59 y/o female patient with pain in left groin following fracture of the left superior and inferior pubic ramus 12 months ago. Images demonstrate progression over a 10 month period. What is the diagnosis?
Figure 1. Plain radiographs (A, C, E) and coronal CT (B,D, F) images of the left hip.
Figure 2: Plain radiographs (A, C, E) and coronal CT (B,D, F) images of the left hip. A&B from July 2018 demonstrate evidence of focal hydroxyapatite deposition (HAD) at the left greater trochanter (red arrow). C&D from August 2018 and March 2019 demonstrate the start of a bony erosion (yellow arrow) and resorption of the calcium deposit (red arrow). E&F dated April and May 2019 show progression of the bony erosion (yellow arrow) and complete resorption of the calcium deposit (red arrow).
Hydroxyapatite crystal deposition disease (HADD) is a condition of uncertain etiology characterized by periarticular and intra-articular deposition of hydroxyapatite crystals. Deposits of calcium hydroxyapatite crystals in the periarticular connective tissue and in other soft tissues can produce painful inflammatory reactions, but symptomatic deposits within the joints are rare. As seen in this case, occasionally crystal deposits result in cortical erosion and osseous invasion. Intraarticular deposits are rarely seen but can lead to rapid joint destruction, and when in the shoulder it is known as Milwaukee shoulder.
In HADD, the majority of the patients are between the ages of 40 and 70 and the clinical picture is nonspecific with acute joint swelling, warmth, stiffness, and pain that may last for days to weeks and resolve spontaneously. The inflammation may lead to loss of range of motion and function of the involved joint.
Symptomatic deposits may be seen in the soft tissues, secondary to generalized hypercalcemia or hyperphosphatemia. The most frequent and often asymptomatic form of HADD is seen in a periarticular distribution due to trauma and overuse. Most often affecting the shoulder it is known as calcific tendinitis or peritendinitis calcarea. Less frequently, intra-articular deposition of calcium hydroxyapatite may be secondary to generalized hypercalcemia or hyperphosphatemia or as part of a congenital metabolic disorder. Acute calcific periarthritis is an arthropathy with juxta-articular deposition of calcium hydroxyapatite crystals and local inflammation leading to acute pain usually involving a single finger or toe.
The majority of calcium and phosphate in the body is stored in the skeleton as calcium hydroxyapatite. However, deposition of calcium hydroxyapatite in the soft tissues results in necrosis and disintegration of the tissue with associated surrounding inflammatory reaction. On radiographs, the calcifications are periarticular, round or oval shaped with well-defined borders (Fig. 2A, B). As in this case, there may be spontaneous resorption of the calcific bodies (Fig. 2E, F). The differential diagnosis includes calcium pyrophosphate dihydrate crystal deposition disease (CPPD), dystrophic calcification, renal osteodystrophy, hyperparathyroidism, hypoparathyroidism, tumoral calcinosis, collagen vascular disease, sarcoidosis, ochronosis, milk-alkali syndrome and gout.
Treatment is usually conservative with analgesia and physiotherapy. Ultrasound barbotage (needling and lavage) or extracorporeal shockwave therapy has been used with some success in refractory cases.
1. Bohndorf K, Jobke B et al. Imaging of Bones and Joints - A Concise, Multimodality Approach; Thieme 2016: 458-465
2. Hottat N, Fumiere E, Declour C. Calcific tendonitis of the gluteus maximus tendon: CT findings. Eur Radiol 1999; 9:1104–1106.
3. Buckens CF, Terra MP, Maas M. Computed Tomography and MR Imaging in Crystalline-Induced Arthropathies. Radiol Clin North Am. 2017 Sep;55(5):1023-1034. Epub 2017 Jun 12. Review. doi: 10.1016/j.rcl.2017.04.008.
4. Freire, V., Moser, T.P. & Lepage-Saucier, M. Radiological identification and analysis of soft tissue musculoskeletal calcifications. Insights Imaging 9, 477–492 (2018). https://doi.org/10.1007/s13244-018-0619-0
5. Hongsmatip P, Cheng KY, Kim C, et. al. Calcium hydroxyapatite deposition disease: Imaging features and presentations mimicking other pathologies. Eur J Radiol. 2019 Nov;120:108653. Epub 2019 Sep 8. Review. https://doi.org/10.1016/j.ejrad.2019.108653
6. Yang I, Hayes CW, Bierman JS. Calcific tendonitis of the gluteus medius tendon with bone marrow oedema mimicking metastatic disease. Skeletal Radiol 2002; 31:358–361.
7. Thornton MJ, Harries SR, Hughes PM, et. al. Calcific tendinitis of the gluteus maximus tendon with abnormalities of cortical bone. Clin Radiol 1998; 53:296–301.
8. Resnick D. Calcium hydroxyapatite crystal deposition disease. In: Diagnosis of bone and joint disorders. Philadelphia: Saunders, 2002: 1619–1657. Amazon
9. Flemming DJ, Murphey MD, Shkitka KM, et. al. Osseous involvement in calcific tendonitis: a retrospective review of 50 cases. AJR 2003; 181:965–972.
10. Chow H, Recht M, Schils J, Calabrese L. Acute calcific tendinitis of the hip. Arthritis Rheum 1997; 40:974–977. DOI: 10.1002/art.1780400528
11. Kraemer EJ, El-Khoury GY. Atypical calcific tendinitis with cortical bone erosion. Skeletal Radiol 2000; 29:690–996. DOI: 10.1007/s002560000278
12. de Witte PB, Kolk A, Overes F, et. al. Rotator Cuff Calcific Tendinitis: Ultrasound-Guided Needling and Lavage Versus Subacromial Corticosteroids: Five-Year Outcomes of a Randomized Controlled Trial. Am J Sports Med. 2017 Dec;45(14):3305-3314. doi: 10.1177/0363546517721686.
Björn Jobke, MD, is a practicing MSK radiologist, Senior Clinical Artificial Intelligence Advisor for Radiology, and sarcoma expert at Telemedicine Clinic (TMC)/Unilabs. Before entering radiology, he undertook a research doctorate at the Institute of Bone Pathology in Hamburg Germany, investigating sarcomas and metabolic bone diseases. He performed an MSK research post-doctorate at UCSF and a clinical MSK fellowship in Leiden, Holland. Later, he was the lead radiologist in several German sarcoma centers.Dr. Jobke has published numerous articles and co-authored several book chapters, including on sarcomas in a popular MSK reference book. He was a lecturer at several MSK meetings including ISS, ESSR and TMC Academy meetings. Radiological-pathological synopsis was the fundamental basis of his early training and which he continues to be passionate about and eager to pass on his knowledge. Since 2016 Dr. Jobke has worked for TMC’s musculoskeletal section and is based in San Francisco.