Atow 448 00
Atow 448 00
Atow 448 00
Edited by: Simeon West, University College Hospital, London, UK; Su Cheen Ng,
University College Hospital, London, UK
†
Corresponding author e-mail: mariapaz.sebastian@nhs.net
KEY POINTS
Knowledge of the nerve supply to the knee joint is essential to choose the appropriate nerve blocks to anaesthetise
the whole knee.
The articular nerves that supply the knee are mainly branches from the femoral (FN), obturator (ON) and sciatic nerve
(SN).
Adductor canal or femoral triangle blocks are used to anaesthetise nerves covering the anterior aspect of the knee
without clinical significant motor block.
The IPACK block is used to anaesthetise articular branches of the posterior part of the knee while sparing motor
branches.
Local infiltration analgesia is another motor-sparing technique but is performed by the surgeon in 3 different stages
during the surgery, aiming to cover the anterior and posterior parts of the knee.
INTRODUCTION
In this article, we describe motor-sparing techniques to block the nerves supplying the knee, in line with enhanced recovery
pathways that encourage early postoperative mobilisation.
Total knee arthroplasty (TKA) is one of the most commonly performed and painful orthopaedic procedures. According to the
National Joint Registry, more than 100000 TKAs are carried out in the United Kingdom every year, with a mean patient age of
68.9 years.1 Effective analgesia and early ambulation in these patients is essential to reduce complications and improve
outcomes.
Multimodal analgesia incorporating regional anaesthesia techniques provides optimum analgesia and minimises the use of
opioids and their side effects. Proximal nerve blocks such as the lumbar plexus, femoral nerve and proximal sciatic nerve
blocks provide excellent analgesia but frequently cause motor weakness, which reduces the patient’s mobility and leads to a
risk of falls.2 Motor-sparing techniques should theoretically provide the optimum balance between analgesia and mobility.
A thorough understanding of the innervation of the knee joint will enable us to provide effective regional anaesthesia following
knee surgeries without motor weakness.
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The articular nerves that supply the knee are derived from the femoral (FN), obturator (ON) and sciatic nerve (SN) via the tibial
(TN) and common peroneal nerve (CPN).
Figure 2. Main nerve branches innervating the anterior knee joint divided into 4 quadrants. Blue: branches of the femoral nerve; yellow:
branches of the common peroneal nerve/sciatic nerve; red: branch of the tibial nerve. NVL, nerve to vastus lateralis; NVI, nerve to vastus
intermedius; NVM, nerve to vastus medialis; SLGN, superior lateral genicular nerve; SMGN, superior medial genicular nerve; ILGN, inferior
lateral genicular nerve; RCPN, recurrent branch of the common peroneal nerve; IPBSN, infrapatellar branch of the saphenous nerve; IMGN,
inferior medial genicular nerve.
The superolateral anterior aspect of the knee capsule is supplied by the nerves to the vastus lateralis and vastus intermedius
(both are branches of the FN), by the superior lateral genicular nerve (either a branch of the CPN or SN) and by the CPN itself.3
The superomedial anterior aspect of the knee capsule is innervated by the nerve to vastus medialis (NVM), the vastus
intermedius nerve and the superior medial genicular nerve, all of which are branches of the FN.3
The inferolateral anterior aspect of the knee capsule is supplied by 2 branches of the CPN: the recurrent branch of the CPN and
the inferior lateral genicular nerve.
The superior part of the inferomedial anterior aspect of the capsule is innervated by the infrapatellar branch of the saphenous
nerve, which is a branch of the saphenous nerve (SPN; the terminal sensory branch of the FN). The inferior medial genicular
nerve, a branch of the TN, supplies the inferior aspect of the inferomedial quadrant of the knee capsule.3
The anterior and posterior branches of the ON sometimes give an additional supply to the cutaneous inferomedial part of the
thigh and the anteromedial knee capsule, respectively.4
the anterior superior iliac spine and the base of the patella on the medial aspect of the thigh to identify and block the SPN
adjacent to the FA and spare blockade of femoral motor branches. However, further research has demonstrated that a block
performed as described above would not be in the AC but is likely to be in the distal part of the femoral triangle (FT).7
This differentiation is important, as the deposit of LA in these 2 places would also lead to a different analgesic effect. A block
performed in the true AC would mainly block the SPN (which is the only nerve that consistently runs inside the AC) and in some
cases the posterior branch of the ON.4 However, the block performed in the distal part of the FT (see the FT block below) would
block the SPN, the NVM (which contributes significantly to the innervation of the anteromedial knee joint) and nerves supplying
the cutaneous dermatomes of the knee such as the medial femoral cutaneous nerve4 but providing similar motor sparing to AC
blocks.8
It is therefore crucial to clarify some basic anatomical concepts and be aware of the use of inconsistent and/or imprecise
terminology.
The FT is formed by the inguinal ligament at its base and the intersection of the medial borders of the sartorius and adductor
longus muscles at its apex.7 The FT can be further divided into a proximal and distal portion, at the intersection of the medial
border of the sartorius muscle and the lateral border of the adductor longus muscle. This point corresponds with the point where
the sartorius muscle begins to cover the femoral neurovascular bundle.4 The end of the FT at its apex marks the beginning of
the AC, which ends at the adductor hiatus, where the FA and femoral vein become the PA and popliteal vein4,7 (see Figure 4).
the screen until the apex of the FT is identified at the point where the medial borders of the sartorius and the adductor longus
muscles meet7 (see Figure 5).
FT Block
Once the apex of the FT is identified, the probe is moved slightly proximal, and the LA is injected anterolateral to the FA below
the sartorius muscle (subsartorial). At this point, the SPN and NVM can usually be identified as hyperechoic structures lateral to
the FA (see Figure 6). It is important to ensure that the injection is made cephalic to the apex of the FT but where the FA is
covered by the sartorius muscle (meaning the distal FT; see Figure 4) to avoid blocking motor branches given off in the
proximal FT.4 To reduce the risk of proximal spread, the use of large volumes (.20 mL) of LA is not recommended.
AC Block
To perform a true AC block, the LA should be injected distally to the apex of the FT but proximally to the end of the AC, which is
identified by the femoral vessels exiting the adductor hiatus to become the popliteal vessels (see ATOTW 301, ‘‘Ultrasound-
Guided Adductor Canal Glock (Saphenous Nerve Block)’’). 10
For both the FT and AC blocks, low concentrations of a long-acting LA (for example, levobupivacaine 0,25%) are used to avoid
motor block but provide prolonged analgesia. For analgesia of knee surgery, we recommend an FT block and low volumes of
LA (,20 mL).
Figure 6. Ultrasound image of the distal FT block and positioning the patient in the ‘frog leg’ position. The yellow * indicates the nerve to vastus
medialis. The red * indicates the saphenous nerve. FT, femoral triangle; FA, femoral artery; FV, femoral vein. —demonstrates the needle
trajectory.
The optimal LA volume and site of infiltration to reach the greatest number of articular branches is still under discussion12;
however, the clinical evidence is based on Sinha’s approach in while the LA is infiltrated at the level immediately superior to the
femoral condyles; we referred to this approach here.
There have been 2 different approaches described to perform IPACK blocks: lateral and posterior. In both approaches, the LA
is deposited in the interspace between the PA and the knee capsule using a 100-mm needle from medial to lateral. However,
the probe position is different; hence, the view of the needle and interspace are different (see Figure 7).
The femoral vessels are then traced distally to observe them diving into the popliteal fossa to become the PA and popliteal vein.
Once the PA is identified posterior to the femur, the probe is moved slightly further distally and posterior to get a better view of
the interspace between the PA and the shaft of the femur just above the femoral condyles. The needle is inserted from medial
to lateral and advanced parallel to the acoustic shadow of the femur between the shaft of the femur and the PA until the tip is
placed 2 cm beyond the PA. The LA is injected as the needle is withdrawn after negative aspiration, filling the gap between the
PA and the femur (see Figure 8).
Regardless of the position of the patient, the probe is placed transversely at the level of the popliteal crease to identify the
femoral condyles and the PA (see Figure 7). The femoral condyles are seen as discontinuous curved hyperechoic lines (see
Figure 9). Once the femoral condyles and PA are identified, the probe is moved slightly proximal until this discontinuous
hyperechoic line changes to a continuous hyperechoic line of the femoral shaft. At this point, just above the femur condyles, the
Figure 9. Posterior infiltration between popliteal artery and capsule of the knee approach. Ultrasound image showing the femoral condyles. PA,
popliteal artery. Yellow * indicates the tibial nerve
needle is inserted using an in-plane technique, from medial to lateral and parallel to the femoral shaft. The needle is advanced
between the femur and PA until the tip is placed 2 cm beyond the PA or near the lateral border of the periosteum. The LA is
injected as the needle is withdrawn after negative aspiration and the space is filled. It is good practice to identify, whenever
possible, the TN and CPN in the image to be sure to avoid them (see Figure 10).
It is recommended to use a low concentration of a long-acting LA to minimise the risk of motor block but prolong the sensory
blockade (for example, levobupivacaine 0,25%). A variable range of 10 to 20 mL of LA is used to infiltrate this tissue plane.
EQUIPMENT
Ultrasound machine with high-frequency linear and curvilinear probes
22-gauge 50- to 100-mm short bevelled insulated ultrasound needle
Skin antiseptic
Gloves
Probe cover
LA for the block; a safe dose should be calculated based on the patient’s weight, and the concentration may be reduced to
allow a sufficient volume when combining multiple blocks
If a continuous peripheral nerve block is performed, strict aseptic precautions must be used and further equipment is needed:
o Peripheral nerve catheter set
o Pump device for delivery of LA, either electronic or disposable elastomeric pumps
SUMMARY
Regional anaesthesia techniques that promote early ambulation and effective pain relief are essential after TKA.
Knowledge of sensory innervation is key to providing the appropriate block for the appropriate surgery. FT blocks
provide sensory cover to the anterior knee and sparing clinical significant motor weakness, whilst IPACK blocks
anaesthetise the articular branches covering the posterior part of the knee without motor block.
ACKNOWLEDGEMENT
We would like to thank Jose Luis Humanes, Ben Butcher and Charles Bishop for their kind contribution to this tutorial.
REFERENCES
1. National Joint Registry Reports. 16th annual report. Accessed November 28, 2019. https://reports.njrcentre.org.uk/
2. Johnson R, Kopp S, Hebl J, et al. Falls and major orthopaedic surgery with peripheral nerve blockade: a systematic review
and meta-analysis. Br J Anaesth. 2013;110(4):518-528.
3. Tran J, Peng PWH, Lam K, et al. Anatomical study of the innervation of anterior knee joint capsule: implication for image-
guided intervention. Reg Anesth Pain Med. 2018;43(4):407-414.
4. Bendtsen TF, Moriggl B, Chan V, et al. The optimal analgesic block for total knee arthroplasty. J.Reg Anesth Pain Med.
2016;41(6):711-719.
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