- Johns Hopkins Medicine defines arthrography as an imaging method to assess joints, such as the shoulder, knee, and hip(1). This procedure may be performed if standard X-rays do not offer the necessary information about the joint’s anatomy and function.
- Arthrography may be indirect, in which contrast material is injected into the blood, or direct contrast material is injected directly into the joint(2). After arthrography, the joint may be scanned using computed tomography (CT), magnetic resonance imaging (MRI), or fluoroscopy.
- Patients may experience discomfort and pain after the examination(3). If the swelling is uncomfortable, patients may apply ice to the affected joint.
An over-the-counter pain reliever may be used for pain.
Usually, the symptoms disappear within 48 hours. Patients should consult a doctor if symptoms persist for more than two days.
- Arthrography is contraindicated for those with active arthritis or joint infections(4). It is essential to Inform a healthcare provider if women are pregnant or believe they may be pregnant(5).
Radiation exposure during pregnancy may cause congenital disabilities. If patients must undergo arthrography, they should take further precautions to limit the fetus’s exposure to radiation.
What Is an Arthrogram?
As Johns Hopkins Medicine defines, arthrography is an imaging technique used to examine joints such as the shoulder, knee, and hip(6). If regular X-rays do not provide the required information on the joint’s anatomy and function, this procedure may be performed.
Also, arthrography may check the wrist, ankle, hip, and elbow.
In arthrography, a long, thin needle injects contrast dye directly into the joint, followed by X-rays obtained in different joint locations. X-rays utilize small amounts of radiation to provide images of the inside of the body. Occasionally, the air serves as the contrast agent when ordinary contrast is unavailable.
Meanwhile, arthrograms assess the joint tissues of the body. This technique determines the shoulder (shoulder arthrogram) or hip (hip arthrogram).
The doctor may prescribe an arthrogram to examine:
- Shoulder discomforts, such as from tendinitis or bursitis
- Elbow discomfort caused by tennis elbow
- Ankle discomfort
- Hip discomfort
- Knee discomfort
Types of Arthrogram
Arthrography may be indirect, in which contrast material is injected into the circulation, or direct contrast material is injected directly into the joint(7). After arthrography, the joint may be observed using computed tomography (CT), magnetic resonance imaging (MRI), or fluoroscopy. These are types of real-time x-ray.
1. Direct Arthrography
RadiologyInfo.org explains how direct arthrography works(8).
Arthrography is an imaging technique used to evaluate and diagnose joint problems. It may be either direct or indirect.
After imaging the joint, both direct and indirect arthrography improves the visibility of the joint space.
Contrast material is injected into the bloodstream and finally absorbed by the joint during indirect arthrography.
However, the radiologist injects the contrast substance directly into the joint with direct arthrography.
Direct arthrography is preferable over indirect arthrography, as the former distends or enlarges the joint, allowing for a greater view of minor interior structures.
Thus, direct arthrography improves the examination of joint illnesses or disorders. Also, this procedure is often conducted only if a non-arthrographic test is deemed insufficient for identifying a joint problem.
There are several techniques for doing direct arthrography.
Conventional direct arthrography of a joint often utilizes fluoroscopy. It aims to guide and assess the injection of iodine contrast material directly into the joint. In some instances, ultrasonography may be used to guide the surgery.
Following injection of contrast material into the joint, magnetic resonance imaging (MRI) or computed tomography (CT) may also be used as alternate techniques for direct arthrography investigations.
One of the most frequently used methods of medical imaging is X-rays.
An X-ray examination aids in the diagnosis and treatment of medical disorders. It uses a modest dosage of ionizing radiation to obtain images of the inside of one’s body.
With fluoroscopy, bones, joints, and internal organs may be seen in real-time instead of a single snapshot using conventional x-rays. When iodine contrast is injected into the joint, the whole joint becomes visible during fluoroscopy, enabling the radiologist to evaluate the anatomy and function of the joint.
Although the injection is usually monitored by fluoroscopy, radiographs are also routinely taken for documentation purposes. Typically, these photographs are kept and viewed electronically.
Similarly, contrast material is injected into the joint during direct MR arthrography. It includes gadolinium, which alters the local magnetic field inside the joint and shows on the MR images.
As with traditional direct arthrography, the contrast material indicates the structures inside the joint. These include cartilage, labrum, ligaments, and bones, allowing the radiologist to analyze them once the MR images have been created.
MRI combines a high magnetic field, radiofrequency pulses, and a computer to create comprehensive images of organs, soft tissues, bone, and other interior body components.
The images may then be viewed on a computer display linked to an image archive (PACS system), printed, or transferred to a CD. MRI does not use ionizing radiation (X-rays).
CT direct arthrography utilizes the same contrast material as conventional direct arthrography. Also, CT direct arthrography may be augmented with air to provide a double-contrast CT arthrogram.
CT can create cross-sectional images using X-rays and a computer.
2. Indirect Arthrography
Here is how indirect arthrography works(9).
Indirect arthrography is an MRI method that generates arthrographic images without requiring direct joint injection.
A conventional dosage of a gadolinium-containing contrast agent is administered intravenously. Imaging of the shoulder is conducted after a delay of generally five to 15 minutes. The joint exercise promotes the diffusion of contrast into the joint.
Although the benefits of indirect arthrography are evident (it does not need a direct injection into the joint), its broad adoption has been hampered by significant disadvantages. The primary problems are the following:
- The unpredictability of intra-articular enhancement based on the synovial surface area, inflammation, and joint fluid volume
- Absence of joint distension (unless a joint effusion is already present)
- Incapacity to identify non-anatomical connections between fluid-containing areas since they all increase concurrently
Uses and How Arthrogram Works
Arthrography may be performed on a joint if there is chronic and unexplained pain, discomfort, loss of range of motion, and alterations in how the joint functions(10). Other reasons for doing this examination may include:
- To search for loose bodies.
- To identify abnormalities (such as tears) in the ligaments, tendons, cartilage, and joint capsules.
- To check for joint deterioration caused by repetitive dislocations.
- To examine prosthetic joints.
Meanwhile, another source briefly explains how arthrogram works(11).
A radiologist (specialized physician) injects the contrast medium into the joint using fluoroscopy, computed tomography (CT), or ultrasound to guide the injection needle to the correct location.
After the injection, images of the joint are captured using magnetic resonance imaging (MRI) or computed tomography (CT). Although an MRI or CT may offer some information about the soft tissue structures, an arthrogram can often provide far more specific information about what is wrong inside the joint.
As a result of advances in technology and X-ray imaging equipment, arthrograms are becoming less prevalent.
Typically, no special preparation is necessary(12).
The time required for the injection of the contrast media is typically about 15 minutes. Patients may have to wait for a while before having any more imaging of the joint.
Depending on the joint being scanned and the number of scans that need to be performed, an MRI exam may take 30 to 45 minutes, whereas a CT scan can take as little as 15 minutes.
When patients arrive at the radiology department, they should give themselves around two hours.
Suppose the patients have had a simple X-ray, ultrasound, CT, or MRI of the joint to evaluate pain or other symptoms. In that case, they must bring these images to the arthrogram session.
In addition, it may be beneficial to wear comfortable clothing that allows easy access to the evaluated joint.
For example, UC Davis Health (Department of Radiology) advises patients of the following(13):
- Patients must come 20 minutes before their scheduled appointment.
- If MRI follows an arthrogram, patients will be required to complete the MRI safety form.
- Patients will be required to don a hospital gown and secure their things.
- Before the examination, patients will meet with the physicians.
- Patients should bring a list of any medications they are currently taking.
- Patients should prepare any questions they may have and ask the attending physician.
- Before starting the arthrogram procedure, patients must provide written approval.
- Only ACC (Ambulatory Care Center) does Arthrogram CT, Arthrogram MRI, and Arthrogram examinations.
An arthrogram MRI is an MRI conducted after gadolinium-containing fluid is injected into a joint. Sometimes, the shortened MRA might be mistaken for MR angiography.
Meanwhile, Johns Hopkins Medicine gives some reminders to the patients before agreeing to the test or operation(14).
Patients must ensure they understand the following:
- Name of the test or procedure
- The purpose of the test or procedure
- What outcomes to anticipate and their importance
- Test or procedure’s risks and advantages
- Potential adverse effects or complications
- When and where to undergo the test or treatment
- Who will do the test or operation and the qualifications
- Repercussions if not subjected to the procedure
- Alternative tests or treatments to consider
- When and how to get the results
- Who to contact with questions or concerns following a test or procedure
- Exam or operations cost
As per Cedars Sinai, patients may drive home following the treatment. However, the patients may also want to arrange for assistance(15).
Who Performs the Arthrogram?
A radiologist (specialist physician) ensures that the required scans are performed after the injection(16). Also, they need to evaluate the images and create a formal report of the results given to the physician who recommended the patients for the test.
A registered nurse or a radiographer (medical imaging technologist) may help the radiologist during the arthrogram. Under the instruction of the radiologist, the radiographer is responsible for capturing the arthrogram and subsequent CT or MRI.
Cleveland Clinic explained the arthrogram procedure(17).
Depending on which joint is being examined, the physician may ask the patients to remove their shirt or trousers.
A radiologist will conduct the examination (a physician specializing in medical imaging technologies). Meanwhile, a technician might assist medical imaging with specialized training. Before and after the joint injection, the doctors may take s X-ray images.
The physician will:
- Place the patients on a cushioned table (most likely lying on the back).
- Clean the skin surrounding the joint using an antiseptic solution.
- Cover the testing region with a towel to reveal the afflicted joint and isolate the testing area.
- Use a local anesthetic (pain-relieving medication) or numbing medicine to numb the skin and surrounding region of the joint.
- Inject the contrast agent directly into or near the joint area.
- Move the joint gently to spread the x-ray dye evenly.
- Remove the small needle and disinfect the injection site.
- Take images of the joint using X-rays, MRI, or another medical imaging technique.
- Move the joint into various postures to see joint tissues in multiple positions.
Fluoroscopy and X-rays are often performed in the same room for joint injections. Suppose patients need a CT or MRI immediately after the joint injection. In that case, they may be escorted to another room by a medical expert.
It is essential to take images immediately after joint injection. Otherwise, the dye will spread throughout the body. Once this occurs, medical imaging no longer reveals additional information surrounding joint tissues.
The physician may inject medicine (such as cortisone) directly into the joint during some arthrogram procedures, intending to lessen inflammation or alleviate discomfort.
The data may provide a more comprehensive knowledge of joint issues to help detect the problem.
The type of contrast medium used depends on the precise nature of the arthrogram and the specialized physician doing the arthrogram(18).
If the arthrogram test utilizes X-rays (fluoroscopy or CT), this is often iodinated contrast material. Occasionally, a CT arthrogram will entail air injection alone or in conjunction with a tiny quantity of X-ray contrast media.
Suppose the patients are undergoing an MRI arthrogram. In that case, the injection will be a very diluted combination of MRI contrast medium (gadolinium chelates) and sterile saline (mildly salty water).
When a local anesthetic is injected into the skin, patients may feel a slight pinprick and momentary stinging(19). As the needle penetrates the joint, patients will likely feel pressure discomfort.
Hence, informing the radiologist is crucial for further administration of local anesthetic(20).
The joint may feel tight as the contrast or steroid drugs get infected. Occasionally, an acute sensation of sweat and nausea may also develop. Therefore, notifying the radiologist is a must since such symptoms may be the first sign of fainting.
Meanwhile, Radiologyinfo.org gives information about after arthrogram procedure(21).
The patients may have soreness and pain after the test. If the swelling is unpleasant, they may apply ice to the joint to reduce it.
For pain, a modest over-the-counter painkiller may be administered. Typically, these symptoms vanish within 48 hours. Contact a doctor if symptoms linger for more than two days.
As there is a small increased risk of dislocation after the treatment, vigorous activity is not advised for at least 24 hours. Typically, if an arthrogram is conducted on a joint, patients may need to limit using the joint for 24 hours, enabling the body to remove the injected fluid.
On the other hand, if steroids or anesthetics are administered into the joint during the arthrogram, patients may have to record the joint pain during the subsequent days and weeks.
This information may help the doctor evaluate the source of persistent joint pain and determine the most effective treatment options. Also, patients should avoid intense joint activity for two weeks.
Sample Patients Instruction After Arthrogram
Here is an example of a patient’s instruction after an arthrogram on UC Davis Health (Department of Radiology)(22).
Dos and don’ts in the days following surgery. Patients should:
- Keep a pain journal if they get steroids injections.
- Keep the injection area dry and clean for 24 hours.
- Avoid vigorous activities for 24 hours.
- Avoid motions that exacerbate pain.
Here is what to anticipate after the procedure, according to the same source(23):
- The local anesthetic often takes effect immediately and lasts for a few hours.
- Steroids typically take effect between two and seven days. Therefore, patients may suffer a period of no pain relief before the steroid works. Thus, taking pain medication may be necessary.
- After a steroid injection, some individuals may have a brief “flare” of discomfort and local edema. The flare may occur during the first 24 to 36 hours.
- Some patients suffer a temporary side effect of facial flushing and a warm sensation the day after a steroid injection.
- If patients have diabetes, they may see an increase in their blood sugar level for a few days after having an injection of steroids. Thus, individuals must monitor these levels carefully and see a physician if they have any concerns.
If patients are experiencing pain or discomfort in the afflicted area, they should:
- Apply a cold compress to the afflicted region.
- Use an over-the-counter anti-inflammatory drug, such as ibuprofen (Motrin or Advil) or acetaminophen (Tylenol), if their doctor permits.
The radiologist who conducted the arthrogram will evaluate the joint images(24). Typically, they will notify the healthcare provider of the test findings within 24 hours.
However, if an individual takes an exam on a Friday, they may have to wait longer for the results.
Then, the healthcare professional will discuss the test findings with the patients. The physician may offer more testing or other treatments, such as joint replacement surgery, to repair the joint and alleviate the symptoms.
Note that the patient information resource for radiology is vast. Hence, individuals may search for updated and reliable medical websites with content regarding different examinations and illness descriptions encompassing diagnostic and interventional radiology, nuclear medicine, radiation therapy, and radiation safety.
However, patients should ask questions to their physicians before and after the arthrogram procedure.
Meanwhile, the time it takes for the doctor to obtain a written report on the test can vary based on:
- The urgency with which the result is required
- The complexity of the test
- If the physician must provide additional information before the radiologist can evaluate the examination
- Whether patients have had prior X-rays or other medical imaging that has to be compared with this current test
- How the report is sent from the radiology facility or hospital to the doctor (i.e., phone, email, fax, or mail)
- The hospital or radiology institution will inform the patients regarding the release of a written report from the attending physician.
Benefits of Using Arthrogram
Here is how an arthrogram may help the patients(25). The injection of contrast medium into the joint increases the quality of the MRI scan or CT scan.
The following are frequent indications for an arthrogram(26):
- If the joint in the shoulder is unstable or if an ultrasound or plain MRI has not shown a potential tendon rupture
- In the hip – to detect any cartilage labrum rupture (or rim of the joint)
- In the wrist – to reveal any rupture of the wrist’s tiny ligaments
Meanwhile, Johns Hopkins Medicine listed why an arthrogram needs to be performed in patients(27). Arthrography may be performed on a joint if there are side effects, such as chronic and unexplained pain, discomfort, loss of range of motion, and alterations in the joint functions.
Other reasons for doing this examination may include(28):
- Identifying abnormalities (such as tears) in the ligaments, tendons, cartilage, and joint capsules
- Searching for loose bodies
- Examining prosthetic joints
- Checking for joint deterioration caused by repetitive dislocations
- Determining other reasons why the doctor recommends arthrography
Patients may want to ask the healthcare professional about the amount of radiation used during the treatment(29) and know the potential hazards.
Thus, keeping a record of the radiation exposure, including previous CT scans and other X-rays, is essential so that patients can alert the healthcare practitioner(30).
The cumulative number of X-ray examinations or treatments over a long period may be associated with radiation-related risks.
Most importantly, individuals should inform the healthcare practitioner if they have allergic reactions or are sensitive to medications, contrast dyes, local anesthetic, iodine, or latex.
Risks of Using Arthrogram
Johns Hopkins Medicine also listed the possible risks that come with the arthrogram procedure(31):
- Infection and bleeding at the contrast dye injection region
- The allergic response to the contrast dye is uncommon with direct arthrography as the dye is not injected into a vein.
Arthrography is not recommended for those with current arthritis or joint infections and pregnant women.
Hence, women should inform their healthcare providers if they suspect that they are pregnant.
Radiation exposure during pregnancy may result in birth abnormalities. If patients must have an arthrography test, extra measures will limit the fetus’s exposure to radiation.
In addition, there may be additional dangers depending on the particular medical condition. Before the operation, individuals should address any concerns with their physician.
Meanwhile, complications are uncommon, and the surgery is quite safe(32).
The same source cited some of the following possible risks.
Joint infection is the most severe consequence. This is often caused by organisms from the patient’s skin being transmitted into the joint during contrast medium injection. Thus, the treatment should not be performed if the skin above the joint is damaged.
Although the risk of infection is unknown, available data indicates that about one in 40,000 individuals undergoing the arthrogram test may be prone to infection.
If patients experienced increased unexplained joint pain and caught a fever, they should visit the doctor immediately.
Occasionally, individuals may be allergic to the injected contrast media. An allergic reaction usually manifests as a more severe form of a rash.
The chance of a mild response (such as hives) has been recorded in one out of every 2,000 tested individuals. It seems that more severe responses are uncommon.
Additionally, very small doses of gadolinium contrast medium used in arthrography have not been associated with complications.
What Is a Joint Steroid Injection?
Joint steroid injection is the medicine injected into the joint that may contain a local anesthetic, such as lidocaine or bupivacaine, and an anti-inflammatory drug, such as a corticosteroid(33).
Types of Technology Used in Arthrogram
The physician may utilize one or more of the following imaging techniques during the arthrogram procedure(34):
- X-rays employ a small radiation dosage to provide images of structures inside the body.
- Fluoroscopy uses X-rays to display real-time images of the joint structures on a computer, similar to viewing a movie generated from the X-rays.
- Ultrasound employs sound waves (not radiation) to produce real-time images on a computer.
- MRI utilizes a strong magnet and computer technologies to create detailed, three-dimensional images of joint tissues. Certain healthcare practitioners prefer radiation-free MRI scans.
- CT scans use X-rays and computers to capture images of the joint from various angles.
Limitation of Arthrogram
Some limitations of arthrography are the following(35):
- Conventional direct arthrography may not identify partial rotator cuff injuries.
- Some joint injuries cannot be identified by standard direct arthrography, such as cartilage abnormalities within and around the borders of some joints, bruising of nearby bones, and ligament injuries outside the joint.
Science Direct gives a brief history of arthrogram, also known as arthrography(36).
In the last century, arthrography has advanced from primitive procedures, including post-procedural radiography imaging, to contemporary CT and MR arthrographic techniques.
After the emergence of cross-sectional imaging modalities, such as CT and MR imaging, indications for arthrography declined considerably in many joints.
Still, arthrography continues to give essential anatomic information about joints and a realistic portrayal of internal disturbance.
Elbow Joint Arthrography
Imaging of the elbow joint after intra-articular contrast material injection goes back to 1952 when Lindblom24 briefly mentioned elbow arthrography is a complete study on arthrography.
Arvidsson and Johansson developed the approach most often employed today, including injection of the radiocapetellar joint immediately proximal to the radial head.
This research demonstrated the limitations of early contrast media. The iodine contrast medium included iodopyracet at a concentration of 35%.
Shoulder Joint Arthrography
Oberholzer created shoulder-joint arthrography in 1933 by evaluating capsule distortions caused by anterior dislocations using intra-articular air as a contrast medium.
He researched the “inferior recess” of the shoulder joint, a phrase he used to refer to the axillary recess and the anterior and posterior bands of the inferior glenohumeral ligament.
On the other hand, Lindblom invented arthrography of the shoulder using the X-ray camera in 1939.
The earliest account of hip arthrography in the English language was published in 1939 by Severin, who documented its use on infants with congenital hip dislocation.
The contrast agent was 35% perabrodil, the first commonly manufactured water-soluble iodinated contrast medium.
The injection was typically administered blindly through an anterior route, guided by anatomic landmarks. However, radiographs might be utilized to orient the arthrographer if necessary.
In 1905, the knee was the first joint to be evaluated using arthrography. Although Werndorff and Robinson first utilized air as a contrast medium, the double-contrast approach eventually proved preferable for evaluating menisci and hyaline cartilage.
In the 1960s, fluoroscopic spot films after knee arthrography became widespread.
Kessler and Silberman initially reported wrist arthrography in 1961, describing radiocarpal-joint injections in patients with “wrist injuries with negative X-ray tests.”
They showed that intra-articular delivery of contrast media into the radiocarpal joint enabled imaging of triangular fibrocartilage (TFC) flaws undetected by standard radiography.
Borak and Goldhamer presented ankle arthrography in 1925. Wolff subsequently described the efficacy of subtalar arthrography in ankle supination injuries in 1940.
In 1944, Berridge and Bonnin concluded that ankle arthrography was beneficial for detecting tibiofibular syndesmotic rupture, which did not appreciably contribute to the information acquired from normal stress radiographs.
- Direct Arthrography
- Direct Arthrography
- Direct Arthrography
- Indirect arthrography
- What is a Joint Arthrogram?
- Arthrography Examination
- What is an Arthrogram or Joint Injection?
- Direct Arthrography
- What is a Joint Arthrogram?
- Arthrography Examination
- What is a Joint Arthrogram?
- Arthrography Examination
- Direct Arthrography
- History of Arthrography