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Arthrocentesis Of The Ankle Joint

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Authors

M. Atef Kotob, M.D.
Fellow Physician
Primary Care Sports Medicine
Department of Family Medicine
Department of Emergency Medicine
University of Iowa Hospitals and Clinics

Mathew Negaard, M.D., CAQ-SM
Sports Medicine Physician
Forte Sports Medicine and Orthopedics
Assistant Professor of Emergency Medicine
University of Iowa Hospitals and Clinics

Summary

  • Ankle arthrocentesis is an essential diagnostic and/or therapeutic procedure that may be performed in the emergency department with or without the use of ultrasound
  • The tibiotalar joint can be aspirated from an anterior/medial or lateral approach
  • The author’s preferred technique for ankle arthrocentesis is via the anterior/medial approach, with an in-plane technique
Ankle corticosteroid injection performed using the anteromedial in-plane approach. Arthrocentesis is performed the same way in this technique.
Dr Karkucak demonstrates an out-of-plane approach with the transducer in short axis to the joint.

Introduction

  • Ankle arthrocentesis is a procedure used to evaluate the cause of an unexplained joint effusion or to relieve a painful joint effusion.
  • The most common causes of ankle joint effusion are crystal arthropathies, septic arthropathy, and hemarthrosis.
  • Determining the cause of the ankle effusion will dictate the further management of the patient.[1]Bartlett SI, Dreyer MA. Ankle Arthrocentesis. StatPearls Publishing; 2022.[2]Drakonaki EE, Allen GM, Watura R. Ultrasound-guided intervention in the ankle and foot. Br J Radiol. 2016;89(1057):20150577. doi:10.1259/bjr.20150577
  • Indications include Septic Arthritis, Crystal Arthropathy, Hemarthrosis, and Unexplained joint effusion

Anatomy

  • The bony ankle joint is composed of the distal tibia, distal fibula and talar dome.
    • The articular part of the talus is sometimes referred to as the pilon
  • The medial malleolus (MM) and lateral malleolus (LM) represent the bony landmarks
    • The medial ankle is stabilized by the deltoid ligament (not pictured)
    • The lateral ankle is stabilized by the ATFL, CFL and PTL (not pictured)
  • The muscles of the 4 compartments of the leg also help stabilize the ankle
  • Arthrocentesis is typically performed from an anterior approach.
    • Noteworthy tendons crossing the anterior joint space include the tibialis anterior tendon (TA), extensor hallucis longus tendon (EHL), extensor digitorum longus tendons (EDL)
Anatomy of the tibialis anterior, extensor digitorum longus, extensor hallucis longus
Anatomy dissection demonstrating EHL (extensor hallucis longus) tendon, EDL (extensor digitorum longus) tendon, and TA (tibialis anterior) tendon. Note that EHB (extensor hallucis brevis) muscle is also labeled.[3]Olewnik Ł, Podgórski M, Polguj M, Ruzik K, Topol M. A cadaveric study of the morphology of the extensor hallucis longus – a proposal for a new classification. BMC Musculoskelet Disord. … Continue reading
Ankle XR Bones of the Ankle Labeled
Radiograph of the ankle joint demonstrating the joint space (tibiotalar joint), anatomic landmarks (medial and lateral malleolus) and corresponding bones (tibia, fibula, talus).[4]Image courtesy of Lecturio.com, “Ankle Joint”

Ultrasound Evaluation

  • Ultrasound can be used to not only identify the presence of an ankle joint effusion, but it can also assist in an accurate aspiration of the joint effusion.
  • A linear transducer should be used
  • The joint can usually easily be located anteriorly in long axis.
    • Find the distal tibia and move the transducer distally until you can see both the tibia and talus.
    • If there is an effusion, you should see a hypoechoic fluid collection
Ankle US Tib Ant, EHL, EDL in Short Axis
Short axis ultrasound of the ankle showing tibialis anterior tendon (TA), extensor hallucis longus tendon (EHL), extensor digitorum longus tendons (EDL) in short axis.
  • In short axis, you can easily identify the tibialis anterior tendon (TA), extensor hallucis longus tendon (EHL), extensor digitorum longus tendons (EDL)
Ankle US Normal Joint in Long Axis
Normal ultrasound of the anterior ankle joint in long axis.
Ankle US Joint Effusion
Ultrasound of the anterior ankle with joint effusion. Tibia is on the left, talus on the right, and the hypoechoic fluid collection superior to them represents the effusion.[5]Image courtesy of ultrasoundcases.info, “Arthritis ankle”

Procedure

  • Landmark vs. Ultrasound Guided Approach
    • US guided arthrocentesis is generally considered to be superior to palpation guided arthrocentesis of small, medium and large joints.
    • In a study of EM residents, US guidance reduced the number of attempts and time to procedural success with US guidance when compared to landmark guidance[6]Berona K, Abdi A, Menchine M, et al. Success of ultrasound-guided versus landmark-guided arthrocentesis of hip, ankle, and wrist in a cadaver model. Am J Emerg Med. 2017;35(2):240-244. … Continue reading
    • This is known to be true for other joints as well[7]Wiler JL, Costantino TG, Filippone L, Satz W. Comparison of ultrasound-guided and standard landmark techniques for knee arthrocentesis. J Emerg Med. 2010;39(1):76-82. … Continue reading
    • For this reason, only the ultrasound guided approach is described in this chapter.
  • Materials
    • 18 gauge draw needle
    • 1.5 – 2 inch, 25-27 gauge needle for local anesthetic administration
    • 1.5 – 2 inch, 18-22 gauge needle for aspiration
    • 5 – 10 cc syringe (at least 2)
    • Local anesthetic
    • Sterile equipment (gauze, skin prep, gloves, probe cover, etc)

Ultrasound Guided Approach

  • General
    • Position: The patient is supine, ankle is in maximal plantarflexion
    • Ultrasound: The linear transducer is used
    • Procedure
      • Use a 25-27G needle to inject your local anesthetic along your planned track or approach with your larger aspiration needle
      • Following the anesthetized needle track, advance your 18-22G needle into the ankle joint
      • Once in the joint, aspirate the effusion
Ankle Arthrocentesis Positioning
Patient positioning for procedure. Note patient is seated or supine, knee flexed, ankle plantarflexed opening up the anterior joint space.
  • Anterior/Medial Tibiotalar (In-Plane)[8]Drakonaki EE, Allen GM, Watura R. Ultrasound-guided intervention in the ankle and foot. Br J Radiol. 2016;89(1057):20150577. doi:10.1259/bjr.20150577[9]Epis O, Iagnocco A, Meenagh G, et al. Ultrasound imaging for the rheumatologist. XVI. Ultrasound-guided procedures. Clin Exp Rheumatol. 2008;26(4):515-518. Accessed February 1, 2022. … Continue reading
    • Ultrasound
      • Identify the TA in long axis and translate medially
      • Identify the tibiotalar medial joint recess
    • Technique: Use an in-plane needle entry from distal to proximal
Transducer and needle position for in-plane anteromedial approach.
Ankle US Arthrocentesis In Plane Approach
Ankle arthrocentesis using the inplane approach.
  • Anterior/Medial Tibiotalar (Out-of-Plane)[10]Roy S, Dewitz A, Paul I. Ultrasound-assisted ankle arthrocentesis. Am J Emerg Med. 1999;17(3):300-301. doi:10.1016/s0735-6757(99)90129-8[11]Firestein G, Budd R, Wise C. Arthrocentesis and Injection of Joints and Soft Tissue. In: Kelley’s Textbook of Rheumatology. Elsevier Health Sciences; 2012.Spinner D. Foot and Ankle. In: Atlas of … Continue reading
    • Ultrasound
      • Identify the TA in long axis and translate medially
      • Identify the tibiotalar medial joint recess
    • Technique: Out-of-plane needle entry from medial to lateral
Ankle Arthrocentesis Medial Approach, Out of Plane
Transducer and needle position for out-of-plane anteromedial approach.
Ankle US Arthrocentesis Out of Plane Approach
Ankle arthrocentesis using the out of plane approach. The needle tip is visualized and labeled.[12]Image courtesy of http://highlandultrasound.com/, “Ankle Arthrocentesis”
  • Lateral Tibiotalar (Out-of-Plane)[13]Browner BD, Fuller RP. Musculoskeletal Emergencies E-Book. 1st ed. Saunders; 2012. Accessed February 1, 2022. https://www.elsevier.com/books/musculoskeletal-emergencies/browner/978-1-4377-2229-1[14]Custalow C, Sanford S. Arthrocentesis. In Roberts and Hedges’ Clinical Procedures in Emergency Medicine. Elsevier/Saunders; 2013
    • Palpate the distal tip of LM
    • Ultrasound
      • Place the transducer in short axis across the ankle
      • Identify the LM on the lateral edge of the screen
      • Identify the tibiotalar lateral joint recess
    • Technique: Out-of-plane needle entry from distal to proximal
Ankle arthrocentesis probe and needle position lateral tibiotalar out of plane technique
Transducer and needle position for out-of-plane lateral approach.
Approximate ultrasound view of lateral out of plane approach. Tibia left and inferior articular border of tibia right. Needle not pictured, no effusion is present.

Additional Considerations

  • Post-Procedure Care
    • Compression of any bleeding
    • Application of dressing
    • Avoidance of contamination or submersion in water for 24-48 hrs[15]Ahmed I, Gertner E. Safety of arthrocentesis and joint injection in patients receiving anticoagulation at therapeutic levels. Am J Med. 2012;125(3):265-269.
  • Risk Factors
    • Infection
    • Injury to surrounding structures
    • Neurovascular bundle passes between EHL and EDL
    • Soft tissue injury
  • Contraindications
    • No absolute contraindication
    • High suspicion for septic ankle arthritis warrants investigation with arthrocentesis[16]Ahmed I, Gertner E. Safety of arthrocentesis and joint injection in patients receiving anticoagulation at therapeutic levels. Am J Med. 2012;125(3):265-269.
  • Relative Contraindication
    • Overlying cellulitis
    • Coagulopathy, generally still safe although may consider smaller needle[17]Bashir MA, Ray R, Sarda P, Li S, Corbett S. Determination of a safe INR for joint injections in patients taking warfarin. Ann R Coll Surg Engl. 2015;97(8):589-591.[18]Yui JC, Preskill C, Greenlund LS. Arthrocentesis and joint injection in patients receiving direct oral anticoagulants. Mayo Clin Proc. 2017;92(8):1223-1226.[19]Reach JS, Easley ME, Chuckpaiwong B, Nunley JA 2nd. Accuracy of ultrasound guided injections in the foot and ankle. Foot Ankle Int. 2009;30(3):239-242. doi:10.3113/FAI.2009.0239
    • Joint prosthesis
    • Acute fracture
    • Osteomyelitis

Pearls & Pitfalls

  • Decisions on which approach to use should always be patient specific. Avoiding areas of cellulitis or specific anatomical variation may clearly make one approach most favorable.
  • Generally, the in-plane anterior/medial tibiotalar approach is most favorable as it allows for full needle visualization and often leads to successful procedure.
  • Between out-of-plane approaches the anterior/medial approach often has easier landmarks to identify however there is little data to suggest one approach over another.[20]Wiler JL, Costantino TG, Filippone L, Satz W. Comparison of ultrasound-guided and standard landmark techniques for knee arthrocentesis. J Emerg Med. 2010;39(1):76-82. … Continue reading[21]Berona K, Abdi A, Menchine M, et al. Success of ultrasound-guided versus landmark-guided arthrocentesis of hip, ankle, and wrist in a cadaver model. Am J Emerg Med. 2017;35(2):240-244. … Continue reading
  • The procedure is generally well tolerated with adequate local anesthesia. Consider additional local anesthesia if the patient is unable to tolerate the procedure. Systemic medications for anxiolysis may be needed in some patients.

References

References[+]