The posterolateral approach for fluoroscopy-guided tibiotalar joint injection

Ultrasound-guided injection of the ankle joint: cadaveric investigation of the anterolateral approach

OBJECTIVE

Injection of the tibiotalar (TT) joint is commonly performed in clinical practice under ultrasound (US) guidance using an anteromedial approach. However, in some patients, this approach may be technically challenging due to post-traumatic and/or degenerative bony changes. Therefore, the aim of this cadaveric investigation was to demonstrate the feasibility of the ultrasound-guided (USG) injection of the ankle joint via the anterolateral sulcus (ALS) by confirming the dye placement/distribution inside the articular space. Likewise, the safety of the procedure has also been evaluated by measuring the distance between the needle and the intermediate dorsal cutaneous nerve of the foot.

DESIGN

A descriptive laboratory study with eight embalmed cadaveric ankles using the Fix for Life (F4L) method was performed at the setting of an academic institution. The interventional technique and the related anatomical findings were illustrated. During the injection, the needle was advanced into the TT joint through the ALS under US guidance, i.e., in-plane anterior-to-posterior approach. With the objective to confirm its correct placement, the needle was kept in situ and-to demonstrate the location of the dye inside the articular space-all eight ankles were injected with 3 mL of green color dye. Thereafter, a layer-by-layer anatomical dissection was performed on all four cadavers.

RESULTS

The position of the needle's tip within the ALS was confirmed in all specimens. Accurate placement of the dye inside the articular space of the ankle was confirmed in seven of the eight cadaveric ankles, with 87.5% of accuracy. Herewith, unintentional spilling of the dye within the superficial soft tissues was reported in two of the eight ankles (25.0%). The mean distance between the needle and the intermediate dorsal cutaneous nerve of the foot, measured in all eight procedures, was 3 cm.

CONCLUSION

USG injection of the ALS using the in-plane, anterior-to-posterior approach can accurately place the injectate inside the articular space.

CLINICAL RELEVANCE

This cadaveric investigation described the accuracy and potential pitfalls of USG injection of the ankle via the anterolateral approach which represents an alternative technique in patients with reduced accessibility of the anteromedial recess due to degenerative and/or post-traumatic bony changes.

Fluoroscopic-guided procedures of the lower extremity

This article reviews the literature and the authors' experiences regarding the performance of lower extremity fluoroscopically guided procedures from the hip to the toes. An overview of injections and aspirations, their indications, risks, and complications are provided, focusing on anesthetics, corticosteroids, and contrast agents. A variety of approaches to each joint and the associated pearls and pitfalls of each approach will be discussed.

The Efficacy of Microfracture Combined with Extracorporeal Shock Wave Therapy for Treating Osteochondral Lesion of the Talus and the Quality of Regenerated Cartilage: A Retrospective Cohort Study and MRI Assessment

BACKGROUND

osteochondral lesion of the talus (OLT) is a common disease in the physically active population, and extracorporeal shock wave therapy (ESWT) is a noninvasive treatment. We hypothesized that microfracture (MF) combined with ESWT may have great potential to become a novel combination treatment of OLT.

METHODS

the OLT patients who received MF + ESWT or MF + platelet-rich plasma (PRP) injection were retrospectively included, with a minimal follow up of 2y. The daily activating VAS, exercising VAS, and American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS) were used to assess the efficacy and functional outcome, and ankle MRI T2 mapping was used to evaluate the quality of regenerated cartilage in the OLT patients.

RESULTS

only transient synovium-stimulated complications were found during the treatment sessions; the complication rate and daily activating VAS did not have differences between groups. MF + ESWT had a higher AOFAS and a lower T2 mapping value than MF + PRP at the 2y follow up.

CONCLUSIONS

the MF + ESWT had superior efficacy for treating OLT, which resulted in better ankle function and more hyaline-like regenerated cartilage, superior to the traditional MF + PRP.

Injection Techniques for Common Chronic Pain Conditions of the Foot: A Comprehensive Review

Purpose of Review

This is a comprehensive literature review of the available evidence and techniques of foot injections for chronic pain conditions. It briefly describes common foot chronic pain syndromes and then reviews available injection techniques for each of these syndromes, weighing the available evidence and comparing the available approaches.

Recent Findings

Foot and ankle pain affects 20% of the population over 50 and significantly impairs mobility and ability to participate in activities of daily living (ADLs), as well as increases fall risk. It is commonly treated with costly surgery, at times with questionable efficacy. Injection therapy is challenging when the etiology is anatomical or compressive. Morton’s neuroma is a budging of the interdigital nerve. Steroid, alcohol, and capsaicin injections provide some benefit, but it is short lived. Hyaluronic acid (HA) injection provided long-term relief and could prove to be a viable treatment option. Achilles tendinopathy (AT) is most likely secondary to repeat tendon stress—platelet-rich-plasma (PRP) and prolotherapy have been trialed for this condition, but more evidence is required to show efficacy. Similar injections were trials for plantar fasciitis and achieved only short-term relief; however, some evidence suggests that PRP injections reduce the frequency of required therapy. Tarsal tunnel syndrome, a compressive neuropathy carries a risk of permanent neural injury if left untreated. Injection therapy can provide a bridge to surgery; however, surgical decompression remains the definitive therapy. When the etiology is inflammatory, steroid injection is more likely to provide benefit. This has been shown in several studies for gout, as well as osteoarthritis of the foot and ankle and treatment-refractory rheumatoid arthritis. HA showed similar benefit, possibly due to anti-inflammatory effects. Stem cell injections may provide the additional benefit of structure restoration.

Summary

Chronic foot pain is common in the general population and has significant associated morbidity and disability. Traditionally treated with surgery, these are costly and only somewhat effective. Injections provide an effective alternative financially and some evidence exists that they are effective in pain alleviation. However, current evidence is limited and the benefit described from injection therapy has been short-lived in most cases. Further studies in larger populations are required to evaluate the long-term effects of these treatments.

Pearls and pitfalls of fluoroscopic-guided foot and ankle injections: what the radiologist needs to know

OBJECTIVE

This article provides a comprehensive, joint-by-joint review of fluoroscopic-guided foot and ankle injections and emphasizes pre-procedural planning, relevant anatomy, appropriate technique, troubleshooting the difficult procedure, and the importance of communicating unexpected findings with the referring clinician. The interrogation of pain generators including variant ossicles, fractures, and post-surgical/traumatic findings is also described.

CONCLUSIONS

Even the most challenging foot and ankle injections may be successfully completed with a solid anatomical understanding and thoughtful approach.

Comparison of Platelet Rich Plasma and Prolotherapy in the Management of Osteochondral Lesions of the Talus: A Retrospective Cohort Study

BACKGROUND Osteochondral lesions of talus (OLT) are among the most common ankle problems. Platelet-rich plasma (PRP) and prolotherapy (PrT) are 2 successful injection-based techniques for treatment of chronic musculoskeletal problems. The aim of the present study was to compare PRP and PrT injections for the management of OLT. MATERIAL AND METHODS This was a retrospective cohort study of 49 patients with OLT symptoms of more than 6 months who had been refractory to 3 months of treatment using conservative methods. The patients were divided into 2 groups: PrT injections (PrT group, n=27) or PRP injections (PRP group, n=22). The patients were given 3 injections of 4 mL solution into periarticular and intra-articular ankle joint spaces. After treatment, patients were evaluated via Visual Analogue Scale (VAS), American Orthopedic Foot and Ankle Society Score (AOFAS), and Ankle Osteoarthritis Scale (AOS) at baseline and 21-, 90-, 180-, and 360-day follow-up periods. RESULTS Both PRP and PrT treatments resulted in greater improvement in pain and ankle functions at follow-up periods extending to 1 year (P<0.001) and there was no difference between the groups for the outcomes at follow-up periods (P>0.05). Excellent or good outcomes were reported by 88.8% of the patients in PrT group and 90.9% of the patients in PRP group. CONCLUSIONS Both PRP and PrT are efficient and safe methods in treatment of OLT. PrT offers advantages of less cost and minimal invasiveness.

Implications of Classification of Os Trigonum: A Study Based on Computed Tomography Three-Dimensional Imaging

BACKGROUND The os trigonum is an accessory bone that is not fully fused with the talus during secondary ossification, and is one of the risk factors of posterior malleolus impact syndrome. The purpose of this study was to classify the os trigonum and to guide the diagnosis and treatment of related clinical diseases. MATERIAL AND METHODS Ankle computed tomography (CT) scans of 586 Chinese patients between October 2014 and October 2018 were reviewed. CT images of 1011 ankle joints were reconstructed to evaluate the classification of the os trigonum and the measurement of anatomical parameters. RESULTS The incidences of os trigonum in 3 groups were determined as type I (1.9%), type II (10.5%), and type III (14.7%). The macro-axis of type II (0.89±0.31) cm was significantly larger than with type I (0.65±0.24 cm) and type III (0.74±0.23 cm) (p<0.05).The minor axis of similar of type I (0.41±0.23 cm) was significantly shorter than that of type II (0.58±0.32 cm) and type III (0.55±0.16 cm) (p<0.05).The distance from os trigonum to calcaneal tubercle was significantly different than that of type I (1.33±0.52 cm), type II (1.67±0.55 cm), and type III (1.84±0.45 cm) (p<0.05). CONCLUSIONS This study showed that os trigonum has a high incidence. Type I was the least common, the volume of type II was larger, and type III was more common. The anatomical parameters of each type may improve treatment of related diseases and the further development of ankle arthroscopic surgery.