Zeki OGURTAN1 Kadircan OZKAN2 Cengiz CEYLAN3
1. DVM, Ph D., Assistant Professor,
Department of Surgery, College of Veterinary Medicine, University of Selcuk,
Kampus, Konya, 42031.
2. DVM, Ph D., Professor, Department of Surgery, College of Veterinary Medicine,
University of Selcuk, Kampus, Konya, 42031.
3. DVM, Ph D., Research Assistant, Department of Surgery, College of Veterinary
Medicine, University of Selcuk, Kampus, Konya, 42031.
The wide use of single contrast, either negative or positive, and double contrast
arthrography in man, led veterinary radiologist to acceptance of either technique
in their diagnostic procedures. Each techniques has its proponents with regard
to dominating factors involved. Employment of arthroscopy, and computed tomography
in determining knee derangements are considered to be complementary to arthrography
rather than competitive. In this literature review, effectiveness of contrast
arthrography was compared with respect to human beings and companion animals
in experimental and clinical cases.
Double contrast arthrography utilizing fluoroscopy (4, 5, 8, 13, 19, 26), without
fluoroscopy (7, 14, 20, 21, 23, 27), single contrast arthrography (9, 10-13,
18, 24, 25, 28) and the combined use of arthrography with computed tomography
(16, 24) have been described in man and dog.
Double contrast arthrography is of diagnostic value in detecting the status
of overlying articular cartilages (5-7, 13), popliteal cysts (4, 7), menisci
(2, 5-7, 14, 17, 19, 20, 28), meniscal cysts (8, 21, 26), capsular ruptures
(13), medial collateral ligaments (MCL) tears (8, 13), joint capsule in experimental
models (1). The synovium and ligaments (2), anterior cruciate ligament (ACL)
ruptures (5, 19), intracarticulaginous loose bodies (5), chondromalacia of patella
(13), osteochondral fractures (13), and Blount's disease (popliteal cysts) (7,
13) in knee joint; and shoulder dislocations, cartiloginous lesions (10) and
rotator cuff injuries (10, 27) in shoulder joint.
Single contrast arthrography is far more superior in diagnosing intra-articular
osteocartilaginous loose bodies, utilizing negative contrast media (10, 13).
Positive contrast media is effective in osteochondritis dissecans (OCD) (12,
13), osteoarthritis chondromalacia (12), ACL tears (24, 25), articular cartilages
(13), synovial inflammation, proliferation, and cyst formation, ligamentous
and capsular injuries and checking prostheses for lucency, especially in the
hip and knee (10), lateral and medial menisci tears (28) in the knee joint;
adhesive capsulitis (10), articular cartilage (29) and rotator cuff injures
(11) in the shoulder joint.
Double contrast arthrography utilized in diagnostic procedures are regarded
to be more difficult and complicated to employ, to teach, and to be learned
than that of single contrast arthrography (10, 12, 14, 20, 23, 25, 27, 28).
Double contrast arthrography uses less contrast media compared to single contrast
arthrography (24, 28). Diagnosis of small tears and surface irregularities are
interfered with pooling of large amount of contrast material (28). The use of
non-ionic compounds causes less synovitis than ionic compounds (22, 30).
The diagnosis of ACL tears is highly accurate with single contrast arthrography,
but differentiation between torn and attenuated ligament is not very accurate
(25, 28). Double contrast arthrography is of questionable value in detecting
of ACL injuries (5, 24). The accuracy rate obtained in the possibility of ACL
disruption, was only 17 % (5). However, low accuracy rate was found in the diagnosis
of attenuated ACL injury with single contrast arthrography (28). The posterior
cruciate ligament is easier to be demonstrated than ACL injuries (28). Ninety
percent of accuracy rate was obtainable in differentiating a normal and intact
ligament from injured one with double contrast arthrography. Since the synovial
sleeve around the ligament is not completely disrupted, giving the appearance
of an intact ligament, has always been explained to be the main reason for the
low accuracy rate in the diagnosis of ACL injuries. In addition to this, hematoma
formation around the ligament tear creates difficulties in the diagnosis of
ACL injuries. The status and the degree of severity to ACL could be appreciated
only at surgery, after opening the synovial sleeve and manipulating the ligament
(5).
Because of quick absorption of contrast agent by the synovium compared to menisci,
examination of cruciates was suggested prior to menisci examination (24), but
in another study the sequence of examining the intra-articular structures was
different in the order of menisci, articular cartilage of patella and cruciate
ligaments (13). Cruciate ligament tears and articular cartilage disruption were
not diagnosed with an acceptable accuracy (6), but with increasing knowledge
and getting experienced with the technique, arthrographic results are rewarding.
Double contrast arthrography provided 96 % and 93 % of accuracy rate for medial
and lateral menisci respectively (5). The high accuracy rate for the lateral
meniscus tears was attributed to the use of double contrast arthrography (5).
In another study, 30 % of lateral meniscus tears was missed, using single contrast
arthrography (25). However 97% of high accuracy rate for medial and 96% for
lateral menisci were obtained with single contrast arthrography (28). It appears
that double contrast arthrography has high accuracy rate in detecting medial
meniscus tears. When compared to arthroscopically confirmed meniscal injuries,
accuracy rate increased from 94 % to 98 % for the medial meniscal tears, 88
% to 100 % for the lateral meniscal tears, and arthrography had the capability
of high accuracy rate for medial meniscus tears. It was low for lateral meniscus
tears (19). This is also inconsistent with the findings of difficulties in diagnosing
lateral meniscus tears (8, 13, 26). The confusion is generally caused by popliteal
bursa. In examination of the anterior horn of the medial meniscus, it must be
taken into consideration that as tears in this area are frequently overlooked
(8). The anterior horn of either menisci can be overlapped by margins of the
infrapatellar fat pad (8, 13) or parapatellar synovial space (13). Improved
visualization of the posterior horn of the lateral meniscus was observed by
utilizing the double contrast arthrography (13).
Chronic MCL tears may be detected by calcification adjacent to the medial femoral
condyle (8). Arthrography is not of significant importance in detecting MCL
tears. Arthrographic demonstration of leakage of dye in an assesment of degree
of laxity is not of significant value (5), but in complete MCL tears, contrast
leakage will be presented in the vicinity of the ligament (6, 8, 13). The arthrographic
diagnosis of MCL tears must be performed within 24-36 hours, by time the tears
will not seal off (5). Since lateral collateral ligament (LCL) is an extracapsular
structure, arthrographic evaluation of this anatomic structure can not be done
(5, 8, 13). In a study reported by Bonomo, duble- contrast arthrography was
found to be accurate in the diagnosis of the type of meniscal tears (3). In
OCD lesions, favorable results have been obtained with double contrast arthrography
in children (7), and adults (13). This is inconsistent with achievement of good
results in articular cartilage diagnosis (6). However; only 20 % of accuracy
rate was attainable in the diagnosis of articular cartilage distruption with
double contrast arthrography (5). The arthrogram has the capablity of showing
the size of the defect in the cartilage, and the degree to which the bone and
cartilage defects have healed (12). Although double contrast arthrography was
advocated and found to be valuable for loose bodies, only 18 % of accuracy rate
was obtained, and single contrast, arthrography is usually accepted proper diagnostic
tool for demonstration of loose bodies (8, 13). Osteochondral fractures lend
themselves to be demonstrated on an arthrogram, because the subchondral defect
in bone and articular cartilage will fill with contrast media. Contrast imbition
and thinning of the affected cartilage on the condylar surface can be seen,
and separate fragments may be observed within the joint space in condylar articular
cartilage degeneration (13).
The diagnosis of chondromalacia patella is difficult on arthrography in children
(7). Chondromalacia is a clinical diagnosis, reinforced by normal arthrogram
in questionable cases (8).
In Blount's disease arthrography is a necessity to determine the degree of angulation
for the osteotomy and whether surgical intervention is required (7).
Difficulties in detecting the lateral meniscal tears were atributed to the popliteal
bursa, of which, the diagnosis is made by the establishment of opacification
(8, 13).
Both lateral and medial large thick meniscus so-called discoid meniscus are
diagnosed rarely (15). Double contrast is of choice to diagnose the discoid
meniscus (21).
Cysts of the menisci are more common on the lateral meniscus (13, 21, 26). Approximately
75 % of cysts occurs in the posterior third where peripheral separation of the
horn of the lateral meniscus occurs (21). This is also seen in the middle portion
of the lateral meniscus (13). Cysts of the menisci are not common (8, 26) and
the diagnoses of these cysts are very rare findings during arthrography. Although
the appearance of cysts up to 20 % was encountered during menisectomy, their
small size and lack of communication with the synovial cavity make the diagnosis
difficult (8).
Ratator-cuff tears and tears of joint capsule frequently result in shoulder
pain and stiffness in man (27). Double contrast arthrography is superior to
single contrast arthrography for arriving at definitive diagnosis of rotator-cuff
tears (10).
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