Post-arthrogram synovitis: MRI and histopathologic findings.

A 57-year-old patient developed severe, persistent pain following MR arthrography with iodinated contrast. MRI 1 week later showed synovitis which was new compared to the prior MRI. Arthroscopy showed severe synovitis. Histopathology showed synovitis characterized by lymphocytes, neutrophils, and necrosis. One out of 4 intraoperative cultures was positive, but ultimately believed to be due to contaminants. CRP normalized within 1 month. Repeat MRI 2 years later showed progressive degenerative findings, but no evidence of ongoing infection, or stigmata of previous infection. We believe this to be an unusually severe case of reactive synovitis. The purpose of the report is to add to knowledge of reactions to intra-articular contrast injection.

What Is the Diagnostic Accuracy of Flat-panel Cone-beam CT Arthrography for Diagnosis of Scapholunate Ligament Tears?

BACKGROUND: Cone beam CT (CBCT) is a widely available technique with possible indications in carpal ligament injuries. The accuracy of CBCT arthrography in diagnosing traumatic tears of the scapholunate ligament has not been reported. QUESTIONS/PURPOSES: (1) What is the diagnostic accuracy of CBCT and how does it relate to the accuracy of multislice CT arthrography and conventional arthrography in diagnosing scapholunate ligament tears? (2) What is the estimated magnitude of skin radiation doses of each method? METHODS: This secondary analysis of a previous prospective study included 71 men and women with suspected scapholunate ligament tears and indications for arthroscopy. Preoperative imaging was conventional arthrography and either MSCT arthrography for the first half of patients to be included (n = 36) or flat-panel CBCT arthrography for the remaining patients (n = 35). Index tests identified therapy-relevant SLL tears with dorsal or complete SLL ruptures, and these tears were compared with relevant SLL tears which were determined through arthroscopy as Geissler Stadium III and IV by probing the instable SL joint with a microhook or arthroscope. These injuries were treated by open ligament repair and Kirschner wire fixation. Accuracy values and 95% confidence intervals were calculated. Additional estimates of the radiation skin doses of each CBCT exam and two MSCT protocols were subsequently calculated using dose area products, dose length products, and CT dose indices. RESULTS: The diagnostic accuracy was high for all imaging methods. 95% CIs were broadly overlapping and therefore did not indicate differences between the diagnostic groups: Sensitivity of CBCT arthrography was 100% (95% CI 77 to 100), specificity was 95% (95% CI 76 to 99.9), positive predictive value was 93% (95% CI 68 to 99.8), and negative predictive value was 100% (95% CI 83 to 100). For MSCT arthrography, the sensitivity was 92% (95% CI 64 to 99.8), specificity was 96% (95% CI 78 to 99.9), positive predictive value was 92% (95% CI 64 to 99.8), and negative predictive value was 96% (95% CI 78 to 99.9). For conventional arthrography, the sensitivity was comparably high: 96% (95% CI 81 to 99.9). Specificity was (81% [95% CI 67 to 92]); the positive predictive value was 77% (95% CI 59 to 89) and negative predictive value was 97% (95% CI 86 to 99.9). Estimated mean (range) radiation skin doses were reported in a descriptive fashion and were 12.9 mSv (4.5 to 24.9) for conventional arthrography, and 3.2 mSv (2.0 to 4.8) for CBCT arthrography. Estimated radiation skin doses were 0.2 mSv and 12 mSv for MSCT arthrography, depending on the protocol. CONCLUSION: Flat-panel CBCT arthrography can be recommended as an accurate technique to diagnose scapholunate ligament injuries after wrist trauma. Estimated skin doses are low for CBCT arthrography and adapted MSCT arthrography protocols. LEVEL OF EVIDENCE: Level III, diagnostic study.

Posterior Glenohumeral Instability: Diagnosis and Management.

Posterior glenohumeral instability can manifest as posterior shoulder pain and dysfunction, particularly among athletes. Repetitive, posteriorly-directed axial loads, as commonly encountered by contact athletes (American football linemen, rugby players), result in microtrauma that can induce posteroinferior labral tears. Alternatively, SLAP tears commonly seen in throwing athletes may propagate in a posteroinferior direction (i.e., a type VIII SLAP tear), owing to a complex pathologic cascade involving glenohumeral capsular contracture and imbalances among the dynamic stabilizing muscles of both the glenohumeral joint and shoulder girdle. The diagnosis of posterior glenohumeral instability is elucidated by a thorough history and physical examination. Posterior shoulder pain is oftentimes insidious in onset. The throwing athlete with posterior glenohumeral instability may complain of diminished control, accuracy, and generalized shoulder discomfort. A number of provocative physical examination maneuvers have been described (Kim test, Jerk test), which load the humeral head against the labral lesion and recreate patients' symptoms. Magnetic resonance imaging and magnetic resonance arthrography can be of value in demonstrating avulsions of the labrum from the posteroinferior glenoid, and computed tomography is useful for quantifying the location and amount of attritional glenoid bone loss, although in contradistinction to anterior glenohumeral instability, clearly defined thresholds that would otherwise guide treatment have not been established. In the absence of substantial bone loss, arthroscopic posterior capsulolabral repair remains the gold standard for the surgical management of symptoms refractory to nonoperative treatment, and excellent clinical outcomes have generally been reported. However, high rates of return to play at the previous level of participation, particularly among throwing athletes, have been less consistently observed. Risk factors for the need for revision stabilization include surgery on the dominant extremity, female sex, and capsulolabral repairs involving either anchorless techniques or the use of less than 4 anchors.

[Magnetic resonance arthrography]. / MR-Arthrographien.

Magnetic resonance (MR) arthrography is a sensitive examination technique. In this institute the majority of MR arthrography examinations are carried out on the shoulder (57 %), followed by hand (24 %) and hip joints (16 %). The use of MR arthrography is superior to native MR imaging (MRI) particularly for detection of partial thickness tendon tears of the shoulder joint. Nevertheless, this technique is invasive, time-consuming and may be uncomfortable for patients. This article summarizes the indications, risks and contraindications of MR arthrography, highlights the puncture technique and illustrates possible pitfalls.

Introduction of Meglumine Diatrizoate into the Middle Cranial Fossa: A Rare Fatal Complication of Temporomandibular Joint Arthrography.

The authors here report a rare fatal complication of temporomandibular joint (TMJ) arthrography. A 57-year-old woman suddenly exhibited spasm and dizziness during TMJ arthrography. A multislice CT scanning of head demonstrated a defect in the roof of the glenoid fossa and unanticipated introduction of meglumine diatrizoate into the middle cranial fossa, which should account for neurotoxic symptoms of the patient and could be fatal if not appropriately treated in time. As TMJ puncture is widely performed in clinical practice and generally considered a safe technique, this case might serve as a reminder of the potential risk of the anatomical variation-a defect in the roof of the glenoid fossa-to TMJ clinical practitioners.

A prospective randomized study comparing three different approaches to fluoroscopy-guided shoulder arthrography according to the experience of practitioners.

OBJECTIVE: To compare three approaches via the anterior and posterior glenohumeral joints, and the rotator interval in fluoroscopy-guided shoulder arthrography according to the experience of the practitioners. MATERIALS AND METHODS: This prospective randomized study was originally designed to have 34 subjects for each approach, and finally evaluated 98 patients (mean age: 51.5 years; 55 men) from July to December 2014, who had shoulder arthrography via the anterior (n = 41) or posterior glenohumeral joint (n = 27) approaches, or via the rotator interval approach (n = 30) by residents (n=76) or fellows (n=22). The success rate, number of punctures, fluoroscopy time, radiation dose, and complications of the three methods were compared, and according to the practitioners. RESULTS: The success rate was 100% for the anterior glenohumeral joint approach (34 out of 34), 90.0% for the posterior glenohumeral joint approach (23 out of 30), and 88.2% for the rotator interval approach (30 out of 34; p = 0.013). There was no difference in the success rate according to the practitioners' experience. Fluoroscopy time was longest for the posterior glenohumeral joint approach (mean: 95.44 s) and shortest for the rotator interval approach (mean: 31.57 s, p = 0.006). Radiation dose was larger by 1st- or 2nd-year residents (p = 0.014), with no difference among the three approaches. Only one patient who underwent arthrography using the posterior glenohumeral joint approach complained about post-procedural pain. CONCLUSION: Fluoroscopy-guided shoulder arthrography via the posterior glenohumeral joint or rotator interval approach may be difficult for trainees, and the posterior glenohumeral joint approach may need a long fluoroscopy time.

Risk of bleeding associated with interventional musculoskeletal radiology procedures. A comprehensive review of the literature.

This review compiles the current literature on the bleeding risks in common musculoskeletal interventional procedures and attempts to provide guidance for practicing radiologists in making decisions regarding the periprocedural management of patients on antithrombotic therapy. The practitioner must weigh the risk of bleeding if therapy is continued against the possibility a thromboembolic occurring if anticoagulation therapy is withheld or reversed. Unfortunately, there is little empirical data to guide evidence-based decisions for many musculoskeletal interventions. However, a review of the literature shows that for low-risk procedures, such as arthrograms/arthrocenteses or muscle/tendon sheath injections, bleeding risks are sufficiently small that anticoagulants and antiplatelet therapies need not be withheld. Additionally, relatively higher-risk procedures, such as needle biopsies of bone and soft tissue, may be safely performed without holding antithrombotic therapy, provided pre-procedural INR is within therapeutic range. Thus, while a patient's particular clinical circumstances should dictate optimal individualized management, anticoagulation alone is not a general contraindication to most interventional musculoskeletal radiology procedures.

Postprocedural pain in shoulder arthrography: differences between using preservative-free normal saline and normal saline with benzyl alcohol as an intraarticular contrast diluent.

OBJECTIVE: The purpose of this study was to prospectively evaluate the effect of benzyl alcohol, a common preservative in normal saline, on postprocedural pain after intraarticular injection for direct shoulder MR arthrography. SUBJECTS AND METHODS: From April 2011 through January 2013, 138 patients underwent direct shoulder MR arthrography. Using the Wong-Baker Faces Pain Scale, patients were asked to report their shoulder pain level immediately before and immediately after the procedure and then were contacted by telephone 6, 24, and 48 hours after the procedure. Fourteen patients did not receive the prescribed amount of contrast agent for diagnostic reasons or did not complete follow-up. Sixty-two patients received an intraarticular solution including preservative-free normal saline (control group) and 62 patients received an intraarticular solution including normal saline with 0.9% benzyl alcohol as a contrast diluent (test group). Patients were randomized as to which intraarticular diluent they received. Fluoroscopic and MR images were reviewed for extracapsular contrast agent administration or extravasation, full-thickness rotator cuff tears, and adhesive capsulitis. The effect of preservative versus control on pain level was estimated with multiple regression, which included time after procedure as the covariate and accounted for repeated measures over patients. RESULTS: Pain scale scores were significantly (p = 0.0382) higher (0.79 units; 95% CI, 0.034-1.154) with benzyl alcohol preservative compared with control (saline). In both study arms, the pain scale scores decreased slightly after the procedure, increased by roughly 1 unit over baseline for the test group and 0.3 unit over baseline for the control group by 6 hours after the procedure, were 0.50 unit over baseline for the test group and 0.12 unit over baseline for the control group at 24 hours, then fell to be slightly greater than baseline at 48 hours with benzyl alcohol and slightly less than baseline without benzyl alcohol. These trends over time were highly significant (p < 0.0001). CONCLUSION: Shoulder arthrography is often associated with postprocedural discomfort that begins immediately after the procedure and resolves by 48 hours. There is significantly increased patient discomfort at 6 and 48 hours when using normal saline preserved with benzyl alcohol as a diluent compared with using normal saline without preservative as a diluent.

Carbon dioxide gas arthrography for the evaluation of pediatric hip conditions: what is the risk and reliability?

BACKGROUND: Various pediatric conditions often necessitate a morphologic examination of the hip joint in infancy or childhood, and multiple imaging options have been employed to achieve this goal. Arthrography is one such modality. Different types of contrast media have been utilized and include pharmacologic contrast agents, air, and carbon dioxide. There are scattered reports of complications related to the typical various media used during arthrography. Some of the most concerning are related to gas emboli following the use of air or carbon dioxide. This study assesses the potential complications of carbon dioxide hip arthrography in a series of children over a 12-year period. METHODS: A retrospective review of the medical records of children between the ages of 0 and 3 years who underwent hip arthrography using carbon dioxide gas as the contrast medium was conducted. Outcome measures analyzed included volume of CO2 injected, vital signs, and perioperative and postoperative end-tidal CO2. RESULTS: Our study population was comprised of 118 hips in 90 children. We found no correlation between the volume of CO2 injected and the patient's vital signs or end-tidal CO2 at any point during the perioperative or postoperative period. None of the children exhibited any evidence for cardiopulmonary compromise or clinical signs of embolism. DISCUSSION: To our knowledge, there have been no large studies reporting on carbon dioxide arthrography and its potential complications. There were no gas embolisms and/or cardiopulmonary complications in our patients in the perioperative, postoperative, or 1-year follow-up period. Utilizing carbon dioxide gas as the contrast media for hip arthrography in children is safe and can help aid in the treatment of pediatric hip conditions. LEVEL OF EVIDENCE: Therapeutic Level IV.

Diagnostic discography: what is the clinical utility?

The diagnosis and treatment of discogenic back pain is challenging. Provocation discography, an invasive spinal procedure, has been suggested as a diagnostic test for internal disc disruption to provide information on disc morphology and reproduction of symptoms. Current applications consist of the evaluation of persistent spinal pain in individuals, including postoperative patients, as well as providing a guide for patient selection for spinal fusion surgery and minimally invasive interventional pain procedures. While the validity of discography has been questioned by multiple scientific studies, technical refinements have addressed many of the initial limitations. An updated review on the safety and utility of discography will be provided, covering key areas of debate including false-positive rates, technical parameters, clinical utility, and risk of discography procedural-related intervertebral disc damage.

Cauda equina compression post lumbar discography.

Discography is used as an aid in the diagnosis of back pain related to intervertebral disc pathology. It involves attempting to elicit the patient's pain symptoms by injecting contrast into the suspected pathological disc. The overall complication rate of discography is low, with discitis being the most common complication and acute disc herniation post lumbar discography being reported in a small number of cases. We describe the case of a patient who developed cauda equina compression post lumbar discography.

Cerebral air embolism after arthrography of the ankle.

BACKGROUND: The accidental migration of air from the venous circulation into the systemic arterial circulation is called paradoxical air embolism. This is a potential disastrous complication after diagnostic and surgical procedures. Arthrography has been a useful technique in joint imaging for the past decades. Paradoxical cerebral air embolism is a very rare complication, only a few cases have been reported after arthrography of the hip in children. Here, we describe a patient with progressive encephalopathy after computer tomography (CT) arthrography of the ankle. CASE REPORT: We describe a 64-year-old male who underwent CT-arthrography of the left ankle, after the intra-articular injection of 20 ml of air he experienced progressive neurologic and hemodynamic deterioration. A brain CT showed a small amount of air in a right frontal sulcus. Hyperbaric oxygen therapy (HBO) was initiated after a delay of 16 hours and resulted in a complete recovery. A transesophageal echocardiography confirmed the presence of a right-left shunt. CONCLUSIONS: This case of paradoxical air embolism with severe neurological manifestations after arthrography of the ankle, emphasizes that air embolism should be considered in all patients with neurologic and/or hemodynamic deterioration after the injection of intra articular air. Furthermore a delay of more then 6 hours is no reason to withhold HBO in these patients.

Development of acute schmorl nodes after discography.

We report the development of acute Schmorl nodes at the L3-L4 intervertebral disc level after discography in a 36-year-old man. Although a few cases of acute Schmorl nodes have been reported in the literature, they have not been described because of discography. We surmise that the herniation of disc material through the vertebral endplates, with the ensuing formation of Schmorl nodes, should be regarded as a potential, but fortunately rare, complication of discography.

Hip Arthrography Complicated by Air Embolism in Infants: A Report of 2 Cases.

CASE: We report 2 cases of infants with developmental dysplasia of the hip who underwent arthrography of the hip with use of air for structure identification, which resulted in a presumed air embolism and deep oxygen desaturation. This led to the hypothesis that there is an increased potential of air embolism in the pediatric population given the vascular anatomy of the hip. CONCLUSION: These 2 cases document the important and not well-known complication of air embolism during air arthrography, which resulted in a change of practice for the authors. We strongly recommend against the use of air as an adjunct to routine arthrography in children.

Anterior approach for knee arthrography: tolerance evaluation and comparison of two routes.

PURPOSE: To prospectively evaluate patient tolerance and technical success of the anterior knee puncture approach for arthrography by using two different routes. MATERIALS AND METHODS: The study had Strasbourg University Hospital review board approval. Informed consent was obtained from all patients (and from their parents, if patients were minors). In 159 patients (89 male and 70 female; age range, 14-82 years; mean age, 44.3 years +/- 16 [standard deviation]) referred for computed tomographic (CT) arthrography, anterior puncture of the knee was performed by using an anterolateral (n = 73) or anterior paramedian (n = 86) route. For each patient, body mass index, absolute pain on a visual analog scale, relative pain (compared with anticipatory pain), and history of previous knee arthrography were recorded. A score reflecting the technical success of the procedure was established by using a five-point scale. Factors influencing tolerance and technical success were analyzed with Pearson correlation coefficients. Student t and chi2 tests were used to compare the two routes. RESULTS: The anterior approach for knee arthrography was well tolerated (mean visual analog scale score, 12.9 +/- 16.4) and technically successful (mean technical success score, 1.36 +/- 0.84) in most cases. Absolute pain was not influenced by age, sex, or body mass index and was only weakly correlated (r = 0.33) with the technical success score. The technical success score weakly correlated (r = 0.23) with the body mass index. A slight but significant reduction in absolute (P < .05) and relative (P < .01) pain was observed for the anterolateral route compared with the anterior paramedian route, while no significant differences (P > .05) were found for other parameters, including the technical success score. CONCLUSION: The anterior approach for knee arthrography is technically successful and well tolerated, particularly when an anterolateral route is used.

Shoulder magnetic resonance arthrography: a prospective randomized study of anterior and posterior ultrasonography-guided contrast injections.

BACKGROUND: Magnetic resonance (MR) arthrography is an accurate imaging method for internal shoulder derangements and rotator cuff pathologies. Both anterior and posterior contrast injection techniques, under palpatory, fluoroscopic, or ultrasonographic guidance have been described in the literature. However, clinical comparisons of the injection techniques remain few. PURPOSE: To compare the performance of anterior and posterior ultrasonography (US)-guided arthrography injections of the shoulder regarding patient discomfort and influence on diagnostic MR reading, and to illustrate the typical artifacts resulting from contrast leakage in the respective techniques. MATERIAL AND METHODS: 43 MR arthrographies were prospectively randomized into anterior and posterior US-guided contrast injections and performed by two radiologists, with the study of artifacts from contrast leakage. Pain from the injections was assessed by a survey utilizing a 100-mm visual analogue scale (VAS). RESULTS: Of the 23 anterior injections, nine caused contrast artifacts in the subscapular tendon, and in three the leakage extended further anteriorly. Of the 20 posterior injections, 12 showed injection artifacts of the rotator cuff, extending outside the cuff in seven. Two of the anterior and none of the posterior artifacts compromised diagnostic quality. In posterior injections, the leakage regularly occurred at the caudal edge of the infraspinatus muscle and was easily distinguishable from rotator cuff tears. All patients completed the pain survey. Mean VAS scores were 25.0 (median 18, SD 22) for anterior, and 25.4 (median 16, SD 25) for posterior injections. The two radiologists achieved different mean VAS scores but closely agreed as to anterior and posterior VAS scores. CONCLUSION: Arthrography injections were fairly simple to perform under US guidance. Patient discomfort for anterior and posterior injections was equally minor. A tailored approach utilizing anterior or posterior injections, depending on anticipated shoulder pathology, is recommended. Because in posterior injections all artifacts were posterior and readily recognizable, it seems especially suitable for suspected anterior rotator cuff, joint capsule, and labral pathologies.

Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial.

BACKGROUND: Hydrodilatation of the glenohumeral joint is by several authors reported to improve shoulder pain and range of motion for patients with adhesive capsulitis. Procedures described often involve the injection of corticosteroids, to which the reported treatment effects may be attributed. Any important contribution arising from the hydrodilatation procedure itself remains to be demonstrated. METHODS: In this randomized trial, a hydrodilatation procedure including corticosteroids was compared with the injection of corticosteroids without dilatation. Patients were given three injections with two-week intervals, and all injections were given under fluoroscopic guidance. Outcome measures were the Shoulder Pain and Disability Index (SPADI) and measures of active and passive range of motion. Seventy-six patients were included and groups were compared six weeks after treatment. The study was designed as an open trial. RESULTS: The groups showed a rather similar degree of improvement from baseline. According to a multiple regression analysis, the effect of dilatation was a mean improvement of 3 points (confidence interval: -5 to 11) on the SPADI 0-100 scale. T-tests did not demonstrate any significant between-group differences in range of motion. CONCLUSION: This study did not identify any important treatment effects resulting from three hydrodilatations that included steroid compared with three steroid injections alone. TRIAL REGISTRATION: The study is registered in Current Controlled Trials with the registration number ISRCTN90567697.

Predictors of Pain and Discomfort Associated with CT Arthrography of the Shoulder.

RATIONALE AND OBJECTIVES: The objective of this study was to investigate predictors of pain associated with computed tomographic arthrography of the shoulder. MATERIALS AND METHODS: Before shoulder arthrography, all participants were assessed with the Hospital Anxiety and Depression Scale (HADS) and the World Health Organization Quality of Life Short Version Instrument (WHOQOL-BREF). The participants were nonrandomized into two groups: the anesthesia group, who underwent prior local infiltration anesthesia before shoulder arthrography, and the nonanesthesia group, who did not undergo prior local infiltration anesthesia. The pain levels at intraprocedure, at 1, 2, 6, and 12 hours, and at 1 and 2 days after injection were assessed by using a visual analog scale. Univariate and multivariate generalized linear model analyses were conducted. RESULTS: Sixty participants in the anesthesia group and 60 participants in the nonanesthesia group were included. The pain level at intraprocedure (3.37 ± 1.94 in the anesthesia group and 3.20 ± 1.34 in the nonanesthesia group) was the highest of the whole pain course. The psychological domain (P = .0013) of WHOQOL-BREF, gender (P = .042), body mass index (P = .0001), and the total number of reinsertion and redirection of needle (P< .0001) were independent predictors of arthrography-related pain. CONCLUSIONS: The pain associated with shoulder computed tomographic arthrography depends on the psychological domain of WHOQOL-BREF, gender, body mass index, and the total number of reinsertion and redirection of needle.

Near-fatal air embolus during arthrography of the hip in a baby aged four months.

We describe a near-fatal event, probably due to air embolism, following an air arthrogram for developmental hip dysplasia in a baby aged four months. The sequence of events and the subsequent treatment are described. There is little information about this complication in the literature. The presumed mechanism and alternative methods for confirmation of placement of the needle are discussed. We no longer use air arthrography in children.

Direct shoulder magnetic resonance arthrography for superior labral anterior-to-posterior (SLAP) and Bankart lesions: investigation into the appropriate dose and level of local anesthesia.

OBJECTIVE: To compare contrast leakage, pain score, image quality and diagnostic performance at different doses and levels of local anaesthesia for direct shoulder magnetic resonance arthrography. METHODS: Patients (n = 157) were prospectively enrolled and allocated to Group 1 (no local anaesthetic), Group 2 (local anaesthesia to subcutaneous fat level; lidocaine 1-2 ml), Group 3 (to deltoid muscle level; 3-5 ml), or Group 4 (to subscapularis muscle level; 6-8 ml). We evaluated the frequency of contrast leakage, periprocedural/postprocedural pain, contrast-to-noise ratio of the intra-articular signal, and subjective image noise/image sharpness. Radiological diagnoses of superior anterior-to-posterior (SLAP) and Bankart lesions were assessed. All data were analysed by one-way analysis of variance/Kruskal-Wall, Χ2/Fisher's exact and DeLong's tests. RESULTS: The frequency of contrast leakage from the injection path and subjective image noise were significantly lower in Groups 1 and 2 than in Groups 3 and 4 (p = 0.001-0.04). Periprocedural/postprocedural pain scores among Groups 2-4 were similar and lower than those of Group 1. The contrast-to-noise ratio (p = 0.11-0.97) and image sharpness (p = 0.12-0.43) were similar among Groups 2-4 and significantly lower than those of Group 1 (p = 0.001-0.02). The diagnostic performance for the assessment of superior anterior-to-posterior and Bankart lesions was better in Groups 2-4 than in Group 1, although there were no significant differences (p = 0.23-0.99). CONCLUSION: Local anaesthesia with 1-2 ml lidocaine at subcutaneous fat level reduced pain and provided optimal image quality in direct shoulder magnetic resonance arthrography. Advances in knowledge: This method can increase image quality, reduce periprocedural/postprocedural pain and potentially reduce the need for re-examination.