Metatarsophalangeal Arthrocentesis

Metatarsophalangeal Arthrocentesis

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Metatarsophalangeal (MTP) arthrocentesis is a critical diagnostic tool in the setting of acute monoarticular arthritis. Joint aspiration is useful for distinguishing inflammatory from noninflammatory musculoskeletal disorders and is the gold standard for ruling out septic arthritis. It also is an effective therapeutic option for pain relief, injection of medications, or drainage of a septic or inflammatory effusion. When done properly and with aseptic technique, it is a safe and well-tolerated procedure that is associated with a low frequency of adverse events. [1]

The clinician performing the procedure should be familiar with the anatomy of the involved joint in order to avoid puncture of tendons, blood vessels, and nerves. The MTP joint line is located at the base of the metatarsals on the extensor surface of the foot. It can be best appreciated by applying gentle passive flexion while extending the toe.

Diagnostic indications for MTP arthrocentesis include the following:

Therapeutic indications for MTP arthrocentesis include the following:

There are no absolute contraindications for MTP arthrocentesis. Relative contraindications include the following [2] :

Consider hospitalization if arthrocentesis is performed for the administration of intravenous (IV) antibiotics.

When there is a high probability of a septic joint, the joint should be aspirated regardless of the patient’s bacteremia or septicemia.

In patients with a joint prosthesis, it is preferable that aspiration be done by an orthopedic surgeon.

Proper skin cleansing and the use of aseptic technique minimize the risk of introducing infection into a sterile joint.

Potential damage to cartilage can be minimized by understanding the joint anatomy and by avoiding further advancement of the needle into the joint space, indicated by synovial fluid entering the syringe. [5]

Hemarthroses are typically small and self-limited and require only observation. Hemarthrosis in patients with coagulopathy requires correction of the coagulopathy in consultation with a hematologist.

When arthrocentesis is performed through infected skin for the diagnosis of a potentially septic joint, IV antibiotics should be given immediately following the procedure. The patient should be hospitalized for continuation of antibiotics.

Pain may occur, as with any musculoskeletal procedure. [2]

Taylor WJ, Fransen J, Dalbeth N, et al. Diagnostic Arthrocentesis for Suspicion of Gout Is Safe and Well Tolerated. J Rheumatol. 2016 Jan. 43 (1):150-3. [Medline].

Bettencourt RB, Linder MM. Arthrocentesis and therapeutic joint injection: an overview for the primary care physician. Prim Care. 2010 Dec. 37 (4):691-702, v. [Medline]. [Full Text].

Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the ankle and foot. Am Fam Physician. 2003 Oct 1. 68 (7):1356-62. [Medline].

Solan MC, Calder JD, Bendall SP. Manipulation and injection for hallux rigidus. Is it worthwhile?. J Bone Joint Surg Br. 2001 Jul. 83 (5):706-8. [Medline].

Jones A, Regan M, Ledingham J, Pattrick M, Manhire A, Doherty M. Importance of placement of intra-articular steroid injections. BMJ. 1993 Nov 20. 307 (6915):1329-30. [Medline].

Doherty M, Hazleman B, Hutton C, Maddison P, Perry J. Rheumatology Examination and Injection Techniques. 2nd ed. London: WB Saunders; 1998.

Haslock I, MacFarlane D, Speed C. Intra-articular and soft tissue injections: a survey of current practice. Br J Rheumatol. 1995 May. 34 (5):449-52. [Medline].

Southwood TR. Appendix: a guide to needle placement for aspiration of synovial fluid and intra-articular injection of corticosteroids. Baillieres Clin Paediatr. 1993. 1:919-22.

Manadan AM, Mushtaq S, Block JA. Radiocarpal and first metatarsophalangeal intraarticular injection site confirmation with fluoroscopy and review of accuracy of intraarticular injections. Am J Ther. 2015 Jan-Feb. 22 (1):11-3. [Medline].

Yablon CM. Ultrasound-guided interventions of the foot and ankle. Semin Musculoskelet Radiol. 2013 Feb. 17 (1):60-8. [Medline].

Greenlund LJS, Ward WJ. Use of Ultrasound by Internists to Improve Diagnostic Small Joint Aspiration. Am J Med. 2017 Feb. 130 (2):234-236. [Medline].

Naylor JF, Dekay KB, Donham BP, Hall BT. Ultrasound Versus Landmarks for Great Toe Arthrocentesis. Mil Med. 2017 Mar. 182 (S1):216-221. [Medline].

Jefferson R Roberts, MD Chief of Rheumatology Service, Tripler Army Medical Center; Assistant Clinical Professor of Medicine, Uniformed Services University of the Health Sciences

Jefferson R Roberts, MD is a member of the following medical societies: American College of Physicians, American College of Rheumatology, Society for Simulation in Healthcare

Disclosure: Nothing to disclose.

Luke A Monteagudo, MD Resident Physician, Department of Internal Medicine, Tripler Army Medical Center

Luke A Monteagudo, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Rachel Robbins, MD, FACP Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Staff Rheumatologist, Walter Reed National Military Medical Center

Rachel Robbins, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, Association of Program Directors in Internal Medicine

Disclosure: Nothing to disclose.

Anthony T Cancio, MD Resident Physician, Department of Internal Medicine, Tripler Army Medical Center

Disclosure: Nothing to disclose.

Daniel H Desmond, MD Resident Physician, Department of Internal Medicine, Tripler Army Medical Center

Daniel H Desmond, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Metatarsophalangeal Arthrocentesis

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