Every ultrasound specialty. One professional network.
Accuracy of Sonographically Guided Posterior Subtalar Joint Injections – Comparison of 3 Techniques (Smith, et al)
The selected article for discussion during the month of November is:
Accuracy of Sonographically Guided Posterior Subtalar Joint Injections – Comparison of 3 Techniques (Smith, et al) [Access the article and CME test] (Log-in may be required.)
Background: Research has shown that history, physical examination, and radiographic findings are insufficient to accurately identify the PSTJ as the etiology of hindfoot pain. Consequently, PSTJ injections have been used to support a clinical and radiographic diagnosis of a symptomatic PSTJ and facilitate therapeutic decision making.
The clinical challenge: Many authors recommend image guidance when performing PSTJ injections because of the joint’s complex anatomy and tightly packed joint surfaces. However, fluoroscopic approaches are limited by the inability to image nearby tendon and neurovascular structures, and both fluoroscopy and CT require expensive and at times cumbersome equipment, expose the operator and patient to ionizing radiation, and incur the additional risk of contrast agent reactions.
The role of ultrasound as a diagnostic tool: Sonography can identify effusion and synovitis in the lateral PSTJ with greater sensitivity than the history, physical examination, and plain radiographs. Compared with fluoroscopy and CT, sonography is widely available, is portable, lacks ionizing radiation, and provides detailed images of the adjacent tendinous and neurovascular structures at risk during PSTJ injections.
The research: These authors investigated the accuracy of sonographically guided PSTJ injections using the anterolateral, posterolateral, and posteromedial approaches in a cadaveric model.
Conclusions: This investigation indicates that 3 different sonographically guided PSTJ techniques may be used to access the PSTJ with a high degree of accuracy. Results suggest these technical considerations:
• It is advantageous to become comfortable with all 3 techniques.
• Patient positioning is critically important.
• Clinicians should be aware of adjacent neurovascular structures and proceed accordingly.
• Pre- and post-procedure sonographic findings of fluid in structures of potential interest should be considered in the interpretation of injection results.
The authors state these limitations to this study:
• Clinicians may choose to exercise caution when extrapolating the study’s cadaveric results to patients.
• The authors’ choice of 12 cadaveric specimens for this investigation may be considered a small number by some clinicians.
• The cadaveric specimens were free from major deformity, prior surgery, or severe arthritis. It is possible that the accuracy rate of sonographically guided PSTJ injections may be reduced when these conditions are present.
Question for discussion:
1. What has been your experience performing sonographically guided PSTJ injections?
Accuracy of Sonographically Guided Posterior Subtalar Joint Injections – Comparison of 3 Techniques (Smith, et al) [Access the article and CME test] (Log-in may be required.)
Background: Research has shown that history, physical examination, and radiographic findings are insufficient to accurately identify the PSTJ as the etiology of hindfoot pain. Consequently, PSTJ injections have been used to support a clinical and radiographic diagnosis of a symptomatic PSTJ and facilitate therapeutic decision making.
The clinical challenge: Many authors recommend image guidance when performing PSTJ injections because of the joint’s complex anatomy and tightly packed joint surfaces. However, fluoroscopic approaches are limited by the inability to image nearby tendon and neurovascular structures, and both fluoroscopy and CT require expensive and at times cumbersome equipment, expose the operator and patient to ionizing radiation, and incur the additional risk of contrast agent reactions.
The role of ultrasound as a diagnostic tool: Sonography can identify effusion and synovitis in the lateral PSTJ with greater sensitivity than the history, physical examination, and plain radiographs. Compared with fluoroscopy and CT, sonography is widely available, is portable, lacks ionizing radiation, and provides detailed images of the adjacent tendinous and neurovascular structures at risk during PSTJ injections.
The research: These authors investigated the accuracy of sonographically guided PSTJ injections using the anterolateral, posterolateral, and posteromedial approaches in a cadaveric model.
Conclusions: This investigation indicates that 3 different sonographically guided PSTJ techniques may be used to access the PSTJ with a high degree of accuracy. Results suggest these technical considerations:
• It is advantageous to become comfortable with all 3 techniques.
• Patient positioning is critically important.
• Clinicians should be aware of adjacent neurovascular structures and proceed accordingly.
• Pre- and post-procedure sonographic findings of fluid in structures of potential interest should be considered in the interpretation of injection results.
The authors state these limitations to this study:
• Clinicians may choose to exercise caution when extrapolating the study’s cadaveric results to patients.
• The authors’ choice of 12 cadaveric specimens for this investigation may be considered a small number by some clinicians.
• The cadaveric specimens were free from major deformity, prior surgery, or severe arthritis. It is possible that the accuracy rate of sonographically guided PSTJ injections may be reduced when these conditions are present.
Question for discussion:
1. What has been your experience performing sonographically guided PSTJ injections?
Views: 95
Replies to This Discussion
-
Permalink Reply by Brigitte Ala on -
We use ultrasound for a variety of foot joint injections. We can usually see the joint or anatomy quite well, we are able to get a 25g needle into the joint. Advantage of ultrasound is ability of multiplanar imaging that allows choosing the best approach for access. We use Marcaine 0.05% 1cc and Depomedrol 40mg.
-
-
Permalink Reply by William Blake on -
I have used the anterolateral approach and posterolateral approaches with good success. Ultrasound guidance is key for the posterolateral approach. I have never used the medial approach to the PSTJ, but would be interested in finding out the success of others in a clinical setting.
-
-
Permalink Reply by Jay Smith on
-
My preference is to use the anterolateral approach, followed by the posterolateral approach. I favor the posteromedial approach least because of the proximity to the neurovascular structures. Like most injections, I think the key is to be versatile. Certainly, in clinical practice, due to deformity or lack of an acoustic window, I can't use the anterolateral approach and therefore will look towards one of the other approaches. I typically would do this injection with a 25 gauge needle as well.
-
© 2012 Created by AIUM.
