '''not''' contributory for the diagnosis of infection.<ref name=pmid17545426/>
*Finding of [[plasma cell]]s and lymphocytes is '''not''' contributory for the diagnosis of infection.<ref name=pmid17545426/>
*[[Granuloma|Granulomatous]] inflammation that isn't of a foreign-body type should get the usual work-up.<ref>URL: [http://path.upmc.edu/cases/case174.html http://path.upmc.edu/cases/case174.html]. Accessed on: 8 January 2012.</ref>
*[[Granuloma|Granulomatous]] inflammation that isn't of a foreign-body type should get the usual work-up.<ref>URL: [http://path.upmc.edu/cases/case174.html http://path.upmc.edu/cases/case174.html]. Accessed on: 8 January 2012.</ref>


====Feldman criteria====
====Feldman criteria====
*>= Five neutrophils / [[HPF]] (x400) in at least five separate microscopic fields.<ref name=pmid17545426/><ref name=pmid21131917>{{Cite journal  | last1 = Bori | first1 = G. | last2 = Muñoz-Mahamud | first2 = E. | last3 = Garcia | first3 = S. | last4 = Mallofre | first4 = C. | last5 = Gallart | first5 = X. | last6 = Bosch | first6 = J. | last7 = Garcia | first7 = E. | last8 = Riba | first8 = J. | last9 = Mensa | first9 = J. | title = Interface membrane is the best sample for histological study to diagnose prosthetic joint infection. | journal = Mod Pathol | volume = 24 | issue = 4 | pages = 579-84 | month = Apr | year = 2011 | doi = 10.1038/modpathol.2010.219 | PMID = 21131917 | URL = http://www.nature.com/modpathol/journal/v24/n4/full/modpathol2010219a.html }}</ref>
*>= Five neutrophils / [[HPF]] (x400) assessed in '''at least five''' separate microscopic fields.<ref name=pmid17545426/><ref name=pmid21131917>{{Cite journal  | last1 = Bori | first1 = G. | last2 = Muñoz-Mahamud | first2 = E. | last3 = Garcia | first3 = S. | last4 = Mallofre | first4 = C. | last5 = Gallart | first5 = X. | last6 = Bosch | first6 = J. | last7 = Garcia | first7 = E. | last8 = Riba | first8 = J. | last9 = Mensa | first9 = J. | title = Interface membrane is the best sample for histological study to diagnose prosthetic joint infection. | journal = Mod Pathol | volume = 24 | issue = 4 | pages = 579-84 | month = Apr | year = 2011 | doi = 10.1038/modpathol.2010.219 | PMID = 21131917 | URL = http://www.nature.com/modpathol/journal/v24/n4/full/modpathol2010219a.html }}</ref>


====Athanasou criterion====
====Athanasou criterion====
*>= Ten neutrophils / ten [[HPF]] (x400).<ref name=pmid17545426/>
*>= Ten neutrophils / ten [[HPF]] (x400).<ref name=pmid17545426/>
====Morawietz criteria====
*23 neutrophils / 10 HPF, where the field diameter = 0.625 mm.<ref name=pmid19635104>{{Cite journal  | last1 = Morawietz | first1 = L. | last2 = Tiddens | first2 = O. | last3 = Mueller | first3 = M. | last4 = Tohtz | first4 = S. | last5 = Gansukh | first5 = T. | last6 = Schroeder | first6 = JH. | last7 = Perka | first7 = C. | last8 = Krenn | first8 = V. | title = Twenty-three neutrophil granulocytes in 10 high-power fields is the best histopathological threshold to differentiate between aseptic and septic endoprosthesis loosening. | journal = Histopathology | volume = 54 | issue = 7 | pages = 847-53 | month = Jun | year = 2009 | doi = 10.1111/j.1365-2559.2009.03313.x | PMID = 19635104 }}</ref>
Notes:
*The 0.625 mm field diameter is uncommon; it corresponds to a 25 mm eye piece with a 40x objective (25 mm/40 = 0.625 mm).
**The PMNs/area is: 23 PMNs / (pi/4*0.625^2) = 7.49 PMNs/mm*mm
*If one uses a 22 mm eye piece microscope and the 40x objective, the field diameter is 0.55 mm; thus, one would need to count PMNs in 12.91 HPFs ( 3.0680 mm*mm / 0.2376 mm*mm = 12.91 ) to get the same sample area.
====A comparison of the criteria====
A study by Bori ''et al.''<ref name=pmid17545426/> compared the criteria of ''Feldman'' and ''Athanasou'':
{| class="wikitable sortable"
! Measure
! Feldman
! Athanasou
|-
| [[Sensitivity]]
| 29%
| 71%
|-
| [[Specificity]]
| 100%
| 64%
|}
===Sign out===
<pre>
Tissue from Left Hip, Revision Arthroplasty:
- Connective tissue with focally increased neutrophils (at least
  11 neutrophils/HPF).
- Negative for microorganisms with routine stains.
- NEGATIVE for malignancy.
Comment:
The findings raise the possibility of a joint infection; correlation with
cultures is required.
1 HPF = 0.2376 mm*mm.
</pre>
====Block letters====
<pre>
HEMATOMA, RIGHT HIP, IRRIGATION AFTER HIP REPLACEMENT/TISSUE REMOVAL:
- FIBROADIPOSE TISSUE WITH POSTSURGICAL CHANGES INCLUDING:
-- FOREIGN-BODY TYPE MULTINUCLEATED GIANT CELLS AND FOREIGN MATERIAL.
-- GRANULATION TISSUE.
-- FAT NECROSIS (FOCAL).
- FIBRIN, BLOOD.
- NEUTROPHILS IN BLOOD VESSEL WALLS/PERIVASCULAR (FOCAL), SEE COMMENT.
- NEGATIVE FOR MICROORGANISMS WITH ROUTINE STAIN.
COMMENT:
Up to 17 neutrophils per high power field (0.55 mm field diameter) are seen.
</pre>
<pre>
FEMUR, LEFT, BIOPSY:
- BONE MARROW WITH A PATCHY MILD FOCAL PROMINENCE OF PLASMA CELLS AND NEUTROPHILS.
- FIBROUS TISSUE WITH HEMOSIDERIN, ISOLATED NEUTROPHILS AND RARE
MACROPHAGES.
- BONE FRAGMENTS.
- NEGATIVE FOR MICROABSCESS FORMATION.
- NEGATIVE FOR MICROORGANISMS WITH ROUTINE STAINS.
</pre>
<pre>
BONE AND SOFT TISSUE, LEFT HIP, EXCISION:
- FIBROADIPOSE TISSUE, SKELETAL MUSCLE AND FRAGMENTS OF BONE WITH SURGICAL CHANGES.
- NEGATIVE FOR MICROABSCESS FORMATION.
- NEGATIVE FOR MICROORGANISMS WITH ROUTINE STAINS.
</pre>


==Juxta-articular myxoma==
==Juxta-articular myxoma==
*Abbreviated ''JAM''.
===General===
===General===
*Classically present as a mass or with pain.<ref name=pmid1592386>{{Cite journal  | last1 = Meis | first1 = JM. | last2 = Enzinger | first2 = FM. | title = Juxta-articular myxoma: a clinical and pathologic study of 65 cases. | journal = Hum Pathol | volume = 23 | issue = 6 | pages = 639-46 | month = Jun | year = 1992 | doi =  | PMID = 1592386 }}</ref>
*Classically present as a mass or with pain.<ref name=pmid1592386>{{Cite journal  | last1 = Meis | first1 = JM. | last2 = Enzinger | first2 = FM. | title = Juxta-articular myxoma: a clinical and pathologic study of 65 cases. | journal = Hum Pathol | volume = 23 | issue = 6 | pages = 639-46 | month = Jun | year = 1992 | doi =  | PMID = 1592386 }}</ref>
*May recur.
*Described as (microscopically) indistinguishable from ''[[intramuscular myxoma]]''.<ref name=Ref_WMSP624>{{Ref WMSP|624}}</ref>
===Gross===
Features:
*Close to large joints - classically around the knee.
**>85% of cases around the knee in one large series.<ref name=pmid1592386/>


===Microscopic===
===Microscopic===
Line 34: Line 142:
DDx:
DDx:
*[[Ganglion cyst]].
*[[Ganglion cyst]].
*[[Intramuscular myxoma]] - surrounded by muscle.


Images:  
Images:  
Line 40: Line 149:
==Morton neuroma==
==Morton neuroma==
{{Main|Morton neuroma}}
{{Main|Morton neuroma}}
==Ganglion cyst==
{{Main|Ganglion cyst}}
==Rheumatoid arthritis==
{{Main|Rheumatoid arthritis}}
==Acute synovitis==
{{Main|Acute synovitis}}


=See also=
=See also=

Latest revision as of 14:03, 11 October 2018

Schematic of a synovial joint. (WC/OpenStax College)

Joints are important for locomotion. This article collects tidbits about their pathology.

A general differential diagnosis for joints is dealt with in the cartilage article.

Septic arthritis

Septic joint redirects here.

General

  • Uncommon.
  • May be treated in a one-stage or two-stage procedure.[1]

Microscopic

Features:

Note:

Sign out

RIGHT FEMORAL HEAD AND SURROUNDING TISSUE, REMOVAL:
- OSTEOMYELITIS, ACUTE.
- OSTEONECROSIS, FOCAL.
- DEGENERATIVE JOINT DISEASE.
- SOFT TISSUE WITH FOCAL NECROSIS AND COCCI MICROORGANISMS, CORRELATION
  WITH MICROBIOLOGY SUGGESTED.
- NEGATIVE FOR MALIGNANCY.

Prosthetic joint infection

General

  • Bits of tissue come for frozen section to r/o infection.
  • The interface membrane (not the pseudocapsule) should be sampled to obtain a high sensitivity.[2]

Microscopic

Features:

  • Neutrophils - key feature.

Notes:

  • Various criteria for the number of neutrophils exist (see below).[3]
    • The definitions (with the exception of Morawietz et al.[4]) suffer from HPFitis.
  • Finding of plasma cells and lymphocytes is not contributory for the diagnosis of infection.[3]
  • Granulomatous inflammation that isn't of a foreign-body type should get the usual work-up.[5]

Feldman criteria

  • >= Five neutrophils / HPF (x400) assessed in at least five separate microscopic fields.[3][2]

Athanasou criterion

  • >= Ten neutrophils / ten HPF (x400).[3]

Morawietz criteria

  • 23 neutrophils / 10 HPF, where the field diameter = 0.625 mm.[4]

Notes:

  • The 0.625 mm field diameter is uncommon; it corresponds to a 25 mm eye piece with a 40x objective (25 mm/40 = 0.625 mm).
    • The PMNs/area is: 23 PMNs / (pi/4*0.625^2) = 7.49 PMNs/mm*mm
  • If one uses a 22 mm eye piece microscope and the 40x objective, the field diameter is 0.55 mm; thus, one would need to count PMNs in 12.91 HPFs ( 3.0680 mm*mm / 0.2376 mm*mm = 12.91 ) to get the same sample area.

A comparison of the criteria

A study by Bori et al.[3] compared the criteria of Feldman and Athanasou:

Measure Feldman Athanasou
Sensitivity 29% 71%
Specificity 100% 64%

Sign out

Tissue from Left Hip, Revision Arthroplasty:
- Connective tissue with focally increased neutrophils (at least 
  11 neutrophils/HPF).
- Negative for microorganisms with routine stains.
- NEGATIVE for malignancy.

Comment:
The findings raise the possibility of a joint infection; correlation with 
cultures is required.

1 HPF = 0.2376 mm*mm.

Block letters

HEMATOMA, RIGHT HIP, IRRIGATION AFTER HIP REPLACEMENT/TISSUE REMOVAL:
- FIBROADIPOSE TISSUE WITH POSTSURGICAL CHANGES INCLUDING:
-- FOREIGN-BODY TYPE MULTINUCLEATED GIANT CELLS AND FOREIGN MATERIAL.
-- GRANULATION TISSUE.
-- FAT NECROSIS (FOCAL).
- FIBRIN, BLOOD.
- NEUTROPHILS IN BLOOD VESSEL WALLS/PERIVASCULAR (FOCAL), SEE COMMENT.
- NEGATIVE FOR MICROORGANISMS WITH ROUTINE STAIN.

COMMENT:
Up to 17 neutrophils per high power field (0.55 mm field diameter) are seen.

FEMUR, LEFT, BIOPSY:
- BONE MARROW WITH A PATCHY MILD FOCAL PROMINENCE OF PLASMA CELLS AND NEUTROPHILS.
- FIBROUS TISSUE WITH HEMOSIDERIN, ISOLATED NEUTROPHILS AND RARE
MACROPHAGES.
- BONE FRAGMENTS.
- NEGATIVE FOR MICROABSCESS FORMATION.
- NEGATIVE FOR MICROORGANISMS WITH ROUTINE STAINS.

BONE AND SOFT TISSUE, LEFT HIP, EXCISION:
- FIBROADIPOSE TISSUE, SKELETAL MUSCLE AND FRAGMENTS OF BONE WITH SURGICAL CHANGES.
- NEGATIVE FOR MICROABSCESS FORMATION.
- NEGATIVE FOR MICROORGANISMS WITH ROUTINE STAINS.

Juxta-articular myxoma

  • Abbreviated JAM.

General

  • Classically present as a mass or with pain.[6]
  • May recur.
  • Described as (microscopically) indistinguishable from intramuscular myxoma.[7]

Gross

Features:

  • Close to large joints - classically around the knee.
    • >85% of cases around the knee in one large series.[6]

Microscopic

Features:[6]

  • Myxomatous stroma.
  • +/-Cystic changes.
  • Large nuclei with hyperchromasia and nuclear scalloping.[8]

DDx:

Images:

Morton neuroma

Main article: Morton neuroma

Ganglion cyst

Main article: Ganglion cyst

Rheumatoid arthritis

Main article: Rheumatoid arthritis

Acute synovitis

Main article: Acute synovitis

See also

References

  1. ↑ Chen CE, Wang JW, Juhn RJ (October 2008). "Total hip arthroplasty for primary septic arthritis of the hip in adults". Int Orthop 32 (5): 573–80. doi:10.1007/s00264-007-0366-1. PMC 2551720. PMID 17483946. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2551720/.
  2. ↑ 2.0 2.1 Bori, G.; Muñoz-Mahamud, E.; Garcia, S.; Mallofre, C.; Gallart, X.; Bosch, J.; Garcia, E.; Riba, J. et al. (Apr 2011). "Interface membrane is the best sample for histological study to diagnose prosthetic joint infection.". Mod Pathol 24 (4): 579-84. doi:10.1038/modpathol.2010.219. PMID 21131917.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Bori, G.; Soriano, A.; García, S.; Mallofré, C.; Riba, J.; Mensa, J. (Jun 2007). "Usefulness of histological analysis for predicting the presence of microorganisms at the time of reimplantation after hip resection arthroplasty for the treatment of infection.". J Bone Joint Surg Am 89 (6): 1232-7. doi:10.2106/JBJS.F.00741. PMID 17545426.
  4. ↑ 4.0 4.1 Morawietz, L.; Tiddens, O.; Mueller, M.; Tohtz, S.; Gansukh, T.; Schroeder, JH.; Perka, C.; Krenn, V. (Jun 2009). "Twenty-three neutrophil granulocytes in 10 high-power fields is the best histopathological threshold to differentiate between aseptic and septic endoprosthesis loosening.". Histopathology 54 (7): 847-53. doi:10.1111/j.1365-2559.2009.03313.x. PMID 19635104.
  5. ↑ URL: http://path.upmc.edu/cases/case174.html. Accessed on: 8 January 2012.
  6. ↑ 6.0 6.1 6.2 Meis, JM.; Enzinger, FM. (Jun 1992). "Juxta-articular myxoma: a clinical and pathologic study of 65 cases.". Hum Pathol 23 (6): 639-46. PMID 1592386.
  7. ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 624. ISBN 978-0781765275.
  8. ↑ URL: http://path.upmc.edu/cases/case38/micro.html. Accessed on: 2 January 2011.
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