History of Arthrography

Utilization trends for MR arthrography of the hip and shoulder: a retrospective cross-sectional analysis of 20-year data from a tertiary care academic medical center

OBJECTIVE

The purpose of this study is to analyze changes in the utilization of MRA of the hip and shoulder at a large tertiary care academic medical center during a period of significant technological advancements over the last 20 years.

MATERIALS AND METHODS

This retrospective cross-sectional analysis identified MRA of the hip and shoulder performed at our institution over a 20-year period (2/2003-2/2023) in relation to the total number of MR hip and shoulder examinations during the same period. Patient characteristics and referring provider demographic information were extracted. Descriptive statistics and trend analysis were performed.

RESULTS

The total number of MRIs of the hip and shoulder increased overall, with small dips in 2020 and 2022. MRA of the hip increased significantly over the first 10 years of the study period (p = 0.0005), while MRA of the shoulder did not change significantly (p = 0.33). The proportion of both MRA of the hip and shoulder declined over the last 10 years (hip, p = 0.0056; shoulder, p = 0.0017). Over the same period, there was significant increase in the proportion of examinations performed at 3 Tesla versus 1.5 (p < 0.0001).

CONCLUSION

Overall, there was a downward trend in MR shoulder and hip arthrogram utilization in the second half of this 20-year study period. However, utilization varied somewhat by referring specialties and credentials. These changes are likely reflective of both improvements in image quality and evolving practice recommendations. Awareness of such trends may be valuable in ensuring appropriate patient care, as well as for anticipating the needs of a musculoskeletal radiology practice.

Frequency of technical success of ultrasound-guided arthrogram injections in children

BACKGROUND

MR arthrography is an essential diagnostic tool to assess and guide management of labral, ligamentous, fibrocartilaginous, and capsular abnormalities in children. While fluoroscopy is traditionally used for intra-articular contrast administration, ultrasound offers advantages of portability and lack of ionizing radiation exposure for both the patient and proceduralist.

OBJECTIVE

The purpose of this retrospective study is to quantify technical success and frequency of complications of ultrasound-guided arthrogram injections at our institution.

MATERIALS AND METHODS

This retrospective analysis investigates the results of 217 ultrasound-guided arthrograms of the shoulder, elbow, and hip in patients aged 5-18 years. Successful injection of contrast into the target joint, clinical indication for MR arthrography, and complications were reviewed.

RESULTS

Accurate ultrasound-guided intra-articular administration of contrast into the target joint was successful for 100% of shoulder cases (90/90), 97% of elbow cases (77/79), and 98% of hip cases (47/48). Leak of contrast outside the target joint occurred in 1.4% (3/217) of cases. No major side effects including excessive bleeding, paresthesia, allergic reactions, or infection occurred during or after the procedure. Additionally, no major vessel, nerve, or tendon complications were observed on MR images.

CONCLUSION

Ultrasound guidance is a reliable, effective, and safe approach to arthrography in children.

Trends in MR Arthrogram Utilization at a Tertiary Care Academic Center

The purpose is to evaluate the trends in MR arthrogram utilization at a tertiary care academic institution and to determine if there are factors that can be implicated in the utilization trends. Number of MR arthrograms of the shoulder, hip, and elbow from 2013-2020 at our institution were identified (n = 1882). Patient demographics including age, sex, sports participation, history of prior surgery, and physician referral were obtained. Descriptive statistics were performed to determine the prevalence of MR arthrograms. Linear regression analyses were performed to determine the relationship of time with prevalence of arthrograms. Chi-square tests and posthoc analyses with Bonferroni correction were used to assess if categorical variables were different between the years. There was overall decrease in the prevalence of MR arthrograms of the shoulder, hip, and elbow despite an increase in the overall MR volume during the study period. Linear regression models significantly predicated decrease in arthrogram prevalence with each passing year (P < 0.001). The percentage of orthopedic referrals for arthrograms in the hip (P = 0.002) and shoulder (P = < 0.001) decreased significantly towards the end of the study period. None of the other variables assessed were significant. At our tertiary care academic institution, arthrogram utilization has been drastically decreasing over the past 8 years. The percentage of orthopedic referrals for shoulder and hip arthrograms significantly decreased at the end of the study period.

Fluoroscopic-guided procedures of the lower extremity

This article reviews the literature and the authors' experiences regarding the performance of lower extremity fluoroscopically guided procedures from the hip to the toes. An overview of injections and aspirations, their indications, risks, and complications are provided, focusing on anesthetics, corticosteroids, and contrast agents. A variety of approaches to each joint and the associated pearls and pitfalls of each approach will be discussed.

Non-ionic CT contrast solutions rapidly alter bovine cartilage and meniscus mechanics

OBJECTIVE

To evaluate effects of a common CT contrast agent (iohexol) on the mechanical behaviors of cartilage and meniscus.

METHODS

Indentation responses of juvenile bovine cartilage and meniscus were monitored following exposure to undiluted contrast agent (100% CA), 50% CA/water, 50% CA/Phosphate Buffered Saline (PBS) or PBS alone, and during re-equilibration in PBS. The normalized peak force (Fpk¯), effective osmotic strain (εosm), and normalized effective contact modulus (Ec¯) were calculated for every cycle, with time constants determined for both exposure and recovery via mono- or biexponential fits to Fpk¯.

RESULTS

All cartilage CA groups exhibited long-term increases in Fpk¯ following exposure, although the hyperosmolal 100% CA and 50% CA/PBS groups showed an initial transient decrease. Meniscus presented opposing trends, with decreasing Fpk¯ for all CA groups. Re-equilibration in PBS for 1hr after exposure to 100% CA produced recovery to baseline Fpk¯ in cartilage but not in meniscus, and extended tests indicated that meniscus required ∼2.5 h to recover halfway. Ec¯ increased with CA exposure time for cartilage but decreased for meniscus, suggesting an increased effective stiffness for cartilage and decreased stiffness for meniscus. Long-term changes to εosm in both tissues were consistent with changes in Ec¯.

CONCLUSION

Exposure to iohexol solutions affected joint tissues differentially, with increased cartilage stiffness, likely relating to competing hyperosmotic and hypotonic interactions with tissue fixed charges, and decreased meniscus stiffness, likely dominated by hyperosmolarity. These altered tissue mechanics could allow non-physiological deformation during ambulatory weight-bearing, resulting in an increased risk of tissue or cell damage.

Evaluation of Gadolinium Deposition in the Brain After MR Arthrography

OBJECTIVE

Although significant investigation has been done into the deposition of gadolinium in the brains of patients receiving IV gadolinium, there is little research concerning nonintravenous uses of gadolinium, specifically in conjunction with musculoskeletal MR arthrography. Although small in volume, intraarticular administration is an off-label use of gadolinium, necessitating careful scrutiny for patient safety. Thus, we investigated the relationship between intraarticular gadolinium administration during MR arthrography and the presence of intracranial gadolinium deposition on subsequent brain MRI.

MATERIALS AND METHODS

An institutional review board-approved retrospective study was performed of patients with no history of gadolinium exposure who underwent MR arthrography from 2006 to 2016 followed by an unenhanced brain MRI examination. ROIs were manually placed within bilateral dentate nuclei (DN), bilateral globus pallidi (GP), bilateral thalami, bilateral middle cerebral peduncles (MCP), and the central pons (CP) on T1-weighted sequences. The left and right ROIs were averaged, and ratios of signal intensity were calculated for DN/MCP, DN/CP, GP/MCP, GP/CP, thalamus/MCP, and thalamus/CP. Similar ROIs were placed and ratios calculated for age-matched control subjects who had a history of brain MRI but no prior gadolinium exposure. We used t testing to compare signal intensity ratios between patients and control subjects.

RESULTS

A total of 31 patients met the inclusion criteria. We found no significant difference in signal intensity between patients and control subjects for DN/MCP (p = 0.40), DN/CP (p = 0.76), GP/MCP (p = 0.51), GP/CP (p = 0.86), thalamus/MCP (p = 0.93), and thalamus/CP (p = 0.30).

CONCLUSION

No association was found between intraarticular gadolinium administration for MR arthrography and detectable gadolinium deposition within the brain.

Visualisation of facet joint recesses of the cadaveric spine: a micro-CT and sheet plastination study

Objectives

The size and shape of a joint cavity are the key determinates for the mobility of the joint. The anatomy and configuration of the facet joint (FJ) recesses at different levels of the spine remain unclear and controversial. The aim of this study was to identify the configuration of the FJ recesses in the cervical, thoracic and lumbar spine using a combination of micro-CT and sheet plastination techniques.

Methods

Of 19 cadavers (9 males, 10 females, age range of 54–89 years), the FJ cavities of 3 spines were injected with contrast filling and scanned with micro-CT, and 16 plastinated spines were prepared as the series of sagittal (9 sets), transverse (5 sets) or coronal (2 sets) sections with a thickness of 2.5 mm and examined under a stereoscopic microscope.

Results

This study characterised the FJ spaces and recesses of the spine and found that (1) the configuration and extent of the FJ recesses varied along the spine. The optimal needle approach to the FJ cavity was via an anterolateral or posterolateral recess at the cervical level, along the tip of the inferior articular process at the thoracic level and via the posteromedial recess at the lumbar level. (2) The FJ cavity did not communicate with the retrodural space.

Conclusion

The anatomical features of the FJ recesses at different levels of the spine confirm no direct communication between the FJ cavity and retrodural space.

A practical guide for performing arthrography under fluoroscopic or ultrasound guidance

Abstract

We propose a practical approach for performing arthrography with fluoroscopic or ultrasound guidance. Different approaches to the principal joints of the upper limb (shoulder, elbow, wrist and fingers), lower limb (hip, knee, ankle and foot) as well as the facet joints of the spine are discussed and illustrated with numerous drawings. Whenever possible, we emphasise the concept of targeting articular recesses, which offers many advantages over traditional techniques aiming at the joint space.

Teaching Points

• Arthrography remains a foremost technique in musculoskeletal radiology

• Most joints can be successfully accessed by targeting the articular recess

• Targeting the recess offers several advantages over traditional approaches

• Ultrasound-guidance is now favoured over fluoroscopy and targeting the recess is equally applicable

Effect of SonoVue on the synovial membrane in rabbit knees

OBJECTIVES

The purpose of this study was to evaluate the effect of intra-articular injection of SonoVue (sulfur hexafluoride with a phospholipid shell; Bracco SpA, Milan, Italy) on the synovial membrane in an animal model.

METHODS

Twenty-one New Zealand White rabbits (42 knees) were used in this study. We injected the knees with normal saline (saline group; n = 21) and SonoVue (SonoVue group; n = 21). A histologic examination of the knees was performed out at 3 and 12 hours and 3, 7, 15, 30, and 45 days after injection. Four histologic parameters (synovial hyperplasia, synovial stroma, vascular dilatation, and inflammatory infiltrates) were graded separately.

RESULTS

We found no significant differences in this study for synovial hyperplasia, vascular dilatation, or inflammatory infiltrates between the saline and SonoVue groups. A significant difference was only observed for synovial stroma (P < .05), and most of the histologic changes were mild in the saline group and moderate in the SonoVue group. The histologic changes observed in this study are considered transitory and reversible.

CONCLUSIONS

The results suggest that intra-articular injection of SonoVue is a safe procedure.