Juvenile chronic arthritis: diagnosis and management of tibio-talar and sub-talar disease

Abstract

The aim of this study was to compare clinical evaluation of the site of hindfoot synovitis with contrast-enhanced magnetic resonance imaging (MRI) findings in children with juvenile chronic arthritis (JCA), and to evaluate the efficacy of selective guided intra-articular steroid injections. Thirteen symptomatic ankles of 11 consecutive JCA patients were examined clinically and with contrast-enhanced MRI. Pannus was demonstrated on MRI in both tibio-talar and sub-talar joints in 10 ankles, in the tibio-talar joint only in one ankle and in neither joint in two ankles. Correlation of clinical and MRI findings was good for the tibio-talar joint with concordance in 11/13 cases. Correlation was poor for the sub-talar joints. Of the 10 sub-talar joints shown to have pannus on MRI, only two were thought to have had definite clinical evidence of synovitis. Guided intra-articular steroid injection resulted in at least 6 months remission in 6/9 ankles compared with 1/10 ankles which had had previous unguided injections. We therefore recommend the use of image guidance for intra-articular triamcinolone hexacetonide injection in children with hindfoot synovitis.

Impact of ultrasound imaging on local corticosteroid injections of symptomatic ankle, hind‐, and mid‐foot in chronic inflammatory diseases

“…Moreover, the presence of inflammatory signs (synovitis or effusion) seems to correlate with the degree of improvement (22). An improved outcome after the use of magnetic resonance imaging to show synovitis in the subtalar joint, and after injection into both tibiotalar and subtalar joints using radiographic guidance, was demonstrated in children (23).…”

The posterolateral fluoroscopy-guided injection technique into the posterior subtalar joint: description of the procedure and pilot study on patient outcomes

“…Studies have shown that injections performed using imaging guidance (fluoroscopy, ultrasound, or CT) more accurately deliver the medications to the desired target joint compared to injections using palpation alone [1,[3][4][5][6][7][8][9][10][11].…”

“…The posterior subtalar joint is one of the most typically injected foot articulations [10][11][12][13][14][15]. There are various techniques described in the literature for injecting medication into this joint, including the anterolateral, posteromedial, lateral oblique, and posterolateral approaches [10][11][12][13]15].…”

“…There are various techniques described in the literature for injecting medication into this joint, including the anterolateral, posteromedial, lateral oblique, and posterolateral approaches [10][11][12][13]15]. Previously the anterolateral approach was claimed to be the best for injecting the posterior subtalar joint [11,16] as this approach appeared to be comparably easy with less chance of contrast leakage or side effects.…”

“…Two prospective and one retrospective outcomes studies performed on patients with the specific diagnosis of juvenile chronic arthritis documented substantial clinical improvement in up to 44% of these patients. Sample sizes were rather small, consisting of 6, 10, and 38 subtalar joint injections, respectively [10,12,13]. A larger, prospective outcomes study (done recently from this orthopedic university hospital) demonstrated that 64% of the 118 adult patients who received subtalar injections reported at least a 50% reduction in their pain 20-30 min after injection [14].…”