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Ultrasound-guided injection of the ankle joint: cadaveric investigation of the anterolateral approach

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Abstract

Objective

Injection of the tibiotalar (TT) joint is commonly performed in clinical practice under ultrasound (US) guidance using an anteromedial approach. However, in some patients, this approach may be technically challenging due to post-traumatic and/or degenerative bony changes. Therefore, the aim of this cadaveric investigation was to demonstrate the feasibility of the ultrasound-guided (USG) injection of the ankle joint via the anterolateral sulcus (ALS) by confirming the dye placement/distribution inside the articular space. Likewise, the safety of the procedure has also been evaluated by measuring the distance between the needle and the intermediate dorsal cutaneous nerve of the foot.

Design

A descriptive laboratory study with eight embalmed cadaveric ankles using the Fix for Life (F4L) method was performed at the setting of an academic institution. The interventional technique and the related anatomical findings were illustrated. During the injection, the needle was advanced into the TT joint through the ALS under US guidance, i.e., in-plane anterior-to-posterior approach. With the objective to confirm its correct placement, the needle was kept in situ and—to demonstrate the location of the dye inside the articular space—all eight ankles were injected with 3 mL of green color dye. Thereafter, a layer-by-layer anatomical dissection was performed on all four cadavers.

Results

The position of the needle’s tip within the ALS was confirmed in all specimens. Accurate placement of the dye inside the articular space of the ankle was confirmed in seven of the eight cadaveric ankles, with 87.5% of accuracy. Herewith, unintentional spilling of the dye within the superficial soft tissues was reported in two of the eight ankles (25.0%). The mean distance between the needle and the intermediate dorsal cutaneous nerve of the foot, measured in all eight procedures, was 3 cm.

Conclusion

USG injection of the ALS using the in-plane, anterior-to-posterior approach can accurately place the injectate inside the articular space.

Clinical relevance

This cadaveric investigation described the accuracy and potential pitfalls of USG injection of the ankle via the anterolateral approach which represents an alternative technique in patients with reduced accessibility of the anteromedial recess due to degenerative and/or post-traumatic bony changes.

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Data availability

The authors confirm that the data supporting the findings of this study are available within the article [and/or] its supplementary materials.

Abbreviations

TT:

Tibiotalar

US:

Ultrasound

USG:

Ultrasound-guided

ALS:

Anterolateral sulcus

F4L:

Fix for Life

BMI:

Body mass index

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Acknowledgements

The pictures of the anatomic specimens were elaborated using donated bodies with the approval of the Institute of Anatomy, First Faculty of Medicine, Charles University, Prague. The authors sincerely thank those who donated their bodies to science, so that anatomical research could be performed. Results from such research can potentially increase mankind’s overall knowledge that would improve patient care. Therefore, these donors and their families deserve our highest gratitude.

Funding

No funding was received.

Author information

Author notes

  1. Ondřej Naňka and Levent Özçakar have equally contributed to this work.

Authors and Affiliations

  1. Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy

    Vincenzo Ricci

  2. Department of Rehabilitation Medicine, Charles University, First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic

    Kamal Mezian

  3. Department of Physical Medicine and Rehabilitation and Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan

    Ke-Vin Chang

  4. Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA

    Kentaro Onishi

  5. Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA

    Kentaro Onishi

  6. Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey

    Murat Kara & Levent Özçakar

  7. Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic

    Ondřej Naňka

Authors
  1. Vincenzo Ricci
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  2. Kamal Mezian
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  3. Ke-Vin Chang
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  4. Kentaro Onishi
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  6. Ondřej Naňka
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  7. Levent Özçakar
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Contributions

Author Contributions: Conceptualization, V.R. and K.M.; writing—original draft preparation, V.R. and O.N.; writing—review and editing, V.R., K.M., KV.C., K.O., M.K., O.N., L.Ö.; supervision, KV.C., L.Ö. All authors have read and agreed to the published version of the manuscript.

Corresponding author

Correspondence to Vincenzo Ricci.

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None.

Ethical approval statement

This study was carried out with the approval of the Institute of Anatomy, First Faculty of Medicine, Charles University, Prague. Informed consent had been obtained from the donors for scientific and educational purposes prior to death. An ethics committee or institutional review board approval was therefore not required. This study was supported by Cooperation project—Morphological Disciplines of Medicine, Charles University.

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Ricci, V., Mezian, K., Chang, KV. et al. Ultrasound-guided injection of the ankle joint: cadaveric investigation of the anterolateral approach. Surg Radiol Anat 46, 241–248 (2024). https://doi.org/10.1007/s00276-023-03282-w

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  • DOI: https://doi.org/10.1007/s00276-023-03282-w

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