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CHONDROCALCINOSIS IN ELDERLY PERSONS MICHAEL H. ELLMAN and BERTRAM LEVIN Fifty-eight elderly people were surveyed for chondrocalcinosis with knee, hip and pelvic roentgenograms using Type M industrial x-ray film. Chondrocalcinosis was found in 16 subjects (27.6v/,), an incidence greater than reported in previous studies. Roentgenograms of the knees alone showed the presence of chondrocalcinosis in 15 subjects. Varus deformity of the knees, increased wrist complaints and wrist involvement with clinical arthritis were significantly more common in subjects with chondrocalcinosis. Symptoms associated with acute inflammatory arthritis were not more common in people with chondrocalcinosis. In 1958 Zitnan and Sitaj (1) described three patients with both arthritis and characteristic puncFrom the Department of Medicine and the Department of Radiology. Michael Reese Medical Center, 2929 So. Ellis Avenue, Chicago, Illinois 60616. Supported by grants from the Illinois Arthritis Foundation and the Medical Research Institute of Michael Recse Medical Center. Michael H. Ellman, MD: Attending Physician, Michael Reese Hospital and Medical Center, and Assistant Professor of Medicine, University of Chicago, Pritzker School of Medicine; Bertram Levin, MD: Chief of Radiology, Michael Reese Hospital and Medical Center, and Professor of Radiology, University of Chicago, Pritzker School of Medicine. Address reprint requests to Michael H. Ellman, MD, Department of Medicine, Michael Rcese Medical Center. Submitted for publication June 1 1 , 1974; accepted August 8, 1974. Arthritis and Rheumatism, Vol. 18, No. 1 (January-February 1975)

tate and linear radiodensities in hyaline and fibrocartilage, subseqaently called chondrocalcinosis (2). In 1962 McCarty, Kohn and Faires (3) described the pseudogout syndrome which combined the clinical and roentgenologic features of the arthritis with the presence of calcium pyrophosphate dihydrate crystals in synovial fluid. The deposition of sufficient numbers of these crystals in cartilage produces chondrocalcinosis on x-ray examination which is strikingly distinctive and serves as a marker of the disease (1-5). Rheumatologists frequently diagnose pseudogout in elderly patients seen at arthritis clinics and hospital inpatient services. In the largest reported study, the clinical incidence of pseudogout was approximately half that of gout (6). The most common clinical pattern of pseudogout is that of a clironic arthritis, especially of the knee, with superimposed acute inflammatory episodes (4). During acute attacks the disease is usually diagnosed by finding calcium pyrophosphate crystals in synovial fluid leukocytes (3). In nonacute intervals or in the absence of synovial fiuid, pseudogout is diagnosed by combining the clinical picture with the presence of radiographic chondrocalcinosis (4). The diagnostic value of chondrocalcinosis depends on its prevalence in the asymptomatic elderly population. In a roentgenologic survey of knees in elderly persons by Bocher et a1 (7) chondrocalcinosis was found in 32 of 455 subjects. Twenty-one of these patients were studied in detail and none gave histories

ELLMAN AND LEVIN

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Table 1. Medical Questionnaire Results Comparing Subjects with and Without Chondrocalcinosis Chondrocalcinosis

Total in group Number of womeii Mean age and standard deviation History of arthritis Joint swelling Severe or very severe joint pain Constant joint pain Nocturnal joint pain Aspirin use* Morning stiffness None 15 minutes 30 minutes > 30 minutes Arthritis of Knees Hips Wrists Hands Shoulders Back Diabetes mellitus Heart disease Kidney stones Peptic ulcer

Nonchondrocalcinosis

No.of Subjects

Percent

No. of Subjects

Percent

16 16

-

42 34

81 .o

-

100.0

84.3 2 5.5

I3

-

1

81.3 6.3

4 4 5 5

33

-

81.9 2 5.8

-

7

78.6 16.7

25.0 25.0 31.3 31.3

12 16 7 13

28.6 38.1 16.7 31.0

7 6 1 2

43.8

23 12 2 5

54.8 28.6 4.8 11.9

6 2 5t 2

37.5 12.5 31.3 12.5 18.8 43.8 25.0

11 8 2t 10

26.2 19.0 4.8 23.8 16.7 23.8 16.7 50.0 0 2.4

3 7 4 9 1 0

37.5 6.3 12.5

56.8

6.3 0

7 10 7 21

0 1

~ _ _ _ ~

*Weekly aspirin use for arthritis tP < 0.05: chi square with Yates Correction

considered suggestive of pseudogout, although no comparison was performed with a control group. T h e authors concluded that chondrocalcinosis may be a nonspecific finding. This disparity of opinion regarding the diagnostic significance of chondrocalcinosis prompted this report. We studied 58 elderly volunteers with roentgenograms of the knees, wrists and pelvis. These fintlings were correlated with a medical questionnaire emphasizing detection of arthritic symptoms and a clinical joint examination.

MATERIALS AND METHODS Fifty-eight active, ambulatory residents from the Drexel Home, a n institution for the Jewish elderly, volunteered for a roentgenologic survey of the wrists, knees and pelvis. An teroposterior roentgenograms of the wrists and knees were performed with Kodak T y p e M industrial Rapid Process Film. GAF-HR 1000 film was used for anteroposterior pelvic x-rays. Roentgenograms were interpreted independently by three physicians, a rheumatologist and two radiologists, for the presence of chontlrocalcinosis. Unanimity of opinion was required for a roentgenogram to be considered positive. Participants i n the study completed a medical questionnaire emphasizing arthritic symptoms (Table I). Sub-

jects with chondrocalcinosis were examined and compared with 18 randomly selected, sex-matched residents from the volunteer population without chondrocalcinosis. T h e clinical examination evaluated tenderness, warmth, synovial thickening and effusion of all joints except the spine. Joints were considered abnormal if any of the above was present. Varus and valgus abnormalities of the knees were noted if the deformity was greater than 10 degrees. O n e physician who was unaware of the roentgenologic and questionnaire results performed all the clinical examinations. Only residents known by the Drexel Home staff to be mentally alert and reliable were asked to participate in the study. Those residents unable to understand fully the questions in the medical questionnaire were not included. Assistance in reading the questions and recording the answers when needed was provided by two volunteer personnel who were unaware of study results. I n order to document the reliability of the questionnaire, five randomly selected residents completed duplicate questionnaires 1 week to 1 month after the initial one with no variability in response.

RESULTS AND DISCUSSION T h e occurrence of chondrocalcinosis in 27.6% (16 of 58) of subjects surveyed with knee, wrist and

pelvic roentgenograms was Iiigher than reported in

CHONDROCALCINOSIS IN T H E ELDERLY

Table 2. Summary of Roentgenologic Findings in Subjects with Chondrocalcinosis Joints Involved with Chondrocalcinosis Bilateral knees with bilateral wrists Bilateral knees only Unilateral knee Bilateral knees, bilateral wrists and symphysis pubis Bilateral knees and symphysis pubis Bilateral knees, wrists and hips Unilateral wrist

Total

Number of Subjects 6

4

2 1 1 1 1 16

Joints with chondrocalcinosis: knee 28; wrist 17; hip 2; symphysis pubis 2

previous studies. This high incidence was not completely unprecedented. McCarty et a1 observed at least one small deposit of calcification in 2270 of menisci excised from 215 cadavers using Type M roentgenograms (8). I n most cases the calcifications were too small for crystal identification but seven sets of menisci (3.3% of cadavers) had calcium pyrophosphate dihydrate crystals. I n 1929 Tobler found calcifications in 25% of 400 menisci obtained from 100 cadavers ranging in age from the newborn to the elderly (9). Bocher et al, however, only found a 10% incidence of chondrocalcinosis in their entire series of 455 patients (7). Weaver combined five roentgenologic surveys and found meniscal calcifications of the knee joint in 0.42% of 12,268 roentgenograms (10). Several features of our study explain the high incidence of chondrocalcinosis. a) T h e Type M radiographic film was able to detect minimal cartilage calcifications. I n several subjects chondrocalcinosis was demonstrable on Type M film that was not visible on standard radiographs. b) T h e study may have inadvertently selected patients with a n increased incidence of arthritis. Residents were queried regarding participation in a medical research project that included roentgenography of the knees, wrist and hips. T h e emphasis on articular structures suggested that the project was primarily concerned with detection of arthritis. A possible offsetting feature was the exclusion of nonambulatory residents, including those with disabling arthritis. c) This investigation studied an extremely old population; the mean age of the 58 subjects was 82.6 years (range 70 to 94) and the mean age of subjects with chondrocalcinosis was 84.3 years (range 70 to 91). Five other large studies of patients with pseudogout or chondrocalcinosis had younger subjects with average ages of 67 (ll), 70 (12),

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Table 3. Results of Clinical Examination Chontlrocalcinosis (16*) Mean age and standard deviation Abnormal joints Knee Wrist Hip Shoulder Varus deformity of knees > 10" Valgus deformity of knees > 10"

Controls (18*) 84.3 +- 5.5

80.7 C 6.2

9

6

8t

It

9t

2t

1

4

1 0

1 1

*Number of subjects t P < 0.05 (chi square with Yates Correction)

72.3 (G), 76 (13) and 80 (7) years respectively. T h e incidence of pseudogout increases with age (14) and is not usually found in young patients in the United States (4). T h e occurrence of chondrocalcinosis in 27.GyOof the subjects in our study probably represents the approximate prevalence of chondrocalcinosis in the very elderly. No correlation between the presence of chondrocalcinosis and symptoms of inflammatory arthritis such as joint swelling, morning stiffness and severe or constant joint pain was found (Table 1). T h e number of subjects using aspirin was not greater in the chontlrocalcinosis group. Residents with chondrocalcinosis complained more often of nocturnal joint pain, 31.3% (5 of 16), than did control subjects, 16.7% (7 of 42), but this was not statistically significant. This lack of inflammatory arthritic symptoms associated with chondrocalcinosis demonstrated that the deposition of calcium pyrophosphate dihydrate crystals on cartilage may be asymptomatic. These results corroborated the data of Bocher et a1 (7) and others (4,14,15). T h e knee was the most commonly involved joint (Table 2). Bilateral involvement of the knee was present in 13 subjects and unilateral involvement in two. Varus deformity was more common in the chondrocalcinosis group (Table 3). Nine knees with varus deformity greater than 10 degrees were observed in subjects with chondrocalcinosis compared with two knees in the control group (P < 0.05') (Table 3). Five subjects with wrist chondrocalcinosis, 31.3y0 (5 of 16), complained of wrist pain as compared with two subjects, 4.8y0 (2 of 42), without chondrocalcinosis (P < 0.05'). Chondrocalcinosis was pres*Chi square, Yates correction.

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ent in 17 wrists, eight of which were abnormal on clinical examination compared with only one abnormal wrist in the control group (P < 0.05 ). Synovial thickening was present in six of the eight wrists, two of these were also warm and had effusion. T h e remaining abnormal wrists were tender to palpation. Clinical examination of hands demonstrated osteoarthritis in all subjects. Difficulties encountered in grading severity of hand osteoarthritis made comparison bet ween chondrocalcinosis and nonchondrocalcinosis subjects unreliable. Pelvic x-rays were the least useful for detecting chondrocalcinosis. Two subjects had involvement of the symphysis pubis and one patient had bilateral hip involvement. Malrotation or pelvic deformities of several subjects prevented unobstructed views of the symphysis pubis. Hip joint calcifications were difficult to interpret because of underlying acetabular bone. No subject had hip or symphysis pubis chondrocalcinosis without having knee chondrocalcinosis. T h e only person with chondrocalcinosis without knee involvement had unilateral wrist involvement. Eight of the 58 subjects in this study were men and none had chondrocalcinosis. Because the number of men was so small, a meaningful statistical analysis regarding sex differences in chondrocalcinosis was not possible. Pseudogout and chondrocalcinosis occur in an age group where women predominate. Bocher et a1 reported that 72y0of patients in his survey with chondrocalcinosis were women (7). This contrasts with the experience of McCarty, who observed a 1.48,’l.O ratio of men to women in 238 cases of pseudogout (4) and our previous experience which also found a slightly higher male incidence of pseudogout.? It is interesting to speculate that women may have asymptomatic chondrocalcinosis more frequently than men. T h e historical occurrence of diabetes mellitus, heart disease, kidney stones and peptic ulcers was not increased in our patients with chondrocalcinosis. Diabetes mellitus, hyperparathyroidism and a number of other disorders have been described coexisting with pseudogout (3,4), although in a recent controlled study comparing pseudogout and osteoarthritis, minimal intergroup differences were found in the incidence of associated metabolic or endocrine diseases (1% +During the preceding 18 months we had diagnosed pseudogout in 16 hospitalized patients, 9 of which were men, at Michael Reese Medical Center.

ELLMAN AND LEVIN

T h e high incidence of chondrocalcinosis in the population we studied was surprising. All of the residents were Jewish, but there have been no reports suggesting an ethnic bias in the occurrence of pseudogout or chondrocalcinosis. If wrist roentgenograms were eliminated from this study the incidence of chondrocalcinosis would decrease only 0.7aj, and elimination of the pelvis x-rays would not change it at all. Therefore future surveys for chondrocalcinosis in the elderly could be limited to knee roentgenograms alone.

ACKNOWLEDGMENTS We wish to thank Dr. Daniel J. McCarty for advice during the planning of this study and for reviewing the manuscript. We are indebted to the staff, volunteer workers and residents of the Drexel Home for their cooperation.

REFERENCES 1. Zitnan D, Sitaj S: Monopocetna familiarna kalcifikacia

artikularynch chrupiek. Bratisl Lck Listy 28:217, 1958 2. Zitnan D, Sitaj S: Chondrocalcinosis articularis. Ann Rheum Dis 22:142-152, 1963 3. McCarty DJ, Kohn NN, Faires JS: T h e significance of calcium phosphate crystals in the synovial fluid of arthritic patients. Ann Intern Med 56:711-737, 1962 4. McCarty DJ: Pseudogout: Articular chondrocalcinosis, Arthritis and Allied Conditions. Eighth edition. Edited by J L Hollander, DJ McCarty. Philadelphia, Lea and Febiger, 1972, pp 1140-1 160 5. McCarty DJ, Haskin ME: T h e roentgenographic aspects of pseudogout. Am J Roentgen01 90:1248-1257, 1963 6. McCarty DJ, Silcox DC: Gout and pseudogout. Geriatrics 28:llO-120, 1973 7. Bocher J, Mankin HJ, Berk RN, et al: Prevalence of calcified meniscal cartilage in elderly persons. N Engl J Med 272:1093-1097, 1965 8. McCarty DJ. Hogan JM, Gatter RA, et al: Studies on pathological calcifications in human cartilage. J Bone Joint Surg 48A:309-325, 1966 9. Tobler T: Makroskopische und histologische Befunde am Kniegelenksmeniskus in verschiedenen Lebensaltern. Schweizerische Med Wochenschr 10: 1359-1360, 1929 10. Weaver JB: Calcification and ossification of the menisci. J Bone Joint Surg 24:873-882, 1942 1 1. Moskowitz RW, Garcia F: Chondrocalcinosis articularis. Arch Intern Med 132:87-91, 1973

CHONDROCALCINOSIS IN T H E ELDERLY

12. O’Duffy JD: Pseudogout syndrome in hospital patients. JAMA 226:4244, 1973 13. Skinner M, Cohen AS: Calcium pyrophosphate dihydrate crystal deposition disease. Arch Intern Med 123: 636-644, 1969 14. Rubinstein H M , Shah DM: Pseudogout. Sem Arthritis

Rheum 2:259-280, 1972-1973

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15. Martel W, Champion CK, Thompson GR, et al: A roentgenologically distinctive arthropathy in some patients with the pseudogout syndrome. Am J Roentgen01 10’33587-605, 1970 16. McCarty DJ, Silcox DC, Coe F, et al: Diseases associated with calcium pyrophosphate dihydrate crystal deposition. Am J Med 56:704-714, 1974

Chondrocalcinosis in elderly persons.

Fifty-eight elderly people were surveyed for chondrocalcinosis with knee, hip and pelvic roentgenograms using Type M industrial x-ray film. Chondrocal...
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