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Arthrography

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Arthrography 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
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