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A Technique for Performing Radiographic Guided Needle Placement Into the Collateral Ligaments of the DIP Joint

Take Home Message

Radiographs can be used to guide needle placement in the distal aspect of the collateral ligaments of distal interphalangeal joints. If clinically indicated this technique can be used to facilitate intra-lesional therapy for treatment of collateral ligament injury.

Introduction

The diagnosis of abnormalities in the collateral ligaments of the distal interphalangeal (DIP) joint distal to the coronary band is occurring with increased frequency. This is due to use of magnetic resonance imaging (MRI) as a diagnostic tool in cases with foot lameness. Collateral ligament (CL) injury proximal and immediately distal to the coronary band can be diagnosed using ultrasound1. Osseous lesions of the distal phalanx at the CL insertions can be diagnosed on radiographs. However, visualization of abnormalities in the collateral ligaments of the DIP joint at the level of the insertion on the distal phalanx can only be diagnosed with MRI or computed tomography (CT)2. Lesions identified in the collateral ligaments of the DIP joint diagnosed on MR images consist of core lesions with fiber disruption, diffuse injury without fiber disruption, margin tears, and complete ligament disruption.3-4
 
Intralesional therapy, such as platelet rich plasma (PRP) and stem cells, is one of the possible treatment options in cases with a diagnosis of soft tissue injury. Imaging modalities can be used to facilitate needle placement for injection of therapeutic agents. Soft tissue is best visualized with MR and ultrasound (US). Therefore, these modalities are often selected to facilitate needle placement into soft tissue lesions. CT can be used in a soft tissue window in conjunction with osseous landmarks for needle placement into soft tissue injuries.5 MRI and CT require general anesthesia, while US and radiography can be performed in the standing horse. Radiography is commonly used to facilitate needle placement when reliable bony landmarks are available, such as injection of the navicular bursa using the navicular bone flexor surface as a landmark.6
 
The collateral ligaments of the DIP joint insert on the fossae of the distal phalanx. The fossae of the distal phalanx can be reliably identified on radiographs and recognized on multiple views. A paper, which was presented at AAEP, was done by Drs. Werpy and Frisbie with Lauren Farrington to provide a description of how to use radiography to facilitate needle placement into the distal aspect of the collateral ligaments of the distal interphalangeal joint for injection of intra lesion therapy.

Materials and Methods

This technique is performed following diagnosis of a lesion in the distal aspect of the collateral ligaments of the DIP joint using high or low field MRI. The MR images are used to determine the desired site of needle placement based on relative distance from the margins of the fossa and whether the lesion is dorsal, palmar or centrally located within the ligament. A 3 ½ inch, 18-gauge needle placed into the fossa and can be performed with the horse standing or under general anesthesia. It can also be performed in conjunction with a MRI exam or other procedure. This report will provide a description of the procedure in a standing sedated horse, but can certainly be adapted to a patient under general anesthesia.
 
Prior to performing the procedure, an abaxial nerve block is performed and the hair is clipped from the injection site. During the procedure, sedation is used at the discretion of the veterinarian to prevent movement of the limbs. To approximate the location of the collateral ligaments for clipping, the coronary band can be palpated for areas of dense tissue at the 10 o'clock and 2 o'clock positions on the dorsal aspect of the foot. If the collateral ligaments are not palpable due to diffuse swelling, ultrasound can be used to locate them. A region of approximately 10 cm extending from the coronary band centered over the collateral ligament of interest is clipped. Properly placing a needle in the collateral ligament fossa is dependent on being able to identify the fossa margins on radiographs. Three radiographic views that are useful in locating the collateral ligament fossae include the lateromedial (LM), horizontal or weight-bearing dorsopalmar (DP), and dorso 60°proximal - palmarodistal (D60°P) views (Fig. 1). Therefore, the horse will need to be positioned with both front feet on foot blocks to allow proper radiographs to be taken once the needle is placed.
 
When taking radiographs it is important that proper safety precautions be taken and protective equipment is worn. In general, sequential radiographs are taken with continued needle advancement toward the fossa. We use a LM view followed by horizontal DP view and then a D60°P view. However, the sequence of radiographs could be adjusted as needed. When first learning this technique it is helpful to estimate the required proximal to distal angle of the needle prior to beginning needle placement. Before taking radiographs, a capped spinal needle can be positioned at the estimated proper angel and then held in place with tape (Fig. 2a). A lateral radiograph can be taken to view the needle placement in relation to the fossa. At this point, the capped needle can be adjusted accordingly until the person performing the procedure is confident it is properly angled. Once the appropriate angle is determined on a lateral radiograph this angle can be marked on the limb with correction fluid, pen or white tape so it can be repeated following sterile preparation of the injection site (Fig. 2b). Prior to removing the capped needle, a DP radiograph can be taken to approximate the medial to lateral angle needed to direct the needle towards the fossa. This initial process will reduce the need for repositioning the needle once it has been inserted through the skin. Once proficiency at this technique is obtained, initial marking of the limb for needle placement is often not necessary. However, this could depend on how exact the needle placement must be based on the size and shape of the lesion. The area of ligament injury is taken into account when positioning the needle. The lesion location in the ligament as identified on MR images should be taken into consideration when planning this procedure. The needle can be inserted dorsal, palmar, or peripheral (abaxial) to the proximal aspect of the collateral ligament. This will avoid passing the needle through the proximal aspect of the ligament and allow placement of needle in the affected area of the ligament.
 
Following sterile preparation of the injection site, the needle is inserted approximately 3 cm toward the fossa. Angles determined by the LM and horizontal DP radiographs, if previously obtained, are used to direct the needle (Fig. 3). Once the needle has been advanced approximately 3 cm, LM and horizontal DP radiographs should be taken to confirm that the needle is at the correct angle to enter the fossa. If needed, the needle can be readjusted by retracting it 1-2 cm and redirecting it (Fig. 4). If the angle and placement are correct, the needle should be advanced 1-2 cm and then a D60°P radiograph is taken to evaluate needle position. Once the correct angles have been obtained, the needle can be advanced until it contacts the fossa of the distal phalanx (Fig. 5). Once the spinal needle has reached the fossa, any additional views needed to confirm proper needle placement should be taken. Intralesional therapy is administered once correct needle placement has been confirmed. Once the needle is removed, the injection site is ­bandaged.

Results

This technique was performed initially on cadaver limbs using MRI compatible needles. The needle placement was confirmed on MR images. Subsequently, this technique was performed using spinal needles with contrast administration. The contrast agent was detectable on radiographs and MR images confirming placement of the contrast into the collateral ligaments. This technique has been used on 18 horses for administration of intralesional therapy following diagnosis of a collateral ligament lesion located in the distal aspect of the ligament. Lesions were diagnosed on MR studies from high and low field systems. No adverse effects from this technique have been observed. Stem cells and platelet rich plasma have been administered using this technique. Recheck examination six months following treatment has been performed in three cases, which demonstrated clinical improvement as well as improvement in the appearance of the ligament on MR images.

Discussion

The technique provides a method for intralesional therapy of distal collateral ligament lesions with equipment commonly available in veterinary practice and without the use of general anesthesia. Proficiency can be achieved with knowledge of anatomy and radiographic technique as well as practice on a limited number of cadaver limbs. Using multiple radiographic views is necessary to ensure proper needle placement. Additional views, such as lateral oblique radiographs may also provide helpful landmarks. These views should be performed at the veterinarians discretion during the procedure such that needle placement is adequately confirmed. However, the needle could be consistently placed in the distal aspect of the collateral ligament using the three described views as was confirmed on MR images.
 
Fine tuning needle placement into specific areas identified on MR images, such as axial, abaxial, dorsal, or palmar aspects of the ligament can be achieved, but requires further practice (Fig. 6-7). Contrast can be used to confirm needle placement when practicing this technique on cadaver limbs. However, the effect of contrast material on most intralesional therapies is not known so contrast use is not recommended when performing this technique on clinical cases.
 
Axial lesions are the most challenging for needle placement, as they are in close proximity to the distal interphalangeal joint. The needle will enter the distal interphalangeal joint if it is placed axial to the ligament at the level of the joint or immediately distal to it. Often axial margin tears communicate with the distal interphalangeal joint. Furthermore, thinning of the ligament often occurs on the axial margin of the ligament. This space is often occupied by synovial membrane and fluid extending from the joint, increasing the possibility of needle placement in the joint. However, these characteristics of the lesion will be apparent on the MR images and can be considered when planning the needle path. In these cases placing the needle abaxial to the peripheral margin of the tear is necessary to prevent placing the needle into the joint.

Conclusions

Radiographic guided needle placement into the distal aspect of the collateral ligaments of the DIP joint can be used to facilitate injection of intra lesion therapy.

References

  1. Busconi V., Lahaye B., Denoix J.M. (2006) Transcuneal ultrasonographic findings in the podotrochlear apparatus: comparison with postmortem in 14 equine digits. J. equine vet. Sci. 26, 113-118.
  2.  
  3. Schneider R.K., Sampson S.N., Gavin P.R. Magnetic Resonance Imaging Evaluation of Horses with Lameness Problems. In: (Ed.), 51 Annual Convention of the American Association of Equine Practitioners - AAEP, 2005 - Seattle, Wash., USA.
  4.  
  5. Dyson S., Blunden T., Murray R. The collateral ligaments of the distal interphalangeal joint: Magnetic resonance imaging and post mortem observations in 25 lame and 12 control horses. Equine vet. J. 2008; 40: 538-544.
  6.  
  7. Gutierrez-Nibeyro S.D., White N.A., 2nd, Werpy N.M., Tyrrell L., Allen K.A., Sullins K.E., Mitchell, R.D. Magnetic resonance imaging findings of desmopathy of the collateral ligaments of the equine distal interphalangeal joint. Vet. Radiol. Ultrasound 2009; 50: 21-31.
  8.  
  9. Anderson J.D., Puchalski S.M., Larson R.F. Delco M.L., Snyder J.R. Injection of the insertion of the deep digital flexor tendon in horses using radiographic guidance Equine vet. Educ. (2008) 20 (7) 383-388.
  10.  
  11. Schramme M. C., Boswell J.C., Hamhougias K., Toulson K., Viitanen M. (2000) An in vitro study to compare 5 different techniques for injection of the navicular bursa in the horse. Equine Veterinary Journal 32, 263-267.
Figure 1. Lateromedial and DP radiographs of the bones of the distal limb with wire (arrow) marking the fossa of the distal phalanx at the insertion site of the medial collateral ligament of the distal interphalangeal joint. These landmarks are used for needle placement.
Figure 2. (a) External placement of a capped spinal needle secured with tape can be used when learning this technique. Radiographs are taken to determine the appropriate angle. (b) This angle is then marked with tape, or other method, and then used to guide needle placement.
Figure 3. (a) Lateral radiograph showing initial needle placement. (b) The needle has been inserted approximately 3cm. The needle is correctly positioned and can be advanced toward the fossa. At this angle the needle will be placed in the dorsal aspect of the fossa.
Figure 4. Horizontal DP radiograph of initial needle placement. This view allows visualization of the medial to lateral angle of the needle. The distal aspect of the needle is angled too far axially or towards midline. Further advancement would place the needle in the DIP joint. The needle should be repositioned placing the hub closer to the limb, at an angle demonstrated by the arrow. This will allow advancement of the needle into the center of the fossa.
Figure 5. (a) Dorsopalmar and (b)D60°P views of the needle at the correct angle advanced into the center of the fossa.
Figure 6. Proton density transverse image at the proximal aspect of the distal phalanx. A focal area of fiber disruption is present in the palmar aspect of the medial collateral ligament of the distal interphalangeal joint (arrow) with an associated osseous cyst like lesion (arrowhead). Although abnormalities are present in the dorsal aspect of the ligament, the palmar aspect is most severely affected. Based on the MR image the needle would be directed into the palmar aspect of the ligament for administration of intralesional therapy.
Figure 7. Three radiographic views of needle placement into specific areas of the collateral ligament for injection of intralesional therapy in a lesion diagnosed on MR images. The location of the lesion was determined on MR images and the needle was placed in the region of injury. (a) The lateral view shows an additional angle which places the needle into the palmar aspect of the ligament. (b) A D60 nP view of the needle in the dorsal aspect of the ligament. (c)A D60 nP view of needle placed in the abaxial aspect of the ligament, just inside the margin of the fossa.
 
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