Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)—part VI, foot and ankle
Authors: Sconfienza Luca Maria , Adriaensen Miraude , Albano Domenico , Alcala-Galiano Andrea , Allen Georgina , Aparisi Gómez Maria Pilar , Aringhieri Giacomo , Bazzocchi Alberto , Beggs Ian , Chianca Vito , Corazza Angelo , Dalili Danoob , De Dea Miriam , del Cura Jose Luis , Di Pietto Francesco , Drakonaki Elena , Facal de Castro Fernando , Filippiadis Dimitrios , Gitto Salvatore , Grainger Andrew J , Greenwood Simon , Gupta Harun , Isaac Amanda , Ivanoski Slavcho , Khanna Monica , Klauser Andrea , Mansour Ramy , Martin Silvia , Mascarenhas Vasco , Mauri Giovanni , McCarthy Catherine , McKean David , McNally Eugene , Melaki Kalliopi , Messina Carmelo , Mirón Mombiela Rebeca , Moutinho Ricardo , Olchowy Cyprian , Orlandi Davide , Prada González Raquel , Prakash Mahesh , Posadzy Magdalena , Rutkauskas Saulius , Snoj Žiga , Tagliafico Alberto Stefano , Talaska Alexander , Tomas Xavier , Vasilevska Nikodinovska Violeta , Vucetic Jelena , Wilson David , Zaottini Federico , Zappia Marcello , Obradov Marina 
Published: August 2021

Abstract
Objectives
Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region.

Methods
We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval.

Results
A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement.

Conclusion
According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton’s neuroma, particularly using platelet-rich plasma and corticosteroids, respectively.

Key Points
• The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle.
• Strong consensus was obtained for all statements.
• The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton’s neuroma and PRP for plantar fasciitis.