Ultrasound Guidance for Intra-articular Injections of the Foot

NewsBot · Sep 17, 2009

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Ultrasound Guidance for Intra-articular Injections of the Foot and Ankle
Khosla S, Thiele R, Baumhauer JF.
Foot Ankle Int. 2009 Sep;30(9):886-90.

BACKGROUND: Ultrasound has been increasingly utilized in procedures involving intra-articular injections. This study's purpose was to compare the accuracy of intra-articular injections of the foot and ankle using palpation versus dynamic ultrasound in a cadaver model.

MATERIALS AND METHODS: Fourteen lightly embalmed cadaver specimens without notable osteoarthritis were used. A 0.22-gauge needle was placed by a foot and ankle orthopaedic surgeon into the first and second tarsometatarsal joints, subtalar joint, and ankle joint. The needle was initially placed using palpation, evaluated with ultrasound by an experienced rheumatologist, and re-inserted if necessary. Needle placement was confirmed with injection of an Omnipaque/methylene blue solution and examined under fluoroscopy, followed by dissection.

RESULTS: Palpation and ultrasound were 100% accurate in subtalar and ankle joint injections. Using palpation, the needle was correctly placed into the first TMT joint in three of 14 cadavers, and in four of 14 cadavers for the second TMT joint. Using ultrasound, the needle was correctly placed into the first TMT joint in ten of 14 cadavers, and into the second TMT joint in eight of 14 cadavers. When grouped, ultrasound was significantly more accurate for intra-articular needle placement compared to palpation in the midfoot (p = 0.003). On three specimens, dye extended beyond the second TMT joint.

CONCLUSION: Intra-articular injections of the subtalar and ankle joints can be successfully performed utilizing palpation alone. Ultrasound guidance significantly increases injection accuracy into the TMT joints compared to palpation alone and therefore US or Fluoroscopy is performed when injecting these TMT joints. When using selective diagnostic injections into a TMT joint to assess for the symptomatic joint and potential need for arthrodesis, the injected anesthetic may not remain isolated within that joint. These isolated TMT injections should not be done to answer that question without fluoroscopy confirmation with radiopaue dye demonstrating the injected fluid remained within the one joint of interest
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NewsBot · Dec 30, 2014

Sonographically Guided Posterior Subtalar Joint Injections via the Sinus Tarsi Approach.
Smith J, Maida E, Murthy NS, Kissin EY, Jacobson JA.
J Ultrasound Med. 2015 Jan;34(1):83-93. doi: 10.7863/ultra.34.1.83.

OBJECTIVES:
To determine the feasibility and accuracy of sonographically guided posterior subtalar joint (PSTJ) injections performed through the sinus tarsi.
METHODS:
A single experienced operator completed 10 sonographically guided PSTJ injections via the sinus tarsi on 10 unembalmed cadaveric ankle-foot specimens. Injections were performed using a 17-5-MHz linear transducer, a 25-gauge, 50-mm needle, and an out-of-plane, anterior-to-posterior needle trajectory parallel to the calcaneal surface. Sonographic assessment for fluid in the posterior and lateral PSTJ recesses, sinus tarsi, and peroneal tendon sheath was performed before and after injections of 2 and 4 mL of tap water. Two additional specimens were injected with a contrast agent: 1 via the sonographically guided approach and another by a computed tomographically guided approach.
RESULTS:
All 10 sonographically guided PSTJ tap water injections were accurate, distending both the posterior and lateral PSTJ recesses. In addition, all 10 specimens showed posterior recess distension by 2 mL, whereas only 2 specimens (20%) showed lateral recess distension at this volume. By 4 mL, both recesses were clearly distended in all specimens. Both contrast agent injections produced similar PSTJ computed tomographic arthrograms and patterns of recess distension similar to the sonographically guided tap water injections. No sonographically guided PSTJ injection placed fluid in the peroneal tendon sheath.
CONCLUSIONS:
Sonographically guided PSTJ injections via the sinus tarsi can accurately and specifically deliver injectate into the PSTJ while monitoring injectate flow within the posterior recess. The sinus tarsi approach may be used as an alternative technique to perform sonographically guided PSTJ injections when clinically appropriate.
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NewsBot · Mar 18, 2017

Ultrasound-guided therapeutic injections for neural pathology about the foot and ankle: a 4 year retrospective review.
Walter WR et al
Skeletal Radiol. 2017 Mar 16. doi: 10.1007/s00256-017-2624-7

OBJECTIVE:
To describe a 4-year clinical experience with ultrasound-guided therapeutic perineural injections of peripheral nerves about the foot and ankle.
MATERIALS AND METHODS:
Retrospective analysis of foot and ankle perineural injections performed between January 2012 and August 2016. Demographics, clinical indications, presence of structural pathology, immediate and interval pain relief, as well as complications were recorded.
RESULTS:
Fifty-nine therapeutic injections were performed among 46 patients, accounting for multiple injections in a single visit or multiple visits [mean age = 43 years (range 18-75), 31 female (67%) and 15 male (33%)]. Most commonly, perineural injections involved the hallux branch of the medial plantar nerve (n = 17, 22%). Least commonly, perineural injections involved the saphenous nerve (n = 3, 4%). Other injections in our series include sural (10), superficial (11) and deep (7) peroneal, medial (5) and lateral (3) plantar nerves, and the posterior tibial nerve (3). Ultrasound evaluation revealed structural abnormality associated with the nerve in 30 cases (51%)-most commonly thickening with perineural scarring (n = 14). Of 45 injections with complete documentation, immediate relief of symptoms was reported in 43 (96%) cases. Interval symptom relief was achieved in 23 injections [short term (n = 12), intermediate (n = 6), and long term (n = 5)] out of 38 for which follow-up was available (61%). Complications are rare, occurring in only one case.
CONCLUSION:
Ultrasound-guided perineural injections about the foot and ankle are safe and provide lasting symptomatic relief for many indications. Concomitant sonographic evaluation identifies structural abnormalities that may contribute to neuropathic symptoms, allowing targeting of injection or clinical therapy.
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NewsBot · Jun 27, 2018

Guided Intra-articular Corticosteroid Injections in the Midfoot.
Protheroe D, Gadgil A
Foot Ankle Int. 2018 Jun 1:1071100718779983.

BACKGROUND:
Intra-articular corticosteroid injections are used for both their therapeutic and diagnostic function. There is a paucity of literature investigating the efficacy of intra-articular corticosteroid injections into the midfoot. The aim of the study was to identify the efficacy of image guided intra-articular corticosteroid (Methylprednisolone) injections for midfoot osteoarthritis The null hypothesis of this study was there would be no benefit or increase of the Self-reported Foot and Ankle Score (SEFAS) from an intra-articular corticosteroid injection.

METHODS:
SEFAS was collected at 4 and 12 months postinjection. A total of 37 consecutive patients who had 67 midfoot injections were recruited into the study over a 6-month period.

RESULTS:
The mean SEFAS score preinjection was 17.0, at 4 months postinjection was 31.8 ( P < .001), and 12 months postinjection 21.3 ( P < .14). There was a statistically significant improvement in postinjection SEFAS ( P < .001) at 4 months. The null hypothesis of this study was rejected. Response to the injection was varied but patients with BMI less than 30 had a sustained ( P < .04) symptomatic improvement at 12 months when compared to the obese patients.

CONCLUSION:
Our findings support the use of corticosteroid injections as a viable diagnostic and therapeutic option following failed conservative treatment options prior to operative intervention. The results at 4 months were statistically significant with an additional finding of a difference observed between obese and nonobese patients. This may have implications for further educating the patient in effective weight loss that may improve symptom relief from intra-articular injection.
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