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Three Part Question

In the diagnosis of [patients with suspected septic arthritis of the ankle joint] is [the anteromedial or anterolateral approach] more likely to result in [successful needle aspiration of synovial fluid]?

Clinical Scenario

A 30 year old male presents with 24 hours of right ankle pain, swelling and fever. You decide to perform needle aspiration of the ankle joint to diagnose a suspected septic arthritis.

Search Strategy

Medline(R) 1948 to present and Embase 1980 to 2011 week 23 were searched on 11/6/2011.
Search terms were (ankle AND (aspirat$ OR injection)).ab,ti,tw.
LIMIT to human

Search Outcome

630 papers were retrieved of which 629 were irrelevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Heidari N, Pichler W, Grechenig S, Grechenig W and Weinberg AM Jan 2010 Austria	76 ankles from 38 cadavers.	Cadaveric. 76 ankles injected with methylene blue (36 anterolateral and 40 anteromedial).	31 of 40 (77.5%) anteromedial and 31 of 36 (86%) anterolateral injections were succesful.	No significant difference in success rates between groups.	Cadaveric study. Not randomised. Successful injection may not necessarily relate to successful aspiration of a joint.

Comment(s)

The cadaveric study suggests that the anteromedial and anterolateral approaches have similar success rates of successful ankle joint puncture. A prospective randomised controlled trial would be helpful to determine whether these findings are also true for aspiration of the ankle joint in the emergency department setting.

Clinical Bottom Line

There is no clinical evidence to support one approach over the other. Local guidelines should be followed.

References

1. Heidari N et al. Does the anteromedial or anterolateral approach alter the rate of joint puncture in injection of the ankle? J Bone Joint Surg (Br) 92-B Jan 2010; 176-8.