Accuracy of anterolateral versus posterolateral subtalar injection

Arch Orthop Trauma Surg DOI 10.1007/s00402-010-1208-y

ORTHOPAEDIC SURGERY

Accuracy of anterolateral versus posterolateral subtalar injection Tanja Kraus • Nima Heidari • Paul Borbas Hans Clement • Wolfgang Grechenig • Annelie-Martina Weinberg

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Received: 12 July 2010 Ó Springer-Verlag 2010

Abstract Introduction Injections into the subtalar joint may be performed for diagnostic or therapeutic reasons. The anterolateral approach is most commonly utilised for this purpose. We evaluated the success of an intra-articular puncture by using the anterolateral in comparison to the posterolateral approach. Methods Sixty-eight cadaver adult feet were used for performing injections into the subtalar joint without fluoroscopic or ultrasound guidance. Methylene blue dye was infiltrated into 34 of the 68 subtalar joints through an anterolateral approach and into 34 through an posterolateral approach. An arthrotomy was then performed to confirm the placement of the dye within the joint. Results Twenty-three of the anterolateral injections (67.6%) were successful as were 31 of 34 (91.2%) of the

posterolateral. The posterolateral approach showed a greater accuracy with a statistically significance (p = 0.016). Conclusion Unintended peri-articular injection can cause complications and an unsuccessful aspiration can delay diagnosis. Comparing the anterolateral to the posterolateral approach with regards to the rate of successful intraarticular puncture of the subtalar joint without the use of imaging there is a greater accuracy with the PL with statistically significance.

T. Kraus (&) Pediatric Orthopedic Unit, Department of Pediatric Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036 Graz, Austria e-mail: [email protected]

Hind foot pain may be due to inflammatory or degenerative arthritis. The treatment of debilitating pain and deformity may be challenging and depends on an accurate diagnosis. When history and clinical examination are not sufficient to form a diagnosis, intra-articular injection of local anaesthetics can pin point the source of pain, confirm the diagnosis and inform further treatment [17]. Therapeutic agents are frequently employed to alleviate pain caused by rheumatic diseases or arthritis [3, 5, 13] and aspiration of joint fluid can assist in the diagnosis of acute conditions including septic arthritis and crystal arthropathy. The accurate placement of the needle tip within the joint capsule is the prerequisite condition for obtaining a diagnosis and conferring therapeutic benefits. Unintentional periarticular placement of injections may be accompanied by serious complications including tendon rupture, scarring, atrophy [1, 6] and tendon bowstringing [8]. An unsuccessful attempt at aspiration of joint fluid may delay diagnosis.

N. Heidari Royal London Rotation, Royal London Hospital, Whitechapel, London E1 1BB, UK P. Borbas Division of General Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria P. Borbas H. Clement W. Grechenig Department of Traumatology, Medical University of Graz, Auenbruggerplatz 7a, 8036 Graz, Austria A.-M. Weinberg Department of Pediatric Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036 Graz, Austria

Keywords Intraarticular Aubtalar Injection Anterolateral Posterolateral Subtalar joint Injection Approach Non-guided

Introduction

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Arch Orthop Trauma Surg

In clinical practice, surgeons and physicians of varying experience routinely perform intra-articular joint punctures. Imaging is not routinely available for confirmation of the intra-articular placement of injections and limited accuracy of injection has been documented previously even in experienced hands [9–11, 16, 19]. In this study, we aimed to compare the accuracy of successful intra-articular subtalar joint injection by two different techniques without the use of ultrasound or fluoroscopic guidance.

Materials and methods Sixty-eight adult (32 right, 36 left) feet, including the distal 15 cm of the tibia and the ankle joint, preserved with the method of Thiel were used for this study [22]. This unique embalming procedure was developed over a period of 30 years in the Department of Anatomy, University of Graz, Austria. It preserves tissue colour and consistency as well as allowing an almost full range of movement at articular joints. Limbs that had physical signs of arthritis, previous trauma or other pathological changes were excluded. A single experienced clinician performed the injections into the subtalar joint without fluoroscopic or ultrasound guidance. Limbs were selected at random so that one half of the specimens were injected through an anterolateral (15 right, 19 left) and the other half through a posterolateral approach (17 right, 17 left). Approximately 1 ml of methylene blue dye was instilled into each joint using a 14-gauge needle mounted on a 5 ml syringe. Approaches 1.

2.

Anterolateral [5, 7, 17] (Fig. 1a, b) the foot was positioned with its medial side on the table and the subtalar joint held in an inverted posture. The angle of Gissane and the anterior edge of the lateral process of talus was palpated and inserted the needle tip at angles 30°–45° cephalad and 45° medial between these two landmarks. Only one skin puncture was performed but one to three attempts at positioning the needle within the joint were permitted. Posterolateral [7, 15, 17, 21] (Fig. 2a, b) with the foot supinated and dorsiflexed, the entry point was palpated 2–5 cm above the distal tip of the fibula, mid-way between the peroneal and Achilles tendons. A 14gauge needle was introduced at a 60° angle to the skin surface with the needle tip being pointed towards the medial malleolus. Only one skin puncture was performed but one to three attempts for positioning the needle were permitted.

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Fig. 1 Anterolateral approach: a anatomical landmarks and suggested direction of the needle, b approach in the anatomical model F fibula, T tibia, C anterior process of calsis

After injection an arthrotomy was performed and an independent orthopaedic resident evaluated the presence of intra-articular dye in each specimen. The presence of the dye within the joint was regarded as a successful intraarticular injection. In the case of a peri-articular injection all structures stained with the dye were recorded. Statistics The proportion of successful injections was reported by comparing the anterolateral to the posterolateral approach using the Chi-square test. A p value B 0.05 was considered


Fig. 3 Success rate of intra-articular subtalar joint injections using different approaches

subcutaneous tissues, superficial to the joint capsule and deep to the superficial fascia. In the posterolateral group, only 3 of 34 injections (8.8%) were extra-articular found to be just superficial to the joint capsule. We did not observe any dye within tendons or in neurovascular structures, including the short saphenous vein, sural nerve or superficial peroneal nerve.

Fig. 2 Posterolateral approach: a anatomical landmarks and suggested direction of the needle, b approach in the anatomical mode

to be statistically significant (SPSS 16.0 for Mac; SPSS Inc., Chicago, IL, USA).

Results Twenty-three of the 34 injections (67.6%) through the anterolateral approach were successful, where as 31 of the 34 posterolateral injections (91.2%) were intra-articular. In total, 54 of 68 injections (79.4%) were intra-articular. The posterolateral approach showed a greater accuracy with a statistically significance (Pearson Chi-square test value 5.757; df = 1; p = 0.016). Results are shown in Fig. 3. In the 11 unsuccessful anterolateral injections (32.4%), the dye was noted to be in the soft tissues. It was within the

Discussion In clinical practice, intra-articular punctures are often required for diagnostic and therapeutic purposes and are routinely performed by surgeons and physicians of varying experience. The accurate placement of the needle tip within the joint capsule is the prerequisite condition for obtaining a diagnosis and conferring therapeutic benefits. Intra-articular puncture is a challenge and limited accuracy of injection has been documented previously even in experienced hands [9–11, 16, 19]. In the daily routine, imaging is often not available for confirmation of the intra-articular placement of injections. This may be related to time- and cost-saving conditions especially in the outpatient clinic. In this study, we compared the anterolateral and posterolateral approaches for subtalar joint puncture by using anatomical landmarks. Our study has several limitations: it is a cadaver study with the outcome perhaps not being transferable to the clinical practice. Although we have a relatively low

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number of specimens, this is by far the largest series for such a comparison in the literature. In clinical practice, patients often have deformity, narrowed joint spaces, instrumentation or overhanging osteophytes, all of which may limit the access to the subtalar joint [12, 17]. Three approaches including the anterolateral [5, 7], the posterolateral [15, 17] and the posteromedial approach [14, 17] have been suggested. Familiarity with all of these techniques would allow versatility and the ability to tailor the procedure to the clinical circumstances. The posterolateral and the anterolateral approaches have the advantage of the lack of proximity to major neurovascular structures in contrast to the posteromedial approach. Injury to the medial plantar nerve has been reported using a posteromedial approach with fluoroscopic guidance. This is not entirely unexpected given the close proximity of the path of the needle to the posteromedial neurovascular bundle [14, 17, 18]. We injected 68 subtalar joints and found that 79.4% of the injections were intra-articular. The posterolateral injection portal had a significantly higher rate of success (91.2%) as compared to the anterolateral (67.6%). Cahill et al. [5] has reported 100% accuracy rate with an anterolateral approach using fluoroscopic guidance. Other authors using either CT or fluoroscopic guidance have also reported 100% success rates with different approaches [12, 17, 18]. However, fluoroscopy and CT requires the injection of contrast medium and exposure to ionising radiation [4]. Smith [20] described accuracy rates of 100% by using sonographically guided posterior subtalar joint injection through the posterolateral, posteromedial and anterolateral approaches. This method avoids the use of ionising radiation, but is technically demanding and requires that the operator is familiar with sonographic equipment and has the ability to use them. The correct placement of the needle may also be confirmed with the aspiration of synovial fluid. However, this is not always possible, especially in the ‘‘dry’’ joint. Insufflation of the joint with saline and subsequent aspiration may confirm placement of the needle but even this method cannot be relied upon in every case [2]. Intra-articular injections are often [16] performed in the office setting without the aid of imaging. The use of anatomical landmarks combined with good technique can be a rapid method for the clinician to perform intra-articular injections and be convenient for the patient. Experienced clinicians can attain a high degree of accuracy for the placement of intra-articular injections into the posterior subtalar joint when using the posterolateral approach. We are unaware of any previous studies comparing the rate of successful intra-articular puncture of the subtalar joint with reference to the approach employed without the use of image guidance. We have demonstrated a statistically significant difference between the anterolateral and

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posterolateral approaches with a greater accuracy with the posterolateral approach. This we feel is due to the posterior recess of the ST joint capsule. We advocate the posterolateral approach especially in patients with poor soft tissues about the foot. The peri-articular injections from the anterolateral approach were within the superficial soft tissues. This may lead to a greater frequency of soft tissue complications associated with the unsuccessful injection where as the posterolateral the periarticular injection are deep within the retrocalcaneal bursa and may be associated with less morbidity. However, in conclusion and in consideration of the study limits we support the use of the posterolateral approach in subtalar joint injection as a safe, minimally invasive reliable and accurate method that provides an effective therapeutic approach. Acknowledgments The authors would like to acknowledge the valuable contributions of Juergen Fechter and Dr. Bernhard Leipold for the assistance in statistics and in the preparation of the photos for this publication. Conflict of interest

None.

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