Joint Distension Research Articles

TMJ synovial chondromatosis - an evaluation of 37 patients.

The authors evaluated a cohort of 37 patients with histologically verified synovial chondromatosis (SC) between 2013 and 2022. The cohort consisted of 37 patients (26 women, 11 men). 36 patients had unilateral involvement, while one patient had bilateral involvement. The average age of the patients was 54.77 years. The authors used the Milgram histopathological classification. They evaluated SC localisation, clinical symptoms, diagnostics and treatment (including recurrence incidence) in this cohort. In 31 patients (83.7%) SC affected only the upper joint space in one patient (2.7%) the lower space, and in five patients (13.6%) both spaces. 12 patients (32%) were Milgram Stage 1 (presence of synovial metaplasia without loose bodies), eight patients (22%) were Stage 2 (presence of synovial changes, loose bodies), and 17 patients (46%) were Stage 3 (presence of loose bodies, no synovial changes). Pain was the dominant clinical symptom (32 patients, 86.4%). Treatment consisted of arthroscopy and open surgery. Two patients underwent primary reconstruction and total TMJ replacement. Treatment was successful in 89.2% of cases (33 patients), with four (10.8%) patients suffering recurrence. As this patient cohort shows, pain was the dominant symptom in patients with SC. Magnetic resonance imaging is fundamental in the diagnosis of SC, demonstrating pathological findings even in patients for whom an initial X-ray was negative. These were mainly patients with Milgram Stages 1 and 2 without calcification, loose bodies or pathological changes of the bone structures. This is why the authors recommend MRI for any patient experiencing pain for more than three months, and if this reveals an effusion, joint distension or intraarticular soft tissue mass, they will always indicate arthroscopy. Thorough follow-up of patients is recommended, although SC recurrence is not very frequent. The authors recommend follow-up one, three and six months after surgery, and then annually for the first five years after surgery. They recommend follow-up MRI one, two and five years after surgery.

Direct MR arthrography without image guidance: a practical guide, joint-by-joint.

Direct MR arthrography (dMRA) is a fundamental technique in diagnosing pathology in major peripheral joints, allowing for precise evaluation of intra-articular structures. Although injection guidance is typically performed using imaging techniques such as ultrasound or fluoroscopy, puncture via anatomical landmarks may be useful in certain circumstances where it has been proven to be a safe and effective procedure. This paper describes the indications and injection technique of dMRA, joint by joint, focusing on the different technical details, from the most common locations, like the shoulder or hip, to those with more restricted clinical indications, such as the wrist, knee, elbow, or ankle. The most relevant anatomical landmarks are detailed for each joint, aiding in the intra-articular introduction of diluted contrast, highlighting the most accessible trajectories and structures to avoid when inserting the needle. Additionally, tips are provided to facilitate proper joint distension. With all this information, this paper aims to serve as a suitable reference guide for performing dMRA without image guidance if needed.

Comparison of standing cone‐beam computed tomography and low‐field magnetic resonance imaging findings in the equine metacarpo‐ or metatarsophalangeal region of standing sedated horses

SummaryBackgroundCone‐beam computed tomography (CBCT) and low‐field magnetic resonance imaging (MRI) are increasingly used in standing horses, so it is important to understand an efficient application of these imaging modalities.ObjectiveTo compare CBCT and MRI findings in the metacarpo (MCP)/metatarsophalangeal (MTP) region of clinical patients imaged for diagnostic purposes.Study designRetrospective study.MethodsThe CBCT and MRI images of the MCP/MTP region from equine clinical patients undergoing both standing MRI and CBCT imaging for lameness localised to the fetlock region (2021–2023) were retrospectively reviewed. Presence, location and imaging features of lesions were compared between modalities using descriptive analysis.ResultsImaging studies of 24 MCP/MTP regions from 22 horses were included. CBCT provided the assessment of subchondral bone integrity in palmar/plantar osteochondral disease, details of the length and associated attenuation changes of third metacarpal/tarsal parasagittal groove and proximal phalanx sagittal groove fissures, structural integrity and attenuation changes of subchondral and trabecular bone injuries, proximal phalanx dorsoproximal defects and anatomical and structural details of proximal sesamoid bone injuries. MRI provided the evaluation of short tau inversion recovery (STIR) hyperintensity associated with bone lesions and the extent of increased fluid accumulation in bone. CBCT revealed reduced joint space, indicating articular cartilage loss, while MRI showed joint distension and synovitis. MRI revealed generalised osseous STIR hyperintensity associated with septic arthritis. Soft tissue injuries were most identified by MRI except for heterotopic mineralisation most detected by CBCT.Main limitationsImaging findings not verified by a gold standard.ConclusionsCBCT and MRI contributed different diagnostic information so optimal information was obtained by using both modalities. Standing CBCT showed changes in bone structure and attenuation but was limited in detecting soft tissue injuries. Standing MRI showed increased fluid accumulation in bone and soft tissue injuries but was limited in assessing structural details of bone injuries.

Use of equine cadaver limb models to enhance veterinary student self-efficacy during arthrocentesis.

To determine if equine cadavers modified with joint distension would yield higher fluid volumes, require fewer needle redirects, and improve student self-efficacy. 19 third-year veterinary students. Voluntary participation was sought during 4 sessions of an equine arthrocentesis and diagnostic analgesia laboratory. Half of the sessions were provided with unmodified cadavers and half were provided with cadavers modified with joint distention. Prior to and after the laboratory, participating students completed surveys regarding their self-efficacy with arthrocentesis of the metacarpophalangeal and distal interphalangeal joints. During the study, the number of needle redirects and the volume of fluid obtained was recorded. Increased fluid volumes were obtained from the modified metacarpophalangeal and distal interphalangeal joints. No difference was identified in number of needle redirects between cadaver types for either joint. Self-efficacy scores increased at the end of the laboratory for arthrocentesis of the metacarpophalangeal joint in both modified and unmodified groups. Self-efficacy scores increased at the end of the laboratory for arthrocentesis of the distal interphalangeal joint for the modified but not unmodified groups. Modified equine cadavers provided a higher fluid yield following arthrocentesis compared to unmodified cadavers, but despite this, multiple attempts were required for proper needle placement. Performing equine arthrocentesis improved student self-efficacy with the task. Given our results, the model used for introduction to performing equine arthrocentesis may be less important than practice with the skill. In order to improve proficiency and self-efficacy, equine arthrocentesis should be provided multiple times throughout the veterinary curriculum.

Direct MR arthrography of the hip joint: anterior approach without imaging guidance.

The purpose of this study is to describe the anterior injection approach, with anatomical landmark guidance, for direct MR arthrography (dMRA) of the hip joint, and to evaluate the effectiveness in joint distension and the security of the technique. Retrospective review of hip dMRAs was conducted on patients with suspected intra-articular pathology from two MR outpatient centers, performed by two radiologists with 25 and 5years of experience, respectively. The analysis included assessing the presence of intra-articular contrast material (gadolinium-based solution), the number of injections performed, the degree of joint distension, and the degree of contrast extravasation. A multi-variant analysis was carried out to determine if the procedure success depend on any of the demographic variants or on the radiologist experience. Additionally, the presence of immediate and medium-term post-puncture complications was evaluated. One hundred patients with 104 hip dMRA were included; 60 were men, with mean age of 38years (16-63years). Contrast material was successfully introduced intra-articularly in 100% of patients, being necessary a second puncture only in 6% of procedures. The capsular distension was considered optimal for diagnosis in 97% of cases. Different degrees of contrast extravasation were found in 30% of dMRA. There was no statistically significant relationship observed between patient variables and the performance of dMRA, nor did it show any correlation with the experience of the radiologists. No puncture-derived complications were found. Hip dMRA through anterior injection guided by anatomical references is an effective and safe alternative for patients with suspected intra-articular pathology.

Shoulder magnetic resonance arthrography in dogs: Comparison of craniolateral and caudolateral approach for ultrasound-guided contrast injection.

Shoulder joint disease is a common cause of forelimb lameness in dogs. To diagnose this condition, shoulder magnetic resonance arthrography (MRA) is performed, which involves the injection of contrast agents into the shoulder joint space under ultrasound (US)-guidance. The objective of this study was to compare the craniolateral and caudolateral approaches for shoulder MRA using US-guided injection techniques, and investigate their clinical feasibility in dogs. Forty shoulder joints from 10 adult beagles were studied in two repetitions. The craniolateral (n = 20) and caudolateral (n = 20) injection techniques were applied randomly under US-guidance. The shoulder MRA was conducted immediately after the contrast agents was injected. The procedure time (scan and injection time), number of attempts, joint distension and degree of extraarticular extravasation were recorded and compared between the two groups. The results showed that the caudolateral approach had significantly more contrast agents extravasation compared to the craniolateral approach (p < 0.05). However, there were no significant differences between the two groups in terms of procedure time (scan time p = 0.80, injection time p = 0.74), number of attempts (p = 0.70) and joint distension (p = 0.23). The craniolateral approach of US-guided contrast injection techniques for shoulder MRA minimizes damage to the juxta-articular structures and reduces extraarticular extravasation, resulting in good-quality images. This study demonstrates the feasibility and advantages of the craniolateral approach under US-guidance for shoulder MRA in dogs.

Washing Out the Septic Knee

Abstract Effective drainage of joint purulence is a key component of the management of the septic knee. Methods from arthrocentesis to open arthrotomy and arthroscopy are mainstays, with different efficacies and morbidities. Percutaneous tube instillation techniques have been employed since World War I. Methods to effect joint distension and irrigation to mimic what is accomplished at arthroscopy employed over the past 65 years have been honed to a simple bedside technique since the 80s and applied successfully in management of several different arthritides, including septic arthritis. Wider employment of this technique has the potential to more effectively treat the septic knee, particularly when access to O.R. based procedures is limited, as well as allow usage by physicians who do not perform arthroscopy.

MRI and CT findings of compressive cervical myelopathy in a dog with suspected immune‐mediated polyarthritis presenting with tetraparesis

AbstractAn 11‐month‐old, male, entire Great Dane dog presented with acute‐onset non‐ambulatory tetraparesis. Three months before presentation, the dog was treated for a suspected dog bite injury. Examination revealed pyrexia (39.7°C) and marked multiple joint swelling, with cervicalgia and non‐ambulatory tetraparesis. Based on clinicopathological findings and diagnostic imaging, a diagnosis of type II immune‐mediated polyarthritis was reached. The tetraparesis was investigated using magnetic resonance imaging and computed tomography, allowing the identification of compressive cranial cervical myelopathy secondary to severe occipitoatlantoaxial joint and multiple facet joint distension. The patient was initially treated with antimicrobial therapy with resolution of the pyrexia. Given the persistent severe multiple joint swelling and tetraparesis, immunosuppressive therapy was started. Due to refractory disease and poor prognosis, euthanasia was elected 97 days following presentation. To the authors’ knowledge, compressive cervical myelopathy associated with immune‐mediated polyarthritis has not been previously reported in the veterinary literature.

Distraction Gap Needed for Safe Central Compartment Access in Hip Arthroscopy

Background: Sufficient distraction of the hip is the key to a safe central compartment (CC) approach in hip arthroscopy. However, an adequate distraction gap has not been scientifically identified. Purpose: To determine the sufficient amount of distraction that could predict a successful CC access as well as to identify the risk factors for a failed or difficult CC access. Study Design: Case-control study; Level of evidence, 3. Methods: All patients who underwent hip arthroscopy by a single surgeon between January 2018 and April 2019 were prospectively enrolled. We analyzed gaps of the hip on 4 C-arm fluoroscopic images: nondistraction, preoperative manual traction, preoperative maximal traction (without distension), and intraoperative maximal traction (at the end of CC procedures in a successful CC approach or after peripheral compartment procedures in a failed or difficult CC approach). A failed CC approach was defined as failure in introducing the anterolateral portal to the CC under arthroscopic control; a difficult CC approach was defined as the presence of an incomplete diagnostic round in the CC because of a small distraction. The amount of distraction was evaluated by the ratio of the distracted gap to the undistracted gap. Patients were classified into the successful CC access group (group 1) and the failed/difficult CC access group (group 2). The amount of distraction, demographic characteristics, and preoperative radiographic parameters were compared between the groups. Results: A total of 240 patients were included in this study. Group 1 consisted of 205 patients (113 males and 92 females; mean ± SD age, 34.5 ± 11.4 years), and group 2 consisted of 35 patients (27 males and 8 females; age, 32.5 ± 11.2 years). The preoperative joint space width was not significantly different between group 1 (mean ± SD, 3.89 ± 0.83 mm) and group 2 (3.68 ± 0.68 mm). The ratio of the amount of distraction at lateral gaps under all traction conditions was significantly greater in group 1 compared with group 2 (1.50 ± 0.54 vs 1.26 ± 0.35, respectively, under preoperative manual traction; 2.84 ± 0.76 vs 2.03 ± 0.63 under preoperative maximal traction; 3.36 ± 0.96 vs 2.50 ± 0.79 under intraoperative maximal traction). An increase of the lateral gap by >2.2 times (P < .001) under preoperative maximal traction and by >2.7 times (P < .001) under intraoperative maximal traction could predict successful CC access. Male sex (odds ratio [OR], 2.94; P = .017) and increased lateral center-edge angle (OR, 1.08 for every 1° increase; P = .004) were significant risk factors for failed/difficult CC access. Conclusion: An increase of the lateral gap by >2.2 times during an unsterile traction test without joint distension could predict successful CC access. Male sex and increased lateral center-edge angle were risk factors for a failed or difficult CC access.

Cross-sectional reliability and concurrent validity of a quantitative 2-dimensional ultrasound image analysis of effusion and synovial hypertrophy in knee osteoarthritis

ObjectiveEffusion-synovitis is related to pain and progression in knee osteoarthritis (OA), but current gold standard ultrasound (US) measures are limited to semi-quantitative grading of joint distension or 1-dimensional thickness measures. A novel quantitative 2-dimensional image analysis methodology is applied to US images of effusion-synovitis; reliability and concurrent validity was assessed in patients with knee OA. MethodsCross sectional analysis of US images collected from 51 patients with symptomatic knee OA were processed in ImageJ and segmented in 3DSlicer to produce a binary mask of the supra-patellar synovitis region of interest (ROI). Area measures (mm2) of total synovitis, effusion and hypertrophy components were exported. Intra-rater reliability and test-retest reliability (1–14 days washout) were estimated with intra-class correlation coefficients (ICCs). Concurrent validity was measured by Spearman correlations between quantitative measures and gold standard OMERACT and caliper measurements of synovitis. ResultsIntra-rater reliability for hypertrophy area was estimated at 0.98, 0.99 for effusion area, and 0.99 for total synovitis area. The test-retest reliability for total synovitis area was 0.63 (SEM 87.8 ​mm2), 0.59 for hypertrophy area (SEM 21.0 ​mm2), and 0.64 for effusion area (SEM 73.8 ​mm2). Correlation between total synovitis area and OMERACT grade was 0.84, 0.81 between total synovitis area and effusion-synovitis calipers, and 0.81 between total effusion area and effusion calipers. ConclusionThis new research tool for image analysis demonstrated excellent intra-rater reliability, good concurrent validity, and moderate test-retest reliability. Quantitative 2D US measures of effusion-synovitis and its individual components may enhance the study and management of knee OA.

Rheumatoid arthritis characteristics and classification of heat and cold patterns–an observational study

IntroductionTraditional Chinese medicine (TCM) has been proven to be an effective complementary therapy in treating rheumatoid arthritis (RA). The cold pattern and the heat pattern were the two main TCM patterns for RA, which is crucial for TCM treatment. The cold pattern is characterized by fear of cold and wind, joint pain with a thin white tongue coating which can be relieved by hot herbs. In contrast, heat pattern patients suffer from severe joint pain with a yellow coating, with red swelling of the skin and high skin temperature which can be relieved by cooling herbs. ObjectiveWe aimed to classify the heat and cold patterns in RA patients with cluster analysis and factor analysis. Moreover, we aimed to explore the association of RA characteristics between these two patterns. Methodsand Design: A cross-sectional observational research method was used, and data was collected on 300 RA patients in Hangzhou in China. Signs and symptoms associated with RA were clustered using SPSS 22.0 software. In addition, factor analysis was also used for the classification. After classification of heat and cold patterns, characteristics and treatment of the RA participants between the two patterns were explored. ResultsRA patients in the study were divided into two categories using cluster analysis. Twenty-two symptoms in the first category were included in the heat pattern of RA patients. After factor analysis, nine principal components were extracted to heat pattern. The component with the highest eigenvalue (2.530) were mainly contributed by shortness of breath, palpitation, heavy limbs, chest tightness and yellow greasy tongue with high factor loading values (0.765, 0.703, 0.504, 0.429 and 0.402, respectively). Ten symptoms in the second category were included in the cold pattern of RA patients. Four principal components were extracted to cold pattern. The component with the highest eigenvalue (2.089) were mainly contributed by joint distension and pain, joint stiffness, fatigue and upset with high factor loading values (0.597, 0.590, 0.491 and 0.481, respectively). Although there were no statistical differences between the levels of rheumatoid factor and anti-cyclic peptide containing citrulline (anti-CCP), the levels of C-reactive protein, platelet count and the disease activity score using 28 joint counts were significantly higher in the heat pattern RA patients compared to the ones in cold pattern. Moreover, heat pattern RA patients were more likely to be prescribed two more disease-modifying anti-rheumatic drugs (DMARDS) combined with Methotrexate (MTX) (70.59% versus 49.72%; P = 0.000). ConclusionsIn conclusion, heat and cold patterns in RA patients could be classified well using cluster analysis and factor analysis. Most of RA patients with heat pattern were active and likely to be prescribed two more DMARDs combined with MTX.

The effect of CT and MRI with and without arthrography on the appearance of the feline carpal ligaments

BackgroundThe current diagnosis of feline carpal injuries is based on radiographic examination including stress views and computed tomography; however, these techniques do not allow for direct evaluation of the carpal ligaments. The purpose of this cadaveric study was to assess the ability of CT arthrography (CTA) and MR arthrography (MRA) to provide this information using a single contrast mixture. A protocol for intra-articular injection of the feline carpus was also described. A contrast solution containing gadolinium and iohexol with a 50% gadolinium solution (Magnevist—gadolinium 0.5 mmol/mL diluted to a 0.05 mmol/mL solution) and 50% of iodine (Iohexol—iodine 300mgI/mL) was injected into the antebrachiocarpal and middle carpal joints of feline carpi using fluoroscopic guidance.ResultsCTA allowed for identification of intra-articular ligaments and the silhouette of select extra-articular ligaments when there was adequate joint distension, however it was not considered to be superior to MRI. MRA allowed for improved identification of the dorsal radiocarpal, accessorioulnocarpal, accessorioquartile, short ulnar and short radial collateral ligaments.ConclusionIn this ex-vivo study, combined CTA and MRA enhanced the appearance of the feline carpal ligaments and may provide a foundation for future studies in the diagnosis of carpal injuries.

Effectiveness of Monthly Low-Dose Emicizumab Prophylaxis without 4-Week Loading Doses Among Patients with Hemophilia a with and without Inhibitor: A Case Series Report

Introduction: Emicizumab is a humanized, bispecific, monoclonal antibody proven as an effective prophylaxis for patients with hemophilia A with and without inhibitor. After the weekly loading of 3 mg/kg for 4 doses followed by maintenance dose of 1.5 to 6 mg/kg at 1 to 4-week intervals, the equivalent factor VIII was maintained at approximately 15% and showed an effective prophylaxis in reducing annual bleeding rate. Due to the health care resource constraint, the dose of emicizumab was reduced to maintain the prophylaxis factor VIII at 1-3%.Methods: The effectiveness of monthly low dose emicizumab prophylaxis without 4 loading doses was evaluated among patients with hemophilia A with and without inhibitor for at least 6 months. The bone mineral density (BMD), ultrasonography of bilateral ankle, elbow and knee as well as Hemophilia Joint Health Score (HJHS) were initially evaluated and planned to be repeated after one year treatment. The vitamin D level was determined initially, and vitamin D supplement was prescribed for 3 patients with low vitamin D levels at 13.3, 23.2 and 24.6 ng/mL. Moreover, the quality of life assessment using Hemo-QoL and CHO-KLAT was performed in 3-month intervals.Results: Five patients without inhibitor (3 severe, 2 moderate) and 1 patient with severe hemophilia A with inhibitor enrolled in the study. They all behaved in low bleeding risk circumstances such as avoidance of contact sport. Their ages ranged from 4 to 40 years of age. The youngest boy had difficulty at peripheral venous access for regular prophylaxis while the remaining 4 patients without inhibitor experienced frequent breakthrough bleeding episodes while receiving a low dose prophylaxis at 500 to 1,000 units of factor VIII concentrate twice weekly. All refused to receive more frequent prophylaxis. For patient with inhibitor, the high inhibitor titer of 65 Bethesda units (BU) declined during the 2 years of immune tolerance induction (ITI) at the intermediate dose of 100 units/kg of extended half-life factor VIII concentrate 3 times weekly. His lowest inhibitor was at 10 BU and was documented as failed ITI. He experienced frequent bleeding at the muscles and joints for which bypassing agents could not be adequately provided.For the baseline study, 2 patients had low BMD Z score ≤-2.0 while the remaining 4 patients had normalized BMD Z score >-2.0. The ultrasonography of bilateral ankle, elbow and knee at anterior, medial, lateral and posterior/inferior spaces revealed joint distension reflecting varying-degree synovial hypertrophy and/or bleeding component of 0-14.0, 0-9.8, 0-9.4, 0-12.8; 0-14.4, 0-17.8, 0-10.7, 0-18.6 and 0-23.8, 0-15.3, 0-17.1, 0-12.9 millimeter, respectively. Varying-degree hyperemia from the ultrasonography reflecting active inflammation of synovium was found in 4 ankles, 6 elbows and 4 knees of the total 36 joints in 4 of 6 patients. The HJHS scores ranged from 6 in the youngest patient to 56 in the patient with inhibitor. All patients except the 4-year-old boy had 1 to 3 target joints.All the studied patients received 1 each of the whole vial of emicizumab at 30, 75, 105 mg monthly except 3 patients receiving 60 mg monthly which was equal to 1.1 to 1.6 mg/kg of emicizumab. The monthly trough levels of emicizumab determined by a modified one stage factor VIII assay using emicizumab calibrator were maintained at 3.8 to 9.8 µg/ml which were equivalent to the levels of FVIII at 1 to 3% (0.3% FVIII per µg/ml of emicizumab). The bleeding rate was markedly decreased from 4-8 episodes monthly to 0-1 episode monthly. The monthly zero bleeding rate was found among 4 patients. Moreover, the swollen target joint gradually dissolved. Their quality of life markedly improved evaluated by the Hemo-QoL and CHO-KLAT. They could attend regular school and work happily. The HJHS and ultrasonography have not been repeated yet.Conclusion: The monthly low dose emicizumab prophylaxis of the whole vial at 1.1 to 1.6 mg/kg without loading dose could achieve emicizumab trough levels at 3.8 to 9.8 µg/ml which were equivalent to the levels of FVIII at 1 to 3%. It showed effective prophylaxis among patients with hemophilia with and without inhibitor who performed low bleeding risk activity. The 3 aspects of body functions and structures, activities and participation were gradually improved. DisclosuresNo relevant conflicts of interest to declare.

Meniscal Root Repair With Mini-Open Medial Collateral Ligament Release

Meniscal root repair is becoming more common with increasing knowledge regarding the function of the meniscal root and its role in long-term joint preservation, as well as improved surgical techniques and instrumentation. Despite this, adequate visualization of the posterior horn of the medial meniscus may be challenging, particularly in those with tight medial compartments. Instrument handling and attempt to visualize and repair the meniscal tear may lead to iatrogenic chondral injuries in these instances. We describe our preferred technique for improved visualization via mini-open release of the distal medial collateral ligament that allows for increased joint distension, increased access to the posterior horn of the medial meniscus, and the ability to repair the released medial collateral ligament.

Radio-carpal wrist MR arthrography: comparison of ultrasound with fluoroscopy and palpation-guided injections.

To compare ultrasound- (US), fluoroscopy- (FL), and palpation-guided contrast injection techniques used for dorsal radio-carpal wrist MRA. Patients with chronic wrist pain were randomized as to which injection technique they underwent into three groups of 50 participants. Dorsal radio-carpal contrast injection was performed under US, FL guidance (one radiologist for each), or palpation guidance by an orthopedic surgeon. The three techniques were compared by procedure time, success rate, number of attempts needed, frequency and grade of extravasation, joint distension, and MRA image quality. Additionally, any change from baseline wrist pain was recorded using the visual analog scale (VAS) at five time points (immediately, 8h, 24h, 48h, and 1week) after injection. One hundred and fifty patients (83 males and 67 females; mean age 29 ± 6.5years) were included. Success rates for US- and FL-guided injections were 100%, while palpation-guided approach was significantly less successful (72%) (P = 0.02) with significantly more frequent extravasation (56%)(P < 0.001). US guidance was the least time-consuming (6.5 ± 1.6min) compared to FL guidance (12.5 ± 1.9min) and palpation guidance (8 ± 1.2min) (all P < 0.001). The mean number of joint puncture attempts was significantly lower with imaging-guided techniques (1.1 ± 0.24 and 1.2 ± 0.4 for US and FL, P = 0.23) compared to palpation-guided one (1.6 ± 0.8) (P = 0.007). The largest increases in baseline-pain were 8-h post-injection, and US guidance was the least painful at all-time points (all P < 0.05). Joint distension and image quality were significantly better with imaging-guided techniques (P < 0.001 and P = 0.003). US-guided radio-carpal injection is a less time-consuming, more tolerable, and successful radiation-free method when compared to FL guidance. Palpation-guided injections require multiple attempts to enter the joint with high failure rates and frequent extravasation.

Venous air embolism during stifle arthroscopy in a horse

SummaryThis case report describes venous air embolism as a complication of stifle joint arthroscopy in a 16‐year‐old French Saddle Pony. Carbon dioxide was used to achieve joint distension during the procedure and accidentally entered the vasculature, causing the embolism. The diagnosis was based on a sudden onset of laboured breathing, tachycardia and dropping end‐tidal carbon dioxide (PE'CO2) and was confirmed by arterial blood gas analysis showing hypercapnia and large PE'CO2—arterial partial pressure of carbon dioxide (PaCO2) difference. This complication was treated by increasing the fraction of inspired oxygen (FIO2) and immediate ceasing of further gas insufflation. The horse suffered no further complications. To our knowledge, this is the first publication reporting this complication during arthroscopy in a horse. Awareness of this complication should be raised between veterinarians performing arthroscopies when using gas as the distending agent. A high index of suspicion and early recognition of the embolism can improve chances for full and unremarkable recoveries.

ASSESSMENT OF HAND AND FINGERS COMPLICATIONS AFTER ARTHROSCOPIC SHOULDER ROTATOR CUFF TEAR REPAIR

Rotator cuff repair (RCR) is a common surgical procedure with results considered acceptable.However, the arthroscopic technique, like any other surgical procedure, still has associated complications. Complications after RC surgery can be either general or specific. Recurrent rotator cuff tears, adhesive capsulitis and post-operative stiffness, suture anchor displacement, deltoid dehiscence, synovitis and iatrogenic acromial fracture, all have been mentioned in the literature.As a specific complication following an arthroscopic rotator cuff tear repair, shoulder hand syndrome is a reflex neurovascular disorder that involves the shoulder and the hand. It is characterized by a peculiar combination of a painful shoulder disability and a unilateral pain, swelling, and limitation of movements of the hand and fingers. Numbness, edema, pain, and limitations of movement of the hand and fingers, all have been reported after rotator cuff repair, suggesting either cubital tunnel syndrome, tenosynovitis, carpal tunnel syndrome, or complex regional pain syndrome.Various possible explanations have been suggested for the nerve injuries that have occurred after arthroscopic rotator cuff tear repair including joint distension, position, fluid extravasation, excessive traction, and manipulation.

Shoulder MR Arthrography: Comparative Evaluation of Three Different Contrast Injection Techniques Using an Anterior Approach.

MR arthrography (MRA) is commonly used in the assessment of shoulder internal derangements. Correct intra-articular contrast injection is required for this modality. Anterior injections under fluoroscopic, ultrasound-guidance, or without image-guidance have been described in the literature. However, no simultaneous comparison has been performed between the three techniques. To compare the accuracy and performance of fluoroscopy (FL)-guided, ultrasound (US)-guided and non-image-guided intra-articular contrast injection via an anterior approach for performing shoulder MRA. Prospective. Two-hundred and ten patients (180 men and 30 women; mean age, 33 ± 12 years; range 20-60 years) with clinically suspected shoulder pathology. 1.5T/fat-suppressed T1 -weighted, T2 -weighted, and 3D-gradient-echo images. Patients underwent shoulder MRA after anterior intra-articular contrast injection under FL- or US-guidance or without image-guidance. Patients were randomized among the three techniques with each group comprising 70. The techniques were compared according to the accuracy of intra-articular needle placement, attempts success rate, pain during and 24 hours after injection, procedure times, contrast extravasation rate, joint distension, and MRA diagnostic efficacy. Pain was assessed by the visual analog scale (VAS) pain-score. Pearson's chi-squared and Kruskal-Wallis tests. FL- and US-guided injections (100% accuracy) were significantly more accurate than non-image-guided (85.7% accuracy) (P < 0.05). US-guidance was the least painful, with statistical differences between image-guided and non-image-guided techniques regarding the first attempt success rate (95.7% and 92.8% for FL- and US-guided vs. 78.6% for blinded), VAS-score 24 hours-post-procedure (1.7 ± 1.7, and 1.5 ± 1.4 vs. 2.2 ± 1.4), procedure time (11.9 ± 1.6, and 7.4 ± 1.7 vs. 4.3 ± 0.76 minutes), and contrast extravasation rate (5.7%, and 8.6% vs. 30%) (all P < 0.05). Procedure time was also significantly different between FL and US-guidance (P < 0.05). Imaging-guided injections are more accurate and tolerable than non-image-guided and should be considered to confirm intra-articular needle position, hence adequate capsular distension and good diagnostic quality of shoulder MRA. US guidance is a less painful, rapid, and safe alternative to the FL approach. Evidence Level: 2 Technical Efficacy Stage: 5. J. MAGN. RESON. IMAGING 2021;53:481-490.

A comparison of ultrasound-guided rotator interval and posterior glenohumeral injection techniques for MR shoulder arthrography

PurposeThe aim of this prospective, randomized study was to compare the performance of a rotator interval approach with the posterior glenohumeral approach for ultrasound-guided contrast injection prior to MR shoulder arthrography. MethodThis study was approved by the institutional review board. One hundred and twenty consecutive patients referred for MR shoulder arthrography were randomized into four groups: rotator interval approach in-plane (n = 30); rotator interval approach out-of-plane (n = 30); posterior approach in-plane (n = 30); and posterior approach out-of plane (n = 30). Outcome measures included procedure time, number of injection attempts, patient-reported pain score (0−10), and radiologist-reported technical difficulty (0–10). MR arthrograms were assessed for adequacy of joint distension, diagnostic utility, and extra-capsular contrast leakage. ResultsAll 120 patients had a successful ultrasound-guided injection with adequate joint distension and diagnostic utility for MR arthrography. In-plane needle guidance was less technically demanding, quicker, required fewer injection attempts, and had a lower frequency of contrast leakage than out-of-plane needle guidance. The posterior glenohumeral approach was less technically demanding though had a higher frequency of contrast leakage and caused more patient discomfort than the rotator interval approach. ConclusionFor ultrasound-guided shoulder joint injection, an in-plane approach is preferable. The posterior glenohumeral approach is less technically demanding though causes more patients discomfort than the rotator interval approach possibly due to the longer needle path.

The effect of intra‐articular mepivacaine administration prior to carpal arthroscopy on anesthesia management and recovery characteristics in horses

To evaluate the effects of intra-articular (IA) mepivacaine administration prior to carpal arthroscopy on anesthetic drug requirements, blood pressure support, hemodynamic variables, and quality of recovery in horses. Experimental, analytical, cohort study. Twenty-two horses (n = 11 horses/group). Horses were anesthetized by using the same protocol, but an IA injection of mepivacaine or saline was performed before carpal arthroscopy. End-tidal isoflurane concentration, heart rate, and mean arterial pressure were recorded at specific time points. Quality of recovery was scored by the anesthetist, who was unaware of group assignment. Data were analyzed by using two-way repeated-measures analysis of variance. Mean arterial pressure was higher during joint distension in the control group compared with baseline (7% higher, P = .02) and with the treatment group (10% higher, P = .04). Heart rate was higher in the control group compared with the treatment group during joint distension (8% higher, P = .04) and chip removal (11% higher, P = .03). Heart rate was higher in the control group compared with baseline during chip removal (5.5% higher, P = .04). Two horses in the control group required additional ketamine vs none in the treatment group. Quality of recovery was not different between groups. Intra-articular mepivacaine resulted in fewer detectable reactions to surgical stimulation, with similar recovery scores and blood pressure support requirements. Intra-articular anesthesia prior to arthroscopy can be used safely in the horse and should be considered as a part of balanced anesthetic protocols.