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Arthrography

(Joint X-ray, Arthrogram)

Procedure Overview

What is arthrography?

Arthrography is a type of diagnostic radiology procedure used to examine a joint, such as the knee or hip, when standard x-rays are not adequate. After the injection into the joint of a radiopaque substance (a substance which appears white on x-rays) and/or air, a series of x-rays is taken with the joint in various positions to assess the soft tissues of the joint.

While arthrography is most commonly used to examine the knee and shoulder joints, it may also be used to examine other joints, such as the wrist, ankle, hip, elbow, or temporomandibular joint (TMJ, or the joint connecting the upper and lower jaw).

Other related procedures that may be used to diagnose problems of the joints may include magnetic resonance imaging (MRI) of the joints, computed tomography (CT scan) of the joints, x-rays, joint aspiration, and arthroscopy. Please see these procedures for additional information.

Anatomy of the shoulder:

The shoulder is made up of several components, including the following:

• bones - the collarbone (clavicle), the shoulder blade (scapula), and the upper arm bone (humerus).
• joints - facilitate movement, including the acromioclavicular (AC) joint (where the clavicle meets the acromion) and the shoulder joint (glenohumeral joint) that facilitates forward, circular, and backward movement of the shoulder.
• ligament - a type of tough, elastic connective tissue that surrounds the joint to give support and limits the joint's movement. The ligaments of the shoulder include the joint capsule (a group of ligaments that connect the humerus to the socket of the shoulder joint on the scapula to stabilize the shoulder and keep it from dislocating), ligaments that attach the clavicle to the acromion, and ligaments that connect the clavicle to the scapula by attaching to the coracoid process.
• acromion - the roof (highest point) of the shoulder that is formed by a part of the scapula.
• tendon - a type of tough connective tissue that connects muscles to bones and helps to control movement of the joint.
• muscle - a strong, contractile tissue that helps support and rotate the shoulder in many directions.
• rotator cuff - composed of tendons, the rotator cuff (and associated muscles) holds the ball of the glenohumeral joint at the top of the upper arm bone (humerus).
• bursa - a fluid-filled sac located between bones, ligaments, or other adjacent structures that helps cushion joints. In the shoulder, the bursa is located between the rotator cuff muscle layer and the outer layer of large, bulky muscles and keeps the rotator cuff from rubbing on the shoulder joint.

Anatomy of the knee:

The knee is a vulnerable joint that bears a great deal of stress from everyday activities such as lifting and kneeling, and from high-impact activities such as jogging and aerobics.

The following parts form the knee:

• tibia - shin bone or larger bone of the lower leg.
• femur - thighbone or upper leg bone.
• patella - kneecap.

Each bone end is covered with a layer of cartilage that absorbs shock and protects the knee. Basically, the knee is two long leg bones held together by muscles, ligaments, and tendons.

There are two groups of muscles involved in the knee, including the quadriceps muscles (located on the front of the thighs), which straighten the legs, and the hamstring muscles (located on the back of the thighs), which bend the leg at the knee.

Tendons are tough cords of tissue that connect muscles to bones. Ligaments are elastic bands of tissue that connect bone to bone. Some ligaments of the knee provide stability and protection of the joints, while other ligaments limit forward and backward movement of the tibia (shin bone).

Reasons for the Procedure

Arthrography may be performed on a joint when there has been persistent and unexplained pain, discomfort, and/or dysfunction in the joint. Other reasons to perform arthrography may include, but are not limited to, the following:

• to identify abnormalities (e.g., acute and chronic tears) in the soft tissues of the joint, such as ligaments, cartilage, and joint capsules
• to detect derangement of the internal joint
• to evaluate damage from recurrent dislocations of the joint
• to visualize synovial cysts

There may be other reasons for your physician to recommend arthrography.

Risks of the Procedure

You may want to ask your physician about the amount of radiation used during the procedure and the risks related to your particular situation. It is a good idea to keep a record of your past history of radiation exposure, such as previous scans and other types of x-rays, so that you can inform your physician. Risks associated with radiation exposure may be related to the cumulative number of x-ray examinations and/or treatments over a long period of time.

Patients who are allergic to or sensitive to medications, contrast dyes, local anesthesia, iodine, shellfish, or latex should notify their physician.

Some potential risks of arthrography include, but are not limited to, the following:

• infection at the puncture site where the radiopaque substance and/or air is injected
• allergic reaction to the radiopaque substance; however, such a reaction is rare because the substance is not injected into a vein

Arthrography is not recommended for persons with active arthritis or with joint infections.

If you are pregnant or suspect that you may be pregnant, you should notify your physician. Radiation exposure during pregnancy may lead to birth defects. If it is necessary for you to have an arthrography examination, special precautions will be made to minimize the radiation exposure to the fetus.

There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.

Before the Procedure

• Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• You may be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.
• Generally, there is no special restriction on diet or activity prior to an arthrography procedure.
• Notify your physician if you are sensitive to or are allergic to any medications, latex, tape, anesthetic agents (local and general), contrast dyes, iodine, and shellfish.
• Notify your physician of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
• Notify your physician if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
• If you are pregnant or suspect that you are pregnant, you should notify your physician.
• Based upon your medical condition, your physician may request other specific preparation.

During the Procedure

Arthrography may be performed on an outpatient basis or as part of your stay in the hospital. Procedures may vary depending on your condition and your physician’s practices.

Generally, arthrography follows this process:

1. You will be asked to remove any clothing, jewelry, or other objects that may interfere with the scan.
2. If you are asked to remove clothing, you will be given a gown to wear.
3. You will be positioned on the examination table in the procedure room.
4. X-rays of the joint may be taken prior to the injection of the radiopaque substance for comparison with the images obtained after the substance is injected.
5. The skin around the joint to be examined will be covered with sterile drapes and cleaned with an antiseptic solution.
6. The area around the joint will be numbed by injection of a local anesthetic. You will feel a numbing sensation.
7. If there is fluid in the joint, this fluid will be aspirated (removed) with a syringe.
8. The radiopaque substance will be injected into the joint. After this injection, you may be asked to move the joint so that the radiopaque substance can be distributed evenly throughout the joint. You may be asked to exercise the joint. In the case of knee arthrography, you may be asked to walk around for a few minutes.
9. Once the radiopaque substance has been distributed through the joint, multiple x-rays will be made with the joint in various positions. In some cases, a special frame or traction may be used to spread out the joint for a wider view of the joint. Items such as pillows or sandbags may be used to help position the joint.

While the arthrography procedure itself causes no pain, having to hold the joint still in certain position for the procedure might cause some discomfort or pain, particularly in the case of a recent injury or invasive procedure such as surgery. The technologist will use all possible comfort measures and complete the procedure as quickly as possible to minimize any discomfort or pain.

After the Procedure

Your physician will give you specific instructions regarding movement of the joint, pain medication, care of the affected joint, symptoms to watch for, and any activity restrictions.

You may be asked to rest the joint for several hours after the procedure.

Some mild swelling may be noted in or around the joint. Your physician may suggest that you apply ice to the joint if swelling occurs. If swelling continues or increases after a day or two, you should notify your physician.

Take a pain reliever for soreness as recommended by your physician. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications.

After a knee arthrogram, the affected knee may be wrapped with an elastic bandage for several days. Your physician will teach you how to unwrap the bandage.

You may notice some clicking or cracking noises with movement of the joint for a few days after the procedure. This is normal, and should resolve within a few days.

Notify your physician to report any of the following:

• fever
• redness, swelling, bleeding, or other drainage from the injection site
• increased pain around the injection site

You may resume your normal diet unless your physician advises you differently.

Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.

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