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A lateral view of the knee in 90 degree flexion can reveal popliteal cysts which do not show on routine arthrography. Flexion causes transfer of intra-articular fluid to the posterior portion of the joint space, lowering pressure within the cyst and allowing it to fill with contrast media.
Temporomandibular joint arthrography has been helpful in selecting patients for reconstructive surgery who have severe temporomandibular joint dysfunction. Structural abnormalities of the soft tissues can be demonstrated where only minimal osseous changes are seen on tomography. The normal arthrographic anatomy of the joint is reviewed and normal and pathological joints are illustrated.
A reproducible technique which does not require special equipment for demonstrating the cruciate ligaments by double contrast arthrography is described. The positive contrast medium coats the synovial surfaces of the ligaments, i.e., the anterior aspect of the anterior cruciate ligament and the posterior aspect of the posterior cruciate ligaments. The ligaments appear lucent by this technique because they are delineated by a sharp positive contrast medium/lucent interface. The study is performed prior to the meniscal exam before medium absorption occurs.
The authors describe a simple technique for establishing satisfactory position of the needle in the shoulder joint for arthrography. Local anesthetic is placed in the hub of the spinal needle and is often drawn into the joint when the needle enters, causing a sudden drop in the fluid level.
Double-contrast arthrography using gravity provides more detail than single-contrast techniques. With gravity, air rises to the uppermost portion of the joint and the positive contrast material settles. The cartilagenous articular surfaces and the synovial lining of the elbow are coated with contrast material and highlighted by the intra-articular air. Cartilagenous intra-articular bodies can be identified and located and the size of cartilagenous encapsulated osseous bodies can be confirmed. This method is faster to perform and easier to interpret than single-contrast studies, exposes the patient less than a tomographic examination, and is helpful before surgical exploration.
Single and double contrast arthrographic techniques were compared in 951 patinets with suspected meniscal injuries. Exploratory surgery of the knee was performed in 384 of these patients and good clinical follow-up was obtained in 135 patients. In the latter two groups of patients, the single contrast technique was 97% accurate in assessing the medial meniscus and 96% accurate in assessing the lateral meniscus. Double contrast arthrography was 97% accurate in assessing the medial meniscus and 93% accurate in assessing the lateral meniscus. Numerical differences in the results from the two techniques were not statistically significant. Therefore both techniques can be considered equally effective diagnostically.
In small infants and children, the medial or adductor approach for arthrography of the hip has several advantages over direct anterior insertion of the needle into the joint capsule, primarily the fact that extravasated contrast material runs along the adductor area and is not superimposed on the hip joint.
Sustentacular-talar tarsal coalitions can be difficult to detect radiographically. The sustentacular-talar articulation is a part of the talocalcaneonavicular joint. Thus, arthrography of this joint, combined with tangential views of the sustentaculotalar articulation (Harris views), provides a new and simple method to detect or exclude talocalcaneal tarsal coalitions.
Magnetic resonance arthrography is superior to other imaging techniques in evaluation of the glenohumeral joint. Normal variants that can be diagnostic pitfalls include the anterosuperior sublabral foramen, the Buford complex, and hyaline cartilage under the labrum. Anteroinferior dislocation is the most frequent cause of anterior glenohumeral instability and produces a constellation of lesions (anteroinferior labral tear, classic and osseous Bankart lesions, Hill-Sachs lesion). Variants of anteroinferior labral tears include anterior labroligamentous periosteal sleeve avulsion and glenoid labral articular disruption. Anterior glenohumeral instability can also involve tears of the anterior or anterosuperior labrum or the glenohumeral ligaments. Posterior glenohumeral instability can involve a posterior labral tear, posterior capsular stripping or laxity; fracture, erosion, or sclerosis and ectopic ossification of the posterior glenoid fossa; reverse Hill-Sachs lesion; McLaughlin fracture; or posterosuperior glenoid impingement. Superior labral anterior and posterior lesions involve the superior labrum with varying degrees of biceps tendon involvement.
This article describes the technique for performance and interpretation of magnetic resonance arthrography of the hip. A description of normal anatomy of the hip is presented, and the appearance of the abnormal labrum is discussed. Labral detachments and tears are the most common clinically significant abnormalities to be identified. These abnormalities are recognized on the basis of the presence of contrast material at the acetabular-labral interface or within the substance of the labrum. Many varied appearances of the labrum have been identified within the asymptomatic population, and the correlation of these appearances is contrasted with those of the abnormal labrum in symptomatic patients. To date, it is difficult to draw conclusions regarding the significance of an absent labrum or of a sulcus at the acetabular-labral junction. Experience suggests that an absent labrum in a symptomatic individual is pathologic and that a sulcus at the anterosuperior acetabular-labral junction may be a normal variant.
A simple method of improving visualization of the posterior horn of the medial meniscus during fluoroscopic spot-filming in arthrography of the knee is described. Since it results in increased diagnostic accuracy at the most common site of occult pathology, the authors recommend that it be part of the routine examination.
A restraining device for arthrography of the knee, made from an automobile safety belt, is described. Contrary to usual practice, the authors place the strap below the knee joint. There is less tendency for the knee to flex when compared with placement above the knee, resulting in improved demonstration ot the meniscus.
The presence of particles in synovial fluid indicates an intra-articular abnormality and can lend support to a positive arthrographic diagnosis. These particles can be readily identified by gross examination at arthrography.
Facet joint arthrography was performed in 11 patients with lumbar spondylolysis. An abnormal communication between the two facet joints bordering the separated par interarticularis was observed in nine of these patients. This communication occurred through a channel in the area of the defect. In one patient with bilateral spondylolysis of the L5 vertebra, both left adjacent apophyseal joints were observed to communicate not only with one another, but also with the contralateral facet joints, through a transverse channel joining the isthmic areas of L5. Significant pain relief following intra-articular administration of anesthetics and corticosteroids was recorded in 5 patients, for periods lasting from 2 to 10 months. Spondylolysis considerably alters the soft tissues of the adjacent facet joints. Irritation of these structures might explain certain complaints of patients with spondylolysis.
Knee arthrography was performed on twenty-one patients with osseous and extraosseous masses about the knee. Twelve patients had arthrographic abnormalities. Joint involvement was accurately delineated in nine of the ten cases where it was present. Three other patients had small suprapatellar bursae with superior flattening, characteristic of noncommunicating suprapatellar synovial cysts. Fluoroscopic spot radiographs and conventional radiographs after injection of contrast material adequately defined the synovial recesses. Tomograms were needed whenever articular cartilage invasion was a possibility. The arthrographic findings were useful in planning the operative approach in all cases except for the one case where the arthrogram did not detect the intra-articular invasion.
Wrist arthrography is a valuable procedure for the identification of scapholunate or lunotriquetral ligament tears. The addition of sequential filming during the injection of contrast material permits the arthrographer to determine accurately the specific ligament which is ruptured.
Arthrography with fluoroscopic monitoring was used to assess the soft tissues of the wrist in 100 patients who had chronic traumatic pain but did not have rheumatoid arthritis. Findings were correlated with plain radiographs and the carpal instability series. Arthrograms were normal in 26% of cases and demonstrated perforation of the triangular fibrocartilage in 26%, radiocarpal-midcarpal communication in 30%, capsular lesions in 31%, lymphatic opacification in 12%, and tendon sheath filling in 10%. Communication between the radiocarpal and pisiform-triquetral compartments, a normal finding, was seen in 69%. There was a significant association between perforation of the triangular fibrocartilage and both ulna-plus variance and carpal instability.
A dynamic approach to evaluation of the temporomandibular joint is described. By combining videofluoroscopy with arthrography, the authors were able to demonstrate anterior displacement with capture by the condyle, anterior dislocation, perforation of the meniscus, and fibrosis. This technique provides clinical information about the position of the meniscus and its integrity with minimal patient discomfort.