| Part ? MRI Imaging Evaluation of Gouty ArthritisBackgroundsGout(GT),also known as monosodium urate(MSU)crystal deposition disease,is a common joint disease of adults,especially in the elderly,eroding almost all human joints,especially those in the hands,knees,hips,and spines.Cellular and molecular researches have shown that osteoclast-like cells in subcutaneous tophus and soft-tissue-bone interface of gout patients,suggesting that osteoclast activation is a potential mechanism of tophus erosion.Chondroitin sulfate-4(CS-4)concentration and degradation of the proteoglycan complex enzyme in vitro reduce uric acid(UA)solubility,which may lead to MSU crystal deposition.A variety of cellular and humoral immune activation mechanisms mediated by MSU crystals,including activation of toll-like receptor 2(TLR-2),TLR-4,Myeloid differentiation factor 88(MyD88),CD14,and myeloid cells trigger receptor expression(TREM1),are considered to be the key of the acute gout development.Animal experiments have demonstrated that increased levels of soluble UA,malnutrition,excessive alcohol intake,and other specific diseases,such as obesity and metabolic syndrome,can lead to acute inflammatory caused by MSU crystal deposition.The rapid development of imaging technology provides another way to explore the mechanism of gout.Analysis of X-ray film and computed tomography(CT)images of gout patients demonstrated that intracranial tophus is a major factor in charge of bone erosion and joint damage in gout damaged joints and the decisive factor in development of bone erosion in gout is the physiological characteristics of MSU crystals deposited in and around the joints,including tophus.The 3.0 T magnetic resonance imaging(MRI)technique was used to study the relationship between cartilage damage in gout and joint inflammation and tophus deposition.The results suggested that the Gout Cartilage score was highly correlated with the total Sharp van der Heijde(SvDH)score and the joint space narrowing component.Further studies showed that cartilage damage of the gout patients is usually associated with osteoarthritis(OA)and ligament rupture coexist,uncommon,focal,and associated with bone erosions,tophi and synovitis,but generally does not result in bone marrow edema.This emphasizes the unique pathophysiology of gout.As gout has a serious impact on the function of the joints,its association with other types of arthritis attracted more and more attention.Related studies have demonstrated that acute gout and calcium phosphate calcium phosphate deposition(CPPD)arthritis was highly similar in the pathophysiology and clinical manifestations.A large number of studies of GT and OA have shown that MSU deposition of individual joints is associated with OA in the joints,and MSU is more susceptible to deposit in the OA affected joints.As GT advance mechanism needs further study,this part carried out retrospective analysis of MRI images of the joints affected by GT.This part aims to reveal the MRI imaging features of different joints of gout arthritis and lay the imaging foundation for the treatment of gouty arthritis.Objective1.To study the MRI features of different joint gouty arthritis.2.To investigate the relationship between the course of gout and bone erosion,bone marrow edema,the formation of tophi and OA.Material and MethodsMRI imaging features of 393 joints from 218 patients with gout were retrospectively analyzed.Participants included 211 male patients and 7 female patients aged 17 to 90 years old(median age was 51).A total of 24 out of 54 patients with ages?40 years old accompanied by OA;out of 164 patients aged>40 years old,107 were afflicted with OA.A total of 111 cases presented single-joint disease,whereas 107 cases manifested multiple-joint disease.The disease duration ranged from one day to more than 30 years,with an average of nine years.Thirty-eight normouricemia cases were considered,whereas 180 cases included those with increasing serum UA at different degrees.Rheumatoid factors were negative.Clinical diagnosis was based on the diagnostic criteria for gout issued by the American College of Rheumatology(ACR)in 2012.All patients underwent routine X-ray and MR examinations.A Philips DR X-ray set was used to obtain frontal and lateral images for each joint.A 0.2 T E-SCAN XQ MRI instruments for joint and joint coil were utilized.Coronal/sagittal plane and axial plane were imaged using SE and short tau inversion recovery(STIR)sequences.For X-ray plain films and MR imaging,major observation indicators comprised the following:bone erosions,existence of tophus in/around joints,peripheral soft-tissue swelling,bone marrow edema,and joint effusion.Bone erosion score was divided into 0 to 10 points according to the volume of bone erosion.Bone marrow edema score,according to the proportion of bone edema volume is divided into 0-3 points.The disease course was divided into five levels according to onset time:?1,1<n?3,3<n?5,5<n?10,and>10 years.Clinical staging methods and criteria for OA consisted of five levels according to the Kellgren-Lawrence grading standard.SPSS 17.0 statistical packages were used to perform statistical analyses on data.To investigate the relationship between bone erosion,bone marrow edema and tophi in patients with gouty arthritis and the relationship between the course of disease and bone erosion,bone marrow edema,tophi,and OA.Results1.For the 393 diagnosed joints with GT,imaging showed 246 joints with bone erosion,201 joints with bone marrow edema,and 260 joints with tophus in/around joints.Bone erosion staging of 393 joints with GT at Stages 0,1,2,3,4,5,6,7,8,9,and10,a total of 147,135,54,28,4,15,3,1,0,0 and 6 joints respectively.Bone marrow edema staging of393 joints with GT at Stages 0,1,2,and 3,a total of 192,172,21,and 8 joints respectively.The course of gouty arthritis is highly correlated with bone erosion,bone marrow edema,and tophus count(P<0.05).2.Bone erosion of distinct joints is link with tophi formation(P<0.05).However,only bone erosion of the first metatarsophalangeal joint is associated with bone marrow edema(P<0.05).3.For the 393 diagnosed joints with GT,imaging showed 224 joints with OA.The course of gouty arthritis is highly correlated with OA(P<0.05).Conclusion1.Patients with arthritis on the first metatarsophalangeal joint occupy the largest proportion of the 393 cases with gouty arthritis,followed by patients with arthritis on the dorsum of foot,ankle joint,hand and wrist joint,knee joint,other metatarsophalangeal joint,elbow joint,and shoulder joint.2.The course of GT is highly correlated with bone erosion,bone marrow edema,and tophus.3.MRI manifestations of GT of separate joints share common characteristics,but each involves distinct features.Bone erosion of separate joints is related to tophus formation.However,only bone erosion of the first metatarsophalangeal joint is associated with bone marrow edema.4.The course of GT is highly correlated with OA.Part ? MRI imaging correlation between gout and osteoarthritisBackgroundsGT and OA,which may damage the joints all over the body,are common joint diseases in adults,especially the elderly,GT is differentiated and associated with OA.The pathogenesis of GT remains unclear.Common sense for the causes of GT is that hyperuricemia is a necessary predisposing factor.Patients who suffered from GT were identified as have hyperuricemia.However,few patients with hyperuricemia finally suffered from GT.The individual differences in formation of crystals and inflammatory responses to those crystals may play a significant role in whether a person with hyperuricemia gets attacked by the disease.MSU crystal is in response to the onset of acute inflammation and inflammation program is considered the key factor in the development of the symptoms of acute GT.The program of chronic GT inflammation is related with urate crystal,and the effects of osteoblasts and osteoclasts.Genome-wide association studies(GWAS)found that allelic genes are involved the possibility of GT.Modifiable risk factors include obesity,diets rich in meat and seafood,alcoholic beverages,carbonated beverages containing high content of fructose or sucrose,chronic kidney disease,and specific drugs.In the past,OA was considered as a normal consequence of aging.Thus,it was also known as degenerative OA.However,modern medical studies have shown that OA is due to multiple factors through complex interactions,including joint integrity,genetic factors,local inflammation,mechanical forces,and cellular and biochemical processes.The crystal deposition including MSU,calcium pyrophosphate dihydrate deposition disease(CPPD),basic calcium phosphates(BCPs),and silicon dioxide(SD)could also promote the initiation and development of OA.Further researches suggested BCPs crystal deposition is more common than CPPD in the joints of OA and is the factor that increases the severity.Calcium deposition-related diseases and the activation changes of metalloproteinases play fundamental roles in cartilage degradation and occurrence of OA.The former studies demonstrated that the deposition of MSU crystals was associated with the presence of OA of individual joint sites,and such joints often got destroyed by the combination of GT and OA.Further investigations showed that the association between OA and GT was caused by the local mechanical forces rather than the organic or genetic factors.As a common and effictive imaging method,MRI has unique advantages over other imaging methods.For the joint examination,MRI is significantly better on the soft-tissue display than X-ray plain film and CT,and is better than ultrasound in deep tissue.MRI can easily find the joint capsule deposition of GT nodules and evaluate degeneration degree in the joints.The pathogenic mechanisms of GT and OA are complex and differ among individuals.Thus,ascertaining this mechanism is helpful in the prevention,diagnosis,and treatment of GT and OA.This study aims to investigate the intrinsic relationship between GT and OA based on the analysis of etiology,pathogenesis,and imaging features of GT and OA.Objective1.To analyze the distribution of GT and GT with OA.2.To reveal the differences and relations between the bone erosion,bone marrow edema and the formation of tophus,and to explore the correlation between GT and OA.3.To explore the correlation between GT and OA.Material and MethodsMRI imaging features of 393 joints from 218 patients with GT were retrospectively analyzed.A total of 111 cases presented single-joint disease,whereas 107 cases manifested multiple-joint disease.The disease duration ranged from one day to more than 30 years,with an average of nine years.Thirty-eight normouricemia cases were considered,whereas 180 cases included those with increasing serum UA at different degrees.Rheumatoid factors were negative.Clinical diagnosis was bulit on the diagnostic criteria for GT issued by the American College of Rheumatology(ACR)in 2012.All patients underwent routine X-ray and MR examinations,major observation indicators comprised the following:Existence of osteophytes,degree of joint-space narrowing,bone erosions,bone marrow edema,the formation of tophus,soft-tissue swelling,and joint effusion.Clinical staging methods and criteria for OA consisted of five levels according to the Kellgren-Lawrence grading standard.GT was not accompanied by the OA in the GT group,and the patients with OA were in the GT with OA group.Bone erosion score divided into 0 to 10 points according to the volume of bone erosion.Bone marrow edema score,according to the proportion of bone edema volume is divided into 0-3 points.The difference between the GT group and the GT with OA group in the bone erosion,bone marrow edema,and the formation of tophi was analyzed,and to investigate the correlation between the GT and GT with OA.SPSS 17.0 statistical package was used to perform statistical analyses on data.Results1.The difference between bone erosion of GT group and GT with OA group in the first metatarsophalangeal joints,other metatarsophalangeal joints,ankle joints,and knee joints is statistically significant(P<0.05).2.The difference of bone marrow edema between the GT group and GT with OA group in the first metatarsophalangeal joints,hand and wrist joints is statistically significant(P<0.05).3.The difference between tophus formation of GT group and GT with OA group in the first metatarsophalangeal joints,other metatarsophalangeal joints,ankle joints,and knee joints is statistically significant(P<0.05).4.The difference between bone erosion and tophus formation of GT group and GT with OA group in the first metatarsophalangeal joints,other metatarsophalangeal joints,ankle joints,and knee joints is statistically significant(P<0.05).5.The difference of bone marrow edema between GT group and GT with OA group in the first metatarsophalangeal joints,hand and wrist joints is statistically significant(P<0.05).Conclusion1.The degree of bone erosion and tophus formation of GT with OA group in the first metatarsophalangeal joints,other metatarsophalangeal joints,ankle joints,and knee joints is severity than GT group.2.The incidence of bone marrow edema of GT with OA group in the first metatarsophalangeal joints,hand and wrist joints is greater than GT group.3.GT is the most likely to occur in joints suffering from OA.For GT with OA group,bone erosion and tophi are more serious than that of GT group.Hence,joints suffering from OA may be the basis of MSU deposition.Meanwhile,chronic inflammation caused by deposition of MSU increases the occurrence of OA inflammation and bone erosion. |
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