Talonavicular Joint Injection

Other Names

• Talonavicular Joint Injection
• Talonavicular Joint Aspiration
• Talonavicular Joint Arthrocentesis

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Background

Ultrasound image of the talonavicular joint space with a joint effusion present.

Key Points

• Needle: 25 gauge, 1.5 inch
• Transducer: high freuqency, linear
• Technically challenging, need to avoid tendons/ neurovascular structures

Anatomy of the Talonavicular Joint

• Ball and socket articulation between the talus and navicular
• Synovial joint with a fibrous capsule
• Part of the broader Chopart Joint, connecting the hindfoot to the midfoot
• Stabilized by the dorsal talonavicular ligament, spring ligament complex, bifurcate ligament
• Medial joint covered by Tibialis posterior, extensor hallucis longus tendons, saphenous vein, saphenous nerve
• Dorsomedial joint covered by: Tibialis anterior tendon, intermediate branch of superficial fibular nerve, medial tarsal arteries
• Dorsolateral joint covered by: lateral branch of deep peroneal nerve, lateral tarsal artery
• Dorsum of joint, deep to extensor retinaculum: Dorsalis pedis artery, medial terminal branch of deep fibular nerve
• Branches of superficial fibular nerve can also be found dorsally and superficially

Palpation Guidance vs Ultrasound Guidance

• Given the technically challenging anatomy, palpation guided approach is not recommended
• To date, there are no studies comparing ultrasound and palpation guided approaches
• Fluoroscopy has been used historically

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Indications

• Talonavicular Joint Pain

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Contraindications

• Absolute
  • Anaphylaxis to injectates
  • Overlying cellulitis, skin lesion or systemic infection
• Relative
  • Can be treated with less invasive means
  • Hyperglycemia or poorly controlled diabetes
  • Lack of symptom improvement with previous injection

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Procedure

Talonavicular joint injection. A. Radiography of talonavicular joint osteoarthritis. Long (B) and short axis (C) view during ultrasound guided injection.

Ultrasound view using the out of plane approach with needle vector in white dots

Needle and probe position for out of plane approach<ref name="malanga">

Needle and probe position for in plane approach<ref name="malanga">

Equipment

• Sterile prep (i.e. chloraprep, chlorhexidine, iodine, etc)
• Gloves
• Needle: typically 21-25 gauge, 1.5 inch
• Syringe: 5-10 mL
• Gauze
• Ethyl Chloride
• Bandage
• Injectate
  • Local anesthetic
  • Corticosteroid
• Sterile probe cover

Ultrasound Findings

• Transducer: high frequency, linear
• Place the probe in the sagittal plane to view the dorsal aspect of the joint
• Rotating the probe into an axial plane allows better visualization of the tendons, neurovascular structures
• Potential findings
  • Osteophytes
  • Joint space narrowing
  • Erosions
  • Joint effusion
  • Increased doppler signal

Ultrasound Guided Technique: Long Axis, Out of Plane

• Patient Position
  • Supine
  • Ankle in a position of comfort, slightly plantarflexed
• Transducer Position
  • Medial talonavicular joint
• Needle Approach/ Orientation
  • Out of plane
  • Medial to lateral using step down technique
• Target
  • Talonavicular joint
• Pearls and Pitfalls
  • Carefully pre-scan all relevant structures to find optimal approach

Ultrasound Guided Technique: Long Axis, In Plane

• Patient Position
  • Supine
  • Ankle in a position of comfort, slightly plantarflexed
• Transducer Position
  • Medial talonavicular joint
• Needle Approach/ Orientation
  • Proximal to distal
  • In plane using a step-off approach
• Target
  • Talonavicular joint
• Pearls and Pitfalls
  • Carefully pre-scan all relevant structures to find optimal approach
  • In plane technique allows better needle visualization along the contour of the head of the talus
  • Safer, but more technically challenging than the out of plane approach

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Aftercare

• Motor exam should be intact
• No major restrictions in most cases
• Can augment with ice, NSAIDS
• Consider Ankle Compression Sleeve

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Complications

• Infection
• Damage to surrounding tissue

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See Also

• Procedures Main
• Ultrasound Main
• Ankle Pain Main

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