Arthrography

The danger of injuries and pathologies of the joints lies in the fact that, due to the complex structure, these parts of the musculoskeletal system are almost impossible to display in full for further study. For example, it will be quite difficult to assess the condition of the capsule, some cartilage or other structures from a conventional x-ray. Arthrography refers to the contrast methods of examination of the joints. Its results allow us to study the structural features of the structure and diagnose the presence or development of a number of diseases. Of course, this method is of particular value for sports medicine and traumatology, but its scope is much wider. The most commonly performed types of arthrography, depending on the location, are arthrography of the knee, shoulder, elbow joints and TMJ arthrography (temporomandibular joint).

What is arthrography and why is it performed?

Initially, arthrography was an X-ray method for examining a joint, with its visualization in the picture by introducing a contrast liquid or gas into it. Today, this concept has expanded significantly, and now also includes methods that do not use artificial contrast and X-rays – the so-called non-contact examination. The latter type includes magnetic resonance or MR arthrography without the introduction of a contrast agent.

Computed tomography or CT arthrography provides a detailed image of the joints, their small parts and cavities that are not detected using conventional x-rays, while there is no preliminary puncture of the contrast agent, no special preparation for the procedure is carried out.

Magnetic resonance arthrography is considered the most informative of this line of studies.

This procedure is prescribed to visualize those parts of the joint that are not visible on standard x-rays, for example, capsules or cavities, intra-articular and extra-articular structures – articular cartilage, menisci, ligaments, pathological changes, injuries and damage to them.

The most appropriate is arthrography of large joints – hip, shoulder, knee. The study of the shoulder joint in this way allows you to determine pathological changes in the biceps and rotator muscles of the shoulder. Examination of the knee joint by arthrography reveals pathologies of the meniscus.

As for the study of cartilage and ligaments of small joints, arthrography is not very informative in such cases.

Types of Contrast Used in Arthrography

Depending on the nature of the damage or suspected pathologies, the following methods of artificial contrasting of the joint can be used:

• positive contrast – if a contrast agent is injected into the joint (used for damage to the joint capsule and ligaments);
• negative contrast – when air is introduced into the joint under study (it is used when examining joints in children, with a rupture of the knee meniscus, and also for diagnosing cartilage defects);
• mixed – in this case, a mixture of air and a special substance is used for contrasting.

When is arthrography prescribed, where is it performed

The research method with artificial contrasting of the articular apparatus is usually prescribed by traumatologists, surgeons, oncologists, rheumatologists and arthrologists. It can be passed in most medical institutions, provided that it has an X-ray machine and a doctor of the appropriate qualification.

Such an examination is necessary in the following cases:

• injury for its more accurate diagnosis;
• occurrence of postoperative complications;
• identifying symptoms of arthritis, arthrosis, tumor formations;
• suspicion of the presence of anomalies in the structure of the joint, acute or chronic rupture of the joint capsule, ligamentous apparatus.

The procedure also allows you to detect and examine neoplasms growing from the synovial sac – Baker’s synovial cysts, and also helps to clarify their localization.

The reason for referral to arthrography may be the presence of such symptoms:

• joint pain;
• swelling and redness of the joint and in the tissues surrounding it;
• mobility disorder.

Contraindications to the procedure

Appointment of arthrography is not possible in the following cases:

• pregnancy;
• acute stage of arthritis;
• joint infection;
• pronounced stages of skin diseases;
• blood clotting disorders.

In cases where a patient has been diagnosed with an allergy to some substances commonly used for the procedure (for example, iodine-containing ones), they should not be used. An alternative in cases of contraindications is MRI of the joint.

Among the complications caused by arthrography are the appearance of persistent crepitus (crunching and “clattering” sensations during movement), the development of inflammatory processes (if the requirement of absolute sterility is not met), pain for several hours after the procedure (if the fluid was injected into the periarticular tissues), the appearance of allergic reactions to the contrast agent.

Features of preparation for the study

Doctors usually do not impose special requirements for preparation. There are also no restrictions on diet, work and rest. The basic rule is that the study should be carried out on an empty stomach. Before performing arthrography, the patient is explained the mechanism of the procedure, the essence and purpose of the study, and is also warned that, despite the introduction of an anesthetic, he may feel tingling, heat, burning during the procedure.

It is mandatory to establish the presence or absence of an allergy in a person to any medications – antiseptics, anesthetics, iodine and other contrast agents.

Equipment, fixtures and preparations

The procedure is carried out using an X-ray machine. In addition, you can use:

• 2 needles 20 gauge, 5 centimeters long;
• 3 syringes with a capacity of 3 milliliters;
• needle for spinal anesthesia;
• a 22-gauge needle, 7,5 centimeters long (if arthrography of the shoulder joint is performed);
• sterile test tubes;
• container for synovial fluid;
• sterile swabs and towels;
• elastic knee pad;
• collodion, antiseptic solution, water-soluble contrast agent.

Rules and general procedure for the implementation of arthrography

First of all, the place of study is subjected to pre-treatment: it is thoroughly washed, hair is removed from it, and immediately before the procedure it is wiped with alcohol. The next step is local anesthesia with novocaine solution. After that, the joint cavity is punctured, pathological contents are removed from it, if necessary, it is sent for examination. Next, a high-atomic contrast agent mixed with penicillin, or nitrous oxide or oxygen in gaseous form, is injected into the joint. In some cases, a mixture of gas and a contrast agent is used. After the puncture, the patient needs to move the joint so that the substance is evenly distributed, after which tomography or radiography of the joint is performed in different projections. The patient must be motionless at the time of taking the image. The resulting image can be printed on special plates, film, or displayed on a monitor.

In this order, actions are carried out during arthrography, regardless of its localization. At the same time, each type of examination has its own characteristics.

The mechanism of arthrography of the knee joint

After treating the joint with an antiseptic, the puncture site is anesthetized. Intra-articular anesthesia in this case, most often, is not performed.

A 5 cm long needle is inserted into the joint cavity between the kneecap and the condyle of the femur. Fluid from the cavity is drawn into a sterile test tube and sent for examination. Next, the synovial fluid syringe is replaced with a contrast agent syringe without removing the needle. After that, after checking the correct insertion and location of the needle, a contrast agent is injected into the joint, and the needle is removed. The puncture site is treated with a sterilizing preparation, a sterile swab is applied to it.

The patient needs to move his leg or take a few steps so that the injected substance is evenly distributed over the articular apparatus. Next, a series of images of the joint is taken in different projections and positions. At the end of the procedure, the knee is bandaged with an elastic bandage, if necessary, a knee brace is put on. Both the bandage and the knee brace must be worn for several days after the procedure.

How is the shoulder joint examined?

In a place treated with an antiseptic, an anesthetic injection is made over the scapular-clavicular joint, and an anesthetic is also injected into the head of the humerus. A needle intended for spinal anesthesia is carefully inserted into the joint cavity and advanced inward until it rests against the articular cartilage. The mandrin is separated, and a syringe containing a contrast agent is attached to the needle. Approximately 1 milliliter of the drug is injected into the articular cavity, while the needle is slowly pulled towards itself. Having confirmed by X-ray the correct insertion of the needle, the remaining drug is injected into the joint cavity, the needle is removed, and the puncture site is treated with an antiseptic. After that, it is necessary to take pictures as quickly as possible – the contrast of the resulting image depends on this.

Rehabilitation measures after arthrography

At the end of the study, the study site must be immobilized for 12 hours. For this purpose, elastic bandages are applied, an elastic knee brace can be used. The patient is warned that over the next few days, unpleasant sensations may appear – swelling, heat, feelings of fullness, crepitus. The joint may crackle and click when you try to move it. After 1-2 days, these manifestations disappear. Otherwise, you need to see a doctor. To reduce swelling, ice is applied to the site, and with severe pain, anti-inflammatory and pain medications should be taken.

If the patient notices an increase in temperature, separation of foreign fluid from the puncture site, redness of the skin, you should consult a doctor for advice.

Physical activity during this period should be kept to a minimum.

Interpretation of study results

In the pictures of the knee joint in its normal state, there is a characteristic wedge-shaped shadow, which indicates the absence of pathologies of the medial meniscus. Ruptures and tears of the meniscus can be diagnosed using arthrography in about 90-95% of cases. Also, the doctor may notice chondromalacia of the kneecap, intra-articular fractures, ruptures of cartilage, cruciate ligaments, lateral ligaments and joint capsule.

Arthrographic images of a healthy shoulder joint show the biceps tendon sheath, the lower part of the spacious joint capsule, and an unchanged subscapularis.

In the images of the shoulder joint, in which there are violations and pathologies of work, one can detect adhesive capsulitis, rupture of the tendon of the biceps muscle or rotator muscles.

The resulting conclusion must be shown to the doctor who referred the patient for arthrography.

One of the modern methods of studying the condition of the joints is arthrography. Using this method of research, the doctor can see and recognize disorders and pathologies that are not visualized on a simple x-ray: intra-articular fractures, damage to the joint capsules, ruptures of some cartilage. For its implementation, an X-ray machine and contrast agents are usually used, which, getting into the joint, highlight all the features of its structure, as well as the internal structure of cartilage, cavities and ligaments.