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Calcium Pyrophosphate Dihydrate
Crystal Deposition Disease

  • Terminology
    • Chondrocalcinosis calcification of hyaline (articular) cartilage or fibrocartilage (menisci) or ligaments
      • Usually but not always due to calcium pyrophosphate
        • May also be seen with oxalosis
    • Pseudogout is an older clinical term referring to acute pain (similar to gout) but without response to the usual treatment for gout
    • CPPD Deposition of crystals in the joint with or without chondrocalcinosis
  • Most common crystalline arthropathy
  • Prevalence
    • Widespread in older population
    • M:F = 3:2
  • Clinical findings
    • Intermittent attacks
      • May be mono-articular or polyarticular (more often)
        • Pain
        • Redness
        • Swelling
  • Types
    • Frequently occurs in association with osteoarthritis
    • Aging process with no known etiology
    • In association with metabolic diseases
      • Hyperparathyroidism
      • Hemochromatosis
      • Hypothyroidism
      • Hypomagnesemia
      • Hypophosphatasia
      • Ochronosis
  • Calcium pyrophosphate crystals may be recovered from synovial fluid (most often) or within leukocytes
    • Characteristic weakly positive birefringent diffraction pattern
  • Location
    • Knee
      • Especially meniscus
      • Cartilage of patellofemoral joint
    • Wrist
      • Triangular fibrocartilage in distal radioulnar joint bilaterally
    • Pelvis
      • Sacroiliac joint
      • Symphysis
    • Spine
      • Annulus fibrosis of lumbar intervertebral disk
        • Never in nucleus pulposus as in ochronosis
    • Shoulder
      • Glenoid
      • Hip
        • Labrum
      • Elbow
      • Ankle
      • Acromioclavicular joint
  • Imaging Findings
    • Pyrophosphate arthropathy resembles osteoarthritis
      • Joint space narrowing
      • Extensive subchondral sclerosis
    • Polyarticular chondrocalcinosis (in fibro- and hyaline cartilage)
    • In knee, disproportionate narrowing of patellofemoral joint
      • Large subchondral cysts are a hallmark
      • Numerous intra-articular bodies
        • Fragmentation of subchondral bone
    • In hand, beaklike projections from 2nd, 3rd metacarpal heads
      • Subchondral cysts (esp. carpal bones)
      • Unusual distribution of disease (radiocarpal/ulnar joint, patellofemoral joint)
      • SLAC - scapholunate advanced collapse
        • Caused by laxity of the ligaments and malpositioning of the scaphoid and lunate
        • May develop in 25% with CPPD but also occurs for other reasons
        • Radio-scaphoid, but not radio-lunate, joint is narrowed
        • Usually have a deep concave scaphoid fossa in distal radius in CPPD as opposed to SLAC from trauma

CPPD of hand and wrist - upper photo shows hook-like projections arising from radial aspect of metacarpal heads;
lower photo shows SLAC-scapholunate advanced collapse with characteristic indentation in distal radius by scaphoid bone. There is also chondrocalcinosis of the triangular fibrocartilage of the distal ulna.

  • Treatment
    • Oral anti-inflammatory drugs (NSAIDs) and corticosteroid joint injections successful in shortening the length of pain and dysfunction of acute attacks of pseudogout
    • Treatments to prevent attacks, such as colchicine, may be effective
    • No treatment is available to dissolve the crystal deposits
    • Controlling inflammation helps to halt the progression of joint degeneration


Imaging of the Wrist and Hand: Gilula and Yin, W.B. Saunders, 1996