Cartilage icing and chondrocalcinosis on knee radiographs in the differentiation between gout and calcium pyrophosphate deposition

PLoS One. 2020 Apr 16;15(4):e0231508. doi: 10.1371/journal.pone.0231508. eCollection 2020.


Objective: To determine if findings of "cartilage icing" and chondrocalcinosis on knee radiography can differentiate between gout and calcium pyrophosphate deposition (CPPD).

Methods: IRB-approval was obtained and informed consent was waived for this retrospective study. Electronic medical records from over 2.3 million patients were searched for keywords to identify subjects with knee aspiration-proven cases of gout or CPPD. Radiographs were reviewed by two fellowship-trained musculoskeletal radiologists in randomized order, blinded to the patients' diagnoses. Images were evaluated regarding the presence or absence of cartilage icing, chondrocalcinosis, tophi, gastrocnemius tendon calcification, and joint effusion. Descriptive statistics, sensitivity, specificity, positive and negative predictive values, and accuracy were calculated.

Results: From 49 knee radiographic studies in 46 subjects (31 males and 15 females; mean age 66±13 years), 39% (19/49) showed gout and 61% (30/49) CPPD on aspiration. On knee radiographs, cartilage icing showed a higher sensitivity for CPPD than gout (53-67% and 26%, respectively). Chondrocalcinosis also showed a higher sensitivity for CPPD than gout (50-57% versus 5%), with 95% specificity and 94% positive predictive value for diagnosis of CPPD versus gout. Soft tissue tophus-like opacities were present in gout at the patellar tendon (5%, 1/19) and at the popliteus groove in CPPD (15%, 4/27). Gastrocnemius tendon calcification was present in 30% (8/27) of subjects with CPPD, and 5% (1/19) of gout.

Conclusion: In subjects with joint aspiration-proven crystal disease of the knee, the radiographic finding of cartilage icing was seen in both gout and CPPD. Chondrocalcinosis (overall and hyaline cartilage) as well as gastrocnemius tendon calcification positively correlated with the diagnosis of CPPD over gout.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Calcinosis / diagnosis
  • Calcinosis / diagnostic imaging*
  • Calcium Pyrophosphate / metabolism*
  • Cartilage, Articular / diagnostic imaging*
  • Cartilage, Articular / pathology
  • Chondrocalcinosis / diagnosis
  • Chondrocalcinosis / diagnostic imaging*
  • Diagnosis, Differential
  • Female
  • Gout / diagnosis
  • Gout / diagnostic imaging*
  • Humans
  • Knee Joint / diagnostic imaging*
  • Male
  • Radiography
  • Retrospective Studies


  • Calcium Pyrophosphate