Can Bedside Needle Arthroscopy of the Ankle be an Accurate Option in the Office Setting for Intra- Articular Delivery of Injectable Agents?

CATEGORY: Ankle; Arthroscopy INTRODUCTION/PURPOSE: To evaluate accuracy and patient experience of inspection-injections of the ankle with in-office needle arthroscopy in a relevant clinical setting - including patients with end-stage ankle pathology and/or a history of prior surgery. METHODS: This was a prospective study that included adult patients who were scheduled for an injection with hyaluronic acid to the tibiotalar joint. In our center, these injections are used as a last resort prior to extensive surgery. The primary outcome was injection accuracy, which was defined as injecting through the arthroscopic cannula with intra-articular positioning confirmed by a clear needle arthroscopic view of the joint space. Secondary outcome measures included a patient reported numeric rating scale (NRS, 0-10) of pain during the procedure and willingness of patients to return for the same procedure. NRS of ankle pain at rest and during walking was collected during the intervention and at two-week follow-up. Complications were monitored from inclusion up to a two-week control visit. RESULTS: We performed 24 inspection-injections (11 (46%) males, mean age 47.8 +- 14.5 years). The indication was end-stage osteoarthritis in 21 (88%) cases - eight (33%) Kellgren-Lawrence grade IV, 10 (42%) Kellgren-Lawrence grade III - and an osteochondral defect in three (13%) cases. Fourteen (58%) patients had had prior ankle surgery - 11 (46%) patients had had multiple prior surgeries. Accuracy was confirmed in 22 (88%) cases. The three unsuccessful injections all occurred in patients with Kellgren-Lawrence grade IV osteoarthritis. Median NRS of pain during the procedure was 1 (IQR 0 - 2). Willingness to return was 100%. Median NRS of pain in rest decreased from 4 (IQR 2 - 5) at intervention to 3 (IQR 1 - 5) at follow-up (p < 0.01). The median NRS of pain during walking decreased from 8 (IQR 6 - 8) to 7 (IQR 4 - 8) (p < 0.01). There were no complications. CONCLUSION: In-office needle arthroscopy of the ankle under local anesthesia is a procedure that is well tolerated by patients. It is able to provide intra-articular delivery of injectable agents with high accuracy. Accuracy can be expected to approach 100% if patients with total ventral joint obliteration and a history of extensive prior ankle surgery are excluded.