What is Direct Arthrography?
Arthrography is medical imaging to evaluate conditions of joints. It can either be indirect or direct. Indirect arthrography is a medical imaging technique in which contrast material is injected into the blood stream, which will eventually absorb into the joint. With direct arthrography, the contrast material is injected directly into the joint. Direct arthrography is the preferred method because it is better for distending or enlarging the joint and imaging small internal structures to allow for better evaluation of diseases or conditions within the joint. It, however, is often performed only if a non-arthrographic exam is felt to be inadequate.
There are several methods to perform direct arthrography.
Conventional direct arthrography of a joint uses a special form of x-ray called fluoroscopy after an injection of contrast material containing iodine is administered directly into the joint. Alternate methods of direct arthrography examinations may use magnetic resonance imaging (MRI) or computed tomography (CT) following the various contrast material injections into the joint.
An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging.
Fluoroscopy makes it possible to see bones, joints and internal organs in motion. When iodine contrast is injected into the joint, it fills the entire joint and becomes clearly visible during x-ray evaluation, allowing the radiologist to assess the anatomy and function of the joint. Although the injection is typically monitored by fluoroscopy, the examination also involves taking radiographs for documentation. The images are most often stored and viewed electronically.
Similarly, direct MR arthrography also involves the injection of a contrast material into the joint. The contrast material used for MR evaluation is different from that used for x-ray; it contains gadolinium, which affects the local magnetic field within the joint. As in conventional direct arthrography, the contrast material outlines the structures within the joint, such as cartilage, ligaments and bones and allows them to be evaluated by the radiologist after the MR images are produced.
MRI uses a powerful magnetic field, radiofrequency pulses and a computer to produce detailed pictures of organs, soft tissues, bone and virtually all other internal body structures. The images can then be examined on a computer monitor, printed or copied to CD. MRI does not use ionizing radiation (x-rays).
CT direct arthrography uses the same type of contrast material as conventional direct arthrography and may be supplemented by air to produce a double contrast CT arthrogram. CT makes cross sectional images processed by a computer using x-rays.
How should I prepare?
No special preparation is necessary before direct arthrography. Food and fluid intake do not need to be restricted, unless a sedative will be given.
You should inform your physician of any medications you are taking and if you have any kidney problems or allergies, especially to iodinated or gadolinium-based contrast materials. Also, inform your doctor about recent illnesses or other medical conditions.
Some MRI examinations may require the patient to receive an injection of contrast into the bloodstream. Some of this contrast material can be absorbed into the joint resulting in an indirect arthrogram. The radiologist or technologist may ask if you have asthma, or allergies of any kind, such as allergy to iodine or x-ray contrast material, drugs, food, or environmental agents. However, the contrast material used for an MRI exam, called gadolinium, does not contain iodine and is less likely to cause side effects or an allergic reaction.
The radiologist should also know if you have any serious health problems or if you have recently had surgery. Some conditions, such as severe kidney disease, may prevent you from being given contrast material for having an MRI.
If you are scheduled to have MR or CT arthrography and have claustrophobia (fear of enclosed spaces) or anxiety, you may want to ask your physician about being sedated prior to the scheduled examination.
Jewelry and other accessories should be left at home if possible, or removed prior to the MRI scan. Because they can interfere with the magnetic field of the MRI unit, metal and electronic objects are not allowed in the exam room. These items include:
jewelry, watches, credit cards and hearing aids, all of which can be damaged
pins, hairpins, metal zippers and similar metallic items, which can distort MRI images
removable dental work
pens, pocket knives and eyeglasses
In most cases, an MRI exam is safe for patients with metal implants, except for a few types. People with the following implants cannot be scanned and should not enter the MRI scanning area:
cochlear (ear) implant
some types of clips used on brain aneurysms
some types of metal coils placed within blood vessels
nearly all cardiac defibrillators and pacemakers
You should tell the technologist if you have medical or electronic devices in your body, because they may interfere with the exam or potentially pose a risk, depending on their nature and the strength of the MRI magnet. Many implanted devices will have a pamphlet explaining the MRI risks for that particular device. If you have the pamphlet, it is useful to bring that to the attention of the technologist or scheduler before the exam. Some implanted devices require a short period of time after placement (usually six weeks) before being safe for MRI examinations. Examples include but are not limited to:
artificial heart valves
implanted drug infusion ports
artificial limbs or metallic joint prostheses
implanted nerve stimulators
metal pins, screws, plates, stents or surgical staples
In general, metal objects used in orthopedic surgery pose no risk during MRI. However, a recently placed artificial joint may require the use of another imaging procedure. If there is any question of their presence, an x-ray may be taken to detect and identify any metal objects.
Patients who might have metal objects in certain parts of their bodies may also require an x-ray prior to an MRI. You should notify the technologist or radiologist of any shrapnel, bullets, or other pieces of metal which may be present in your body due to accidents. Foreign bodies near and especially lodged in the eyes are particularly important. Dyes used in tattoos may contain iron and could heat up during MRI, but this is rarely a problem. Tooth fillings and braces usually are not affected by the magnetic field, but they may distort images of the facial area or brain, so the radiologist should be aware of them.
You may be asked to remove some or all of your clothes and to wear a gown during the exam. You may also be asked to remove jewelry, removable dental appliances, eye glasses and any metal objects or clothing that might interfere with the x-ray images.
Women should always inform their physician and x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. See the Safety page for more information about pregnancy and x-rays.
Though MRI does not use ionizing radiation, women should still inform their physician and technologist if they may be pregnant.
Children younger than teenagers may need to be sedated in order to hold still for the procedure. Parents should ask about this beforehand and be made aware of food and drink restrictions that may be needed prior to sedation.
You should plan to have a relative or friend drive you home after your procedure.
How is the procedure performed?
This examination is usually done on an outpatient basis.
The patient is positioned on the examination table. X-rays of the joint may be taken prior to the procedure to help in guiding the injection and also to provide a baseline exam to be compared later with the arthrogram images. If recent x-rays are available, the physician may choose to use these for reference.
Next, the skin around the joint is cleansed with antiseptic and is often covered with a sterile surgical drape. Using a small needle, the physician injects local anesthetic into the area.
After the local anesthetic has taken effect, a longer needle is then inserted into the joint. The radiologist, a physician specially trained to supervise and interpret radiology examinations, will often use fluoroscopy or ultrasound to guide the needle into the correct position. The physician will sometimes use a syringe to drain (or aspirate) the joint fluid, which may be sent to a laboratory for analysis. Aspiration is typically performed when an infection is suspected.
The contrast material and sometimes air are injected into the joint space while the radiologist observes with fluoroscopy or ultrasound. In some cases, additional medications, such as anti-inflammatory steroids, may be injected into the joint along with the contrast material. After the needle is removed, the patient will be asked to move the affected joint to distribute the contrast material throughout the space. The radiologist may move the joint while evaluating the joint motion under fluoroscopy. A conventional direct arthrography exam is usually completed within 30 minutes. Exams involving MRI may take more than one hour.
What will I experience during and after the procedure?
You will experience a slight pinprick and may feel a momentary burning if a local anesthesia is used to numb the joint area. You may feel pressure or even pain when the needle is advanced into the joint. Inform the radiologist performing the procedure if you have pain so more local anesthetic can be injected into the area.
You may feel a fullness as the joint is filled and hear gurgling when the joint is moved.
If your arthrography exam involves MR imaging:
It is normal for the area of your body being imaged to feel slightly warm, but if it bothers you, notify the radiologist or technologist. It is important that you remain perfectly still while the images are being obtained, which is typically only a few seconds to a few minutes at a time. You will know when images are being recorded because you will hear and feel loud tapping or thumping sounds when the coils that generate the radiofrequency pulses are activated. Some centers provide earplugs, while others use headphones to reduce the intensity of the sounds made by the MRI machine. You will be able to relax between imaging sequences, but will be asked to maintain your position without movement as much as possible.
You will usually be alone in the exam room during the MRI procedure. However, the technologist will be able to see, hear and speak with you at all times using a two-way intercom. Many MRI centers allow a friend or parent to stay in the room as long as they are also screened for safety in the magnetic environment.
Children will be given appropriately sized earplugs or headphones during the exam. MRI scanners are air-conditioned and well-lit. Music may be played through the headphones to help you pass the time.
In some cases, intravenous injection of contrast material may be performed. The intravenous needle may cause you some discomfort when it is inserted and you may experience some bruising. There is also a very small chance of irritation of your skin at the site of the IV tube insertion. Some patients may sense a temporary metallic taste in their mouth after the contrast injection.
If you have not been sedated, no recovery period is necessary. You may resume your usual activities and normal diet immediately after the exam. On very rare occasions, a few patients experience side effects from the contrast material, including nausea and local pain. Similarly, patients are very rarely allergic to the contrast material and experience hives, itchy eyes or other reactions. If you experience allergic symptoms, notify the technologist. A radiologist or other physician will be available for immediate assistance.
If you experience allergic symptoms, a radiologist or other physician will be available for immediate assistance.
After the examination, you may experience swelling and discomfort. You may apply ice to the joint to reduce swelling if it is bothersome. A mild over-the-counter analgesic can be taken for pain. These symptoms usually disappear after 48 hours. Contact your doctor if they persist after two days.
Vigorous exercise is not recommended for at least 24 hours after the exam.
If steroids or anesthetic medications are injected into the joint during the arthrogram, you may be asked to keep a log of your level of joint discomfort over the following days or weeks. This information may be helpful to your physician in determining the causes of chronic joint pain and what therapies may be effective. It is also recommended that you refrain from vigorous exercise of the joint for about two weeks.
Who interprets the results and how do I get them?
A radiologist, a physician specifically trained to supervise and interpret radiology examinations, will analyze the images and send a signed report to your primary care or referring physician, who will discuss the results with you.
Follow-up examinations may be necessary, and your doctor will explain the exact reason why another exam is requested. Sometimes a follow-up exam is done because a suspicious or questionable finding needs clarification with additional views or a special imaging technique. A follow-up examination may also be necessary so that any change in a known abnormality can be monitored over time. Follow-up examinations are sometimes the best way to see if treatment is working or if an abnormality is stable over time.
What are the benefits vs. risks?
Direct arthrography is particularly effective for detecting disease of the structures within the joints such as ligaments, tendons and cartilage. This is particularly true for the shoulder in the setting of shoulder dislocation and in the wrist and elbow.
Exams involving x-ray imaging:
No radiation remains in a patient's body after an x-ray examination.
X-rays usually have no side effects in the typical diagnostic range for this exam.
Exams involving MR imaging:
MRI is a noninvasive imaging technique that does not involve exposure to ionizing radiation.
MRI enables the discovery of abnormalities that might be obscured by bone with other imaging methods.
The contrast material used in MRI exams is less likely to produce an allergic reaction than the iodine-based contrast materials used for conventional x-rays and CT scanning.
Any procedure where the skin is penetrated carries a risk of infection. The chance of infection requiring antibiotic treatment appears to be less than one in 1,000.
There is always the possibility of injuring a vessel or a nerve adjacent to the joint. Injury to these structures, however, is minimal particularly when the procedure is performed under ultrasound guidance.
Exams involving x-ray imaging:
There is always a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis far outweighs the risk.
Patients who have known allergies to iodine may have an adverse reaction to the contrast material. Because the contrast material is put in a joint and not a vein, allergic reactions are very rare, although in some cases, mild nausea to severe cardiovascular complications may result.
Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant. See the Safety page for more information about pregnancy and x-rays.
The effective radiation dose for this procedure varies. See the Safety page for more information about radiation dose.
Exams involving MR imaging:
The MRI examination poses almost no risk to the average patient when appropriate safety guidelines are followed.
If sedation is used, there are risks of excessive sedation. The technologist or nurse monitors your vital signs to minimize this risk.
Although the strong magnetic field is not harmful in itself, implanted medical devices that contain metal may malfunction or cause problems during an MRI exam.
There is a very slight risk of an allergic reaction if contrast material is injected. Such reactions usually are mild and easily controlled by medication. If you experience allergic symptoms, a radiologist or other physician will be available for immediate assistance.
Nephrogenic systemic fibrosis is currently a recognized, but rare, complication of MRI believed to be caused by the injection of high doses of gadolinium-based contrast material in patients with very poor kidney function. Careful assessment of kidney function before considering a contrast injection minimizes the risk of this very rare complication.
A Word About Minimizing Radiation Exposure
Special care is taken during x-ray examinations to use the lowest radiation dose possible while producing the best images for evaluation. National and international radiology protection organizations continually review and update the technique standards used by radiology professionals.
Modern x-ray systems have very controlled x-ray beams and dose control methods to minimize stray (scatter) radiation. This ensures that those parts of a patient's body not being imaged receive minimal radiation exposure.
What are the limitations of arthrography?
The limitations of arthrography include:
Partial tears of the rotator cuff may not be detected with conventional direct arthrography.
Some joint injuries cannot be detected with conventional direct arthrography including defects of the cartilage which can be found inside and along the edges of some joints, bruising of neighboring bones and injuries to ligaments outside the joint.