What Is the Diagnostic Accuracy of Flat-panel Cone-beam CT Arthrography for Diagnosis of Scapholunate Ligament Tears?

BACKGROUND

Cone beam CT (CBCT) is a widely available technique with possible indications in carpal ligament injuries. The accuracy of CBCT arthrography in diagnosing traumatic tears of the scapholunate ligament has not been reported.

QUESTIONS/PURPOSES

(1) What is the diagnostic accuracy of CBCT and how does it relate to the accuracy of multislice CT arthrography and conventional arthrography in diagnosing scapholunate ligament tears? (2) What is the estimated magnitude of skin radiation doses of each method?

METHODS

This secondary analysis of a previous prospective study included 71 men and women with suspected scapholunate ligament tears and indications for arthroscopy. Preoperative imaging was conventional arthrography and either MSCT arthrography for the first half of patients to be included (n = 36) or flat-panel CBCT arthrography for the remaining patients (n = 35). Index tests identified therapy-relevant SLL tears with dorsal or complete SLL ruptures, and these tears were compared with relevant SLL tears which were determined through arthroscopy as Geissler Stadium III and IV by probing the instable SL joint with a microhook or arthroscope. These injuries were treated by open ligament repair and Kirschner wire fixation. Accuracy values and 95% confidence intervals were calculated. Additional estimates of the radiation skin doses of each CBCT exam and two MSCT protocols were subsequently calculated using dose area products, dose length products, and CT dose indices.

RESULTS

The diagnostic accuracy was high for all imaging methods. 95% CIs were broadly overlapping and therefore did not indicate differences between the diagnostic groups: Sensitivity of CBCT arthrography was 100% (95% CI 77 to 100), specificity was 95% (95% CI 76 to 99.9), positive predictive value was 93% (95% CI 68 to 99.8), and negative predictive value was 100% (95% CI 83 to 100). For MSCT arthrography, the sensitivity was 92% (95% CI 64 to 99.8), specificity was 96% (95% CI 78 to 99.9), positive predictive value was 92% (95% CI 64 to 99.8), and negative predictive value was 96% (95% CI 78 to 99.9). For conventional arthrography, the sensitivity was comparably high: 96% (95% CI 81 to 99.9). Specificity was (81% [95% CI 67 to 92]); the positive predictive value was 77% (95% CI 59 to 89) and negative predictive value was 97% (95% CI 86 to 99.9). Estimated mean (range) radiation skin doses were reported in a descriptive fashion and were 12.9 mSv (4.5 to 24.9) for conventional arthrography, and 3.2 mSv (2.0 to 4.8) for CBCT arthrography. Estimated radiation skin doses were 0.2 mSv and 12 mSv for MSCT arthrography, depending on the protocol.

CONCLUSION

Flat-panel CBCT arthrography can be recommended as an accurate technique to diagnose scapholunate ligament injuries after wrist trauma. Estimated skin doses are low for CBCT arthrography and adapted MSCT arthrography protocols.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Predictors of Pain and Discomfort Associated with CT Arthrography of the Shoulder

RATIONALE AND OBJECTIVES

The objective of this study was to investigate predictors of pain associated with computed tomographic arthrography of the shoulder.

MATERIALS AND METHODS

Before shoulder arthrography, all participants were assessed with the Hospital Anxiety and Depression Scale (HADS) and the World Health Organization Quality of Life Short Version Instrument (WHOQOL-BREF). The participants were nonrandomized into two groups: the anesthesia group, who underwent prior local infiltration anesthesia before shoulder arthrography, and the nonanesthesia group, who did not undergo prior local infiltration anesthesia. The pain levels at intraprocedure, at 1, 2, 6, and 12 hours, and at 1 and 2 days after injection were assessed by using a visual analog scale. Univariate and multivariate generalized linear model analyses were conducted.

RESULTS

Sixty participants in the anesthesia group and 60 participants in the nonanesthesia group were included. The pain level at intraprocedure (3.37 ± 1.94 in the anesthesia group and 3.20 ± 1.34 in the nonanesthesia group) was the highest of the whole pain course. The psychological domain (P = .0013) of WHOQOL-BREF, gender (P = .042), body mass index (P = .0001), and the total number of reinsertion and redirection of needle (P< .0001) were independent predictors of arthrography-related pain.

CONCLUSIONS

The pain associated with shoulder computed tomographic arthrography depends on the psychological domain of WHOQOL-BREF, gender, body mass index, and the total number of reinsertion and redirection of needle.

Glenohumeral joint sepsis after magnetic resonance imaging arthrogram

A 65-year-old patient presented with right shoulder pain that had increased in severity over the preceding 2 days. The pain began after the patient had a gadolinium arthrogram for magnetic resonance imaging for rotator cuff evaluation. Examination and laboratory test findings were consistent with a septic glenohumeral joint and emergent arthroscopic irrigation and debridement were performed. Streptococcus sanguinis was isolated from the intraoperative culture, and the infection resolved after a course of antibiotics.

Cauda equina compression post lumbar discography

Discography is used as an aid in the diagnosis of back pain related to intervertebral disc pathology. It involves attempting to elicit the patient's pain symptoms by injecting contrast into the suspected pathological disc. The overall complication rate of discography is low, with discitis being the most common complication and acute disc herniation post lumbar discography being reported in a small number of cases. We describe the case of a patient who developed cauda equina compression post lumbar discography.

Cerebral air embolism after arthrography of the ankle

BACKGROUND

The accidental migration of air from the venous circulation into the systemic arterial circulation is called paradoxical air embolism. This is a potential disastrous complication after diagnostic and surgical procedures. Arthrography has been a useful technique in joint imaging for the past decades. Paradoxical cerebral air embolism is a very rare complication, only a few cases have been reported after arthrography of the hip in children. Here, we describe a patient with progressive encephalopathy after computer tomography (CT) arthrography of the ankle.

CASE REPORT

We describe a 64-year-old male who underwent CT-arthrography of the left ankle, after the intra-articular injection of 20 ml of air he experienced progressive neurologic and hemodynamic deterioration. A brain CT showed a small amount of air in a right frontal sulcus. Hyperbaric oxygen therapy (HBO) was initiated after a delay of 16 hours and resulted in a complete recovery. A transesophageal echocardiography confirmed the presence of a right-left shunt.

CONCLUSIONS

This case of paradoxical air embolism with severe neurological manifestations after arthrography of the ankle, emphasizes that air embolism should be considered in all patients with neurologic and/or hemodynamic deterioration after the injection of intra articular air. Furthermore a delay of more then 6 hours is no reason to withhold HBO in these patients.

Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial

BACKGROUND

Hydrodilatation of the glenohumeral joint is by several authors reported to improve shoulder pain and range of motion for patients with adhesive capsulitis. Procedures described often involve the injection of corticosteroids, to which the reported treatment effects may be attributed. Any important contribution arising from the hydrodilatation procedure itself remains to be demonstrated.

METHODS

In this randomized trial, a hydrodilatation procedure including corticosteroids was compared with the injection of corticosteroids without dilatation. Patients were given three injections with two-week intervals, and all injections were given under fluoroscopic guidance. Outcome measures were the Shoulder Pain and Disability Index (SPADI) and measures of active and passive range of motion. Seventy-six patients were included and groups were compared six weeks after treatment. The study was designed as an open trial.

RESULTS

The groups showed a rather similar degree of improvement from baseline. According to a multiple regression analysis, the effect of dilatation was a mean improvement of 3 points (confidence interval: -5 to 11) on the SPADI 0-100 scale. T-tests did not demonstrate any significant between-group differences in range of motion.

CONCLUSION

This study did not identify any important treatment effects resulting from three hydrodilatations that included steroid compared with three steroid injections alone.

TRIAL REGISTRATION

The study is registered in Current Controlled Trials with the registration number ISRCTN90567697.

Technical errors in MR arthrography

This article discusses potential technical problems of MR arthrography. It starts with contraindications, followed by problems relating to injection technique, contrast material and MR imaging technique. For some of the aspects discussed, there is only little published evidence. Therefore, the article is based on the personal experience of the author and on local standards of procedures. Such standards, as well as medico-legal considerations, may vary from country to country. Contraindications for MR arthrography include pre-existing infection, reflex sympathetic dystrophy and possibly bleeding disorders, avascular necrosis and known allergy to contrast media. Errors in injection technique may lead to extra-articular collection of contrast agent or to contrast agent leaking from the joint space, which may cause diagnostic difficulties. Incorrect concentrations of contrast material influence image quality and may also lead to non-diagnostic examinations. Errors relating to MR imaging include delays between injection and imaging and inadequate choice of sequences. Potential solutions to the various possible errors are presented.

Psychophysical measurements during lumbar discography: a heart rate response study

STUDY DESIGN

Prospective clinical data analysis.

OBJECTIVE

To determine if heart rate (HR) response correlates with positive discography results.

SUMMARY OF BACKGROUND DATA

Lumbar discography is a controversial tool for the diagnosis of discogenic low back pain. The subjective nature of discography can make data interpretation difficult, leading to false-positive and false-negative results. HR changes have been found in numerous studies to be a reliable and valid indicator of acute pain. To date, there is no study analyzing the HR response to discography-induced pain.

METHODS

The HR measurements were recorded immediately preceding and after contrast injection into the each disc, and statistically correlated with the provocation of concordant pain, nonconcordant pain, and nonpainful discs.

RESULTS

Discography was performed in 26 subjects with low back pain. Among 75 discograms, 26 discs elicited concordant pain, 9 provoked nonconcordant pain, and 40 elicited no pain response. There was no significant change in HR during disc stimulation for negative [no pain response (P=0.19) and nonconcordant (P=0.26)] discograms, whereas positive discograms [concordant pain (numerical rating scale> or =6/10)] were associated with a statistically significant increase in HR (P=0.000002).

CONCLUSIONS

Lumbar discography induces positive HR response only in positive discograms. Although there is no immediate practical application of these results, 2 implications may deserve future research: (a) correlation of HR response with surgical and intradiscal electrotherapy treatment outcomes; (b) evaluation of HR measurement in cases of false-positive results (concordant pain on discography but no HR response).

Is subcutaneous local anesthesia in shoulder magnetic resonance arthrography necessary?

BACKGROUND

Magnetic resonance arthrography is a well-established diagnostic method in degenerative and traumatic disorders of the shoulder. Some radiologists prefer to apply a local anesthetic to the skin prior to performing the joint puncture. However, no information regarding the efficacy of local anesthetics exists.

PURPOSE

To assess patient discomfort in arthrography injection.

MATERIAL AND METHODS

A patient survey (n = 74) utilizing a visual analog scale (VAS) measured the intensity of pain in arthrography injection by those receiving local anesthetics (n = 36) versus those who did not (n = 38).

RESULTS

Mean VAS scores were 20.8 (median 10.5, SD 24.3) for those receiving local anesthetics versus 19.3 (median 13.0, SD 20.7) for those who did not (P = 0.83, Mann-Whitney U test).

CONCLUSION

Routine use of local anesthesia of the skin in arthrography injection is unnecessary.

Near-fatal air embolus during arthrography of the hip in a baby aged four months

We describe a near-fatal event, probably due to air embolism, following an air arthrogram for developmental hip dysplasia in a baby aged four months. The sequence of events and the subsequent treatment are described. There is little information about this complication in the literature. The presumed mechanism and alternative methods for confirmation of placement of the needle are discussed. We no longer use air arthrography in children.

Contrast reaction from hip arthrogram

Arthrography is considered a safe procedure with rare reactions to intra-articular contrast administration. Although the use of intra-articular contrast carries a small risk of reaction, no prior serious complications had been encountered in our experience with arthrography. We report a patient's prolonged reaction to contrast media after an arthrogram of the hip. Literature review demonstrated no prior report of contrast media reactions to hip arthrography. Therefore, we decided to review the literature and report our case.

Adhesive capsulitis of the shoulder: the rate of manipulation following distension arthrogram

To determine the rate of manipulation under anaesthesia (MUA) following distension arthrogram for adhesive capsulitis of the shoulder. Thirty-nine patients (42 shoulders) between 1998 and 2004 were treated with distension arthrogram for adhesive capsulitis diagnosed by the clinical picture of progressive pain and stiffness. Capsular disruption into the subscapular bursa was demonstrated in 40 of the 42 shoulders (95%). Thirty-seven of 42 (88%) shoulders were painfree following distension arthrogram. 15 of 42 (36%) shoulders underwent MUA following distension arthrogram for stiffness although 10 of these (67%) were painfree. Prior to distension arthrogram, the range of external rotation (ER) was no different between those that had MUA and those that did not (P = 0.36). The improvement in ER was 33% (P = 0.28) in those that had MUA and 50% (P = 0.001) in those that did not. The only complication was a vasovagal episode during the procedure. Distension arthrogram can be used as a therapeutic procedure for achieving symptomatic pain relief in the majority of adhesive capsulitis and decrease the rate of MUA of the shoulder.

Discography-induced acute lumbar disc herniation: a report of five cases

The reported complication rate of provocative lumbar discography is low, ranging from 0-2.5%. We report five cases of acute lumbar disc herniation precipitated by discography, a previously unreported complication. The cases reported comprise of four men and one woman with ages ranging from 23-45 years. All developed an acute exacerbation of radicular leg pain following multilevel provocative lumbar discography. One patient developed an acute foot drop. Comparison of lumbar MRI scans before and after discography demonstrated either a new herniated disc fragment or an increase in size of a preexisting herniation in all cases. On review of each discogram study and pre-discogram MRI an annular tear or small disc herniation was noted in all cases. In each case the patients' symptoms failed to resolve necessitating surgical intervention in all cases. In conclusion, annular deficiency is an obvious predisposing factor to discogram related disc herniation. New onset or a persistent exacerbation of radicular symptoms following provocative discography merits further investigation.

Does the procedure of arthrography affect the range of movement in patients with locking of the temporomandibular joint?

The aim of this study was to investigate whether arthrography itself altered the range of mandibular movements, in a group of patients with locking of the temporomandibular joint (TMJ). The clinical records of a series of 161 patients who were diagnosed with locking of the TMJ were retrospectively analysed. Mouth opening had improved in 57 out of 161 patients (35%). Twenty-three patients (14%) had improved by 5 mm or less. Nineteen patients (11%) had improved by more than 5 mm but less than 10 mm, whereas 15 patients (9%) had improved by more than 10 mm. Of the patients who experienced an improved mouth opening, only nine (15%) had improved from their pre-arthrography restricted maximum opening to beyond the lower limit of normal. This suggests that the injection of contrast medium had an effect on the range of vertical opening in patients with displacement of the disc without reduction.

Suspected case of venous air embolism in an infant undergoing hip arthrogram

An otherwise well ten-week-old girl underwent an air contrast hip arthrogram and application of a hip spica for a developmentally dislocated hip. The child displayed signs consistent with venous air embolism after injection of 5 ml of air into the hip joint. These signs included a decrease in arterial haemoglobin oxygen saturation as measured by pulse oximetry, decreased end-tidal carbon dioxide level and tachycardia. The signs initially resolved, but the patient deteriorated with injection of a further 5 ml of air. The patient responded to cessation of injection and resuscitative measures. The infant remained well postoperatively. The need for the use of air to confirm intra-articular placement of the needle prior to injection of contrast during a hip arthrogram is questioned.

Venous air embolus during arthrography in a child: vital signs changes illustrated by the automated data recording system

We describe an 18-month-old boy who suffered venous air embolism during an arthrogram. Dangers associated with air injection are emphasized, illustrating the importance of careful monitoring to detect adverse events. We recommend caution when employing this method of hip joint evaluation.

Evaluation of the risk factors of avascular necrosis of the femoral head in developmental dysplasia of the hip in infants younger than 18 months of age

Sixty-seven dysplastic hips of 54 infants with an average age of 11.9 months were treated by the same surgical technique, including iliopsoas and adductor tenotomies via medial approach and arthrography for verification of the concentric reduction. The average follow-up period was 44.5 months. The rate of overall avascular necrosis (AVN) was 27% and that of severe AVN was 7%. With the numbers available in the study, a statistically significant relationship could not be found between the rate and severity of AVN and several preoperative and intraoperative components such as age, sex, side, dislocation grade, development of the ossific nucleus and qualitv of intraoperative reduction. Nevertheless, hips of infants treated between 13 months and 15 months of age, hips of male patients and left hips had slightly higher ratios of ischemic changes that were not statistically significant.

Patient's assessment of discomfort during MR arthrography of the shoulder

PURPOSE

To assess patient discomfort during (a) intraarticular contrast material injection (arthrography) and (b) magnetic resonance (MR) imaging in patients referred for MR arthrography of the shoulder and to compare the relative discomfort associated with each part of the examination.

MATERIALS AND METHODS

With use of a visual analogue scale (VAS) and relative ratings, 202 consecutive patients referred for MR arthrography of the shoulder rated the expected discomfort and that actually experienced during both arthrography and MR imaging. The Student t test was used for statistical analysis.

RESULTS

The average VAS score (0 = "did not feel anything," 100 = "unbearable") was 16.1 +/- 16.4 (SD) for arthrography and 20.2 +/- 25.0 for MR imaging. This difference was statistically significant (P =.036, paired t test). The discomfort experienced during arthrography was as expected in 90 (44.6%) patients, less than expected in 110 (54.4%), and worse than expected in two (1.0%). MR imaging-related discomfort was as expected in 114 (56.4%) patients, less than expected in 66 (32.7%), and worse in 22 (10.9%). Arthrography was rated worse than MR imaging by 53 (26.2%) patients, equal to MR imaging by 69 (34.2%), and less uncomfortable than MR imaging by 80 (39.6%).

CONCLUSION

Arthrography-related discomfort was well tolerated, often less severe than anticipated, and rated less severe than MR imaging-related discomfort.

The course of radiologic damage during the first six years of rheumatoid arthritis

OBJECTIVE

To describe the radiologic course in a large cohort of patients with early rheumatoid arthritis (RA) and to analyze individual components of damage.

METHODS

Five hundred two patients with recent-onset RA (disease duration <1 year) underwent annual radiologic assessment for a maximum of 6 years in this longitudinal prospective study. The study was designed to investigate the efficacy of 3 different therapeutic strategies. For the assessment of radiologic damage, radiographs of the hands and feet were scored according to the modified Sharp/van der Heijde method (SHS; range 0-448). A mean of 2.9 (range 1-7) radiographs was read per patient.

RESULTS

Stable rates of progression of the SHS, erosion score, and narrowing score were found over the course of RA: the mean rates were 8.6, 5.4, and 3.2 modified Sharp units per year, respectively. The rate of progression of newly (not previously) damaged joints declined, and the rate of progression of already damaged joints (which became more damaged) increased during followup, leading to an equal contribution to progression of the SHS at 5 years. The joints of the feet, especially the fifth metatarsophalangeal joint, generally became eroded earlier and more of them became eroded compared with the joints of the hands.

CONCLUSION

Radiologic damage progresses at a constant rate. In advanced disease, monitoring the progression of previously existing damage is as important as assessing new abnormalities in previously undamaged joints. Radiographs of the feet should be included in assessments of radiologic damage that are used in clinical intervention trials and daily practice.

Internal derangement of the temporomandibular joint: correlation of arthrographic imaging with surgical findings

Sixty-seven patients, who were surgically treated for internal derangement of the temporomandibular joint (TMJ), were retrospectively examined. The patients were evaluated preoperatively by clinical and arthrographic examinations and these results were compared with findings at surgery. Partial or complete dislocation of the disc was detected by arthrographic examination in 65 joints. Actual disc displacement was demonstrated at surgery in 57 TMJs, giving arthrography a positive predictive value of 88% for detecting disc dislocation. Arthrographic diagnosis of disc perforation was unreliable, as both false positive and false negative observations were recorded. Arthrography was found to have a positive predictive value of only 53% for assessing disc perforation. Based upon its proven inaccuracy, invasiveness and discomfort to the patient, it is recommended to replace arthrography by magnetic resonance imaging.

Synovial fluid cavitation during distraction radiography of the coxofemoral joint in dogs

OBJECTIVE

To determine risk factors for, and prevalence and short- and long-term effects of synovial fluid cavitation during distraction radiography.

DESIGN

Multicenter prevalence survey.

ANIMALS

6,649 purebred dogs comprising 129 breeds.

PROCEDURE

Radiographs from the PennHIP (University of Pennsylvania Hip Improvement Program) Laboratory were subjectively evaluated for evidence of cavitation. Multiple logistic regression was used to determine whether sex, breed, age, weight, distraction index (DI), or examining veterinarian was associated with cavitation. Short-term effects of cavitation were assessed by comparing DI for the hip with cavitation with DI for the contralateral hip in dogs with unilateral cavitation. Long-term effects of cavitation were assessed by comparing DI before and after cavitation was detected.

RESULTS

Cavitation was detected in 279 (4.2%) of the radiographs analyzed. Male dogs, Golden Retrievers, and heavier dogs were at a decreased risk for cavitation. Irish Wolfhounds, Irish Setters, Rhodesian Ridgebacks, and Weimaraners had an increased risk for cavitation. Age and DI were not risk factors for cavitation. Mean DI was 0.08 greater in hips with cavitation than in paired hips without cavitation. Significant differences were not detected between DI before and after cavitation, but only 7 dogs were included in this analysis.

CLINICAL IMPLICATIONS

Cavitation is rare during distraction radiography and can increase measured DI. Radiographs should be routinely examined to ensure accurate reporting of DI.

[A comparison of NMR tomography and arthrography in functional disorders of the temporomandibular joint]

PATIENTS AND METHODS

31 patients with clinically diagnosed dysfunction of the temporomandibular joint (TMJ) were examined by magnetic resonance imaging (MRI; 1.5 Tesla, TR/TE 600/30) in closed and open mouth position and functional arthrography with digital image recording.

RESULTS

Both methods agreed in the evaluation of the disc position. In 23 joints with displaced disc reposition was found in 11 cases and in 14 cases using MRI or arthrography, respectively. MRI proved to be superior in the diagnosis of sideways disc rotations. Joint hypermobility, eccentric disc displacement (n = 4) and perforation (n = 3) were shown by functional arthrography. Due to the good demonstration of osseous, muscular and discoligamentous structures, MRI as a noninvasive imaging modality is the method of choice for TMJ evaluation. Arthrography can be advantageous in complex functional disturbances or if MRI and clinical findings are inconclusive. The clinical diagnosis of disc displacement was found to be accurate in only 68% of the cases.

The outcome of arthritis: measures of function, X-rays damage, pain and patients' satisfaction

The outcome of arthritis has several dimensions. These include mortality, morbidity, radiological measures of joint destruction, pain, and patients' satisfaction with therapy. Functional disability measured by health status questionnaires, is directly associated with long-term outcome and mortality. Long term clinical trials should incorporate functional indices as outcome measures. Studies measuring the outcome of arthritis should define clear end-points involving the determination of functional classes and this will allow standardised and sensitive end points. An example would be the time taken to reach a given functional class or increase from baseline by one functional class. Patients' satisfaction with treatment is a different dimension of response. There are considerable advantages in using an index of patients' satisfaction when determining the therapeutic efficacy in short term clinical trials. It gives a different indication of the response to treatment than conventional clinical and laboratory measures of disease activity. Alleviating pain and preservation of function remain the major therapeutic goals, and both reflect the outcome of arthritis. Outcome measures have shifted from laboratory markers and radiographic techniques to measures of health status, pain, and patients' satisfaction. These should become a routine part of patient assessment.

Venous air embolism during knee arthrography. A case report

A 34-year-old man developed a nonfatal venous air embolism during arthrography of his post-traumatically contractured knee joint. From the arthrographic findings, injected air was assumed to have entered the great saphenous vein via the venous opening in the knee joint. Venous air embolism is an extremely rare complication of knee arthrography, but can occur. As it is potentially fatal, prompt recognition and appropriate positional and supportive therapy are essential.

How invasive is TMJ double-contrast arthrography in combination with cinematography? Patient discomfort versus known diagnostic gain

There is no doubt that double-contrast TMJ fluoroscopic tomography enables a differential diagnosis and treatment in internal derangement pathosis. Its indication is, apart from the expected diagnostic gain, also determined by the degree of its invasiveness, and other alternative diagnostics being available (nuclear magnetic resonance). Data on patient discomfort and complications were gathered in 63 arthrotomographies; pain sensations and mandibular mobility, during and after the procedure in particular, were studied. We consider, along with Westesson, the procedure to be less invasive than commonly considered, once the surgeon-radiologist has gained enough experience.

Transient photopenia of the femoral head following arthrography

In cases of suspected sepsis of the hip, a negative arthrocentesis may precede bone scintigraphy. Routine instillation of contrast material and air for localization and characterization of the hip joint was observed to produce a transient photopenic femoral head on bone scintigraphy. The photopenia, related to venous tamponade created by the temporarily increased intra-articular pressure of the arthrogram, occurs when the isotopic study is performed within a half hour of the arthrocentesis. The cases of four children suspected of having septic arthritis and/or osteomyelitis and ranging in age from 2 to 19 years are presented to illustrate the temporal relationship of reversible femoral head photopenia with sequential arthrocentesis and bone scintigraphy.

Temporomandibular joint arthrography: a comparison between a fluoroscopic and a nonfluoroscopic technique

A nonfluoroscopic temporomandibular joint arthrographic technique is contrasted with a more widely employed fluoroscopically guided technique. The nonfluoroscopic technique uses a posterior approach to joint injection, as contrasted with the lateral injection approach of the fluoroscopically guided technique. The advantages of the nonfluoroscopic technique are less radiation dose to the patient, less expensive and less sophisticated imaging equipment, and less potential for neurovascular trauma. The fluoroscopic technique offers greater control of the procedure, less patient and operator time, and the capability for a dynamic videofluoroscopic study. Both techniques appear to be safe and efficacious. Differences in anatomy, imaging modalities, patient radiation exposure, and potential complications are also discussed as part of this comparison.

[Prostaglandin E2 liberation in the synovial fluid induced by organo-iodinated contrast media. Interrelations with the genesis of post-arthrographic pain]

RCM have been observed to cause--during arthrography--the appearance of a slow onset painful symptomatology with the clinical characteristics of a slight and transient acute arthritis. These substances are supposed to set in a production of humoral mediators of inflammation with algogenic action--PGE2 in particular. During arthrography of the knee the release of synovial fluid PGE2 after RCM introduction was studied. Two RCM were compared: meglumine iothalamate and iopamidol. Twenty patients underwent arthrography of the knee: synovial fluid PGE2 concentration was measured both before and 15' after RCM introduction with 125I-RIA method. Results show a significant increase in PGE2 concentration after both iothalamate (p less than 0.0001) and iopamidol (p less than 0.01) --especially in iothalamate--treated patients (p less than 0.01). A physiopathologic mechanism about post-arthrographic pain and, more generally, about RCM toxicity is thus hypothesized.

Morbidity associated with temporomandibular joint arthrography in clinically normal joints

To document the short- and long-term morbidity of arthrograms done on clinically normal temporomandibular joints, 62 arthrograms were performed on 31 asymptomatic volunteers. All subjects kept a record of any joint pain they experienced during the next five days and were examined by one of the authors at five days and again at two months. Maximum interincisal opening distance was recorded before the arthrogram and at both postarthrographic evaluations. No subjects complained of severe (grade 3) joint pain. Sixteen joints were recorded as moderately painful (grade 2), 32 as mildly painful (grade 1), and 14 as not painful (grade 0). Ten of 31 subjects described transient changes in occlusion one week after arthrography but none of the changes persisted until the two-month examination. Maximum interincisal distance was significantly decreased at one week but not at two months. These findings, although gained from asymptomatic subjects, suggest that complications of arthrography are probably minor and transient when performed by an experienced arthrographer.