Ultrasound-Guided Tibiotalar Joint Injection Technique

MATERIALS 21- to 30-guage 1.5- to 2-inch needle for local anesthesia and injectate 12- to 18-MHz linear array transducer Local anesthetic, steroid, and/or other injectate Sterile ultrasound probe cover Sterile ultrasound gel Sterile gloves Chlorhexidine or other skin antiseptic 4 × 4 gauze Adhesive bandage PATIENT POSITIONING The patient is placed supine with the knee flexed to 90 degrees and the ankle plantar flexed to 30 to 45 degrees, and laid flat on the distal edge of the table. With ergonomic considerations in mind, the provider is seated distal to the affected ankle. The ultrasound screen is to be in direct view across from the provider, in direct line with the clinician’s eye line, the transducer, and the needle trajectory. PROBE POSITIONING The ultrasound transducer is placed in an anatomic longitudinal plane along the anterolateral ankle joint just medial to tibialis anterior tendon. Care is taken to avoid the neurovascular structures including the dorsalis pedis artery and the deep fibular nerve cutaneous branches, as well as the adjacent tibialis anterior tendon. NEEDLE TECHNIQUE The needle is introduced and progressed using an in-plane, anterior-to-posterior, distal-to-proximal approach. Downward angulation of the needle is utilized to achieve necessary depth and clearance of the talar dome. The target needle position is at the anterior ankle joint recess between the distal anterior tibia and the hyaline cartilage of the talus (Video). PEARLS AND PITFALLS The needle can alternatively be introduced using a sterile gel stand-off technique, which may help overcome access difficulties and better allow simultaneous target and needle visualization. Care should be taken to achieve a view before injection which excludes visualization of the tendons, nerves, or blood vessels overlying the anterior view of the joint space in order to avoid needle trauma. Video Legends Ultrasound Guided Injection Video Series: Tibiotalar Joint, https://links.lww.com/PHM/C607