A simple technique for shoulder arthrography

Magnetic resonance arthrography of the shoulder: a painful procedure?

Objective

To compare the pain expected to that effectively caused by magnetic resonance arthrography of the shoulder and, secondarily, to describe a simplified approach to the technique for articular access.

Materials and Methods

We prospectively evaluated 40 participants who used a visual analog scale and a simplified categorical scale to indicate the level of pain expected and that experienced after the procedure, comparing the two with the Wilcoxon matched-pairs test. We also determined gender-related differences in pain conditions using the Mann-Whitney U test. In addition, we described a modified technique involving radiographic localization and the use of standard puncture needles for articular access.

Results

Analysis of the visual analog scales showed that the pain experienced was less than had been expected, with median scores of 1.75 and 3.75, respectively (p < 0.001). The level of pain expected was higher among women than among men, with median scores of 8.0 and 3.0, respectively (p = 0.014), as was the level of pain experienced, with median scores of 3.0 and 1.5, respectively (p = 0.139). The overall categorical evaluation corroborated that difference (p = 0.03). Articular access with the modified technique was successful in all patients.

Conclusion

Magnetic resonance arthrography of the shoulder is less painful than patients expect. In addition, digital radiographic guidance combined with the use of standard puncture needles appears to improve the efficiency of the method.

A prospective randomized study comparing three different approaches to fluoroscopy-guided shoulder arthrography according to the experience of practitioners

OBJECTIVE

To compare three approaches via the anterior and posterior glenohumeral joints, and the rotator interval in fluoroscopy-guided shoulder arthrography according to the experience of the practitioners.

MATERIALS AND METHODS

This prospective randomized study was originally designed to have 34 subjects for each approach, and finally evaluated 98 patients (mean age: 51.5 years; 55 men) from July to December 2014, who had shoulder arthrography via the anterior (n = 41) or posterior glenohumeral joint (n = 27) approaches, or via the rotator interval approach (n = 30) by residents (n=76) or fellows (n=22). The success rate, number of punctures, fluoroscopy time, radiation dose, and complications of the three methods were compared, and according to the practitioners.

RESULTS

The success rate was 100% for the anterior glenohumeral joint approach (34 out of 34), 90.0% for the posterior glenohumeral joint approach (23 out of 30), and 88.2% for the rotator interval approach (30 out of 34; p = 0.013). There was no difference in the success rate according to the practitioners' experience. Fluoroscopy time was longest for the posterior glenohumeral joint approach (mean: 95.44 s) and shortest for the rotator interval approach (mean: 31.57 s, p = 0.006). Radiation dose was larger by 1st- or 2nd-year residents (p = 0.014), with no difference among the three approaches. Only one patient who underwent arthrography using the posterior glenohumeral joint approach complained about post-procedural pain.

CONCLUSION

Fluoroscopy-guided shoulder arthrography via the posterior glenohumeral joint or rotator interval approach may be difficult for trainees, and the posterior glenohumeral joint approach may need a long fluoroscopy time.

Accuracy of intra-articular injection of the glenohumeral joint: a modified anterior approach

PURPOSE

This study examined the accuracy of our modified anterior approach to the glenohumeral joint using arthrography.

METHODS

Two hundred fifty-six consecutive patients with adhesive capsulitis received the glenohumeral joint injection: a mixture of 1 mL of 40 mg of triamcinolone hexacetonide, 2 mL of 2% lidocaine, 3 mL of contrast medium (Ioxitalamate), and 4 mL of normal saline solution, for a total of 10 mL, through a modified anterior approach. Anteroposterior, lateral, and axial arthrography after each injection was performed to determine the accuracy and patterns of the injection. The injection was judged to be successful if some of the contrast medium was placed within the joint.

RESULTS

There were 78 male and 178 female patients, and the mean age was 54 years (range, 28 to 87 years). In 232 of the 256 patients (90.6%), the injection was deemed to have reached the glenohumeral joint, and these cases were considered successful. Among these patients, the contrast medium was shown only in the joint in 189 (73.8%), whereas in 43 (16.8%) it was shown both in and out of the joint. Of the 24 misguided injections, 15 (5.9%) had anterior placement, 6 (2.3%) had posterior placement, and 2 (0.8%) had superior placement, whereas the material was located in all portions outside the joint in 1 (0.4%).

CONCLUSIONS

This study showed that our modified anterior approach had an accuracy greater than 90% for the intra-articular injection of the glenohumeral joint without radiographic guidance.

Glenohumeral joint instability

Due to the configuration of its bony elements, the glenohumeral joint is the most mobile joint of the body, but also an inherently unstable articulation. Stabilization of the joint is linked to a complex balance between static and dynamic soft tissue stabilizers. Because of complex biomechanics, and the existence of numerous classifications and acronyms to describe shoulder instability lesions, this remains a daunting topic for most radiologists. In this article we provide a brief review of the anatomy of the glenohumeral joint, as well as the classifications and the pathogenesis of shoulder instability. Technical aspects related to the available imaging techniques (including computed tomography [CT] arthrography, magnetic resonance imaging [MRI], and MR arthrography) are reviewed. We then describe the imaging findings related to shoulder instability, focusing on those elements that are important to the clinician.

CT arthrography, MR arthrography, PET, and scintigraphy in osteoarthritis

CT arthrography and MR arthrography are accurate methods for the study of surface cartilage lesions and cartilage loss. They also provide information on subchondral bone and marrow changes, and ligaments and meniscal lesions that can be associated with osteoarthritis. Nuclear medicine also offers new insights in the assessment of the disease. This article discusses the strengths and limitations of CT arthrography and MR arthrography. It also highlights nuclear medicine methods that may be relevant to the study of osteoarthritis in research and clinical practice.

Glenohumeral joint injection: a comparative study of ultrasound and fluoroscopically guided techniques before MR arthrography

To assess the variability in accuracy of contrast media introduction, leakage, required time and patient discomfort in four different centres, each using a different image-guided glenohumeral injection technique. Each centre included 25 consecutive patients. The ultrasound-guided anterior (USa) and posterior approach (USp), fluoroscopic-guided anterior (FLa) and posterior (FLp) approach were used. Number of injection attempts, effect of contrast leakage on diagnostic quality, and total room, radiologist and procedure times were measured. Pain was documented with a visual analogue scale (VAS) pain score. Access to the joint was achieved in all patients. A successful first attempt significantly occurred more often with US (94%) than with fluoroscopic guidance (72%). Leakage of contrast medium did not cause interpretative difficulties. With US guidance mean room, procedure and radiologist times were significantly shorter (p < 0.001). The USa approach was rated with the lowest pre- and post-injection VAS scores. The four image-guided injection techniques are successful in injection of contrast material into the glenohumeral joint. US-guided injections and especially the anterior approach are significantly less time consuming, more successful on the first attempt, cause less patient discomfort and obviate the need for radiation and iodine contrast.