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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