Intra-articular injections of the first metatarsophalangeal joint

NewsBot · Jan 23, 2023

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Hit and miss: The accuracy of intra-articular injections of the first metatarsophalangeal joint
Ian N. Reilly
Journal of the International Foot & Ankle Foundation

Introduction: Therapeutic injections provide a treatment option for patients with joint and periarticular pain, those who are not surgical candidates, whom conservative treatment has failed, or those that are awaiting surgery. Injectable glucocorticoids are one of the most common therapeutic interventions in musculoskeletal healthcare and are widely used in pathologies of the first metatarsophalangeal joint. The aim of this paper is to highlight current concepts around first metatarsophalangeal joint injection injection accuracy.

Anatomy: The first metatarsophalangeal joint is a condyloid synovial juncture and consists of the head of the first metatarsal, the base of the proximal phalanx, six muscles, eight ligaments and two sesamoid bones, with associated ligamentous attachments. The joint capsule is shaped like a box.

Methods: To achieve the research aim, a scoping review was undertaken with a search strategy that identified evidence via the following sources: Electronic databases, Google scholar, and Reference lists.

Results: The search yielded 193 articles, 48 of which appeared of potential relevance. After removing duplicate articles this total was reduced to 37 articles. After scanning the content, 27 were excluded to leave 10 articles. Twenty eight further articles were found through related author research, examination of reference lists and free text searches of Google Scholar. One reference was unobtainable. The final count of papers utilised for review was 37 which produced three themes, one of which was injection accuracy.

Injection accuracy: In the long history of injection therapy, infiltrations have often been performed without image guidance, i.e., using palpation guidance, anatomical landmarks and clinical judgement to direct needle entry and advancement. Needle placement may also be confirmed by use of diagnostic imaging. Typical imaging modalities are fluoroscopy or ultrasound, used alone or in combination with contrast media.

Discussion: The perceived wisdom is that if an injectate misses its target it is likely to be less effective and lead to false negative reporting of poor treatment outcomes, but the literature is not equivocal. This article discusses the recent literature in the field.

Conclusions: The literature suggests that steroid injections are safe and effective for the short-term relief of joint pain. When injecting small synovial joints using palpated-guided methods, clinicians must be alert to the potential for failure of technique from the needle penetrating too far into the articulation and exiting the joint on the contralateral side from the entry point. Use of shorter needles and use of imaging, +/- the use of contrast media, might reduce the number of such failures.
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NewsBot · Oct 30, 2023

The key concepts in intra-articular
corticosteroid injection therapy for
pathology of the first metatarsophalangeal joint
Reilly, I. N.
A thesis submitted in partial fulfilment of the requirements
for the Professional Doctorate in Healthcare Sciences

The first metatarsophalangeal joint is a synovial articulation in the forefoot
comprising the first metatarsal, the hallucal proximal phalanx, and two
sesamoid bones. The two most common non-traumatic diseases affecting the
joint are osteoarthritis and hallux abducto valgus, but rheumatoid arthritis, gout,
and sesamoiditis may also affect the joint. Corticosteroids injection therapy is
used in the treatment of musculoskeletal pathology, in particular via intraarticular delivery to treat the pain associated with joint disease.
Given that the first metatarsophalangeal joint corticosteroid injection is one of
the most commonly performed infiltrations in the foot, this project aims to
identify, synthesise and critique the key concepts for injections in the
management of first metatarsophalangeal joint pathology, to highlight gaps in
our knowledge, to provide answers where possible, and to generate research
questions for future studies.
Whilst providing an overview of injection therapy, local anatomy, joint
pathology, and relevant corticosteroid pharmacology, this thesis has attempted
to provide a through critical appraisal of the existing literature. The initial
scoping review on corticosteroid injections in the management of first
metatarsophalangeal joint pathology, identified the range of available evidence
for all joint pathologies, and produced three themes:
1. Injection therapy outcomes for a given joint pathology,
2. Injection techniques, dosage, and regimen,
3. Injection accuracy and needle placement.
The initial inquiries into these topics involved a systematic review that centred
on the utilisation of corticosteroid injections to address hallux limitus/rigidus.
Despite a limited availability of high-level evidence, this indication was identified
as the most commonly encountered scenario for injection therapy. Data
extracted facilitated the production of a best-practice palpation-guided injection
technique. However, the accuracy of such a technique remained uncertain.
The next schema of work sought to establish the accuracy of palpation-guided
injections using radiopaque contrast media in cadaveric specimens to confirm
the needle placement. The study noted the failure of technique in one of the
six specimens used and extra-articular injectate leakage in another three
specimens. This calls into question the confidence of palpation-guided
techniques for injecting the joint.
Whilst the evidence base suggests that corticosteroid injections are safe shortand mid-term treatment options for soft tissue and joint pathology, the specific
outcomes in the first metatarso-phalangeal joint warrant further study. It needs
to be clarified from the available literature what drug, dose, and at what point in
disease regression is optimal for injection therapy in a given patient. Based on
the findings of this work, future research should include conducting structured
research to establish precise injection therapy protocols for addressing first
metatarsophalangeal joint pathology. The primary emphasis of these
forthcoming studies should be on osteoarthritis of the great toe, given its
prevalence as the most frequently treated condition through injections.
Additionally, high-level studies are also needed to assess the efficacy of
injection therapy in managing other great toe joint pathologies.
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NewsBot · Jan 1, 2024

Intraarticular Injections in the Foot and Ankle: Medication Selection Patterns and Perceived Risk Of Chondrotoxicity
Emily B Parker et al
Foot Ankle Orthop. 2023 Dec 21;8(4)

Background: Intraarticular corticosteroid injections (ICIs) are widely used to treat foot and ankle conditions. Although laboratory studies indicate certain corticosteroids and local anesthetics used in ICIs are associated with chondrotoxic effects, and selected agents such as ropivacaine and triamcinolone may have less of these features, clinical evidence is lacking. We aimed to identify the patterns of drug selection, perceptions of injectate chondrotoxicity, and rationale for medication choice among surgeons in the American Orthopaedic Foot & Ankle Society (AOFAS).

Methods: An e-survey including demographics, practice patterns, and rationale was disseminated to 2011 AOFAS members. Frequencies and percentages were calculated for demographic data, anesthetic and steroid choice, rationale for injectate choice, and perception of chondrotoxicity. Bivariate analysis was used to identify practice patterns significantly associated with perceptions of injectate risk and rationale.

Results: In total, 387 surveys were completed. Lidocaine and triamcinolone were the most common anesthetic and corticosteroid used (51.2% and 39.3%, respectively). Less than half of respondents felt corticosteroids or local anesthetics bear risk of chondrotoxicity. Respondents agreeing that corticosteroids are chondrotoxic were more likely to use triamcinolone (P = .037). Respondents agreeing local anesthetics risk chondrotoxicity were less likely to use lidocaine (P = .023). Respondents choosing a local anesthetic based on literature were more likely to use ropivacaine (P < .001).

Conclusion: Corticosteroid and local anesthetic use in ICIs varied greatly. Rationale for ICI formulation was also variable, as the clinical implications are largely unknown. Those who recognized potential chondrotoxicity and who chose based on literature were more likely to choose ropivacaine and triamcinolone, as reflected in the basic science literature. Further clinical studies are needed to establish guidelines that shape foot and ankle ICI practices based on scientific evidence and reduce the variation identified by this study.
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NewsBot · Jan 13, 2024

Implantation of a Cushioning Injectable Implant Using Needle Arthroscopy in the Foot and Ankle and First Carpometacarpal Joint
Tobias Stornebrink et al
Arthrosc Tech. 2023 Nov 27;12(12):e2343-e2352

Injectable implants constitute a newly developed treatment class in the battle against osteoarthritis. They consist of water-formulated supramolecular polymer, coming from a new class of resorbable biomedical materials, and are implanted in encapsulated joints in a liquid form, where they solidify to form a tough, elastic, and cushioning layer between the joint surfaces. To resort any effect, intra-articular delivery should be guaranteed, and the implant should be distributed throughout the entire joint space. Traditional implantation techniques do not seem to suffice for this new implant class, being either imprecise (traditional injection) or overly invasive (open procedures and traditional arthroscopic surgery). We describe a needle arthroscopic implantation technique to reap the benefits of both worlds, ensuring precise implant delivery while avoiding unnecessarily invasive procedures. This study depicts our needle arthroscopic technique for implantation of injectable implants in the ankle, first metatarsophalangeal joint, and first carpometacarpal joint.
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