Arthrography

Arthrography of ligamentum teres tear

Arthrography, as the name suggests, is a way to visualize the joint using X rays.

Etiology of the term

Arhtro means joint, graphy means visualization Arthrography involves injection of a radiopaque contrast material into the joint spaces. The space occupied by the disk can then be visualized lying between the layers of contrast material.

History

Dr. Fleming Norgaard, in 1947 was the first to successfully use contrast arthrography. But it was in the 1970s that Wilkes and others introduced and popularaized the technique in the United States.

Uses of Arthrography

• Arthrography provides information regarding the soft tissue components, specifically the shape and position of the articular disk. It has been demonstrated that with the addition of tomography, the diagnosis of abnormalities in the position and shape of the disk is accurate.
• Fluoroscopic observation of the injection may reveal the presence of adhesions, perforations and discontinuities in the capsule and provides a dynamic study of disk movements, also any abnormal accumulation of joint fluid may be evident.
• Synovial fluid sampling (arthrocentesis) and lavage of the joint can accompany the procedure of arthrography.
• Arthrography assures a correct pre-operative diagnosis of loose bodies (joint mice).
• An arthrogram can clearly distinguish the synovial changes of an inflammatory arthritis from an internal derangement resulting from meniscal dysfunction.

Types of Arthrography

• Single contrast arthrography:

One of the more commonly used approaches involves injection of contrast material into the lower joint spaces, referred to as lower joint space or single contrast arthrography. Perforations of the disk or posterior attachment are demonstrated by contrast material simultaneously fl owing into the upper joint space as the lower space is injected. Another variation of the technique involves injecting contrast material into both the spaces and viewing the more central portions of the joint with tomography. Because contrast material is in both joint spaces, the outline of the disk is profi led, showing its configuration and position

• Double contrast arthrography:

This technique involves injecting a small amount of air along with a small amount of contrast material into both joint spaces, producing a thin coat around the periphery of both joint spaces that highlights the disk and the joint spaces.

How is the procedure performed?

• The patient is placed on the fluoroscopic table in a lateral recumbent position with the head tilted on the tabletop. This allows the joint to project over the skull above the facial bones in a manner similar to a transcranial radiograph.
• Under fluoroscopic guidance the posterosuperior aspect of the mandibular condyle is identified with a metal marker. This area is marked with an indelible pen. Local anesthetic lidocaine is infiltrated into the superficial skin.
• A 0.75- or 1-inch scalp vein needle and the attached tubing is filled with contrast material and care is taken to eliminate air bubbles. Air bubbles may simulate bodies within the joint space.
• In a direction perpendicular to the skin and X-ray beam, the 23-gauge needle is introduced in a predetermined region of the condyle with the jaw in the closed position. Advancement of the needle is done under fluoroscopic observation to ensure proper positioning.
• When the condyle is encountered, the patient is instructed to open the jaw very slightly, and the needle is guided by the feel of the posterior slope of the bony condylar margin. On fluoroscopic observation, the needle will appear contiguous with the posterior condylar outline.
• Approximately 0.4–0.5 ml of contrast material is injected into the lower joint compartment under fluoroscopic guidance. If the contrast is successfully placed into the lower joint space, the opaque material will be seen flowing freely anterior to the condyle in the anterior recess of the lower joint compartment.
• The needle is then withdrawn and fluoroscopic videotape images are recorded during opening and closing maneuvers of the jaws. Spot radiographs are obtained during the fluoroscopic procedure.

Limitations

• Direct medial or lateral displacements are difficult to interpret with arthrography.
• Cannot be used when the disk is severely deformed.

Complications

• The rare serious complications associated with arthrography include joint sepsis, allergic reaction to the iodinated contrast medium and hemarthrosis.
• Pain during and after the procedure, extravasation of the contrast medium, disk perforation and transient facial paralysis are less serious complications of arthrography.
• The radiation exposure to the patient can be significant, depending on the duration of fluoroscopy and the number of tomographic exposures made.
• The most frequent complication of the technique is the extravasation of contrast medium into the capsule and soft tissues around the joint, causing pain. Nonionic contrast media will be the agents of choice to minimize this discomfort.
• Parotitis has been reported following arthrography with large needles and cannulas.
• Some patients experience a vagal reaction, as a result of increased anxiety during the procedure, this can be managed by administering 0.6 mg of atropine intravenously.
• Intravasation of contrast material infrequently occurs. Epinephrine in a dose of 0.03 ml (1:1000) per 3 ml of contrast material is recommended because there is a risk of an acute hypotensive episode with intravasation of higher doses.
• Transient facial paralysis may result from a rapid infiltration of lidocaine. Some patients experience a moderate degree of pain as the needle is placed on the periosteum of the condyle and as the joint is distended with contrast material. This discomfort is transient in a majority of cases. If persistent joint pain occurs following the procedure, aspirin or acetaminophen and cold compress application to the affected side is recommended.

External links

• Detailed instructions

Arthrography Resources
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