Arthritis and Related Affections: Clinic, Pathology, and Treatment

455 Pages·1993·23.73 MB·English

by  Arnold Soren M. D.

This book is dedicated to my wife Frieda
who renounced to innumerable hours of companionship
that I may carry out the forelying work
Arnold Soren
Arnold Soren
-tis and
Related Affections
Clinic, Pathology, and Treatment
With 572 Figures
Springer-Verlag Berlin Heidelberg New York London
Paris Tokyo Hong Kong Barcelona Budapest
Arnold Soren, M. D., Ph. D., D. O. S.
Professor of Orthopaedic Surgery, New York University Medical Center, New York, N.Y.
University Docent of Orthopaedic Surgery, Medical Faculty of University in Vienna
Consultant in Orthopaedic Surgery, Manhattan Veterans Administration Medical Center
Adjunct Attending in Orthopaedic Surgery, Bellevue Hospital, New York, N.Y.
Former Orthopaedic Surgeon of Rheumatic Diseases Study Group, N. Y. U. Medical Center
ISBN-I3: 978-3-642-77697-7 e-ISBN-13: 978-3-642-77695-3
DOl: 10.1007/978-3-642-77695-3
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Softcover reprint ofthe hardcover 1s t edition 1993
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Preface
The records of the National Health Examination Sur features of specimens of articular tissues, and these
vey in 1984 indicate that about 32% of adults in the findings have been incorporated into the present work.
United States suffered from musculoskeletal affec I am also very grateful to Prof. Dr. Waldemar Hort,
tions. The National Arthritis Data Workshop reported Director Emeritus at the Institute of Pathology at the
in 1985 that about 35 millions of Americans had ar University of Dusseldorf, and to Prof. Dr. Joseph
thritis or related conditions. Wagenhaeuser [1700] sim Thurner, Director of the Institute of Pathology at the
ilarly reported in 1969 that 30% of the central Landeskrankenanstalten in Salzburg, both of whom
European adult population presented changes of the provided me with instructive illustrations and his
peripheral joints and vertebral spine. Arthritic symp topathological tissue sections. A number of the his
toms causing incapacity in a significant percentage of topathological illustrations were published previously
the population were reported in the United Kingdom in my volume entitled Histodiagnosis and Clinical
and Sweden in 1984. Correlation of Rheumatoid and Other Synovitis
All relevant statistics emphasize the high incidence (Thieme, Stuttgart, and Lippincott, Philadelphia,
and disabling effects of arthritis of various types in all 1978). Figures 9 and 206 were published previously by
countries. In view of the socioeconomic impact of the F. Huth, A. Soren, and W. Klein in Current Topics in
joint diseases, intensive research, experimental studies, Pathology (56; 55, 1972) and Archives of Pathological
and the use of diverse therapeutic modalities have been Anatomy (359; 201, 1973). Figures 6 and 258 were
undertaken by the medical profession. contributed by Dr. R. Mallinger, Institute of Micromor
A treatise dedicated to the understanding of articular phology at the University of Vienna. Figure 132 was
affections must proceed from the knowledge of the contributed by Dr. A. B. Ackerman, Professor of Der
normal organic condition and of the concomitant phys matology at New York University Medical Center, and
iology of joints. Awareness of these properties is the was published by Dr. B. W. Berger et al. in American
basis for understanding the anatomical changes and the Journal of Dermatopathology (5; 111, 1983); tissue
pathological reactions elicited by internal and external sections for Figures 380 and 381 were also contributed
factors. Correspondingly, this work, containing very by Dr. A. B. Ackerman. Figures 207 and 208 were
instructive illustrations, endeavors to present the essen contributed by Dr. C. Melone. Associate Professor of
tial features of all known joint diseases, thus providing Orthopedic Surgery, New York University Medical
a basis for the effective treatment of those afflicted by Center. Figure 267 presents the treatment of Dr. H. C.
arthritis. Amstutz, Professor and Director of the Department of
As introduction I like to acknowledge the substantial Orthopedic Surgery, University of California in Los
help provided by others in preparing my text. This book Angeles.
was made possible by the continuous support of Finally, I wish to thank Mrs. D. C. Guyett (Dynamic
Theodore R. Waugh, M. D., Professor and Chairman of Business Services) who by outstanding dedication and
the Department of Orthopedic Surgery, New York Uni competence transformed my complicated manuscript
versity Medical Center. For the last 25 years I have had into a clear text. The broadmindedness and support of
the privilege of working with Norman S. Cooper, Springer-Verlag have enabled my text and illustrations
M. D., Professor of Pathology at New York University to appear in an excellent edition.
School of Medicine and Director of Laboratories at
Manhattan Veterans Administration Medical Center; in
weekly conferences we discussed the histopathological New York, NY, 1992 Arnold Soren
Contents
Anatomy and Histology of Joints. 1 4. Gonococcal Arthritis .. . . . . 95
5. Arthritis in Reiter's Syndrome 100
Physiology of Joints ....... . 11 6. Arthritis in Bacillary Dysentery 103
7. Arthritis in Abdominal Typhoid Fever
Examinations in Arthritis and Related and Abdominal Paratyphoid Fever 105
Affections . . . . . . . . . . . . . . . 13 8. Arthritis in Brucellosis 1I0
1. Patient's History . . . . . . . . . 13 9. Arthritis in Scarlet Fever 113
2. Inspection and Palpation of Joints 13 10. Bacteriantigenic Arthritis 1I4
3. Testing Active and Passive Movements of 11. Arthritis in Influenza . . 1I9
Joints ............. . 15 12. Arthritis in Lyme Disease. 121
4. Auscultation of Joints .... . 18 13. Syphilitic Arthritis 123
5. Laboratory Studies of the Blood 18 14. Tuberculous Arthritis 129
6. Urinalysis . . . . . . . . . . . . 24 15. Mycotic Arthritis . . 139
7. Radiological Examination of Joints 25
8. Arthrocentesis and Examination of the IV. Allergic, Rheumatic, and Etiologically
Synovial Fluid . . . . . . . . . . . . . 31 Un clarified Joint Inflammations 151
9. Punch Biopsy of Joint or Arthroscopy and 1. Seroanaphylactic Arthritis .. 151
Examination of Articular Tissue . . . . . . 38 2. Arthritis in Rheumatic Fever 152
10. Arthrotomy, Excision, and Examination of 3. Juvenile Rheumatoid Arthritis 156
Articular Tissue ............. . 42 4. Rheumatoid Arthritis (Rheumatic
Arthritis). . . . . . . . . . . . . 162
Classification of Arthritides 46 5. Arthritis in Sjogren's Syndrome 190
I. Traumatic Alterations of Joints. 47 6. Ankylosing Spondylitis. . . . . 192
1. Contusion ofJoints . . . . 47 7. Arthritis in Mediterranean Fever 198
2. Sprain ofJoints ..... . 51
3. Traumatic Synovitis and Post V. Degenerative Changes of Joints. 201
traumatic Synovitis . . . . . . 55 1. Chondropathia Patellae 201
4. Infrapatellar Liposynovitis . . 58 2. Osteoarthritis . . . . . . . 205
5. Posttraumatic Fibrosis Ossificans of
Joints ............... . 60 VI. Trophic Alterations of Joints . 239
6. Pigmented Villonodular Synovitis 62 1. Osteochondritis Dissecans 239
2. Loose Joint Bodies . . . . 244
II. Idiopathic Inflammations of Joints 67
1. Nonspecific Synovitis . . . . . 67 VII. Joint Affections in Systemic Diseases 249
2. Intermittent Hydrarthrosis. . . 69 1. Joint Affections in Skin Diseases . 249
3. Arborescent Liposynovitis (Lipoma a. Arthropathy in Psoriasis 249
Arborescens) ......... . 74 2. Arthropathies in Intestinal
Inflammations . . . . . . . . . . . . 256
III. Specific Inflammations of Joints by a. Arthropathy in Ulcerative Colitis 256
Microorganisms . . . . . . . 77 b. Arthropathy in Regional Ileitis 259
1. Suppurative Arthritis . . 77 3. Joint Affections in Metabolic
2. Meningococcal Arthritis 89 Disorders ....... 264
3. Pneumococcal Arthritis . 92 a. Arthropathy in Gout . . . . 264
Contents VII
b. Arthropathy in Ochronosis . . . . . 270 VIII. Acquired Dysfunctions and Deformities
c. Arthropathy in Gaucher's Disease . 274 ofJoints ............. . 345
d. Arthropathy in Hyperlipo 1. Laxity and Instability of Joints 345
proteinemia . . . . . . . . . . . . 278 2. Snapping of Joints .. 347
e. Arthropathy in Reticulohistio 3. Contracture of Joints 350
cytosis (Lipoid Dermatoarthritis) 282 4. Ankylosis of Joints 359
4. Joint Affections in Abnormal
Deposition . . . . . . . . . . . 288 IX. Tumors of Joints . . . . 369
a. Calcinosis of Joints ..... 288 1. Benign Tumors of Joints 369
b. Hemochromatosis of Joints 295 2. Malignant Tumors of Joints. 378
5. Joint Affections in Blood Disorders 298
a. Arthropathy in Hemophilia ... 298 X. Related Affections. . . . . . . . 386
b. Arthropathy in Lymphocytic 1. Tenosynovitis and Hygroma 386
Leukemia and Multiple Myeloma 307 2. Bursitis . 392
6. Joint Affections in Neuropathies .. 315 3. Ganglion. 398
a. Arthropathy in Chronic Alcoholism 4. Fibrositis 403
and Other Aseptic Necrosis 316
b. Arthropathy in Diabetic Bibliography 408
Neuropathy . . . . . . . . . 321
c. Arthropathy in Tabes .... 326 Index .... 442
d. Arthropathy in Syringomyelia . 330
7. Joint Affections in Hormonal Disorders 334
a. Endocrine Arthropathies . . . . . . . 334
Anatomy and Histology of Joints
Human joints have developed along those of other water content and the great elasticity of its nucleus
vertebrates and have two main forms. The amphiar pulposus, the disc also keeps the vertebrae apart. The
throses are connections between two bones and are disc bears the pressure exerted on the vertebral column
filled by dense connective tissue or fibrocartilage; ex by the weight of the body and serves as an impact
amples of such connections are the intervertebral discs absorber of the mechanical stresses imposed on the
and the symphysis pubis. The diarthroses are contigu vertebral column during its functioning [192].
ous, cartilage-covered bony ends, separated from each The diarthrodial joints, by contrast, are characterized
other by a capillary joint space and surrounded by a essentially by the presence of a patent joint space
joint capsule; examples include the joints of the ex which separates the epiphyseal ends from each other
tremities and the temporomandibular, costovertebral (Fig. 4). These bones have acquired the property to
and apophyseal vertebral joints. function as articular ends by virtue of their convex or
Among the amphiarthroses those of the vertebral concave configurations, which enable them to fit more
column require special description because of their par or less congruently with each other (Fig. 4).
ticular structure and frequent degenerative changes. The articular ends are further suited to this reciprocal
Between each two vertebrae is interposed an interverte adaptation by an ontogenetically persisting cover or
bral disc (Fig. 1) attached by its fibers to the cartilage cap of hyaline cartilage (Fig. 4), which varies in thick
of the vertebral plates. These fibers penetrate into the ness both within each joint from joint to joint, and from
osseous vertebral end plates and anchor the interverte site to site. The cartilage cover of the acetabulum and
bral disc firmly onto the two adjacent vertebral bodies. femoral head is 3-4 mm thick, that of the patella is
At its circumference, the disc merges with the anterior 2-4 mm thick, on the tibial condyles it is 1.1-1.4 mm
and posterior longitudinal ligaments and with the ob thick, and in the interphalangeal joints of the fingers it
lique intervertebral ligaments (Fig. 2). Structurally the is 0.08-0.15 mm thick.
disc is composed mainly of dense fibrous and fibrocar The articular hyaline cartilage has a smooth, shiny,
tilaginous tissue (Fig. 3), the annulus fibrosus, whose white or bluish-white surface. However, on histologi
plump fibrocytes and chondrocytes lie in a matrix of cal examination [567, 1284] the articular cartilage pre
short fine filaments. The interstitial matrix is rich in sents furrows and ridges, which have been interpreted
polysaccharides and contains longer and thicker colla [604] as the results of shrinking during histochemical
gen fibers which run interstitially. The central fibers of processing, aging or pathological alterations. Histo
the annulus course around the nucleus pulposus. The logical examinations [603, 604, 1589] further disclose
latter is a soft tissue, composed of large vesicular cells that the articular cartilage has a relatively small propor
and a few collagen fibers interspersed in a mucinous tion of chondrocytes (Fig. 5). The cytoplasm of these
ground substance. Mankin [1019] emphasized the im cells contains fine granules, a few vacuoles, and a few
portance of the high water content (up to 65% - 70%) of lipoid globules. Their centrally located nucleus is oval
the annulus fibrosus in comparison with other fibrous or elongated and has an indented outline; it contains a
structures. Besides its collagen content of 50% of dry nucleolus and granular nucleoplasm. On the basis of
weight, glycosarninoglycans, chondroitin sulfate, and the typical arrangement and shapes of the chondro
keratan sulfate are present in high proportions. The cytes, four zones may be discerned in the articular
nucleus pulposus has a higher water content (up to cartilage (Fig. 5). (a) In the tangential zone adjacent to
88%) and a higher glycosaminoglycan content but a the joint cavity, the chondrocytes and their nuclei are
lower collagen content (20% - 30% of the dry weight). elongated, lying close to each other and with their long
By virtue of its rich content and the arrangement of the axes parallel to the surface. (b) Directly beneath fol
fibers of its annulus, the intervertebral disc holds the lows the transitional zone, whose chondrocytes are
vertebrae together. On the other hand, because of its roundish or ovoid, have similarly shaped nuclei, and
2 Anatomy and Histology of Joints
Fig. 1. The bodies of the vertebrae articulate and are held together
by the intervertebral discs and by the ligaments. Their apophyseal
processes also articulate with each other
Fig. 2. The intervertebral disc (from a 45-year-old man) fully
covers the vertebral body but is disrupted by an extensive central
dehiscence and two shorter clefts. The apophyseal joints are well
maintained
are irregularly and loosely distributed. (c) In the subja and is thus an artifact [604, 1589], No lacunae are
cent radial zone, the chondrocytes are round and gener observed with glutaraldehyde fixation.
ally arranged in vertical columns of six to ten cells. In Electron-microscopic examination [603, 604, 1012,
cartilage covers of greater thickness, the columnar zone 1079, 1080, 1589] discloses chondrocytes with jagged
contains at its base one to three layers of irregularly outlines caused by small processes of the cell mem
positioned chondrocytes, the subzone of resting or brane, mostly in the chondrocytes of the middle rows
mother cells. (d) The deepest zone is that of calcified (Figs. 258). Their cytoplasm contains a rough endo
cartilage, discernible by its darker hue; its chondro plasmic reticulum which encloses spaces termed cis
cytes, fewer in number and irregularly shaped, are scat ternae; some of these are filled with granules. Addi
tered, and many of them have deeply wrinkled, dense, tionally, several larger vacuoles and small vesicles are
clumpy, fragmented, or no nuclei - an indication of found, especially close to the parallel lamellae com
local disintegration processes. This zone is demarcated posing the Golgi apparatus (Fig. 6). Fine filaments
from the radial zone by the tidemark or provisional and a small number of mitochondria are scattered
calcification line (Fig. 5), an intensely stained, slightly throughout. The material of the round or ovoid nucleus
wavy line which can be distinguished from the sub may sometimes present densification or fragmentation,
chondral cortical bone by its lamellar structure and with its particles scattered in the cytoplasm and in the
different staining. While degenerative alterations may matrix. These degenerative changes are much more
also be observed occasionally in the nuclei of the chon frequent in the calcified zone, which is impregnated
drocytes of the upper three zones, other changes are with pericellularly and interstitially deposited calcium
regularly observed in most chondrocytes of all four salts.
zones, especially those of the transitional and columnar With their characteristic distribution in the articular
zones. These chondrocytes individually often present a cartilage, the chondrocytes lie in a preponderantly in
broad indentation in their outline which partly sepa tercellular matrix (Figs. 5, 6). This appears homoge
rates them from the immediately pericellular matrix. neous under normal conditions [1639]; it stains slightly
The empty space or "lacuna" is formed by shrinking basophilic with hematoxylin-eosin-phloxin-safran and
and retraction of the cell membrane caused by the also stains metachromatically with toluidine blue, AI
chemical processing for light-microscopic examination cian blue, and other polychromatic stains. Rosenberg
Anatomy and Histology of Joints 3
Fig. 3. The annulus fibrosus of
the intervertebral disc consists
of large chondrocytes which
lie in an abundant matrix with
pericellular collagen fibers.
The ground substance is rich
in mucopolysaccharides. The
nucleus pulposus is not
exposed
Fig. 4. Horizontal section
through a shoulder joint. The
epiphyses of the scapula and
humerus merge on their con
tact surfaces with a thick layer
of articular cartilage, becom
ing articular ends. These are
surrounded and held together
by the joint capsule
[1351, 1353] recommended staining with safranin, a proteoglycans [878, 1680]. These consist of a protein
cationic dye, which binds to the anionic groups of core to which are linked polysaccharides, termed gly
mucopolysaccharides. The interstitial matrix consists cosaminoglycans, which represent 18%-20% of the
of 35%-40% ground substance and collagen in almost dry weight of the articular cartilage. The glycosamino
equal parts of the organic material and of 60%-65% glycans are composed of a small proportion of
freely exchangeable water [157,178,1019]. The mate hyaluronic acid, consisting of glucuronic acid and
rial essentially responsible for the staining and for the acetylglucosamine, and of a larger proportion of both
physical properties of the ground substance and partly chondroitin sulfates, consisting of hexosamine and glu
also for the properties of the articular cartilage are the curonic acid, and keratan sulfate, consisting of hex-