Ankle Arthrocentesis Technique

Updated: Apr 03, 2017
  • Author: Gil Z Shlamovitz, MD, FACEP; Chief Editor: Erik D Schraga, MD  more...
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Technique

Aspiration of Synovial Fluid From Ankle

Prepare the skin with sterile solution, allow drying, and then drape.

Using a sterile technique, attach the 18- or 20-gauge needle to the 20-mL syringe, and pull the plunger to break resistance.

While stretching the skin over the insertion site (see below for choices of insertion site), insert the needle into the joint space while gently aspirating until synovial fluid enters the syringe (usually 1-2 cm in an adult of average size). If a bone is encountered, pull the needle back, verify the anatomic landmarks (see the images below), and readvance the needle in a corrected direction.

Right ankle. Right ankle.
Anatomic landmarks for ankle arthrocentesis. EDL = Anatomic landmarks for ankle arthrocentesis. EDL = extensor digitorum longus; EHL = extensor hallucis longus; TA = tibialis anterior.

If removal of more fluid is desired, a hemostat flush to the skin can be used to secure the needle in place while the syringe is replaced with a new one.

Remove the needle and apply a bandage.

Divide the aspirated synovial fluid into the different specimen containers.

Anterolateral approach (preferred)

This is the preferred approach for ankle joint aspiration because it avoids potential injury to the dorsalis pedis and posterior tibial vessels or the deep peroneal nerve, which course through the medial aspect of the ankle and foot.

Identify the ankle joint line, the lateral malleolus, and the lateral border of the extensor digitorum longus (EDL).

Extension of the foot against the patient’s resistance or active flexion/extension movement by the patient helps the practitioner identify the space between the base of the lateral malleolus and the lateral border of the EDL.

Insert a needle (18-20 gauge) at the joint line midway between the base of the lateral malleolus and the lateral border of the EDL, advancing the needle perpendicular to the fibular shaft.

Anteromedial approach

Exercise care with this approach to avoid injury to both the dorsalis pedis vessels and the deep peroneal nerves that are immediately below and lateral to the extensor hallucis longus (EHL) tendon.

Identify the ankle joint line, the medial malleolus, and the tendons of the EHL and the tibialis anterior.

Extension of the foot against the patient’s resistance or active flexion/extension movement by the patient helps the practitioner identify the space between the medial border of the EHL and the lateral border of the tibialis anterior or between the base of the medial malleolus and the medial border of the tibialis anterior. (See the image below.)

Identification of space between medial malleolus a Identification of space between medial malleolus and medial border of tibialis anterior tendon.

Insert a needle (18-20 gauge) at either insertion point, and advance the needle perpendicular to the tibial shaft. (See the image below.)

Ankle joint aspiration between medial malleolus an Ankle joint aspiration between medial malleolus and medial border of tibialis anterior tendon.
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Analysis of Synovial Fluid

The aspirated synovial fluid is then analyzed (see Table 1 below). [8]

Table 1. Synovial Fluid Analysis in Different Diseases (Open Table in a new window)

  Appearance WBC, cells/μL Polymorphonuclear (PMN) cells, % Glucose concentration, mg/dL Protein concentration, g/dL
Normal Clear <150 <0.25 Serum glucose 1.3-1.8
Noninflammatory Clear <3000 <0.25 Serum glucose 2-3.5
Inflammatory Cloudy >3000 <0.75 <25 >4
Purulent Cloudy >50,000 >0.9 <25 >4
Hemorrhagic Bloody >2000 ~0.3 Serum glucose ...

Operative characteristics of septic joint effusion findings include the following:

  • Total white blood cell (WBC) count >25,000/μL (sensitivity, 77%; specificity, 73%; positive likelihood ratio [LR +], 29; negative likelihood ratio [LR ], 0.71)
  • Total WBC count >50,000/μL (sensitivity, 62%; specificity, 92%; LR +, 7.7; LR , 0.42) [9]
  • Total WBC count >100,000/μL (sensitivity, 22%; specificity, 99%; LR +, 2.9; LR , 0.32)
  • PMN cells ≥90% (sensitivity, 73%; specificity, 79%; LR +, 3.4; LR , 0.34)
  • Synovial glucose or serum glucose concentration <0.5 mg/dL (sensitivity, 51%; specificity, 85%; LR +, 3.4; LR , 0.58)
  • Protein concentration >3 g/dL (sensitivity, 48%; specificity, 46%; LR +, 0.9; LR , 1.1)
  • Lactic dehydrogenase (LDH) concentration >250 U/L (sensitivity, 100%; specificity, 51%; LR +, 1.9; LR , 0.1)

Although uncommon, crystal-induced arthritis and septic arthritis can coexist; therefore, the presence of crystals does not exclude bacterial arthritis. [10]

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Complications

Improper needle placement, a small amount of effusion, mechanical obstruction of the needle against cartilage, or thickened synovium can result in a dry tap.

Potential damage to cartilage can be avoided by understanding the joint anatomy and avoiding further advancement of the needle into the joint space once synovial effusion enters the syringe.

Most hemarthroses are small and self-limited and only require observation. Hemarthrosis in coagulopathic patients may require correction of the coagulopathy after consideration of the relative risks of reversal. Proper skin cleansing and use of aseptic technique reduces the risk of introducing infection into a sterile joint to less than 1:10,000.

When performing arthrocentesis through infected skin for the diagnosis of a potentially septic joint, intravenous antibiotics should be given immediately following the procedure, and the patient should be admitted for continuation of the antibiotics.

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