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RSNA 2009
page 1 of 10
Essentials of Arthrography
Arthrography 101: Shoulders & Hips
Ken Schreibman, PhD/MD
University of Wisconsin
Department of Radiology
Musculoskeletal Section
Originally presented at part of RSNA
Essentials Course, 12/1/2009
Attended by 1,700 Radiologists
©Ken L Schreibman, PhD/MD 2015
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How “essential” is arthrography?
“Arthrography”: Opacify a Joint
Isn’t this an archaic technique?
NO!
UW 2009:
>1100 joint injections Raise
your
Of all of you sitting here,
hand
how many have been asked to
stick a needle into a joint at least
once this year?
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Arthrography common pre-MRI
Double Contrast
Normal
Posterior Horn
Knee Arthrography
Medial Meniscus
1960 – 1990
Disclosures…
I have no financial disclosures
$
I will be mentioning off-label Gd use
Arthrography is an old technique
1906: Pneumoarthrography
TB Synovial thickening
Mosby Year Book, 1992, 1995
(Currently out of print)
Eisenberg p.252
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Arthrography: 21st Century
Therapeutic Tool
 Inject therapeutic agent into a joint
 Hyaluronan (visco-supplementation)
FDA approved for OA knee
@UW 1990: 800!
Vertical Tear
Posterior Horn
Medial Meniscus
Required a lot of varus &
valgus stress on the knee
 Unpleasant for both
patient and radiologist
Courtesy of Arthur De Smet, MD
University of Wisconsin, Madison
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


Typically injected blindly in clinic.
May ask for image guidance when
can’t feel landmarks in knee.
 Steroid: weeks-months pain relief
©Ken L Schreibman, PhD/MD 2/3/15
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RSNA 2009
page 2 of 10
Steroids UW MSK
Triamcinolone
Suspension,
not solution
Granular,
stays locally
Need to
re-suspend prior to use
Commonly used for spine injections
 UW 2009: >1000 ESI, NRB
Solution, used superficial structures
Less subcutaneus fat atrophy
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Therapeutic Tool
Diagnostic Tool
Tend NOT inject steroids
into large joints (hip, shoulder, knee)
Unless specifically requested
Patients awaiting arthroplasty
Deep (Facets, SI): Triamcinolone
Superficial (AC): Dexamethasone
Want to prove pain is from hip
prior to hip arthroplasty surgery.
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Anesthetics UW MSK
ALWAYS provide skin anesthesia
1% Lidocaine: Bicarbonate (9:1)
Local
Our surgical
Anesthesia colleagues
Deep
anesthetic agent into a joint
 Inject
 Prove pain is coming from within joint
Pt with bad DJD of hip and
 e.g. bad
DDD of lumbar spine.

Arthroscopy, Vol 24, No 4 (April) 2009: pp 337-347
Often inject small joints
Dexamethasone 10mg/ml
Steroids in joints
Concern cartilage loss
Lidocaine Potentiates the
Chondrotoxicity of Methylprednisolone
Skin
30g
½"
27g
1½"
often do not
provide skin
anesthesia
prior to their
steroid
injections…
it really hurts!
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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?
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RSNA 2009
page 3 of 10
Injection Cocktails
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Therapeutic Tool
Request:
Sub-deltoid
Fluoro
Bursitis
Asp Septic
(NoShoulder
fluid in joint)
T2fs
Fluid in
sub-deltoid
bursa
No fluid in
Diagnostic Tool
gleno-humeral
joint
T1fs+Gd(IV)
T1fs+Gd(IV)
 Inject
 Aspirate fluid from joint

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 Septic  Culture (Gram Stain, Cell count)
 Crystals  Polarizing microscopy
 Prudent to first confirm there IS fluid in joint
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Sub-deltoid Bursitis (No fluid in joint)
Don’t need to do
fluoroscopicguided aspiration
of shoulder
capsule…
T2fs
T2fs
H,M 43yoF
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Therapeutic Tool
T1fs+Gd(IV)
T1fs+Gd(IV)
Instead, do
ultrasoundguided aspiration
of bursal fluid
collection.
Diagnostic Tool
 Inject
pre-aspiration
post-aspiration
H,M 43yoF
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 Inject contrast prior to MR or CT
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RSNA 2009
page 4 of 10
No longer used as a primary diagnostic tool
Contrast in Bursa
Rotator Cuff Tear
Contrast in capsule
Nowadays, surgeons
want to see more…
They want to see torn
end of supraspinatus:
Arthrography: Why we do it
Therapeutic Tool
Diagnostic Tool
 Inject
Needle in capsule
Contrast in joint
Sagittal
Coronal
W,L 43yoM
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Arthrography: What we need
IMAGE GUIDANCE
 Inject contrast prior to MR or CT
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Ultrasound: Pediatric Hips
Fri 20:55
UW Peds ER
Right
Can’t be assured of getting a needle
into hip/shoulder without imaging
 With experience, should be able to
blindly get a needle into knee
Knees commonly injected in clinic
 Clinics may request image guidance
when injecting knees of “larger” pts.
Left
Joint
Effusion
No Fluid
Diaphysis
Young patients: Ultrasound
Fri 16:25
Outside Clinic
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Ultrasound: Pediatric Hips
Right
Fri 20:55
UW Peds ER
Left
C,I 14moM
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IMAGE GUIDANCE
Can’t be assured of getting a needle
into hip/shoulder without imaging
Joint
Effusion
No Fluid
Diaphysis
Fri 23:30
UW Peds ER
Sat 03:10
UW Peds OR
Post aspiration 2ml pus
C,I 14moM
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 With experience, should be able to
blindly get a needle into knee
 Knees commonly injected in clinic
 Clinics may request image guidance
when injecting knees of “larger” pts.
Young patients: Ultrasound
Most patients: Fluoroscopy
Preferably C-arm Fluoroscopy
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RSNA 2009
page 5 of 10
C-Arm Fluoroscopy
C-Arm Fluoroscopy
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Positioning Patient
Shoulder:
Hip:
External
Rotation
Sandbag
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TARGET SITE 
Keys to Arthrography
Target is NOT the joint
Internal
Rotation
Sandbag
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
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Marty
Joint Capsule: Hip
TARGET SITE 

GT
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Joint Capsule: Hip




TARGET SITE: Capsule widest:
Head-Neck Head-Neck Junction
Junction
LT
M,S 34yoF
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L,J 43yoF
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RSNA 2009
page 6 of 10
Joint Capsule: Shoulder
TARGET SITE : RC Interval
Non-sterile tray

Bursa
=RCT
Cor

GT
LT
 Sub-
M,G 52yoM
Recess
Axillary
A,W 42yoM
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Sterile Tray: Prep & Drapes
Sticky drape
with hole
Clean &
sterilize
skin
 To prove which side

Biceps
Groove
IMAGE GUIDANCE
TARGET SITE 
NON-STERILE TRAY
STERILE TRAY
 To localize & mark target 
Metal R/L

 scapularis
Recess
Places
contrast
normally
flows…
Metal pointer & marker
$1.25/each
B,P 29yoF
J,C 48yoF
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Sterile Tray
If tray is set up before patient enters
it is important to COVER TRAY
to prevent patient contaminating it!
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Sterile Tray: Syringes
Local anesthetic (1% Lido:Bicarb 9:1)
4x4"
sponges
10ml syringe w/skin needle 
Contrast
(iohexol 300 mgI/ml)
5ml syringe w/connecting tube 
Additional sterile
drapes/towels
Sterile covers for
image intensifier
and controls
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Cocktail
10ml syringe w/18g drawing up  needle
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RSNA 2009
page 7 of 10
Arthrography: How we do it
Local anesthesia
Local Anesthesia
Skin: 30g ½" needle
 DON’T raise
a wheal
“You will feel a bee sting”
“This will burn for a few seconds,
and then will be numb”
2 needles
Skin: 30g ½" needle
Deeper: 1½" needle
Skin
Sub-Q
Fat
Advance
needle
vertically
Skin
Pain
Sub-Q
Receptors Fat
Bone
Capsule
Pain
Receptors
Bone
Capsule
www.redbubble.com/people/tkss/art/2578224-2-scary-hairy
schreibman.info
Local Anesthesia
Deeper: 1½" needle Advance
needle
Local Anesthesia
Deeper: 1½" needle Advance
needle
vertically
Shoulder: RC Int
Can reach bone
with 1½" needle
Use 22g
vertically
Skin
Sub-Q
Fat
 Anesthesia
Capsule
 Advance needle
through capsule,
touching bone
Pain
Receptors
Bone
Deep
Lumbar
Epidural
Steroid
Injection
Pain
Receptors
 Anesthesia only
2015
Bone
Capsule
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ADVANCE NEEDLE SLOWLY
Don’t just jab it in there…
Aspirate
Pus
Inject
Shoulder
Anesthesia
Skin
 
30g 27g
½" 1½"
Can’t reach bone
with 1½" needle
Use 27g
Skin
Sub-Q
Fat
Sterile Tray: Needles
Inject
Hip
Hip:
Use 22g 3½"
spinal needle to
reach bone
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Biopsy
Soft
Bone

22g
1½"



18g
25g
22g
3½"
3½"
3½"
Biopsy
Hard
 Bone
13g
Bx

14g
Bx
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RSNA 2009
page 8 of 10
Example: Hip Arthrogram
ADVANCE NEEDLE SLOWLY
Use 2 hands:
One hand on needle hub
One hand on patient’s skin
Allow needle to pass between
your thumb & index finger tips
so you can feel the needle
being advanced
Advance just a few mm at a time
Check fluoro, readjust position
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D,E 93yoM
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ADVANCE UNTIL HIT BONE
Don’t stop at the capsule
WATCH FIRST DROP
OF CONTRAST Skin
Should flow away
from needle tip
If contrast stays
by needle tip,
needle is NOT
in a space!
(Extravasation)
D,E 93yoM
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Bone
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Needle
repositioned
Contrast
flowing
away
from
needle
D,E 93yoM
Synovium
Capsule
Recognizing Extravasation: Hip
Sub-Q
Fat
schreibman.info

Contrast
Contrast
stays
byby
stays
needle
needle
D,J 61yoM
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RSNA 2009
page 9 of 10
& Repositioning Needle
Contrast
flowing
away
from
needle
Needle
re-repositioned
Not contrast
flowing into
capsule
Contrast in
capsule
Sagittal T1
(Fat-Suppressed)
Extravasation
into muscle
D,J 61yoM
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Recognizing Extravasation: Shoulder
S,J 33yoF
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Recognizing Extravasation: Shoulder
& Repositioning Needle
Extravasation into
subscapularis
Cor

Slight amount
contrast in joint

Contrast in
subscapularis
recess
Contrast NOT
flowing away
from needle
Z,A 29yoF
schreibman.info
Shoulder Arthrogram pre MRI
Contrast
flowing away
from needle
Axial T1
(Fat-Suppressed)
Z,A 29yoF
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Sterile Tray: Syringes
Arthrogram MR/CT
Local anesthetic (1% Lido:Bicarb 9:1)
10ml syringe w/skin needle 

Contrast
filling
capsule

Contrast
filling

Contrast filling Biceps
Axillary recess sheath
Contrast
in joint
Contrast
filling
capsule
Mixed Injection
(½ in, ½ out)

Contrast in
biceps
sheath
H,J 71yoM
schreibman.info
 Deep sub-Q needle
 3½" (hip)
20ml syringe
 25-50% Iodine (5-10ml iohexol 300mgI/ml)
 50% anesthetic (5ml 1%Lido, 5ml Ropi)
 0.1ml Gd
Extra needle

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RSNA 2009
page 10 of 10
Two Tips…
MR Arthrogram
 Make sure Gd gets into cocktail!
 0.1ml Gd in 1ml (tuberculin) syringe
Make sure
Gd doesn’t
get trapped
in the hub,
Two Tips…
MR Arthrogram
 Avoid Air Bubbles!
Air in joint causes susceptibility artifact
 Get air out of arthrogram needle hub
 Extra needle on
Drop tip extra
connecting tube
needle into hub
of arthro needle.
Fill the hub from
bottom to top.
Remove extra
needle and do
wet-connect.

actually
but
enters
solution
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Metal Hip: Injecting
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Metal Hip: Aspirating
Can’t see metal needle
Prove you’re “in”
by seeing contrast flow thru metal prosthesis
into synovial capsule Capsule is thick and
fibrotic (like wood)
Loose acetabular component
r/o infection pre replacement
Requested aspiration
Skin
Sub-Q Fat
Synovial capsule
constricted around
head-neck junction
Target: Head-Neck Junct
Don’t stop when
touch wood…
Go until touch
metal
Metal
Capsule
Synovium
S,G 79yoF
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When aspirating 18g Needle
suspected pus, use: 20ml Syringe
S,J 70yoM
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Test needle location
by injecting contrast:
Test needle location
by injecting contrast:
Flowing into
synovial capsule
TargetNot flowing into

synovial capsule
Reposition
needle
Asp 20ml
1st Needle
placement
Asp No Fluid
S,J 70yoM
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S,J 70yoM
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