Ultrasound guidance to perform intra-articular injection of gadolinium-based contrast material for magnetic resonance arthrography as an alternative to fluoroscopy: the time is now
Ultrasound guidance to perform intra-articular injection of gadolinium-based contrast material for magnetic resonance arthrography as an alternative to fluoroscopy: the time is now
Carmelo Messina 0 1 2 3 4 5
Giuseppe Banfi 0 1 2 3 4 5
Alberto Aliprandi 0 1 2 3 4 5
Giovanni Mauri 0 1 2 3 4 5
Francesco Secchi 0 1 2 3 4 5
Francesco Sardanelli 0 1 2 3 4 5
Luca Maria Sconfienza 0 1 2 3 4 5
0 Università Vita-Salute San Raffaele , Via Olgettina 58, 20132 Milano , Italy
1 IRCCS Istituto Ortopedico Galeazzi , Via R. Galeazzi 4, 20161 Milano , Italy
2 Scuola di Specializzazione in Radiodiagnostica, Università degli Studi di Milano , Via Mangiagalli 31, 20100 Milano , Italy
3 Unità di Radiologia Interventistica, Istituto Europeo di Oncologia , Via Giuseppe Ripamonti 435, 20141 Milano , Italy
4 Servizio di Radiologia, IRCCS Policlinico San Donato , Piazza Malan 1, 20097 San Donato, Milanese , Italy
5 Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano , Via Mangiagalli 31, 20100 Milano , Italy
Magnetic resonance (MR) imaging has been definitively established as the reference standard in the evaluation of joints in the body. Similarly, magnetic resonance arthrography has emerged as a technique that has been proven to increase significantly the diagnostic performance if compared with conventional MR imaging, especially when dealing with fibrocartilage and articular cartilage abnormalities. Diluted gadolinium can be injected in the joint space using different approaches: under palpation using anatomic landmarks or using an imaging guidance, such as fluoroscopy, computed tomography, or ultrasound. Fluoroscopy has been traditionally used, but the involvement of ionizing radiation should represent a remarkable limitation of this modality. Conversely, ultrasound has emerged as a feasible, cheap, quick, and radiation-free modality that can be used to inject joints, with comparable accuracy of fluoroscopy. In the present paper, we discuss the advantages and disadvantages of using fluoroscopy or ultrasound in injecting gadolinium-based contrast agents in joints to perform magnetic resonance arthrography, also in view of the new EuroSAFE Imaging initiative promoted by the European Society of Radiology and the recent updates to the European Atomic Energy Community 2013/59 directive on the medical use of ionizing radiation.
Magnetic resonance arthrography; Ultrasound; Fluoroscopy; Ionizing radiation; Radiation protection
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Magnetic resonance (MR) imaging has been definitively
established as the reference standard in the evaluation of joints
around the body, being capable of assessing thoroughly all
a r t i c u l a r c o m p o n e n t s , s u c h a s t e n d o n s , l i g a m e n t s ,
fibrocartilage, hyaline cartilage, and subchondral bone [1].
Similarly, MR arthrography (MRA) has emerged as a
technique that has been proven to increase significantly the
diagnostic performance if compared with conventional MR
imaging, especially when dealing with fibrocartilage and articular
cartilage abnormalities [2, 3]. Even with the advent of higher
field equipment, the diagnostic accuracy of MRA proved to be
still superior compared to conventional MR imaging, as shown
by Magee [4]. MRA is commonly used for imaging of the
shoulder, but it is also used for imaging of other joints,
including the hip, the wrist, the elbow, the ankle, and the knee [5–7].
MRA can be performed with a direct or indirect approach.
While the indirect approach implies the intravenous
administration of 0.2 mmol/kg of a gadolinium-based contrast
material (GBCM) [2], direct MRA is obtained with the injection of
a solution of diluted GBCM into the joint space. This allows
for safely distending joint space, thus highlighting even
minimal abnormalities that may be missed at conventional MRI
[2, 3, 8].
When ruling out certain diagnostic problems, direct MRA
especially achieves almost the same sensitivity and specificity
as the surgical reference standard [8–10]. For these reasons, in
recent years, orthopaedic surgeons are increasingly
prescribing this examination [11]. There are no official data regarding
the number of MRA performed per year worldwide. In
2013 at our institution, a medium-sized university general
hospital in Milan, Italy, out of 4,239 musculoskeletal MR
examinations (excluding spine MRI), we performed 394
MRAs (9.3 %). This number is certainly expected to be higher
in orthopaedic hospitals.
Diluted GBCM can be injected into the joint space using
different approaches: under palpation using anatomic
landmarks or using an imaging guidance, such as fluoroscopy,
computed tomography (CT), MR imaging, or ultrasound
(US) [2, 12]. In particular, fluoroscopy is still used in most
institutions, being a low-cost, efficient, and easy technique
[13, 14]. Nevertheless, fluoroscopic guidance has relevant
disadvantages. First, it exposes both patients and operators to
ionizing radiation. According to a report of the United Nations
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