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==
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==Ganglion cyst==
==Ganglion cyst==
===General===
{{Main|Ganglion cyst}}
*Very common.
**Most common tumour of the hand.<ref name=emed_gc>URL: [http://emedicine.medscape.com/article/1253223-overview http://emedicine.medscape.com/article/1253223-overview]]. Accessed on: 8 February 2012.</ref>
*Classically on the wrist.<ref name=pmid17488856>{{Cite journal  | last1 = Hasham | first1 = S. | last2 = Burke | first2 = FD. | title = Diagnosis and treatment of swellings in the hand. | journal = Postgrad Med J | volume = 83 | issue = 979 | pages = 296-300 | month = May | year = 2007 | doi = 10.1136/pgmj.2005.043992 | PMID = 17488856 }}</ref>
*May be painful.<ref name=Ref_Derm322>{{Ref Derm|322}}</ref>
 
===Gross===
*Mass at a joint - classically in the hand.
 
DDx - clinical:
*Metacarpal boss - degenerative [[arthritis]].<ref name=pmid432327>{{Cite journal  | last1 = Cuono | first1 = CB. | last2 = Watson | first2 = HK. | title = The carpal boss: surgical treatment and etiological considerations. | journal = Plast Reconstr Surg | volume = 63 | issue = 1 | pages = 88-93 | month = Jan | year = 1979 | doi =  | PMID = 432327 }}</ref>
 
===Microscopic===
Features:<ref name=emed_gc>URL: [http://emedicine.medscape.com/article/1243454-overview http://emedicine.medscape.com/article/1243454-overview]. Accessed on: 8 February 2012.</ref><ref name=Ref_Derm322>{{Ref Derm|322}}</ref>
*Empty space(s); usually multiple.
*Fibrotic wall.
*No epithelial lining.†
*+/-Myxoid change - very common.
**May have some spindled fibroblasts.
 
<br>
† The entity is really a pseudocyst.<ref name=emed_gc/>
 
DDx:
*[[Synovial cyst]] - true cyst(has an epithelial lining), villous projections into the cystic space.
*[[Juxta-articular myxoma]].
*Myxoma.
*[[Digital mucous cyst]] - has many spindled fibroblasts, usu. superficial.<ref name=Ref_Derm322>{{Ref Derm|322}}</ref>
 
Images:
*[http://commons.wikimedia.org/wiki/File:Ganglion_Cyst,_Hand.jpg Ganglion cyst of the hand (WC/Uthman)].
*[http://www.surgicalpathologyatlas.com/glfusion/mediagallery/media.php?f=0&sort=0&s=2008080217190580 Ganglion cyst (surgicalpathologyatlas.com)].
 
===Sign out===
<pre>
SOFT TISSUE ("GANGLION CYST"), LEFT WRIST, EXCISION:
- GANGLION CYST.
</pre>
 
====Micro====
The sections show fibroadipose tissue with cyst-like spaces surrounded by fibrous tissue. There are no villous projections into the cyst-like spaces. Focal myxoid areas are present with rare bland spindle cells. There is no nuclear atypia and no mitotic activity is appreciated. Dense connective tissue consistent with tendon is present focally.


==Rheumatoid arthritis==
==Rheumatoid arthritis==
{{Main|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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