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The technique of CT arthrography and arthrotomography of the major joints is discussed. Also, the types of contrast media, double or single contrast technique, film-screen combinations, injection techniques and additional pain testing are discussed.
Digital and manual subtraction images obtained during the arthrographic evaluation of 78 painful hip prostheses were reviewed retrospectively. Revision arthroplasty was performed in 53 of these cases, and the arthrographic and surgical findings were correlated. The digital and manual subtraction images were evaluated without knowledge of the surgical results using established criteria for component loosening. Digital subtraction arthrography of the femoral component demonstrated a 96% sensitivity and 100% specificity for the diagnosis of component loosening. Sensitivity and specificity for acetabular component loosening were 83% and 80%, respectively. Plain film subtraction of the femoral component demonstrated a 79% sensitivity and 100% specificity; the sensitivity and specificity for the acetabular component were 75% and 80%, respectively. The difference between detection of femoral component loosening on digital as opposed to manual subtraction images was statistically significant (P less than 0.05). This study demonstrate that digital subtraction improves the evaluation of femoral component loosening in painful hip prostheses.
The configuration of the articular cavities of the cervico-occipital region have been demonstrated by an experimental technic of positive contrast arthrography in postmortem specimens.
Arthrography of the wrist was performed on 50 consecutive patients with obscure post-traumatic wrist pain by injecting contrast separately into the radiocarpal joint, midcarpal compartment, and distal radioulnar joint. When distal radioulnar joint and midcarpal compartment injections were added to the standard radiocarpal injection, many significant unsuspected abnormalities were identified. Of the 25 triangular fibrocartilage complex abnormalities identified, six (24%) were found only with the distal radioulnar joint injection. Of the 29 abnormal communications between the midcarpal compartment and the radiocarpal joint, ten (35%) were found only with the midcarpal injection. Similarly, five of 29 (17%) of the abnormal radiocarpal-midcarpal communications would have been missed if a midcarpal injection alone had been performed. These findings indicate that separate injections into the radiocarpal joint, midcarpal compartment, and distal radioulnar joint are needed to identify a large number of abnormalities not seen with injections into one compartment alone.
Dysplasia epiphysealis hemimelica can be diagnosed on plain radiographs of the affected areas. However, double contrast arthrography in three new cases provided additional information. The cartilaginous portions of the lesion at the articular surface of the bone were precisely demonstrated, aiding the orthopedic surgeon in deciding which patients should have surgery and planning the extent of operation necessary.
The newer diagnostic modalities such as computed tomography and magnetic resonance imaging are becoming increasingly used in the evaluation of joint trauma. The combination of computed tomography and arthrography can also be of significant diagnostic value in certain specific situations. In our case report, we describe its use in post-traumatic recurrent hip dislocation and its value, not only in depicting a posterior capsular tear, but also in the diagnosis of an internal joint derangement which may contribute to incongruous reduction of the hip joint.
The authors describe a case of a recurrent posterior traumatic dislocation of the hip in a child in whom early arthrography demonstrated a large defect of the posterior capsule. The authors emphasize the necessity of prolonged immobilization and long-term follow-up. The operation of the patient was performed on the 7th day after the third recurrence of the dislocation. Revision and suture of the capsular defect from Gibson's approach were done.
Knowledge of the anatomy of the anterior cruciate ligament (ACL), including its course and orientation in relation to the roof of the intercondylar fossa, is a prerequisite for successful intra-articular ACL reconstruction. To attain precision placement of the tibial attachment site and to avoid graft/roof conflict in the extended knee position, we assessed the anteroposterior tibial insertion of the ACL in the midsagittal plane of the extended knee. We measured the anterior-posterior (AP) limits and the center of the tibial attachment area of the ACL from the anterior tibial margin. The inclination angle of the intercondylar fossa roof was measured with respect to the shaft axis of the femur. The tibial attachment area of the ACL was determined in ten cadaveric knees. Using the cryoplaning technique, we determined the tibial attachment of the ACL in five knees. Using contrast magnetic resonance arthrography (MRA), we measured the tibial insertion of the ACL in 35 patients (23 male and 12 female) with intact ACLs. The total AP midsagittal diameter of the tibia averaged 51.0 +/- 5.8 mm in the cadaveric knees, 49 mm on cryosections, and 53.7 mm in men and 49.0 mm in women with MRA. The average anterior limit of the ACL, measured from the anterior tibial margin, was 14 +/- 4.2 mm in the cadaveric knees, 12.1 mm at cryosectional anatomy, and 15.2 mm in men and 13.4 mm in women with MRA.(ABSTRACT TRUNCATED AT 250 WORDS)
We report on our experience with cervical analgesic facet joint arthrography in 11 patients (30 joints), of whom nine had previous spinal surgery. In this type of patient we have found the procedure to be a diagnostic test as well as a preoperative guide to the neurosurgeon, but not a permanent therapy.
Radiographic examination of infants' hips is still indicated sometimes in addition to the sonographic examination. The legs have to be kept in a neutral position. The pelvis should not be turned to the side or tilted. Hilgenreiner's acetabular index is preferred in the diagnosis of hip dysplasia. Long-term follow-ups of critical values show spontaneous improvement in some cases, but also joints with increasing dysplasia. Critical values between one and two standard deviations of our material and somewhat above have to be followed. The axial orthograde view of the hip as a lateral view of the femoral head is recommended in Perthes' disease to determine the Catterall groups more exactly than in the Lauenstein position. Arthrography is still indicated in dislocated hips that cannot be reduced into the socket because of a narrow cartilaginous inlet. Here the risk of avascular necrosis is high and traction is indicated.
Magnetic Resonance imaging with its excellent soft tissue contrast represents the method of choice for examination of intraarticular and periarticular structures of joints. However, conventional MR-imaging without intraarticular contrast application is not suitable for the diagnosis of labral lesions. MR-arthrography (MRA) of the hip clearly demonstrates labral pathology by distension of the joint space and entrance of the contrast medium into the lesion. Multiplanar 3-D-gradient echo sequences enable visualisation of the most important cranio-ventral portion of the labrum. With the MRA labral lesions can be subdivided into different, clinically relevant stages. Furthermore accompanying lesions (intra- and extraosseous ganglia, stress-bone marrow-edema) can be demonstrated. In our study including operatively verified cases, MRA showed excellent sensitivity (90%) and accuracy (91%) in detecting labral lesions. So far no complication occurred with more than 100 MRA's. Therefore this technique represents the method of choice for the radiological evaluation of labral lesions of the hip joint. In this review the technical details and results of our MRA method will be presented.
OBJECTIVE: A meta-analysis was carried out of clinical trials published between 1987 and 2001 in respect of the clinical pharmacology and safety as well as the diagnostic efficacy of gadolinium-DTPA (Gd-DTPA) for direct intra-articular injection before MRI examination. DESIGN: Scientific papers (clinical, postmortem and experimental studies) and information from the manufacturer regarding intra-articular injection of Gd-DTPA that addressed questions of mode of action, optimal concentration and dose, elimination and safety were reviewed. Clinical studies were classified according to their study design. The sensitivity, specificity and accuracy of MR arthrography (MRA) were compared with a "gold standard" (arthroscopy, arthrotomy) and other radiological evidence for different joints. RESULTS: Fifty-two clinical studies of the overall 112 studies addressed aspects of diagnostic efficacy of MRA in patients or in healthy volunteers. The shoulder was the most assessed joint (29 of 52 studies). Good (>80%) or even excellent (90-100%) sensitivity, specificity and accuracy were found for MRA in most indications, especially for the shoulder and knee joints and induced extension of rotator cuff lesions, labrum abnormalities and postoperative meniscal tears. Two millimoles per liter has proven to be the best concentration for intra-articular administration of Gd-DTPA. After passive complete diffusion from the joint within 6-24 h, complete and rapid renal elimination takes place after intra-articular injection. Local safety proved to be excellent after intra-articular administration of Gd-DTPA. Regarding systemic tolerance almost no side effects have been reported, but the same safety considerations apply for intra-articular administration of Gd-DTPA as for intravenous injection. CONCLUSIONS: The diagnostic efficacy of intra-articular MRA in most clinical conditions affecting major joints is greater than that of plain MRI. In some diagnostic problems MRA achieves almost the same sensitivity and specificity as the surgical gold standard. Given a sterile application, the intra-articular administration of Gd-DTPA in a concentration of 2 mmol/l prior to MRI is a safe procedure.
Indirect MR arthrography is useful for evaluation of joints such as the elbow, wrist, ankle and shoulder where there is a large synovial surface area relative to joint volume. It allows simultaneous assessment of both intra-articular and extra-articular soft tissues with the added advantage of minimal invasiveness. The established and potential uses of this imaging technique are reviewed below and the pathology that is demonstrated by this technique is discussed.
OBJECTIVE: To develop a new method of magnetic resonance arthrography (MRA) of the knee using an anterior approach analogous to the portals used for knee arthroscopy. DESIGN: An anterior approach to the knee joint was devised mimicking anterior portals used for knee arthroscopy. Seven patients scheduled for routine knee MRA were placed in a decubitus position and under fluoroscopic guidance a needle was advanced from a position adjacent to the patellar tendon into the knee joint. After confirmation of the needle tip location, a dilute gadolinium solution was injected. RESULTS AND CONCLUSION: All the arthrograms were technically successful. The anterior approach to knee MRA has greater technical ease than the traditional approach with little patient discomfort.
This study assessed the diagnostic effectiveness of multidetector spiral CT arthrography (MDCTa) in detecting hyaline cartilage abnormalities of the shoulder joint, with correlation to arthroscopy. Shoulder MDCTa images prospectively obtained in 22 consecutive patients (mean age, 50 years; age range, 23-74 years; 12 female, 10 male) were evaluated for glenohumeral cartilage lesions. Two musculoskeletal radiologists independently analysed the cartilage surfaces of the humeral head and of the glenoid fossa in nine anatomical surface areas. Observations of MDCTa were compared to arthroscopic findings. The sensitivity and specificity of MDCTa for grade 2 (substance loss <50%) or higher and grade 3 (substance loss >or=50%) or higher cartilage lesions, the Spearman correlation coefficient between arthrographic and arthroscopic grading, and K statistics for assessing Intra and Interobserver reproducibility were determined. At MDCTa, sensitivities and specificities ranged between 80% and 94% for the detection of grade 2 or higher cartilage lesions, and between 88% and 98% for the detection of grade 3 or higher cartilage lesions. Spearman correlation coefficients between MDCTa and arthroscopic grading of articular surfaces ranged between 0.532 and 0.651. Interobserver agreement was moderate for grading all articular surfaces (kappa = 0.457), but substantial to almost perfect for detecting lesions with substance loss (kappa, 0.618-0.876). In conclusion, MDCTa is accurate for the study of cartilage surface in the entire shoulder joint. This technique may beneficially impact patient's management by means of selecting the proper treatment approach.
The intention was to compare the sensitivity and specificity of radial planes with oblique coronal and oblique axial planes for the detection of labral abnormalities of the acetabulum on magnetic resonance arthrography (MRa). Twenty cadaveric hip joints were examined by radiography and MRa. For MRa, 15 ml of a solution of iodinated contrast material and gadolinium diethylene triamine tetra-acetic acid (Gd-DTPA; 100:1) were injected under fluoroscopic guidance. MRI was performed on a 1.5-T MR scanner with a fat-suppressed 3D-FLASH sequence (TR/TE/flip-angle 42 ms/10 ms/40 degrees; field of view 16 cm, matrix 256 x 256, section thickness 1.5 mm, pixel size 0.7 x 0.7 mm). Multiplanar image reconstructions were done perpendicular to the acetabulum in oblique coronal and oblique axial planes and in radial planes. Macroscopic and histopathologic examination of the labral specimens was performed. Labral lesions were found in 15/20 hips (75%) on pathologic examination. Six hips demonstrated labral degeneration. The labrum was partially detached in 7 hips and completely detached in 2 hips. A flap-like labrum was found in 2 cases, 1 with partial detachment of the labrum and 1 with a degenerated labrum. Using oblique coronal and oblique axial reconstructions, pathologic findings were confirmed by MRa in 9/15 specimens (sensitivity 60%). There were no false-positive findings (specificity 100%, accuracy 70%). Also, 3/6 labral degenerations without detachment, 4/7 partial detachments, and 2/2 complete detachments were correctly diagnosed. Two flap-like labra were not recognized. With radial reconstructions, pathologic findings were correctly confirmed in 12/15 specimens (sensitivity 80%) without false-positive findings (specificity 100%, accuracy 85%). Also, 3/6 labral degenerations without detachment, 6/7 partial detachments, 2/2 complete detachments, and 1/2 flap-like labra were correctly diagnosed. MRa of the acetabular labrum using radial reconstructions is well suited to delineate the acetabular labrum and to diagnose labral detachments. Radial reconstructions allow for perpendicular display of the whole acetabular circumference and are more accurate for the diagnosis of acetabular labral lesions, when compared with oblique coronal and oblique axial reconstructions.
We studied the utility of magnetic resonance imaging (MRI) in detecting obstacles to reduction in developmental dysplasia of the hip (DDH) by comparing MRI findings with two-directional arthrograms and intraoperative findings. In 36 patients there were 38 DDHs; 23 complete dislocations and 15 residual subluxations. Coronal and transverse sections of T1-weighted images were used. Interpositions in the acetabulum and the anterior, superior, and posterior portions of the limbus, which were intracapsular obstacles to reduction, were evaluated. MRI and arthrography were useful for assessing the shape of the anterior portion of the limbus. In complete dislocations, MRI findings proved more valuable to detect deformities of the posterior portion of the limbus. Four of ten limbus excisions showed intermediate intensity signals on MRI. The histology was characterized by reparative granulation tissue with new capillary formation and organized thrombi. MRI proved useful for detecting obstacles to reduction, as well as for assessing morphological and histological abnormalities.
To explore the relationships among dysfunction of the two heads of the lateral pterygoid muscle, temporomandibular joint (TMJ) internal derangement, and the mechanism of TMJ sounds, a comparative study was undertaken with electromyography of the two heads of the muscle and arthrography in 38 patients with temporomandibular joint disturbance syndrome sounds. Results suggested that the electromyograph shows various characteristics of dysfunction, when compared with the electromyograph of normal adults, that are significantly relevant to temporomandibular joint internal derangement, especially anterior disk displacement with reduction and without reduction. The mechanism of the sounds was further explained on the basis of the observation of this study. Summing up the data, the authors propose that the dysfunction of the superior head of the muscle is one cause of temporomandibular anterior disk displacement.