Flouroscopy without contrast for intra-articular injection

[properexercise]

Why would a physician not use contrast when relying on flouroscopy alone for intra-articular injection? Is flouroscopy without contrast any better than a blind injection?

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[Agast]

Are we talking pre-contrast shortage or post-contrast shortage apocalyptic times

 

[lobelsteve]

Why would a physician not use contrast when relying on flouroscopy alone for intra-articular injection? Is flouroscopy without contrast any better than a blind injection?

air arthrogram is commonly used. But I would also say it depends on the joint. Knee: AP/lat can show the needle under the patella.
Hip/Shoulder: would not know if subcapsular if not using contrast.

 

[properexercise]

Are we talking pre-contrast shortage or post-contrast shortage apocalyptic times

I'm talking Latin American stem cell clinics using Wharton's Jelly. I don't know if it's related to the shortage but I think it's standard procedure for most/all of them not to use contrast.

 

[Agast]

I'm talking Latin American stem cell clinics using Wharton's Jelly. I don't know if it's related to the shortage but I think it's standard procedure for most/all of them not to use contrast.

Sketchy clinic, sketchy practice. Goes together like peanut butter and (Wharton’s) jelly.

 

[bedrock]

Sketchy

And regarding the shortage. Im using gadolinium for my peripheral joints right now. Not as a good as omni, but better than no contrast

 

[lobelsteve]

Sketchy

And regarding the shortage. Im using gadolinium for my peripheral joints right now. Not as a good as omni, but better than no contrast

What is the kidney risk?

 

[deleted875186]

Probably just cutting corners.

I personally wouldnt do a hip without contrast. If no contrast then need to use US.

Knee would be fine no contrast, I would also be fine doing shoulder with fluoro and no contrast, I come down AP over the humeral head and hit bone, no way not to be in the joint imo.

 

[lobelsteve]

Probably just cutting corners.

I personally wouldnt do a hip without contrast. If no contrast then need to use US.

Knee would be fine no contrast, I would also be fine doing shoulder with fluoro and no contrast, I come down AP over the humeral head and hit bone, no way not to be in the joint imo.

Lots of ways to push the capsule into periosteum and not be in the joint. That's why hips/shoulders both need contrast. I'd sat 25% of the time I am not in once I hit os. I have to rotate the needle and skive in.

 

[unchockey21]

I’ve never peddled that snake oil so it’s been awhile since I’ve read up on it. But I thought I remembered something about contrast being harmful to the stem cells? No idea if that’s true or not.

 

[deleted875186]

Lots of ways to push the capsule into periosteum and not be in the joint. That's why hips/shoulders both need contrast. I'd sat 25% of the time I am not in once I hit os. I have to rotate the needle and skive in.

Interesting, for sure I’ve seen it with hips often, personally not often with shoulders. I’m curious how do you do you shoulders?

 

[MitchLevi]

Probably just cutting corners.

I personally wouldnt do a hip without contrast. If no contrast then need to use US.

Knee would be fine no contrast, I would also be fine doing shoulder with fluoro and no contrast, I come down AP over the humeral head and hit bone, no way not to be in the joint imo.

I'm perfectly placed in the shoulder without intra articular contrast quite frequently. I retract 3-4 mm and spin the needle. One or two adjustments and I'm good. Hip is the same.

 

[Ferrismonk]

Latin America "Stem cell" injections are a sketchy as they come. I wouldn't trust anything like this is anywhere close to standard of care.

That being said, contrast isn't critical for most joints using multiplanar imaging but is advised. It is hard to trash a bottle of expensive contrast for a $50 injection.

I use ultrasound for all joints except hips, so no contrast needed. I use contrast for my hips.

 

[bedrock]

Latin America "Stem cell" injections are a sketchy as they come. I wouldn't trust anything like this is anywhere close to standard of care.

That being said, contrast isn't critical for most joints using multiplanar imaging but is advised. It is hard to trash a bottle of expensive contrast for a $50 injection.

I use ultrasound for all joints except hips, so no contrast needed. I use contrast for my hips.

I’m sure you guys are solid with your ultrasound.

Our newest orthopedic surgeon is a fresh grad and does his hips and a few other injections under ultrasound so he doesn’t have to book the fluoro procedure room for later. Good idea in theory.

Nice guy. Trained at good places.
He has been here for a year and I’ve repeated two hip injections on his patients who supposedly had no hip pathology (which is why he sent them to me).

I was still concerned for hip and repeated hip injections. Both patients did dramatically better with my flouro guided, contrast confirmed, IA hip joint injections, despite having previously “failed” his US guided hip injections.

I’m looking for the right time to gently suggest to him that he perform his future hip injections under Fluoro instead of US.

 

[RoloTomassi]

Contrast generally not used or minimized with orthobiologics due to perceived cytotoxicity. Same with local.

 

[SSdoc33]

Shoulders and hips and sij in the past all used contrast. Now? Nope. Haven't noticed much of a difference, but will go back to contrast when its readily available again

 

[DrMDAware]

I’m sure you guys are solid with your ultrasound.

Our newest orthopedic surgeon is a fresh grad and does his hips and a few other injections under ultrasound so he doesn’t have to book the fluoro procedure room for later. Good idea in theory.

Nice guy. Trained at good places.
He has been here for a year and I’ve repeated two hip injections on his patients who supposedly had no hip pathology (which is why he sent them to me).

I was still concerned for hip and repeated hip injections. Both patients did dramatically better with my flouro guided, contrast confirmed, IA hip joint injections, despite having previously “failed” his US guided hip injections.

I’m looking for the right time to gently suggest to him that he perform his future hip injections under Fluoro instead of US.

Financially speaking it unfortunately likely won’t be worth it to do a hip injection with fluoro in the ASC.

 

[deleted131481]

I’m sure you guys are solid with your ultrasound.

Our newest orthopedic surgeon is a fresh grad and does his hips and a few other injections under ultrasound so he doesn’t have to book the fluoro procedure room for later. Good idea in theory.

Nice guy. Trained at good places.
He has been here for a year and I’ve repeated two hip injections on his patients who supposedly had no hip pathology (which is why he sent them to me).

I was still concerned for hip and repeated hip injections. Both patients did dramatically better with my flouro guided, contrast confirmed, IA hip joint injections, despite having previously “failed” his US guided hip injections.

I’m looking for the right time to gently suggest to him that he perform his future hip injections under Fluoro instead of US.

I do shoulder and knee with US. Not familiar with hip under US or how accurate it is. I have some southern size patients so I imagine it's tough.

 

[lobelsteve]

Interesting, for sure I’ve seen it with hips often, personally not often with shoulders. I’m curious how do you do you shoulders?

Prone. Posterior capsule. Superior medial on the head.

 

[oreosandsake]

I’m sure you guys are solid with your ultrasound.

Our newest orthopedic surgeon is a fresh grad and does his hips and a few other injections under ultrasound so he doesn’t have to book the fluoro procedure room for later. Good idea in theory.

Nice guy. Trained at good places.
He has been here for a year and I’ve repeated two hip injections on his patients who supposedly had no hip pathology (which is why he sent them to me).

I was still concerned for hip and repeated hip injections. Both patients did dramatically better with my flouro guided, contrast confirmed, IA hip joint injections, despite having previously “failed” his US guided hip injections.

I’m looking for the right time to gently suggest to him that he perform his future hip injections under Fluoro instead of US.

Maybe he needs a refresher on hip injections under US

 

[lobelsteve]

Maybe he needs a refresher on hip injections under US

You greatly overestimate the abilities of docs to know what they are looking at under US. I can name two docs who I trust to inject my hip under US. One in Cali, the other in Seattle.

 

[SSdoc33]

Prone. Posterior capsule. Superior medial on the head.

go anterior with flouro. SOOOOOOOOOOOO much easier

 

[SSdoc33]

as far as hips, you could struggle with the goop and look at a snowstorm for 5 minutes.... or you could use flouro and do the shot in 8 seconds. it is like dropping a golf ball into a basketball hoop.

 

[bedrock]

go anterior with flouro. SOOOOOOOOOOOO much easier

Agree completely

 

[drusso]

You greatly overestimate the abilities of docs to know what they are looking at under US. I can name two docs who I trust to inject my hip under US. One in Cali, the other in Seattle.

What am I? Chopped liver? I've been doing hips under US for 15 years.

 

[oreosandsake]

You greatly overestimate the abilities of docs to know what they are looking at under US. I can name two docs who I trust to inject my hip under US. One in Cali, the other in Seattle.

youre right about that... but there are more out there. and really, it's not that tough.

fwiw, under ultrasound magnification the area to put your needle is huge. like landing a helicopter on a football field. just need to make sure the pilot can recognize what's grass vs seats

 

[lobelsteve]

What am I? Chopped liver? I've been doing hips under US for 15 years.

You know I love chopped liver but after we spent all that time together I would feel dirty having you inject my hip.

 

[SSdoc33]

youre right about that... but there are more out there. and really, it's not that tough.

fwiw, under ultrasound magnification the area to put your needle is huge. like landing a helicopter on a football field. just need to make sure the pilot can recognize what's grass vs seats

did you just steal my analogy?

 

[oreosandsake]

did you just steal my analogy?

i must have been inspired somewhere.

i was going to say landing a golf ball on a football field but I know how badly most of you play golf

 

[Agast]

I do shoulder and knee with US. Not familiar with hip under US or how accurate it is. I have some southern size patients so I imagine it's tough.

I use the back of my left hand (which is holding the probe) to heave the pannus out of the way…

 

[Baron Samedi]

US hip about as easy as it gets. Patient supine, shoot beam down femoral neck and aim for head/neck junction. Curvilinear prone for most, 22G needle easy to visualize.

Pic from sports med review.

I've also started doing SIJ under ultrasound. I find its taking me about the same amount of time as fluoro, and far less "difficult access".

 

[GoBeers]

US hip about as easy as it gets. Patient supine, shoot beam down femoral neck and aim for head/neck junction. Curvilinear prone for most, 22G needle easy to visualize.

Pic from sports med review.

I've also started doing SIJ under ultrasound. I find its taking me about the same amount of time as fluoro, and far less "difficult access".

can you post your experience and techniques for SIJ ultrasound? i hate it with fluoro and only get true arthrograms maybe 25% of the time.

 

[Baron Samedi]

can you post your experience and techniques for SIJ ultrasound? i hate it with fluoro and only get true arthrograms maybe 25% of the time.

1. Patient prone, drape slightly more inferior than for fluoro.
2. Placed probe(linear for most works) over sacral hiatus -- two nuns walking down the street view described in Furman. This is the view for causal ESI.
3. Scan laterally to identify lateral border of the sacrum.
4. Follow lateral border of the sacrum superiorly until ilium comes into view.
5. Continue superior until S2 foramen is visualized medial to the sacral Iliac joint. Visualization of the foramen helps prevent inadvertent entry into it.
6. 22G medial to lateral approach, pop into joint and inject.

Picture from NYSORA. You can see the unmarked foramen in the center of the image just medial to the needletip.

 

[RoloTomassi]

Anyone learning to do US should do on fluoro table for confirmation

 

[Ducttape]

fyi... it is the 25th anniversary of your namesake...

 

[bedrock]

Anyone learning to do US should do on fluoro table for confirmation

Agree. Best way to be certain

 

[bedrock]

Financially speaking it unfortunately likely won’t be worth it to do a hip injection with fluoro in the ASC.

We do all our scheduled MR arthrograms, and hip/SIJ in a dedicated procedure room. We do have to schedule time in that space.

Thankfully, my ortho partners do their own flouro guided gad injections for MR arthrograms.


I think my ortho partner only does US hips as part of clinic so they get it same day.

 

[MitchLevi]

I have done a lot of US hips, and I simply don't do them any longer bc they're inferior to fluoro. I believe Bedrock said above he's had to redo a few US hips with XRAY...That's my experience too.

 

[epidural man]

can you post your experience and techniques for SIJ ultrasound? i hate it with fluoro and only get true arthrograms maybe 25% of the time.

There is an easy solution to that. Quit using contrast and looking for an arthrogram. If you place the needle in the joint, the lateral will tell you if you are in far enough.

If you INSIST on putting in contrast, I suggest using the lateral. You will most often see the contrast pool at the caudal portion of the curved joint but in the AP still looks like a blob-o-gram.

Constrast has risks. And I know anaphylaxix is probably rare - but if it happened to you, you may ask yourself "did I really need that blob-o-gram in the SI-Joint?" I mean - if you feel the capsule, feel the needle crunch along in the joint, and get a lateral and see you are well within the joint - where the hell else could your needle be?

 

[MitchLevi]

There is an easy solution to that. Quit using contrast and looking for an arthrogram. If you place the needle in the joint, the lateral will tell you if you are in far enough.

If you INSIST on putting in contrast, I suggest using the lateral. You will most often see the contrast pool at the caudal portion of the curved joint but in the AP still looks like a blob-o-gram.

Constrast has risks. And I know anaphylaxix is probably rare - but if it happened to you, you may ask yourself "did I really need that blob-o-gram in the SI-Joint?" I mean - if you feel the capsule, feel the needle crunch along in the joint, and get a lateral and see you are well within the joint - where the hell else could your needle be?

Position in the joint matters. You can be in the SIJ and watch your contrast push directly extra articular.

 

[epidural man]

Position in the joint matters. You can be in the SIJ and watch your contrast push directly extra articular.

OK maybe.

However, I believe clinically it doesn't matter. Extra-articular injection (peri-articular) likely works as well.

 

[deleted875186]

There is an easy solution to that. Quit using contrast and looking for an arthrogram. If you place the needle in the joint, the lateral will tell you if you are in far enough.

If you INSIST on putting in contrast, I suggest using the lateral. You will most often see the contrast pool at the caudal portion of the curved joint but in the AP still looks like a blob-o-gram.

Constrast has risks. And I know anaphylaxix is probably rare - but if it happened to you, you may ask yourself "did I really need that blob-o-gram in the SI-Joint?" I mean - if you feel the capsule, feel the needle crunch along in the joint, and get a lateral and see you are well within the joint - where the hell else could your needle be?

Agreed. Biggest risk of contrast is trying to continually get a good arthrogram, keep repositioning needle, more fluoro time, etc.

I agree I have stopped using contrast for SIJ, now just check a lateral to confirm depth, and haven’t seen a big difference in results

 

[Ducttape]

Position in the joint matters. You can be in the SIJ and watch your contrast push directly extra articular.

what about US stops this from happening? is it only the fact that you stop when you think you have just penetrated the joint on US?

 

[Baron Samedi]

what about US stops this from happening? is it only the fact that you stop when you think you have just penetrated the joint on US?

I would argue US might be superior in this regard as you can easily see if your injectate is flowing outside of the joint and adjust accordingly.

 

[lobelsteve]

I would argue US might be superior in this regard as you can easily see if your injectate is flowing outside of the joint and adjust accordingly.

Umm, we see this with live fluoroscopy.

 

[Baron Samedi]

Umm, we see this with live fluoroscopy.

But only for the. 5cc of contrast and maybe a washout pic. For the record, I don't think it matters.

 

[lobelsteve]

But only for the. 5cc of contrast and maybe a washout pic. For the record, I don't think it matters.

If you are not injecting under live and then adding washout, you are not doing it right. And I also do not think it matters much.

 

[oreosandsake]

Small group 1:3 Hyperbolic time chamber training

 

[MitchLevi]

what about US stops this from happening? is it only the fact that you stop when you think you have just penetrated the joint on US?

Huh?

 

[Baron Samedi]

If you are not injecting under live and then adding washout, you are not doing it right. And I also do not think it matters much.

You do live fluoro for the entire injection? I don't claim to be the best but I've worked with numerous other docs and never seen anyone do that before unless I am misunderstanding something.