a & hesi C st lin e ic n a A l f R o e l s Journal of Anesthesia & Clinical e a a n r r c u h o Canales et al., J Anesth Clin Res 2015, 6:8 J ISSN: 2155-6148 Research DOI: 10.4172/2155-6148.1000553 Review Article Open Access The Popliteal Nerve Block in Foot and Ankle Surgery: an Efficient and Anatomical Technique Michael B Canales1-3, Homer Huntley4, Matthew Reiner5*, Duane J Ehredt6 and Mark Razzante7 1Private Practice, St. Vincent Medical Group, Rockside Physician’s Center, USA 2Department of Orthopedic Surgery, Podiatry Section, PMR+RRA Residency Training Program, St. Vincent Charity Medical Center, USA 3Kent State University College of Podiatric Medicine, USA 4Department of Anesthesia, Saint Vincent Charity Medical Center, USA 5PGY-1 PMR+RRA Residency Training Program, St. Vincent Charity Medical Center, USA 6PGY-3 PMR+RRA Residency Training Program, St. Vincent Charity Medical Center, USA 7PGY-2 PMR+RRA Residency Training Program, St. Vincent Charity Medical Center, USA *Corresponding author: Matthew M Reiner, DPM PGY-1 PMR+RRA Residency Training Program, St. Vincent Charity Medical Center Cleveland, Ohio, USA, Tel: 216-363-2725; Fax: 216-363-2731; E-mail: [email protected] Received date: Jul 11, 2015, Accepted date: Aug 17, 2015, Published date: Aug 24, 2015 Copyright: © 2015 Canales et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract The popliteal sciatic nerve block is a form of regional anesthesia most commonly used as a form of postoperative analgesia. It has shown to be effective for 15-20 hours postoperatively. It can also be used for various foot and ankle pathologies including fracture and dislocation reduction, exploration of foreign bodies, and bedside incision and drainage. The popliteal sciatic nerve block has an additional benefit in that it decreases amount of postoperative opioid consumption limiting the complications of these medications. There are several techniques in administering this form of anesthesia including a posterior approach for prone patients, or a lateral approach for a supine patient which requires less time. It is physician preference whether the use of single or double injection technique is employed; however, ultrasound guidance and neurostimulation are typically utilized during this procedure. When using neurostimulation, a plantarflexion response is more predictive of complete sensory blockade than a dorsiflexion response. Using ultrasound with neurostimulation has greater efficacy at 60 minutes than using neurostimualtion alone. While this article’s primary purpose is to review the current literature regarding the popliteal sciatic nerve block, the technique employed at our institution is described. Our technique utilizes a lateral approach in the operating room following induction of general anesthesia. Both ultrasound guidance and neurostimulation are used. An assistant holds the leg with the hip slightly flexed and the knee extended to allow for a taut neurovascular bundle. The approach is approximately 5-7 cm cranial to the lateral femoral condyle at a groove between the anterior border of the biceps femoris tendon and the vastus lateralis muscle. The neurostimulation device is set a 1.0 mA and is advanced until a plantarflexion response is noted. A total of 20-30 cc of 0.5% bupivacaine with epinephrine 1:200,000 is injected. The saphenous nerve can be anesthetized between the sartorius and vastus medialis muscles just anterior to the femoral artery. A combination of the popliteal sciatic nerve block and saphenous nerve block has shown to be efficacious in patient satisfaction and pain relief for 24 hours. Keywords Popliteal nerve block; Peripheral nerve block; Post- debridements. Popliteal blocks can potentially be utilized as the sole operative pain relief source of anesthesia for foot and ankle surgery. This can be beneficial in medically compromised patients. Profound analgesia during both Introduction the operative and post-operative time periods and the avoidance of systemic complications such as nausea and vomiting are also potential The popliteal nerve block is a form of regional anesthesia utilized benefits of the popliteal nerve block. Other advantages include earlier for a variety of foot and ankle conditions. This form of anesthesia has discharge from the post-anesthesia care unit and decreased opioid become a popular technique to decrease postoperative pain, decrease consumption perioperatively [3]. narcotic use, and increase patient satisfaction. This is evident by an increase in published techniques within foot and ankle literature in the There are several approaches to administering a popliteal sciatic 21st century [1]. Furthermore, a publication by Hegewald et al. has nerve block, all with unique advantages and disadvantages. demonstrated that not only is the popliteal block highly efficacious, Commonly, a posterior approach is employed with the patient but can also be executed by the novice foot and ankle surgeon [2]. positioned prone. Alternatively, the lateral approach can be used with While principally used as a form of postoperative analgesia, it can be patient in the supine position. The medial approach has been employed for fracture and dislocation reduction, exploration of described in the literature, although it is less frequently utilized [4]. foreign bodies, bedside incision and drainage procedures, and wound There are various techniques when administering anesthetic to the J Anesth Clin Res Volume 6 • Issue 8 • 1000553 ISSN:2155-6148 JACR, an open access journal Citation: Canales MB, Huntley H, Reiner M, Ehredt DJ, Razzante M (2015) The Popliteal Nerve Block in Foot and Ankle Surgery: an Efficient and Anatomical Technique. J Anesth Clin Res 6: 553. doi:10.4172/2155-6148.1000553 Page 2 of 7 therapeutic plexus of nerves of the popliteal fossa. Single and double proximal and 1.0 cm lateral to the crease [9]. It is important to note injection, continuous infusion and bolus dosing through a perineural the sciatic nerve divides into its tibial and common peroneal catheter, and the use of electrical stimulation with or without components at a mean distance of 60.5 millimeters superior to the ultrasound guidance have all been described. In all cases, it is popliteal fossa [10]. In a study by Rangel, the authors noted the tibial paramount to note the presence of the distal medial region of the foot nerve component was located 10.7 millimeters deep to the posterior and ankle innervated solely by the saphenous nerve [2]. This is a surface of the popliteal fossa. In this study, there was a successful block cutaneous branch of the femoral nerve. This region may need to be in all twenty-eight cases through a posterior approach in the supine anesthetized separately when working in the dorsomedial aspect of the position [11]. Lee performed an extensive anatomic study of the sciatic foot and ankle [2]. Recently, the use of liposomal bupivacaine has been nerve and its components at the popliteal crease. The authors found utilized in popliteal nerve blocks seen in a small case series of three the bifurcation point of the sciatic nerve was a mean 7.9 cm superior to patients. The purpose was to provide long acting regional anesthesia the popliteal crease. Measuring from the most lateral aspect of the without the risks of using a perineural catheter as liposomal popliteal fossa, the tibial and common peroneal nerves crossed the bupivacaine can last up to 72 hours [5,6]. popliteal crease at 5.5 cm and 2.9 cm, respectively. As the tibial and common peroneal nerves intersected the popliteal crease, the depths Complications from popliteal nerve blocks are uncommon as the were 1.4 cm and 0.7 cm respectively [12]. reported rate is 0-10% [6,7]. The most common complications include incomplete anesthesia, infection, and neuropraxia. Hajek performed a retrospective study of 157 procedures where a continuous popliteal nerve block was used for hallux valgus surgery. He reported a complication rate of 1.26% in the form of postoperative peripheral neuropathy, complete block failure in 4%, and partial failure in 10% [7]. In a study of 400 continuous popliteal nerve blocks for post- operative analgesia, Compére recorded one infection and two neuropathies. There were also three unsuccessful and twelve difficult popliteal blocks [8]. Reflex sympathetic dystrophy was also seen in one patient following popliteal nerve block after the nerve was punctured. Published Techniques While the sciatic nerve can be anesthetized in the gluteal region, the popliteal fossa is a more accessible region prior to performing foot and ankle surgery. Typically, the popliteal block is approached posteriorly which has a more direct anatomic access to the sciatic nerve for the prone patient. Medial Figure 1: Shown are the anatomical landmarks of the popliteal In 2004, Guntz introduced a medial approach to the popliteal block. fossa. Following an anatomical study on six cadavers, a medial popliteal block was performed on twenty patients. The patient was placed in a supine position with the thigh flexed, abducted and externally rotated 30 degrees, while the leg was flexed 130 degrees. The location for Lateral needle entry was located superior to the adductor tubercle in an area The lateral approach allows for a more practical and similarly known as Jobert’s Fossa, a depression located anterior to sartorious efficacious application of the popliteal nerve block. For this reason, the and gracilis muscles and posterior to vastus medialis. At this location, lateral approach is the authors’ preferred technique. With the patient the mean distance between skin and sciatic nerve was 6.62 cm. The in a supine position, a point is marked 7.0 cm cephalad to the lateral mean time to perform the block was 5.6 minutes, in contrast to 4.10 femoral condyle in the groove between biceps femoris and vastus minutes by the lateral approach.