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Including calcifications on radiographic reports is essential, as they may become symptomatic.
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The 3 manifestations of calcium pyrophosphate dihydrate crystal deposition disease: chondrocalcinosis, acute calcium pyrophosphate crystal arthritis, and pyrophosphate arthropathy may overlap or be seen in isolation.
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In crystal deposition diseases a cascade of reactions leading to joint inflammation can be age related, triggered by a trauma or disease, and result in sometimes rapid joint destruction.
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Ultrasound-guided barbotage procedure is straightforward and accelerates the natural course of hydroxyapatite crystal deposition disease.
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Dual-energy computed tomography is rapid, noninvasive, and enables diagnosis and follow-up of gout, in multiple joints on a single scan without the use of contrast agents.
Introduction
In the elderly population a variety of calcifications and crystal depositions can be appreciated on conventional imaging. These might be asymptomatic but may become symptomatic in time and deserve to be mentioned in the radiological report. The clinical presentation of crystal deposition diseases is variable and diagnosis might be challenging.
Resnick D. Calcium hydroxyapatite crystal deposition disease. In: Diagnosis of bone and joint disorders. 4th edition. Articular diseases, vol 1. Philadelphia (PA): WB Saunders; 2002. p. 1619–1657.
The purpose of this review article is to explain the disease spectrum and pathophysiology of calcium pyrophosphate dihydrate crystal deposition disease (CPPD), hydroxyapatite crystal deposition disease (HADD), and gout; to describe imaging findings; and to learn about differential diagnoses, choice of imaging modalities, and possible clinical consequences. Pearls and pitfalls relevant to point of care are provided.
CPPD is caused by the deposition of calcium pyrophosphate (CPP) crystals predominantly in, but also around, joints, and it is common in elderly persons.
Resnick D. Calcium hydroxyapatite crystal deposition disease. In: Diagnosis of bone and joint disorders. 4th edition. Articular diseases, vol 1. Philadelphia (PA): WB Saunders; 2002. p. 1619–1657.
There is no gender difference. Its prevalence increases with age: using radiographic knee chondrocalcinosis as diagnostic criterion, it is uncommon in those younger than 55 years and increases to 20% to 30% in those older than 80 years.
The mechanism of CPP crystal accumulation in cartilage is unknown. The theory is that it is secondary to cartilage damage: age related, posttraumatic, or disease induced.
Less commonly genetic or various metabolic disorders such as hereditary hemochromatosis, primary hyperparathyroidism, and hypomagnesemia are the cause,
The arthritis of hemochromatosis. A review of 25 cases with special reference to chondrocalcinosis, and a comparison with patients with primary hyperparathyroidism and controls.
Its clinical expression is variable; patients may present with chondrocalcinosis, acute CPP crystal arthritis (also called pseudogout), or pyrophosphate arthropathy, as a result of chronic CPP arthritis
Treatment of acute or chronic arthritis in CPPD is based on expert opinion and evidence based on treatment of gout. A recent review article showed that the administration of nonsteroidal antiinflammatory drugs (NSAIDs), colchicine, and corticosteroids has not been evaluated by randomized controlled trials.
Fig. 2Granular calcifications of hyaline cartilage parallel to the cortical bone in femorotibial and patellofemoral joints A, B. Fibrocartilage calcifications in the menisci and proximal patella enthesopathy.B
Acute CPP crystal arthritis (pseudogout syndrome): CPPD was first recognized as a source of acute crystal-induced peripheral-joint inflammation. Most cases develop spontaneously, but there are situations that trigger arthritis, for instance joint trauma, medical illness, surgery, or a blood transfusion.
Resnick D. Calcium hydroxyapatite crystal deposition disease. In: Diagnosis of bone and joint disorders. 4th edition. Articular diseases, vol 1. Philadelphia (PA): WB Saunders; 2002. p. 1619–1657.
The European League Against Rheumatism has made recommendations for the diagnosis of CPPD based on rapid development of inflammatory symptoms, the location of arthritis (knee, shoulders, wrist), age of the patient (>65 years), imaging findings, and absence of another disease (eg, rheumatoid arthritis and septic arthritis).
The theory of pathogenesis of acute arthritis and synovitis in CPPD is shown in the drawing of Fig. 3A, B . The shedding of CPP crystals into the joint is key in this process. This acute onset of CPP arthritis is self-limiting.
Fig. 3Pathogenesis of CPPD (A, B) and gout (C). (A) Acute CPPD attack hypothesis. Crystal deposits around chondrocytes (chondrocalcinosis) lead to cell death, cartilage loss, and deposit coalescence. Crystal shedding results in arthritis. (B) Pyrophosphate arthropathy pathogenesis. Cartilage loss and crystal shedding with synovial depositions result in synovitis. In time degenerative cysts and progressive cartilage and bone destruction is seen. (C) Gout. MTP1 is preserved; MSU crystals erode the bone in intra- and extraarticular eccentric locations, leading to overhanging margins.
(Adapted from Resnick D. Gouty arthritis. In: Diagnosis of bone and joint disorders, 4th edition (Articular diseases, vol 1). Philadelphia: WB Saunders; 2002. P.1519-1559.)
Pyrophosphate arthropathy: the clinical presentation often simulates osteoarthritis. CPPD flares may occur, and a chronic and progressive form of arthritis develops. Its presence is often bilateral and symmetric. Preferential locations include the knee, hip, metacarpophalangeal joints, elbow, ankle, wrist, and glenohumeral joints.
Resnick D. Calcium hydroxyapatite crystal deposition disease. In: Diagnosis of bone and joint disorders. 4th edition. Articular diseases, vol 1. Philadelphia (PA): WB Saunders; 2002. p. 1619–1657.
The intraarticular deposition of CPP crystals is almost exclusively seen into articular hyaline cartilage and fibrocartilage and is the most common cause of chondrocalcinosis (see Fig. 3). Examples of fibrocartilage calcifications include knee menisci, symphysis pubis, triangular cartilage of the wrist, annulus fibrosis of the intervertebral disc, and labra of hip and shoulder. However, not all calcifications are identified on radiographs; this can be based on low density of the calcifications or an already severely deranged joint at presentation.
Calcifications can also be seen in the synovial membrane (eg, the knee, wrist, metacarpophalangeal, and metatarsophalangeal [MTP] joints) and the joint capsules. In addition, periarticular calcifications in tendons, bursae, and ligaments can be observed, mimicking hydroxyapatite deposition.
Resnick D. Calcium hydroxyapatite crystal deposition disease. In: Diagnosis of bone and joint disorders. 4th edition. Articular diseases, vol 1. Philadelphia (PA): WB Saunders; 2002. p. 1619–1657.
In the spine all ligaments may be affected. Periodontoid deposition is called the crowned dens syndrome.
The term pyrophosphate arthropathy is used for the structural joint changes in CPPD (see Fig. 3). Characteristics include the following:
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Cystic degeneration and sclerosis (no erosions)
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Fragmentation of bone and cartilage
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Debris in synovial membrane
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Ultrasonography (US)
US can show synovitis and can sensitively show CPP deposits in cartilage, with a typical appearance of hypoechoic (cartilage) and echoic (CPPD) layers, being part of the EULAR criteria.
The value of MR imaging is limited in the diagnosis of CPPD. The calcifications are low of signal intensity on all MR sequences and difficult to identify especially in ligaments, and correlation with conventional radiographs is necessary.
Radiographic/MR imaging correlation of paravertebral ossifications in ligaments and bony vertebral outgrowths: anatomy, early detection, and clinical impact.
Resnick D. Calcium hydroxyapatite crystal deposition disease. In: Diagnosis of bone and joint disorders. 4th edition. Articular diseases, vol 1. Philadelphia (PA): WB Saunders; 2002. p. 1619–1657.
Deposition of calcium HA crystals is predominantly periarticular in tendons and bursae but also in ligaments being the source of inflammatory periarthritis, such as bursitis or tendinitis.
The second most common site is the hip followed by elbow, wrist, hand, and knee, but any joint can be affected, including the cervical and lumbar spine.
Radiographic/MR imaging correlation of paravertebral ossifications in ligaments and bony vertebral outgrowths: anatomy, early detection, and clinical impact.
Milwaukee shoulder syndrome is associated with rotator cuff pathology, and arthropathy in other joints, especially the knee, is reported, typically unicompartmental
(Fig. 5). The differential diagnosis includes CPPD arthropathy, neuropathic arthropathy, and infection.
Fig. 4Milwaukee shoulder syndrome. Posttraumatic left shoulder (A) of an 80-year-old woman without fracture and preexisting rotator cuff pathology. After 6 weeks (B) complete destruction of the humeral head and a large soft tissue mass with multiple bony fragments is seen. Axial CT image (C), T1TSE (D), and coronal T2fatsat MR images (E) show complete humeral head destruction with several bony fragments, surrounded by fluid and debris, extending into the subacromial bursa secondary to rotator cuff pathology.
Fig. 5Arthropathy of the right knee in same patient as Fig. 4. Intraarticular fluid, valgus deviation, and large lateral tibia plateau impression with demarcated sclerosis A. Multiple intraarticular bony fragments are present A, B.
The cause and pathogenesis of calcium HA deposition is unknown. Several theories in the past included tendon degeneration, hypoxia, (repetitive) trauma, and aging.
Most calcifications are incidental findings, and other pathology should be excluded before focusing on the calcific deposit as the source of complaints. Calcific tendinitis of the rotator cuff has a reported prevalence of 6.8% to 54% in patients with shoulder pain.
However, symptoms can be severe and long-lasting, and several treatments have been initiated including subacromial corticosteroid injections, high-energy extracorporeal shock wave therapy, barbotage, and surgery.
Comparing ultrasound-guided needling combined with a subacromial corticosteroid injection versus high-energy extracorporeal shockwave therapy for calcific tendinitis of the rotator cuff: a randomized controlled trial.
Rotator cuff calcific tendinitis: ultrasound-guided needling and lavage versus subacromial corticosteroids: five-year outcomes of a randomized controlled trial.
Type I calcifications have a sharp border and a dense structure
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Type II calcifications either have a sharp border and inhomogeneous structure or a vague border and a homogenous structure
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Type III calcifications have a vague border, and are more or less transparent, with a cloudy appearance.
In the phase of resorption, calcifications can migrate into the soft tissues: the tendon, bursa, joint, but also the bone. On radiographs faint small calcifications can be appreciated in the area of the bursa (Fig. 6). This chemical bursitis can be extremely painful and important to recognize. A calcification can also migrate into the bone, leading to cortical erosions (Fig. 7). In the resorptive phase the radiograph might not show calcific deposits, and other imaging modalities such as ultrasound and MR imaging might be of help.
Radiographic/MR imaging correlation of paravertebral ossifications in ligaments and bony vertebral outgrowths: anatomy, early detection, and clinical impact.
Fig. 6Large unsharply defined calcification (type II) in the supraspinatus tendon (A). Two days after barbotage the patient presented with severe shoulder pain. The calcification (B) shows resorption and fragmentation on ultrasound present in SSP tendon (C) and bursa (D).
Fig. 7Unremarkable radiograph (A). Ultrasound (B) of the supraspinatus insertion shows multiple small calcifications and a cortical break with intraosseous extension of calcifications. No bursitis. Coronal T1TSE (C) and T2fatsat MR images (D) show SSP enthesitis and several subchondral cysts and extensive bone marrow edema at the footprint.
On US the calcifications will have a different appearance based on their content. A dense type I calcification will show acoustic shadowing, whereas a type II can be more clearly visualized with a hyperechoic margin (Fig. 8A). During a barbotage procedure the calcific deposit can show a change in echogenicity because crystals are washed out (Fig. 8D, E) and the posterior border can become visible.
Fig. 8Large subscapularis calcification with a hyperechoic demarcated rim and less hyperechoic content, surrounding hyperemia in longitudinal (left) and axial view (right) (A). Bursal injection of 1cc corticosteroid (40 mg/ml) and 4cc bupivacaine 5 mg/ml (B, C). Lavage of the calcification (D), with hypoechoic saline (E).
US can visualize radiographic undetected calcifications because of size or density and determine their exact location (see Fig. 6). In addition, US-Doppler will show inflammation in bursae, tendons and joints (see Fig. 8A). Moreover, US is the ideal tool for an accurate bursal injection and barbotage procedure (Fig. 8; Figs. 9 and 10).
Fig. 9Anteroposterior and axial views of the right shoulder, before (A, B), after (C, D), and 6 weks after barbotage (E, F). The large calcification in the subscapularis tendon has decreased in size.
Barbotage treatment is invasive, needs coordinating skills, and is time consuming. It can be painful during and after the intervention but is reported to accelerate the natural course of HADD in randomized controlled trials.
Rotator cuff calcific tendinitis: ultrasound-guided needling and lavage versus subacromial corticosteroids: five-year outcomes of a randomized controlled trial.
CT and MR imaging are less frequently used in HADD
However, in unclear diagnosis these modalities might be of help: CT in detecting small calcifications, intraosseous erosion, and for example, evaluation of deposits in the spine. On MR imaging calcifications are less evident; however, soft tissue involvement and bone marrow edema can be detected (see Fig. 7).
Radiographic/MR imaging correlation of paravertebral ossifications in ligaments and bony vertebral outgrowths: anatomy, early detection, and clinical impact.
Resnick D. Gouty arthritis. In: Diagnosis of bone and joint disorders. 4th edition. Articular diseases, vol 1. Philadelphia (PA): WB Saunders; 2002. p. 1519–1559.
Contemporary Prevalence of Gout and Hyperuricemia in the United States and Decadal Trends: The National Health and Nutrition Examination Survey, 2007-2016.
Sustained elevation of serum urate levels results in a deposition of monosodium urate (MSU) especially in or around joints, which can lead to formation of tophi and joint damage.
Peripherally located structures and structures of the lower limbs are especially frequently affected by gout, with a predilection for the first MTP joint; this is classically described as podagra and is reported in up to 80% of untreated patients.
A recent survey showed that gout presented with single joint involvement in more than 90% of patients, whereas fewer than 1% of patients presented with gout affecting more than 4 joints.
Clinical presentation typically consists of recurrent episodes of acute arthritis with a rapid onset of severe pain, swelling, and erythema. Gout further has a strong association with cardiovascular diseases.
Elevation of serum urate levels can have several causes: exogenous, due to excessive intake of purines (eg, meat, seafood, alcohol), or endogenous, for example, cell lysis during chemotherapy or myeloproliferative disorders.
Insufficient uric acid clearance also plays a major role in the development of elevated serum urate, either from chronic kidney disease, drug interactions, or genetic predispositions.
(Fig. 11). However, this is invasive with potential contraindications, leading to the increasing role of US and dual-energy computed tomography (DECT) in gout detection.
Response to: "Monosodium urate crystal deposition associated with the progress of radiographic grade at the sacroiliac joint in axial SpA: a dual-energy CT study.
Both US and DECT are included in the new 2020 American College of Rheumatology classification criteria, along with radiographs, elevated serum urate levels, clinical evidence of tophus, and MSU crystals in synovial fluid.
Fig. 11Needle-shaped crystals of monosodium urate (A), showing strongly birefringent crystals on polarization (B) Zeiss Axioskop and Leica DM2000 light microscope: 400x enlargement.
Radiographs are indicated to search for imaging evidence of MSU crystal deposition but have limited value for the diagnosis of gout flare. The radiographic changes take several years to develop, thus helpful in supporting diagnosis of chronic gout. In patients with 4 years duration of disease, sensitivity and specificity for erosions were 0.12 and 0.96.
Radiographic manifestations are classified into early, intermediate, and late stage.
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Early findings are nonspecific soft-tissue swelling in the affected joint secondary to synovitis, capsular distension, and periarticular soft tissue edema. Fine lacy periosteal reaction may be observed secondary to urate crystals in adjacent soft tissue.
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Intermediate-stage features include faint calcification of affected soft tissues, intracortical erosions and irregularity, and osteochondral compression or cupping. The joint space is preserved until late in the disease.
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Late stage is characterized by well-defined juxta-articular erosions with sclerotic rims and overhanging margins. Progressive erosions and intraarticular deposits may result in tapering deformities of the shafts, subluxation, and mutilating arthritis. Progressive joint space narrowing with secondary degenerative changes is a late manifestation. Rarely, ankylosis may occur. Appositional bone deposition may cause apparent expansion of bone ends with a bulbous appearance.
US is an ideal first-line examination technique for suspected gout. MSU deposits can have several different appearances, including the “double contour sign” (DC-sign), “snow storm sign,” and delineation of tophi.
An abnormal hyperechoic band over the superficial margin on the hypoechoic articular hyaline cartilage, which may be homogeneous or inhomogeneous, irregular or regular, and continuous or intermittent. There may be posterior acoustic shadowing, depending on both the amount and density of the MSU deposits.
The thickness of the DC sign should be similar to the cortex; however, in early stages it may be thinner (Fig. 12A, B ).
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Snow-storm sign and tophi: hyperechoic microtophi appearing as white spots within the fluid collection generate the typical snow storm appearance. Larger, dense aggregates develop into hypoechoic to hyperechoic (mainly chronic tophi) inhomogeneous tophi, with a cloudy appearance and a hypoechoic or anechoic rim
Fig. 13Large gout tophus at the level of the Achilles tendon insertion on lateral radiograph of the right ankle (A). Longitudinal ultrasound (B) shows an inhomogeneous hyperechoic mass with a surrounding hypoechoic rim, without hyperemia (C).
Fig. 12(A) Double contour (DC) sign (arrows) in an axial US scan of the knee in a patient with gouty arthritis, with a hyperechoic band over the articular cartilage (hypoechoic) of the condyles. (B) DC sign in a sagittal US scan of an MCP joint with surrounding hypervascularization.
Although those appearances are very specific for gout, data regarding specificity and sensitivity are highly variable depending the examined region. Although regions that can be easily assessed by US such as the MTP1 joint show great data, regions such as the hand and wrist show poor gout detection, as these joints are less accessible. In these joints US showed a sensitivity of 70.1% (extraarticular: 42.5%, P < .001; intraarticular: 80.3%, P = .14) and a specificity of 51%.
On MR imaging, tophi can be seen as amorphous or nodular regions of low-intensity signal on T1-weighted images, variable intensity on T2-weighted images and with variable enhancement after intravenous contrast media. Other MR imaging features of gout are synovial pannus, joint effusions, and soft-tissue edema.
Magnetic resonance imaging bone edema is not a major feature of gout unless there is concomitant osteomyelitis: 10-year findings from a high-prevalence population.
A particular advantage of MR imaging is the ability to assess bone involvement in detail, being more sensitive than both CT and US in detecting bone erosion in patients with gout. A main disadvantage is that MSU crystals cannot be directly observed by MR imaging, leading to poor specificity
Fig. 14Left foot dorsoplantar (A) and ¾ view (B) show erosive destruction in the tarsus and MTP joints. Sagittal MR images, T1TSE (C), T2TSE fatsat (D), and T1TSE fatsat after intravenous contrast (E) show multiple sharply delineated erosions in the tarsal bones. The moderately high T2 content shows a peripheral zone of enhancement. Absence of intraosseous edema. DECT, 3D-formatted (F), axial subtracted images in bone (G) and soft tissue (H) setting. Color-coded green MSU deposits in the erosions. 3D, 3-dimensional.
The unique chemical composition of uric acid precipitates results in a distinct radiographic attenuation when compared with other materials, and this results in characteristic patterns of CT numbers at high versus low kilovolts (kV), allowing imaging software to differentiate MSU from other materials.
Data are acquired at 80 and 140 kV with a plot of the attenuation of each voxel at 80 kV (y-axis) against attenuation at 140 kV (x-axis). The pixels containing calcium and monosodium urate can be separated and presented as a color image for easy identification. Although the color coding can vary across manufacturers, the most common software color codes are green for MSU deposits, lavender for cortical bone, and pink for trabecular bone. These color-coded images are displayed as an overlay on either 2-dimensional conventional gray-scale CT images or as 3-dimensional volume-rendered images
(see Figs. 14 and 15; Fig. 16). DECT can therefore provide color-coded information about the composition of certain materials, including urate, calcium pyrophosphate (CPPD), and hydroxyapatite (HADD). Mallinson and colleagues concluded that nail bed deposits, submillimeter deposits, skin deposits, and deposits obscured by motion, beam hardening, and vascular artifacts should not be classified as positive findings, and they are especially dependent on the postprocessing protocols used.
Park and colleagues concluded that setting the minimum attenuation to a higher value of 150 Hounsfield units in their study reduced the frequency of artifacts and that adding a tin filter to DECT greatly reduced their occurrence.
Not all green is tophi: the importance of optimizing minimum attenuation and using a tin filter to minimize clumpy artifacts on foot and ankle dual-energy CT.
showed 84% sensitivity and 93% specificity for detection of MSU deposits by DECT in the lower extremities, as well as wrists and hands. The role of DECT has also been shown by Hu and colleagues
reporting a high sensitivity and specificity of 75.2% and 92.7% of DECT for the detection of gouty arthritis in upper and lower extremities. In recent studies a modified postprocessing protocol with lowering of the threshold of attenuation from 150 HU to 120 HU and keeping the kilovoltage settings constant showed promising results.
Impact of Dual-Energy CT postprocessing protocol for the detection of gouty arthritis and quantification of tophi in patients presenting with podagra: comparison with ultrasound.
Crystal arthropathies are a group of joint disorders due to deposition of crystals in and around joints, which lead to joint destruction and soft tissue masses. Clinical presentation is variable and diagnosis might be challenging. Therefore, first-line imaging of ultrasound in accessible joints is recommended to assess crystal arthropathies; however, DECT is a useful adjunct to differentiate gout from CPPD.
Clinics care points
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Aging is the main risk factor for CPPD crystal deposition disease.
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CPP crystals almost exclusively deposit into articular fibrocartilage and hyaline cartilage, the most common cause of chondrocalcinosis.
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Calcifications need to be part of the radiological report, as they may become symptomatic.
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Absence of crystal deposit detection on radiographs does not exclude the diagnosis of CPPD, gout, or HADD.
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Rapid joint destruction without visible calcifications should raise the diagnosis of CPPD.
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Barbotage is an effective method to accelerate the natural course of HADD.
Resnick D. Calcium hydroxyapatite crystal deposition disease. In: Diagnosis of bone and joint disorders. 4th edition. Articular diseases, vol 1. Philadelphia (PA): WB Saunders; 2002. p. 1619–1657.
The arthritis of hemochromatosis. A review of 25 cases with special reference to chondrocalcinosis, and a comparison with patients with primary hyperparathyroidism and controls.
Radiographic/MR imaging correlation of paravertebral ossifications in ligaments and bony vertebral outgrowths: anatomy, early detection, and clinical impact.
Comparing ultrasound-guided needling combined with a subacromial corticosteroid injection versus high-energy extracorporeal shockwave therapy for calcific tendinitis of the rotator cuff: a randomized controlled trial.
Rotator cuff calcific tendinitis: ultrasound-guided needling and lavage versus subacromial corticosteroids: five-year outcomes of a randomized controlled trial.
Resnick D. Gouty arthritis. In: Diagnosis of bone and joint disorders. 4th edition. Articular diseases, vol 1. Philadelphia (PA): WB Saunders; 2002. p. 1519–1559.
Contemporary Prevalence of Gout and Hyperuricemia in the United States and Decadal Trends: The National Health and Nutrition Examination Survey, 2007-2016.
Response to: "Monosodium urate crystal deposition associated with the progress of radiographic grade at the sacroiliac joint in axial SpA: a dual-energy CT study.
Magnetic resonance imaging bone edema is not a major feature of gout unless there is concomitant osteomyelitis: 10-year findings from a high-prevalence population.
Not all green is tophi: the importance of optimizing minimum attenuation and using a tin filter to minimize clumpy artifacts on foot and ankle dual-energy CT.
Impact of Dual-Energy CT postprocessing protocol for the detection of gouty arthritis and quantification of tophi in patients presenting with podagra: comparison with ultrasound.
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