Continuous Adductor Canal Blocks
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Updated: December, 9th, 2020 MSI ANATOMY LAB: STRUCTURE LIST Lower Extremity Lower Extremity Osteology Hip bone Tibia • Greater sciatic notch • Medial condyle • Lesser sciatic notch • Lateral condyle • Obturator foramen • Tibial plateau • Acetabulum o Medial tibial plateau o Lunate surface o Lateral tibial plateau o Acetabular notch o Intercondylar eminence • Ischiopubic ramus o Anterior intercondylar area o Posterior intercondylar area Pubic bone (pubis) • Pectineal line • Tibial tuberosity • Pubic tubercle • Medial malleolus • Body • Superior pubic ramus Patella • Inferior pubic ramus Fibula Ischium • Head • Body • Neck • Ramus • Lateral malleolus • Ischial tuberosity • Ischial spine Foot • Calcaneus Ilium o Calcaneal tuberosity • Iliac fossa o Sustentaculum tali (talar shelf) • Anterior superior iliac spine • Anterior inferior iliac spine • Talus o Head • Posterior superior iliac spine o Neck • Posterior inferior iliac spine • Arcuate line • Navicular • Iliac crest • Cuboid • Body • Cuneiforms: medial, intermediate, and lateral Femur • Metatarsals 1-5 • Greater trochanter • Phalanges 1-5 • Lesser trochanter o Proximal • Head o Middle • Neck o Distal • Linea aspera • L • Lateral condyle • L • Intercondylar fossa (notch) • L • Medial condyle • L • Lateral epicondyle • L • Medial epicondyle • L • Adductor tubercle • L • L • L • L • 1 Updated: December, 9th, 2020 Lab 3: Anterior and Medial Thigh Anterior Thigh Medial thigh General Structures Muscles • Fascia lata • Adductor longus m. • Anterior compartment • Adductor brevis m. • Medial compartment • Adductor magnus m. • Great saphenous vein o Adductor hiatus • Femoral sheath o Compartments and contents • Pectineus m. o Femoral canal and ring • Gracilis m. Muscles & Associated Tendons Nerves • Tensor fasciae lata • Obturator nerve • Iliotibial tract (band) • Femoral triangle: Boundaries Vessels o Inguinal ligament • Obturator artery o Sartorius m. • Femoral artery o Adductor longus m. -
Clinical Anatomy of the Lower Extremity
Государственное бюджетное образовательное учреждение высшего профессионального образования «Иркутский государственный медицинский университет» Министерства здравоохранения Российской Федерации Department of Operative Surgery and Topographic Anatomy Clinical anatomy of the lower extremity Teaching aid Иркутск ИГМУ 2016 УДК [617.58 + 611.728](075.8) ББК 54.578.4я73. К 49 Recommended by faculty methodological council of medical department of SBEI HE ISMU The Ministry of Health of The Russian Federation as a training manual for independent work of foreign students from medical faculty, faculty of pediatrics, faculty of dentistry, protocol № 01.02.2016. Authors: G.I. Songolov - associate professor, Head of Department of Operative Surgery and Topographic Anatomy, PhD, MD SBEI HE ISMU The Ministry of Health of The Russian Federation. O. P.Galeeva - associate professor of Department of Operative Surgery and Topographic Anatomy, MD, PhD SBEI HE ISMU The Ministry of Health of The Russian Federation. A.A. Yudin - assistant of department of Operative Surgery and Topographic Anatomy SBEI HE ISMU The Ministry of Health of The Russian Federation. S. N. Redkov – assistant of department of Operative Surgery and Topographic Anatomy SBEI HE ISMU THE Ministry of Health of The Russian Federation. Reviewers: E.V. Gvildis - head of department of foreign languages with the course of the Latin and Russian as foreign languages of SBEI HE ISMU The Ministry of Health of The Russian Federation, PhD, L.V. Sorokina - associate Professor of Department of Anesthesiology and Reanimation at ISMU, PhD, MD Songolov G.I K49 Clinical anatomy of lower extremity: teaching aid / Songolov G.I, Galeeva O.P, Redkov S.N, Yudin, A.A.; State budget educational institution of higher education of the Ministry of Health and Social Development of the Russian Federation; "Irkutsk State Medical University" of the Ministry of Health and Social Development of the Russian Federation Irkutsk ISMU, 2016, 45 p. -
Proximal Versus Distal Continuous Adductor Canal Blocks
Proximal Versus Distal Continuous Adductor Canal Blocks: Does Varying Perineural Catheter Location Influence Analgesia? A Randomized, Subject-Masked, Controlled Clinical Trial Jacklynn F. Sztain, MD, Bahareh Khatibi, MD, Amanda M. Monahan, MD, Engy T. Said, MD, 06/24/2018 on HRKGxsQg0SuoZn4utVXOmk5z97Ja58gACMhy7Bn6J3AP6ghkXyb1tI+UeqR7yrM9qMCtumnaZizf7u+BFX+JxKfAaCZ2GwhaiucBBv+CqffnLy74g548/g== by https://journals.lww.com/anesthesia-analgesia from Downloaded Wendy B. Abramson, MD, Rodney A. Gabriel, MD, MAS, John J. Finneran IV, MD, Richard H. Bellars, MD,* Patrick L. Nguyen, MD,* Scott T. Ball, MD, Francis† B. Gonzales, MD,* Downloaded Sonya S. Ahmed, MD, Michael* C. Donohue, PhD, Jennifer*‡ A. Padwal, BS, and *‡ Brian M. Ilfeld, MD, MS *(Clinical Investigation) * § § from § ∥ ¶ https://journals.lww.com/anesthesia-analgesia BACKGROUND: A continuous adductor canal*‡ block provides analgesia after surgical procedures of the knee. Recent neuroanatomic descriptions of the thigh and knee led us to speculate that local anesthetic deposited in the distal thigh close to the adductor hiatus would provide superior analgesia compared to a more proximal catheter location. We therefore tested the hypothesis that during a continuous adductor canal nerve block, postoperative analgesia would be improved by placing the perineural catheter tip 2–3 cm cephalad to where the femoral artery descends posteri- orly to the adductor hiatus (distal location) compared to a more proximal location at the midpoint between the anterior superior iliac spine and the superior border of the patella (proximal location). by HRKGxsQg0SuoZn4utVXOmk5z97Ja58gACMhy7Bn6J3AP6ghkXyb1tI+UeqR7yrM9qMCtumnaZizf7u+BFX+JxKfAaCZ2GwhaiucBBv+CqffnLy74g548/g== METHODS: Preoperatively, subjects undergoing total knee arthroplasty received an ultrasound- guided perineural catheter inserted either in the proximal or distal location within the adductor canal in a randomized, subject-masked fashion. -
Anomalous Tendinous Contribution to the Adductor Canal by the Adductor Longus Muscle
SHORT COMMUNICATION Anomalous tendinous contribution to the adductor canal by the adductor longus muscle Devon S Boydstun, Jacob F Pfeiffer, Clive C Persaud, Anthony B Olinger Boydstun DS, Pfeiffer JF, Persaud CC, et al. Anomalous tendinous Methods: During routine dissection, one specimen was found to have an contribution to the adductor canal by the adductor longus muscle. Int J Anat abnormal tendinous contribution to the adductor canal. Var. 2017;10(4): 83-84. Results: This tendon arose from the distal portions of adductor longus and ABSTRACT created part of the roof of the canal. Introduction: Classically the adductor canal is made from the fascial Conclusions: The clinical consequences of such an anomaly may include contributions from sartorius, adductor longus, adductor magnus and vastus conditions such as saphenous neuritis, adductor canal compression medialis muscles. The contents of the adductor canal include femoral syndrome, as well as paresthesias along the saphenous nerve distribution. artery, femoral vein, and saphenous nerve. While the femoral artery and vein continue posteriorly through the adductor hiatus, the saphenous nerve Key Words: Adductor Canal; Anomalous tendon; Compressions syndrome; travels all the way through the adductor canal and exits the inferior opening Saphenous neuralgia of the adductor canal. INTRODUCTION he adductor canal is a cone shaped tunnel between the anterior and Tmedial compartments of the thigh through which the femoral artery, femoral vein, and saphenous nerve travel in the distal thigh (1-3). It is bordered anteromedially by the vastoadductor membrane and the Sartorius muscle, anterolaterally by the vastus medialis muscle, and posteriorly by the adductor longus and adductor magnus muscles (3). -
The Nerves of the Adductor Canal and the Innervation of the Knee: An
REGIONAL ANESTHESIA AND ACUTE PAIN Regional Anesthesia & Pain Medicine: first published as 10.1097/AAP.0000000000000389 on 1 May 2016. Downloaded from ORIGINAL ARTICLE The Nerves of the Adductor Canal and the Innervation of the Knee An Anatomic Study David Burckett-St. Laurant, MBBS, FRCA,* Philip Peng, MBBS, FRCPC,†‡ Laura Girón Arango, MD,§ Ahtsham U. Niazi, MBBS, FCARCSI, FRCPC,†‡ Vincent W.S. Chan, MD, FRCPC, FRCA,†‡ Anne Agur, BScOT, MSc, PhD,|| and Anahi Perlas, MD, FRCPC†‡ pain in the first 48 hours after surgery.3 Femoral nerve block, how- Background and Objectives: Adductor canal block contributes to an- ever, may accentuate the quadriceps muscle weakness commonly algesia after total knee arthroplasty. However, controversy exists regarding seen in the postoperative period, as evidenced by its effects on the the target nerves and the ideal site of local anesthetic administration. The Timed-Up-and-Go Test and the 30-Second Chair Stand Test.4,5 aim of this cadaveric study was to identify the trajectory of all nerves that In recent years, an increased interest in expedited care path- course in the adductor canal from their origin to their termination and de- ways and enhanced early mobilization after TKA has driven the scribe their relative contributions to the innervation of the knee joint. search for more peripheral sites of local anesthetic administration Methods: After research ethics board approval, 20 cadaveric lower limbs in an attempt to preserve postoperative quadriceps strength. The were examined using standard dissection technique. Branches of both the adductor canal, also known as the subsartorial or Hunter canal, femoral and obturator nerves were explored along the adductor canal and has been proposed as one such location.6–8 Early data suggest that all branches followed to their termination. -
Anatomy and Clinical Implications of the Ultrasound-Guided Subsartorial Saphenous Nerve Block
Regional Anesthesia & Pain Medicine: first published as 10.1097/AAP.0b013e318220f172 on 1 June 2011. Downloaded from ULTRASOUND ARTICLE Anatomy and Clinical Implications of the Ultrasound-Guided Subsartorial Saphenous Nerve Block Theodosios Saranteas, MD, PhD,* George Anagnostis, MD,* Tilemachos Paraskeuopoulos, PhD,Þ Dimitrios Koulalis, MD,þ Zinon Kokkalis, MD,þ Mariza Nakou, MD,* Sofia Anagnostopoulou, PhD,Þ and Georgia Kostopanagiotou, PhD* landmark, whereas Krombach and Gray7 described a more dis- Background: We evaluated the anatomic basis and the clinical results tal approach, 5 to 7 cm proximal to the popliteal crease and of an ultrasound-guided saphenous nerve block close to the level of the performed a trans-sartorial approach to saphenous nerve block. nerve’s exit from the inferior foramina of the adductor canal. Manickam et al8 also performed a descriptive study to evaluate Methods: The anatomic study was conducted in 11 knees of formalin- the efficacy of an ultrasound-guided saphenous nerve block tech- preserved cadavers in which the saphenous nerve was dissected from nique at the distal part of adductor canal. The authors identified the near its exit from the inferior foramina of the adductor canal. The clinical saphenous nerve within the adductor canal and found that with study was conducted in 23 volunteers. Using a linear probe, the femoral this technique the nerve was blocked successfully in all 20 of vessels and the sartorius muscle were depicted in short-axis view at the their patients. level where the saphenous nerve exits the inferior foramina of the ad- The adductor canal is an aponeurotic tunnel in the middle ductor canal. -
Femoral Nerve Block Versus Adductor Canal Block for Analgesia After Total Knee Arthroplasty
Review Article Knee Surg Relat Res 2017;29(2):87-95 https://doi.org/10.5792/ksrr.16.039 pISSN 2234-0726 · eISSN 2234-2451 Knee Surgery & Related Research Femoral Nerve Block versus Adductor Canal Block for Analgesia after Total Knee Arthroplasty In Jun Koh, MD1,2, Young Jun Choi, MD1,2, Man Soo Kim, MD1,2, Hyun Jung Koh, MD3, Min Sung Kang, MD1, and Yong In, MD1,2 1Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, Seoul; 2Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul; 3Department of Anesthesia and Pain Medicine, Seoul St. Mary's Hospital, Seoul, Korea Inadequate pain management after total knee arthroplasty (TKA) impedes recovery, increases the risk of postoperative complications, and results in patient dissatisfaction. Although the preemptive use of multimodal measures is currently considered the principle of pain management after TKA, no gold standard pain management protocol has been established. Peripheral nerve blocks have been used as part of a contemporary multimodal approach to pain control after TKA. Femoral nerve block (FNB) has excellent postoperative analgesia and is now a commonly used analgesic modality for TKA pain control. However, FNB leads to quadriceps muscle weakness, which impairs early mobilization and increases the risk of postoperative falls. In this context, emerging evidence suggests that adductor canal block (ACB) facilitates postoperative rehabilitation compared with FNB because it primarily provides a sensory nerve block with sparing of quadriceps strength. However, whether ACB is more appropriate for contemporary pain management after TKA remains controversial. The objective of this study was to review and summarize recent studies regarding practical issues for ACB and comparisons of analgesic efficacy and functional recovery between ACB and FNB in patients who have undergone TKA. -
Defining the Location of the Adductor Canal Using Ultrasound
REGIONAL ANESTHESIA AND ACUTE PAIN Regional Anesthesia & Pain Medicine: first published as 10.1097/AAP.0000000000000539 on 1 March 2017. Downloaded from BRIEF TECHNICAL REPORT Defining the Location of the Adductor Canal Using Ultrasound Wan Yi Wong, MMed, MBBS,* Siska Bjørn, MS,† Jennie Maria Christin Strid, MD,† Jens Børglum, MD, PhD,‡ and Thomas Fichtner Bendtsen, MD, PhD† represents an injection into the true adductor canal. Lund et al in- Background and Objectives: The precise location of the adductor ca- troduced a more proximal approach at the midthigh level, defined nal remains controversial among anesthesiologists. In numerous studies of by anatomical surface landmarks as the midpoint between the an- the analgesic effect of the so-called adductor canal block for total knee terior superior iliac spine (ASIS) and the base of patella. This ap- arthroplasty, the needle insertion point has been the midpoint of the thigh, proach has become the well-known “ACB.”6,9–11 determined as the midpoint between the anterior superior iliac spine and It is a common notion that the AC is located in the middle of “ ” base of patella. Adductor canal block may be a misnomer for an approach the thigh and that an injection at the midthigh is indeed an injection “ that is actually an injection into the femoral triangle, a femoral triangle into the middle of the AC. However, an injection at the midthigh ” block. This block probably has a different analgesic effect compared with can be into the AC or in the femoral triangle (FT), depending on an injection into the adductor canal. -
Adductor Canal Blocks
Adductor Canal Blocks: An Observational Ultrasound Study in Volunteers to Identify the Relationship of the True Adductor Canal to Commonly Described Block Approaches and a Review of the Literature Yatish S. Ranganath University of Iowa Roy J and Lucille A Carver College of Medicine Amanda Yap University of Iowa Roy J and Lucille A Carver College of Medicine Cynthia A. Wong University of Iowa Roy J and Lucille A Carver College of Medicine Sapna Ravindranath University of Iowa Roy J and Lucille A Carver College of Medicine Anil Alexander Marian ( [email protected] ) University of Iowa Roy J and Lucille A Carver College of Medicine https://orcid.org/0000-0002-8445- 7619 Research article Keywords: Adductor canal block; Ultrasound Anatomy Posted Date: July 26th, 2019 DOI: https://doi.org/10.21203/rs.2.11977/v1 License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Page 1/17 Abstract Background There is controversy over the site at which the ultrasound-guided adductor canal blocks (ACB) should be performed, and the anatomic relationship of these sites to the true adductor canal (AC). Most studies describe performing the ACB at the anatomical mid-point of the thigh (mid-thigh ACB, mtACB), or 2-3 cm above the inferior border of AC (distal ACB, dACB). The aim of the study was to determine the relationship of these approaches to the true anatomical AC in volunteers. Methods Using ultrasonography and surface landmarks, we characterized the AC anatomy of both lower limbs in 60 adult volunteers (30 males, 30 females). -
Effects of Adductorcanalblockade on Pain and Ambulation After Total Knee
Acta Anaesthesiol Scand 2012; 56: 357–364 © 2012 The Authors Printed in Singapore. All rights reserved Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation ACTA ANAESTHESIOLOGICA SCANDINAVICA doi: 10.1111/j.1399-6576.2011.02621.x Effects of Adductor-Canal-Blockade on pain and ambulation after total knee arthroplasty: a randomized study M. T. Jenstrup1, P. Jæger2, J. Lund1, J. S. Fomsgaard3, S. Bache3, O. Mathiesen2, T. K. Larsen3 and J. B. Dahl2 1Department of Anaesthesia, Hamlet Hospital, Frederiksberg, Denmark, 2Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Denmark and 3Department of Anaesthesia, Copenhagen University Hospital, Glostrup, Denmark Background: Total knee arthroplasty (TKA) is associated with compared with the placebo group (40 Ϯ 21 vs. 56 Ϯ 26 mg, intense post-operative pain. Besides providing optimal analge- P = 0.006). Pain was significantly reduced in the ropivacaine sia, reduction in side effects and enhanced mobilization are group during 45 degrees flexion of the knee (P = 0.01), but not at important in this elderly population. The adductor-canal- rest (P = 0.06). Patients in the ropivacaine group performed blockade is theoretically an almost pure sensory blockade. We the ambulation test, the Timed-Up-and-Go (TUG) test, at 24 h hypothesized that the adductor-canal-blockade may reduce mor- significantly faster than patients in the placebo group (36 Ϯ 17 phine consumption (primary endpoint), improve pain relief, vs. 50 Ϯ 29 s, P = 0.03). enhance early ambulation ability, and reduce side effects (sec- Conclusion: The adductor-canal-blockade significantly ondary endpoints) after TKA compared with placebo. -
Medial Side of Thigh
Adductor canal • Also named as Hunter’s canal • Present in middle one third of thigh medially deep to sartorius muscle • Extends from apex of femoral triangle to adductor hiatus • Boundaries- Anterolaterally vastus medialis • Posteriorly adductor longus above & adductor magnus below • Medially Strong fibrous membrane deep to sartorius. • Subsartorial plexus present in roof consists of medial cutaneous nerve of thigh, saphenous nerve & anterior division of obturator nerve Contents • Femoral artery • Femoral vein • Saphenous nerve • Nerve to vastus medialis • Antr. Division of obturator nerve • Subsartorial plexus of nerves Applied • Femoral artery easily approached here for surgery • Ligation of femoral artery is done in femoral canal. Collateral circulation is established thru anastomosis between Descending branch of lateral circumflex femoral & descending genicular arteries, between 4th perforating artery & the muscular branch of popliteal artery Medial side of thigh • Compartment between medial & ill defined posterior intermuscular septum • Also called as adductor compartment as muscles cause adduction of hip joint Contents • Muscles- Adductor longus Ad.brevis, ad magnus, gracilis. Pectineus, obturator externus Nerve – obturator nerve Vessels- medial circumflex artery, profunda femoris artery & obturator artery Vein- obturator vein Origin & insertion of muscles Pectineus • Origin- Superior ramus of pubis, pecten pubis & pectineal surface • Insertion- Posterior aspect of the femur on a line passing from lesser trochanter to linea aspara -
Femoral Sheath • This Oval, Funnel-Shaped Fascial Tube Encloses the Proximal Parts of the Femoral Vessels, Which Lie Inferior to the Inguinal Ligament
Femoral Sheath • This oval, funnel-shaped fascial tube encloses the proximal parts of the femoral vessels, which lie inferior to the inguinal ligament. • It is a diverticulum or inferior prolongation of the fasciae lining of the abdomen (trasversalis fascia anteriorly and iliac fascia posteriorly). • It is covered by the fascia lata. • Its presence allows the femoral artery and vein to glide in and out, deep to the inguinal ligament, during movements of the hip joint. • The sheath does not project into the thigh when the thigh is fully flexed, but is drawn further into the femoral triangle when the thigh is extended. Subdivided by two vertical septa into three compartments: • (1) Lateral compartment for femoral artery • (2) Intermediate compartment for femoral vein • (3) Medial compartment or space called femoral canal. Femoral Triangle Clinically important triangular subfascial space in the superomedial one-third part of the thigh. Boundaries: • Superiorly by the inguinal ligament • Medially by the medial border of the adductor longus muscle • Laterally by the medial border of the sartorius muscle • T h e m u s c u l a r f The muscular floor is not flat but gutter-shaped. • Formed from medial to lateral by the adductor longus, pectineus, and the iliopsoas. • It is the juxtaposition of the iliopsoas and pectineus muscles that forms the deep gutter in the muscular floor. • Roof of the femoral triangle is formed by the fascia lata which includes the cribiform fascia. Contents : • This triangular space in the anterior aspect of the thigh contains femoral artery and its branches • Femoral vein and its tributaries • Femoral nerve and its branches • Lateral cutaneous nerve • Femoral branch of the genitofemoral nerve, • Lymphatic vessels • Some inguinal lymph nodes.