MR arthrography of the ankle

Direct MR arthrography without image guidance: a practical guide, joint-by-joint

Direct MR arthrography (dMRA) is a fundamental technique in diagnosing pathology in major peripheral joints, allowing for precise evaluation of intra-articular structures. Although injection guidance is typically performed using imaging techniques such as ultrasound or fluoroscopy, puncture via anatomical landmarks may be useful in certain circumstances where it has been proven to be a safe and effective procedure. This paper describes the indications and injection technique of dMRA, joint by joint, focusing on the different technical details, from the most common locations, like the shoulder or hip, to those with more restricted clinical indications, such as the wrist, knee, elbow, or ankle. The most relevant anatomical landmarks are detailed for each joint, aiding in the intra-articular introduction of diluted contrast, highlighting the most accessible trajectories and structures to avoid when inserting the needle. Additionally, tips are provided to facilitate proper joint distension. With all this information, this paper aims to serve as a suitable reference guide for performing dMRA without image guidance if needed.

SSR white paper: guidelines for utilization and performance of direct MR arthrography

OBJECTIVE

Direct magnetic resonance arthrography (dMRA) is often considered the most accurate imaging modality for the evaluation of intra-articular structures, but utilization and performance vary widely without consensus. The purpose of this white paper is to develop consensus recommendations on behalf of the Society of Skeletal Radiology (SSR) based on published literature and expert opinion.

MATERIALS AND METHODS

The Standards and Guidelines Committee of the SSR identified guidelines for utilization and performance of dMRA as an important topic for study and invited all SSR members with expertise and interest to volunteer for the white paper panel. This panel was tasked with determining an outline, reviewing the relevant literature, preparing a written document summarizing the issues and controversies, and providing recommendations.

RESULTS

Twelve SSR members with expertise in dMRA formed the ad hoc white paper authorship committee. The published literature on dMRA was reviewed and summarized, focusing on clinical indications, technical considerations, safety, imaging protocols, complications, controversies, and gaps in knowledge. Recommendations for the utilization and performance of dMRA in the shoulder, elbow, wrist, hip, knee, and ankle/foot regions were developed in group consensus.

CONCLUSION

Although direct MR arthrography has been previously used for a wide variety of clinical indications, the authorship panel recommends more selective application of this minimally invasive procedure. At present, direct MR arthrography remains an important procedure in the armamentarium of the musculoskeletal radiologist and is especially valuable when conventional MRI is indeterminant or results are discrepant with clinical evaluation.

Anterolateral talar palpation: A complementary test for ankle instability

BACKGROUND

The anterior drawer test is traditionally used to assess ankle instability, but we believe that there is room for a small but effective improvement by adding digital palpation of the talus. We aimed to determine the accuracy of anterolateral talar palpation (ATP) in the diagnosis of ankle instability by comparing it with the traditional anterior drawer test.

METHODS

Fourteen symptomatic and 10 asymptomatic patients were examined for excessive mobility through comparison of both ankles by two blinded orthopedic surgeons, each one using one of the above-mentioned tests. Symptomatic patients were also referred for stress radiography and magnetic resonance imaging (MRI).

RESULTS

ATP was the most sensitive test, but also the least specific, yielding more positive results than the other tests, including tests with negative MRI. ATP and radiography had the highest accuracy and highest level of agreement with MRI.

CONCLUSIONS

ATP significantly improved diagnostic accuracy in detecting ankle instability.

LEVEL OF EVIDENCE

IV: cross-sectional study.

Imaging of impingement lesions in the ankle

Ankle impingement and instability are well-recognized complications of ankle sprain. Ankle impingement is an important cause of chronic ankle pain in active populations, particularly in the professional athlete. Depending on anatomical location and the structures involved, impingement syndromes are classified into anterolateral, anterior, posterior, posteromedial, and anteromedial types. Clinically, impingement syndromes are characterized by painful limitation of full-ankle movement. Ankle impingement results from repetitive subclinical trauma due to overuse injuries, which, in the subacute or chronic situation, lead to abnormal osseous and soft-tissue thickening within the ankle joint. Various imaging techniques can be used in the diagnosis of ankle impingement. Usually, radiography is the initial imaging technique performed to rule out bony trauma and identify potential anatomical bony abnormalities. Use of computed tomography and isotope bone scanning is largely superseded by magnetic resonance imaging, although with variable sensitivity and specificity. Arthrographic techniques, using computed tomography or magnetic resonance, are useful for exquisite demonstration of capsular recesses and synovial abnormalities. Imaging-guided injection techniques can be used in the management of impingement for pain ablation and to aid clinical diagnosis, especially in hind foot pain.

MR arthrography of the ankle: indications and technique

MR arthrography has become an important tool for the assessment of a variety of ankle disorders. MR arthrography permits more sensitive imaging of suspected intra-articular pathology in cases in which conventional MR imaging is either insufficient or inadequate for diagnosis or treatment planning. The main indications for MR arthrography are the evaluation of ligamentous injuries, impingement syndromes, cartilage lesions, osteochondral lesions of the talus, loose bodies, and several synovial joint disorders. Indirect MR arthrography can be a useful adjunct to conventional MR imaging and may be preferable to direct MR arthrography in those cases in which an invasive procedure is contraindicated or image guidance is not available.

Introduction to diagnostic musculoskeletal ultrasound: part 2: examination of the lower limb

This is the second of two articles focusing on ultrasound examination of musculoskeletal components of the upper and lower limbs. Treatment of musculoskeletal injuries is based on establishing an accurate diagnosis. No one would dispute that a good history and physical examination by a competent clinician can help achieve that in the majority of cases. However, musculoskeletal imaging is also an essential adjunct in the work-up of many musculoskeletal disorders. This article describes the ultrasound examination of the lower limb in terms of anatomic structure. Normal and pathologic ultrasound features of these structures, including muscles, tendons, ligaments, bursae, and other soft tissues of the lower limb, will be described by reviewing several representative pathologies commonly seen in musculoskeletal medicine.

Impingement syndromes of the ankle

Ankle impingement syndromes are categorised according to their anatomical site around the tibiotalar joint. Anterolateral, anterior and posterior ankle impingement has been extensively described in the orthopaedic and radiology literature with more recent studies describing posteromedial and anteromedial impingement. This article aims to demonstrate the potential spectrum of imaging findings for each ankle impingement syndrome as well as the relative contributions of ultrasound and MR imaging for diagnosis and image-guided treatment.

Técnica e indicaciones de la resonancia magnética artrografía. Extremidad inferior (II)

Magnetic resonance (MR) is the imaging technique of election in the evaluation of the articular pathology. MR arthrography (MRA) consists of the direct punction of the joint with intraarticular injection of diluted gadolinium or saline solution. MRA produces distention of the capsular recess, delineates the intraarticular structures and separates annexed structures of difficult evaluation, with which it is able to improve the reliability diagnoses of the articular and periarticular pathology. MRA allows to solve some of the diagnostic problems of conventional MR imaging in the evaluation of the articular pathology, avoiding to make unnecessary diagnostic arthroscopy and allowing a better therapeutic plan. In the greater joints of the inferior extremity (hip, knee and ankle) MRA has established indications standing out the evaluation of the injuries of the acetabular labrum of the hip, the operated meniscus of the knee and the study of the "impingement" syndromes of the ankle. This article reviews the present utility of the MRA in the hip, knee and ankle joints. The more relevant anatomical aspects, the technique and the applications are reviewed. Finally, the value of this technique in pathologies that can affect any joint of the organism such as osteochondral injuries, loose intraarticular bodies and synovial pathology is reviewed.

Chronic ankle instability: management of chronic lateral ligamentous dysfunction and the varus tibiotalar joint

Many techniques have been described in acute and chronic lateral ligament insufficiency in the ankle. At present, the Bostrom-Gould and Chrisman-Snook procedures and their variations remain the "gold standard". Recent assessment of important etiologic factors has shed some light on the relationship between the original injury or injuries and the subsequent development of the varus tibiotalar joint with or without secondary osteoarthritis. The development of Taylor Spatial Frame may well revolutionize its management. In the meantime, further consideration should be given to well-designed and evaluated randomized controlled trials, improved understanding of the biomechanics, and function of the ligaments, for example, proprioceptive function and their healing. Newer and less invasive arthroscopic and percutaneous techniques are being developed.

Magnetic resonance arthrography

For decades, fluoroscopic arthrography was the only method available to image a joint with contrast enhancement. Advances in CT led to the natural development of CT arthrography. Development of MRI and its capability for multiplanar imaging led to direct magnetic resonance arthrography (MRA). This technique has been performed since 1987 and has surpassed CT arthrography in popularity in the United States. Indirect MRA developed subsequently to offer a less invasive alternative. This article presents an overview of direct MRA and addresses joint-specific issues regarding direct MRA. An overview of indirect MRA also is provided.

An overview of MR arthrography with emphasis on the current technique and applicational hints and tips

Magnetic resonance (MR) arthrography has been investigated in every major peripheral joint of the body, and has been proven to be effective in determining the integrity of intraarticular ligamentous and fibrocartilaginous structures and in the detection or assessment of osteochondral lesions and loose bodies in selected cases. Several methods could be used to create arthrogram effect during MR imaging, however, direct MR arthrography using diluted gadolinium as the contrast agent is the most commonly used technique and is the most reliable of all. MR arthrography is useful for demonstrating labrocapsular-ligamentous abnormalities and distinguishing partial thickness rotator cuff tears from focal full thickness tears in the shoulder, identifying or excluding recurrent tears following meniscal operations in the knee, demonstrating perforations of the triangular fibrocartilage complex (TFCC) and ligaments in the wrist, showing labral tears in the hip, diagnosing ligament tears in the ankle and identifying osteochondral lesions or loose bodies in any of the aforementioned joints. In this article, an overview of techniques of MR arthrography is provided with emphasis on direct MR arthrography using diluted gadolinium as the contrast agent. The current applications of the technique in major peripheral joints are reviewed, with emphasis given to the shoulder joint where the role of this technique has become well established.

Ankle MR Arthrography: How, Why, When

MR arthrography has become an important tool for the assessment of a variety of ankle disorders. MR arthrography may facilitate the evaluation of patients with suspected intra-articular pathology in whom conventional MR imaging is not sufficient for an adequate diagnosis and be useful for therapy planning. MR arthrography is valuable in the evaluation of ligamentous injuries, impingement syndromes, cartilage lesions, osteochondral lesions of the talus, loose bodies, and several synovial joint disorders. Indirect MR arthrography is a useful adjunct to conventional MR imaging and may be preferable to direct MR arthrography in cases in which an invasive procedure is contraindicated or when fluoroscopy is not available.

Diagnostic and therapeutic injections of the foot and ankle

Directed injections of the foot and ankle performed under fluoroscopic guidance have both considerable diagnostic value and the potential for targeted therapy by accurately delivering corticosteroid and/or anesthetic to the source of pain. Both large and small joints in the foot and ankle are readily accessed, offering precise information to the foot and ankle surgeon who may be contemplating arthrodesis or other intervention. In addition to its role in pain management, ankle arthrography may be performed in conjunction with MRI or CT, with improved evaluation of articular cartilage and capsular abnormalities.

Diagnosis and Management of the Painful Ankle/Foot. Part 2: Examination, Interpretation, and Management

Diagnosis, interpretation, and subsequent management of ankle/foot pathology can be challenging to clinicians. A sensitive and specific physical examination is the strategy of choice for diagnosing selected ankle/foot injuries and additional diagnostic procedures, at considerable cost, may not provide additional information for clinical diagnosis and management. Because of a distal location in the sclerotome and the reduced convergence of afferent signals from this region to the dorsal horn of the spinal cord, pain reference patterns are low and the localization of symptoms is trustworthy. Effective management of the painful ankle/foot is closely linked to a tissue-specific clinical examination. The examination of the ankle/foot should include passive and resistive tests that provide information regarding movement limitations and pain provocation. Special tests can augment the findings from the examination, suggesting compromises in the structural and functional integrity of the ankle/foot complex. The weight bearing function of the ankle/foot compounds the clinician's diagnostic picture, as limits and pain provocation are frequently produced only when the patient attempts to function in weight bearing. As a consequence, clinicians should consider this feature by implementing numerous weightbearing components in the diagnosis and management of ankle/foot afflictions. Limits in passive motion can be classified as either capsular or non-capsular patterns. Conversely, patients can present with ankle/foot pain that demonstrates no limitation of motion. Bursitis, tendopathy, compression neuropathy, and instability can produce ankle/foot pain that is challenging to diagnose, especially when they are the consequence of functional weight bearing. Numerous non-surgical measures can be implemented in treating the painful ankle/foot, reserving surgical interventions for those patients who are resistant to conservative care.

Soft-tissue and osseous impingement syndromes of the ankle: role of imaging in diagnosis and management

Soft-tissue and osseous impingement syndromes of the ankle can be an important cause of chronic pain, particularly in the professional athlete. The main impingement syndromes are anterolateral, anterior, anteromedial, and posterior impingement. These conditions arise from initial ankle injuries, which, in the subacute or chronic situation, lead to development of abnormal osseous and soft-tissue thickening within the ankle joint. The relative contributions of the osseous and soft-tissue abnormalities are variable, but whatever component is dominant there is physical impingement and painful limitation of ankle movement. Conventional radiography is usually the first imaging technique performed and allows assessment of any potential bone abnormality, particularly in anterior and posterior impingement. Computed tomography (CT) and isotope bone scanning have been largely superseded by magnetic resonance (MR) imaging, but the accuracy and role of MR imaging in assessment of possible ankle impingement have not been clearly established. MR imaging can demonstrate osseous and soft-tissue edema in anterior or posterior impingement. Studies of conventional MR imaging have produced conflicting sensitivities and specificities in assessment of anterolateral impingement. CT and MR arthrographic techniques allow the most accurate assessment of the capsular recesses, albeit with important limitations in diagnosis of clinical impingement syndromes.

MR arthrography of the lower extremity

MR arthrography by virtue of its ability accurately to demonstrate intra-articular structures and abnormalities of these structures has become an important tool for the evaluation of a variety of articular disorders. Although not necessary in all patients, MR arthrography may facilitate the evaluation of patients with suspected intra-articular pathology in whom conventional MRI is not sufficient for an adequate therapy planning. MR arthrography combines the advantages of arthrography, like joint distention and delineation of intra-articular structures, with the superior spatial resolution of MRI. This technique improves diagnostic confidence, particularly in the assessment of subtle lesions and of complex anatomic structures. MR arthrography is of high value in the evaluation of osteochondral defects, loose bodies, previously operated menisci, and acetabular labral lesions.

Anterolateral ankle impingement: mr arthrographic assessment of the anterolateral recess

PURPOSE

To determine the accuracy of magnetic resonance (MR) arthrography in assessing the anterolateral recess of the ankle.

MATERIALS AND METHODS

Thirty-two patients with chronic ankle pain prospectively underwent gadolinium-enhanced MR arthrography of the tibiotalar joint. All underwent clinical examination and were included if anterolateral impingement (n = 13) or a control condition (n = 19; suspected osteochondral defect, intraarticular bodies, instability, osteoarthritis) was diagnosed. MR imaging included transverse and coronal T1-weighted and sagittal T2-weighted imaging sequences. Images were prospectively analyzed by two readers blinded to the clinical diagnosis. The anterolateral gutter contour was assessed. MR arthrographic findings were correlated with subsequent arthroscopic appearances.

RESULTS

MR arthrographic assessment of the anterolateral soft tissues had an accuracy of 97%, sensitivity of 96%, specificity of 100%, negative predictive value of 89%, and positive predictive value of 100%. Accuracy was 100% with clinical anterolateral impingement, with an arthroscopically confirmed abnormality in 12 cases and a normal appearance in one. Anterolateral soft-tissue thickening was identified at MR arthrography in 11 control cases, with arthroscopic confirmation in all. The remaining cases had normal appearances, with an arthroscopic soft-tissue abnormality in one case and a normal appearance in seven.

CONCLUSION

MR arthrography of the tibiotalar joint is accurate in assessing the anterolateral recess of the ankle.

Foot and ankle sonography

Sonography of the foot and ankle offers many advantages. Currently, sonographic evaluation rivals or exceeds MR imaging for evaluation of tendons, joint and bursal pathology, and specific soft tissue pathology. The advantages of sonographic evaluation provide a strong impetus for applying this modality to imaging of foot and ankle pathology. Those who accept the challenge will have an expanded repertoire to offer in the pursuit of efficient and effective patient care.