Ankle and Foot Procedures

Ankle and Foot Procedures

KEY FACTS

Preprocedure

• Indications

Aspiration or injection of joint fluid

Intraarticular injection of medication or contrast

Paraarticular aspiration or injection

– Cyst aspiration, peritendon, plantar fasciitis, Morton neuroma, or forefoot bursitis injection

Procedure

• Joint aspiration or injection

Diagnostic to determine site of pain or therapeutic to relieve pain

Anterolateral approach to ankle preferred
• Ganglion cyst aspiration

≥ 19-g needle for more viscous contents

Steroid injection after aspiration is useful even if there is limited content aspirated
• Peritendon injection: Approach depends on site of tendon disease

Steroid injection to peritendon region

Platelet-rich plasma (PRP) within tendon substance
• For Achilles tendinosis, various treatments and approaches are possible

Stimulate healing response: Dry needling, autologous blood, PRP, or prolotherapy

Reduce neovascularity: Sclerotherapy, electrocoagulation, or brisement

Reduce inflammation: Steroid
• Plantar fasciitis: Medial approach preferable

Dry needling, steroid (short acting, preferably)
• Ligament injection

PRP within and around ligament substance
• Morton neuroma

Steroid ± alcohol ablation (if not responsive)
• Forefoot bursitis: Plantar approach

Steroid injection

PREPROCEDURE

Indications

• Aspiration or intraarticular injection

Suspected septic arthritis or crystal arthropathy

Therapeutic for control of inflammation or pain relief

Diagnostic to determine origin of pain

MR, CT, or conventional arthrography
• Ganglion cyst aspiration ± steroid injection: Pain relief

No pretest US predictor of content viscosity
• Peritendon therapy: Pain relief

Mainly to Achilles tendon, posterior tibialis, and peroneal tendons
• Plantar fasciitis injection: Pain relief

Helpful in cases resistant to standard treatment
• Ligament therapy: Pain relief
• Morton neuroma injection: Pain relief
• Forefoot bursal injection: Pain relief

Submetatarsal or intermetatarsal bursitis
• Sinus tarsi injection: Pain relief

Getting Started

• Things to check

Check patient identity and type and side of procedure

Signed informed consent

– Achilles tendon intervention: Risk of tendon rupture

– Plantar fascia injection: Risk of fascial rupture and heel pad atrophy

– Superficial steroid injection: Skin depigmentation change, particularly in patients who have had multiple injections and those with darker skin

Discuss risk of infection, allergy, and bleeding
• Medications

Local anesthetic (LA) for skin (2 mL of 1% lignocaine)

Local anesthetic for intraarticular injection

– 2-5 mL of 1-2% lignocaine or 3-5 mL of 0.25-0.50% bupivacaine (Marcaine)

Steroid

– Short acting (hydrocortisone), medium acting (methylprednisolone), and long acting (dexamethasone)

– Equivalent dosage

20 mg of hydrocortisone = 5 mg of methylprednisolone = 0.75 mg of dexamethasone

Hyaluronic acid

– Replaces synovial fluid

– Good response, better than steroid, especially in early osteoarthritis

– Relatively expensive

Contrast

– CT arthrography: Iodinated contrast, e.g., iohexol (Omnipaque) 300 ± 0.1 mL of 1:1,000 epinephrine

– MR arthrography: Dilute gadolinium (1:1,000), e.g., 0.1 mL gadolinium in 10.0 mL normal saline solution
• Equipment list

Sterile set

18- to 25-g spinal or intravenous needle

Thin extension tubing (250 mm long, 8.5 Fr, 0.4 mL dead space)

Syringes for LA, aspiration, and injection

Sterile bottle and specimen bottle

PROCEDURE

Joint Aspiration or Injection

• Sterile technique
• Tibiotalar joint injection

Anterior approach: Patient supine, probe in sagittal plane

– Avoid anterior tibial neurovascular bundle located just medial to midline

– Anterolateral side is preferred over anteromedial side as joint is more superficial and capacious and removed from neurovascular bundle
• Subtalar joint injection

Lateral approach: Anterior or posterior, needle passing deep to fibula

Posterior approach: Patient in prone position

– Sweep off Achilles tendon

– Visualize posterior recess of subtalar joint

– Posteromedial approach preferred to avoid sural nerve

Only gold members can continue reading. Log In or Register to continue

Share this:
Click to share on Twitter (Opens in new window)
Click to share on Facebook (Opens in new window)

Related posts:

Hand Vessels Musculoskeletal Ultrasound Artifacts Epidermoid Cyst Shoulder Hip and Pelvis Procedures Baker Cyst

Stay updated, free articles. Join our Telegram channel

Tags: Diagnostic Ultrasound Musculoskeletal

Apr 9, 2020 | Posted by admin in MUSCULOSKELETAL IMAGING | Comments Off

Full access? Get Clinical Tree

Get Clinical Tree app for offline access

Get Clinical Tree app for offline access