Arthrography

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RSNA 2009 page 1 of 10 Essentials of Arthrography Arthrography 101: Shoulders & Hips Disclosures… I have no financial disclosures Ken Schreibman, PhD/MD University of Wisconsin Department of Radiology Musculoskeletal Section $ Originally presented at part of RSNA I will be mentioning off-label Gd use Essentials Course, 12/1/2009 Attended by 1,700 Radiologists

©Ken L Schreibman, PhD/MD 2015 schreibman.infoschreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

How “essential” is arthrography? Arthrography is an old technique “Arthrography”: Opacify a Joint 1906: Pneumoarthrography Isn’t this an archaic technique? TB Synovial thickening NO! UW 2009: >1100 joint injections Raise Of all of you sitting here, your how many have been asked to hand stick a needle into a joint at least Mosby Year Book, 1992, 1995 once this year? (Currently out of print) ©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 2015 Eisenberg p.252 schreibman.info

Arthrography common pre-MRI Arthrography: 21st Century Double Contrast Normal Therapeutic Tool Knee Arthrography Posterior Horn Inject therapeutic agent into a joint Medial Meniscus  1960 – 1990 Hyaluronan (visco-supplementation) @UW 1990: 800! FDA approved for OA knee Vertical Tear Posterior Horn Medial Meniscus  Required a lot of varus & valgus stress on the knee  Typically injected blindly in clinic.  Unpleasant for both May ask for image guidance when patient and radiologist can’t feel landmarks in knee. Courtesy of Arthur De Smet, MD University of Wisconsin, Madison  Steroid: weeks-months pain relief ©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info RSNA 2009 page 2 of 10 Essentials of Arthrography Steroids UW MSK Steroids in joints Triamcinolone Concern cartilage loss Suspension, Lidocaine Potentiates the not solution Chondrotoxicity of Methylprednisolone Granular, Arthroscopy, Vol 24, No 4 (April) 2009: pp 337-347 stays locally Need to Tend NOT inject steroids re-suspend prior to use into large joints (hip, shoulder, knee) Commonly used for spine injections Unless specifically requested  UW 2009: >1000 ESI, NRB Patients awaiting arthroplasty Dexamethasone 10mg/ml Often inject small joints Solution, used superficial structures Deep (Facets, SI): Triamcinolone Less subcutaneus fat atrophy Superficial (AC): Dexamethasone ©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

Arthrography: 21st Century Anesthetics UW MSK Therapeutic Tool ALWAYS provide skin anesthesia  Inject therapeutic agent into a joint 1% Lidocaine: Bicarbonate (9:1) Hyaluronan (visco-supplementation) Local Our surgical Steroid: weeks-months pain relief Anesthesia colleagues Diagnostic Tool Deep often do not Inject anesthetic agent into a joint provide skin  Skin anesthesia Prove pain is coming from within joint prior to their  e.g. Pt with bad DJD of hip and steroid bad DDD of lumbar spine. injections… Want to prove pain is from hip 30g 27g  prior to hip arthroplasty surgery. ½" 1½" it really hurts! ©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

Anesthetics UW MSK Intra-articular: Ropivacaine Longer acting than Lidocaine (Bupivacaine is chondrotoxic) DON’T mix in Bicarbonate Will precipitate Can mix in Lidocaine

Which injection cocktail for which joint?

©Ken L Schreibman, PhD/MD 2015 schreibman.infoschreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info RSNA 2009 page 3 of 10 Essentials of Arthrography Injection Cocktails

©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

Arthrography: 21st Century Request:Sub-deltoid Fluoro Bursitis Asp Septic (No Shoulder fluid in joint) Therapeutic Tool T2fs Fluid in  Inject therapeutic agent into a joint sub-deltoid Hyaluronan (visco-supplementation) bursa Steroid: weeks-months pain relief No fluid in Diagnostic Tool T1fs+Gd(IV)gleno-humeral T1fs+Gd(IV) joint  Inject anesthetic agent into a joint Prove pain is coming from within joint  Aspirate fluid from joint Septic  Culture (Gram Stain, Cell count) Crystals  Polarizing microscopy   Prudent to first confirm there IS fluid in joint T2fs T2fs ©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 2015 H,M 43yoF schreibman.info

Sub-deltoid Bursitis (No fluid in joint) Arthrography: 21st Century Don’t need to do Therapeutic Tool fluoroscopic- guided aspiration  Inject therapeutic agent into a joint of shoulder Hyaluronan (visco-supplementation) capsule… Steroid: weeks-months pain relief T1fs+Gd(IV) T1fs+Gd(IV) Diagnostic Tool  Inject anesthetic agent into a joint Instead, do Prove pain is coming from within joint ultrasound- guided aspiration  Aspirate fluid from joint of bursal fluid Septic  Culture (Gram Stain, Cell count) collection. Crystals  Polarizing microscopy pre-aspiration post-aspiration  Inject contrast prior to MR or CT ©Ken L Schreibman, PhD/MD 2015 H,M 43yoF schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info RSNA 2009 page 4 of 10 Essentials of Arthrography Arthrography: 21st Century Arthrography: Why we do it No longer used as a primary diagnostic tool Therapeutic Tool Contrast in Bursa Nowadays, surgeons  Inject therapeutic agent into a joint Rotator Cuff Tear want to see more… Hyaluronan (visco-supplementation) They want to see torn Steroid: weeks-months pain relief end of supraspinatus: Contrast in capsule Diagnostic Tool Needle in capsule  Inject anesthetic agent into a joint Prove pain is coming from within joint

Contrast in joint  Aspirate fluid from joint Septic  Culture (Gram Stain, Cell count) Crystals  Polarizing microscopy Sagittal Coronal  Inject contrast prior to MR or CT ©Ken L Schreibman, PhD/MD 2015 W,L 43yoM schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

Arthrography: What we need Ultrasound: Pediatric Hips Right Fri 20:55 Left IMAGE GUIDANCE UW Peds ER Can’t be assured of getting a needle into hip/shoulder without imaging Joint With experience, should be able to Effusion No Fluid blindly get a needle into knee Knees commonly injected in clinic Diaphysis Clinics may request image guidance when injecting knees of “larger” pts. Young patients: Ultrasound

Fri 16:25 Outside Clinic ©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 2015 C,I 14moM schreibman.info

Ultrasound: Pediatric Hips Arthrography: What we need Right Fri 20:55 Left UW Peds ER IMAGE GUIDANCE Can’t be assured of getting a needle Joint into hip/shoulder without imaging Effusion No Fluid With experience, should be able to blindly get a needle into knee Diaphysis Fri 23:30 Sat 03:10 Knees commonly injected in clinic UW Peds ER UW Peds OR Clinics may request image guidance when injecting knees of “larger” pts. Young patients: Ultrasound Most patients: Fluoroscopy Post aspiration 2ml pus Preferably C-arm Fluoroscopy ©Ken L Schreibman, PhD/MD 2015 C,I 14moM schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info RSNA 2009 page 5 of 10 Essentials of Arthrography C-Arm Fluoroscopy C-Arm Fluoroscopy

©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

Positioning Patient Arthrography: What we need Shoulder: Hip: TARGET SITE  External Internal Keys to Arthrography Rotation Rotation Sandbag Sandbag Target is NOT the joint Don’t necessarily need to position needle between 2 articular surfaces Target is the CAPSULE Just need to have the needle touch a bone within the capsule

©Ken L Schreibman, PhD/MD 2015 Marty schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

Joint Capsule: Hip Joint Capsule: Hip TARGET SITE 

GT      TARGET SITE: Capsule widest: Head-Neck Head-Neck Junction LT Junction

©Ken L Schreibman, PhD/MD 2015 M,S 34yoF schreibman.info ©Ken L Schreibman, PhD/MD 2015 L,J 43yoF schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info RSNA 2009 page 6 of 10 Essentials of Arthrography Joint Capsule: Shoulder Arthrography: What we need TARGET SITE : RC Interval Non-sterile tray Metal pointer & marker  To localize & mark target  Bursa Metal R/L =RCT To prove which side Cor  GT LT  Sub-   scapularis  Recess Biceps Places Groove contrast Axillary normally  Recess flows… A,W 42yoM $1.25/eachB,P 29yoF J,C 48yoF ©Ken L Schreibman, PhD/MD 2015 M,G 52yoM schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

Arthrography: What we need Sterile Tray IMAGE GUIDANCE If tray is set up before patient enters TARGET SITE  it is important to COVER TRAY NON-STERILE TRAY to prevent patient contaminating it! STERILE TRAY

©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

Sterile Tray: Prep & Drapes Sterile Tray: Syringes Sticky drape Local anesthetic (1% Lido:Bicarb 9:1) with hole Clean & 4x4" sterilize sponges skin 10ml syringe w/skin needle  Contrast (iohexol 300 mgI/ml) Additional sterile 5ml syringe w/connecting tube  drapes/towels

Sterile covers for Cocktail image intensifier and controls 10ml syringe w/18g drawing up  needle ©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info RSNA 2009 page 7 of 10 Essentials of Arthrography Arthrography: How we do it Local Anesthesia Local anesthesia Skin: 30g ½" needle  DON’T raise Advance “You will feel a bee sting” a wheal needle vertically Skin Skin “This will burn for a few seconds, Sub-Q Pain Sub-Q Pain and then will be numb” Fat Receptors Fat Receptors 2 needles Bone Bone Capsule Skin: 30g ½" needle Capsule Deeper: 1½" needle www.redbubble.com/people/tkss/art/2578224-2-scary-hairy ©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

Local Anesthesia Local Anesthesia Skin: 30g ½" needle Skin: 30g ½" needle Advance Advance Deeper: 1½" needle needle Deeper: 1½" needle needle vertically vertically Shoulder: RC Int Skin Hip: Skin Sub-Q Pain Sub-Q Pain Can reach bone Receptors Can’t reach bone Receptors with 1½" needle Fat with 1½" needle Fat Use 22g Bone Use 27g Anesthesia Capsule Anesthesia only Advance needle Use 22g 3½" through capsule, spinal needle to Bone touching bone reach bone Capsule ©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 20092015 schreibman.infoschreibman.info

Sterile Tray: Needles Keys to Arthrography ADVANCE NEEDLE SLOWLY

Lumbar Inject Don’t just jab it in there… Epidural Hip Aspirate Steroid Pus Injection Inject Deep Shoulder

Anesthesia Skin Biopsy Soft Bone Biopsy Hard  Bone    13g 30g 27g 22g Bx 1½"  ½" 1½"    18g 14g 25g 22g Bx 3½" 3½" 3½" ©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info RSNA 2009 page 8 of 10 Essentials of Arthrography Keys to Arthrography Example: Hip Arthrogram ADVANCE NEEDLE SLOWLY Use 2 hands: One hand on needle hub One hand on patient’s skin Allow needle to pass between your thumb & index finger tips so you can feel the needle being advanced Advance just a few mm at a time Check fluoro, readjust position ©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 2015 D,E 93yoM schreibman.info

Example: Hip Arthrogram Keys to Arthrography ADVANCE UNTIL HIT BONE Don’t stop at the capsule WATCH FIRST DROP OF CONTRAST Skin Should flow away Sub-Q from needle tip Fat If contrast stays Synovium by needle tip, Bone needle is NOT Capsule in a space! (Extravasation) ©Ken L Schreibman, PhD/MD 2015 D,E 93yoM schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

Example: Hip Arthrogram Recognizing Extravasation: Hip

Needle repositioned Contrast flowing away   from ContrastContrast staysstays by by needle needleneedle

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info RSNA 2009 page 9 of 10 Essentials of Arthrography Recognizing Extravasation: Hip Recognizing Extravasation: Hip & Repositioning Needle Not contrast Contrast in flowing into Contrast Needle capsule capsule re-repositioned flowing Sagittal T1 away (Fat-Suppressed) from needle Extravasation into muscle

Recognizing Extravasation: Shoulder Recognizing Extravasation: Shoulder & Repositioning Needle Extravasation into subscapularis

Cor  Contrast NOT   Slight amount flowing away Contrast in Contrast in subscapularis biceps contrast in joint from needle recess sheath Contrast Mixed Injection Contrast in joint filling (½ in, ½ out) Axial T1 capsule (Fat-Suppressed) ©Ken L Schreibman, PhD/MD 2015 Z,A 29yoF schreibman.info ©Ken L Schreibman, PhD/MD 2015 Z,A 29yoF schreibman.info

Shoulder Arthrogram pre MRI Sterile Tray: Syringes Contrast Arthrogram MR/CT flowing away Local anesthetic (1% Lido:Bicarb 9:1) from needle 10ml syringe w/skin needle  Deep sub-Q needle  3½" (hip) Contrast filling capsule 20ml syringe  25-50% Iodine (5-10ml iohexol 300mgI/ml) Contrast 50% anesthetic (5ml 1%Lido, 5ml Ropi)  filling Contrast filling Biceps 0.1ml Gd Axillary recess sheath Extra needle  ©Ken L Schreibman, PhD/MD 2015 H,J 71yoM schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info RSNA 2009 page 10 of 10 Essentials of Arthrography Two Tips… Two Tips… MR Arthrogram MR Arthrogram  Make sure Gd gets into cocktail!  Avoid Air Bubbles! 0.1ml Gd in 1ml (tuberculin) syringe Air in joint causes susceptibility artifact Get air out of arthrogram needle hub Make sure Extra needle on Drop tip extra Gd doesn’t connecting tube needle into hub get trapped of arthro needle.  in the hub, Fill the hub from bottom to top. but actually Remove extra enters needle and do solution wet-connect. ©Ken L Schreibman, PhD/MD 2015 schreibman.info ©Ken L Schreibman, PhD/MD 2015 schreibman.info

Metal Hip: Injecting Metal Hip: Aspirating Prove you’re “in” Can’t see metal needle Loose acetabular component thru metal prosthesis by seeing contrast flow r/o infection pre replacement into synovial capsulecapsule Capsule is thick and fibrotic (like wood) Requested aspiration Skin Sub-Q Fat Don’t stop when touch wood… Go until touch Metal Synovial capsule metal constricted around Capsule head-neck junction Synovium When aspirating 18g Needle Target: Head-Neck Junct suspected pus, use: 20ml Syringe ©Ken L Schreibman, PhD/MD 2015 S,G 79yoF schreibman.info ©Ken L Schreibman, PhD/MD 2015 S,J 70yoM schreibman.info

Metal Hip: Aspirating Metal Hip: Aspirating

Test needle location by injecting contrast:

Test needle location Flowing into by injecting contrast: synovial capsule Target  Not flowing into  synovial capsule

1st Needle Reposition placement needle Asp No Fluid Asp 20ml When aspirating 18g Needle When aspirating 18g Needle suspected pus, use: 20ml Syringe suspected pus, use: 20ml Syringe ©Ken L Schreibman, PhD/MD 2015 S,J 70yoM schreibman.info ©Ken L Schreibman, PhD/MD 2015 S,J 70yoM schreibman.info