Adult Recon
Regional AnesthesiaSelene G. Parekh, MD, MBAAssociate Professor
of SurgeryPartner, North Carolina Orthopaedic ClinicDepartment of
Orthopaedic SurgeryAdjunct Faculty Fuqua Business SchoolDuke
UniversityDurham, NC919.471.9622http://seleneparekhmd.comTwitter:
@seleneparekhmd
Peripheral NervesSaphenous Common peroneal (CPN)SPN10-12cm
proximal to the distal fibulaMedial, intermediate, lateral
branchesDPNTibialMedial plantarLateral plantarSuralBranches from
CPN & tibial nerves
Nerves of the Leg
Nerves of the Leg
Nerves of the Foot
Orthopaedist vs AnesthesiologistGeneral, Spinal/Epidural,
popliteal: anesthesiologist
Ankle block, digital block: orthopaedist
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EfficiencyLocal (no sedation): minor procedure room or officeNo
anesthesiologistLess controlled, less sterlie
Popliteal or ankle block:Block room?
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Local Anesthetic w SedationShort cases w minimal expected
post-op pain
Medical comorbidities making other anesthesia unsafe
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Spinal versus GeneralSpinal (epidural for long case)+ quick
acting, less overall sedation- Risk of spinal leak/headache
General (LMA)+ Avoids risk of spinal headache- Risks of
aspiration and other CV complications, more nausea
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Regional BlocksCan be used with general/spinalCan be also be
used in isolation
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Regional BlocksAfford good post-op pain reliefDuration depends
on blockAllows return to home before painDecreases need for
sedation/anesthesiaSets good early course for post-op pain
control
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Regional BlocksHigh satisfaction
Low complication
Decreased time in hospital decreased costs
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Regional Blocks: principlesType of block depends on:Location of
surgeryMagnitude of surgery (expected post-op pain)
Complications (general)InfectionHematomaNerve InjurySystemic
Toxicity
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Regional Blocks: Awake or Asleep?Awake: patient can report pain
to avoid intra-neural injection
Asleep: avoids uncontrolled movement by patient
Literature: nothing to support either way
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Digital Block: Technique0.5% marcaine (1% lidocaine w/o epi)
Insert needle dorsally at medial and lateral base of toe
adjacent to proximal phalanx
Advance to plantar skin
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Digital Block: IndicationsIdeal cases:Corn or callus
removalFlexor tenotomySimple hardware removal
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Digital Block: ComplicationsRare
Infection
Nerve injury
Inadequate analgesia
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Ankle Block: TechniqueMeds30cc - 0.5% marcaine w/o epi10cc - 1%
lidocaine w/o epiSyringes20cc x 110cc x 221 gauge needle
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Ankle Block: TechniquePosterior tibial nerveLevel of ankle, 1 cm
behind medial mal
Superficial peroneal nerve (SPN)Immediately under skin, many
branchesFourth Toe Flexion SignFind 10 cm proximal to ankle where
it exits fascia
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Fourth Toe Flexion Sign
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Ankle Block: TechniqueDeep Peroneal Nerve (DPN)In line with 1st
webspace, just distal to ankle
Saphenous nerveSuperficial, adjacent to saphenous vein, anterior
medial mal
SuralSuperficial, way b/t Achilles and fibula
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Ankle Block: Technique
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Ankle Block: ProblemsUsually does not control pain of thigh
tourniquetAnkle tourniquet binds tendons
ComplicationsDysesthesiasSkin sloughing or breakdown
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Ankle Block: IndicationsForefoot surgeryHammertoesSesamoid
excisionNeuroma excisionSome bunions
Pain relief: 6 to 12 hours after surgeryDoes allow for early
WBAT
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Ankle Block: CombinationCan use for postop pain at same time as
spinalSpin-ankleSpinal sets up quick, ankle blocks lasts longer
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Popliteal BlockLateral approachPatient supine
Posterior approachPatient prone or lateral decubitus
Aspirate before administering: popliteal vesselsInjection
peri-neurally
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Popliteal Block: StimulatorLook for muscle twitch (motor
response)Proximity of needle to nerve judged by current at which
response disappears: ideal 0.5mA.
Inversion of foot best predicts sensory blockade
Plantar-flexion better than dorsiflexion
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Popliteal Block: UltrasoundIdentify neurovascular structures
before placing needle
Can also visualize needle movement
Ultrasound may allow visualizationNo evidence to determine
success of block.
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Popliteal Block: Benefits
Can take a while to set upGiven along with spinal or generalRole
for block room and use in isolation?
Long lasting pain relief: 13 to 18 hoursClonidine: may prolong
blockDecadron: on rare occasion, 24 to 72 hours
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DexamethasoneAnalgesia avg 24 hours, some > 72 hrs Doses
larger than 4 mg/40 ml have not been shown to have a greater
durationSuggestion that 1 mg/30 ml is as effectiveSuggestion that 8
10 mg IV results in less post-op pain (?prolonged block)No known
side effects
Popliteal Block: Drawbacks
Patient satisfaction not shown to be better than ankle block
despite longer duration
Does not get saphenous
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Popliteal Block: Complications
Can not put weight on until block wears offFracture ankle
Nerve Injury: intraneural injectionFoot drop
Intravascular injection
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Popliteal Indwelling CatheterAllows for continuous infusion of
anesthetic after surgery
Usually removed 2 days after surgery
Strong evidence showing:Reduced need for opiates and reduced
postop pain
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Popliteal Indwelling CatheterDischarge home with catheter?
Our experience:Hard to find right patientLong acting popliteal
block without catether allows for discharge home and good pain
relief
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SummaryThe foot hurts: safe and reliable analgesia is
crucial
Regional anesthesia is safeFew complications, most transient
High patient satisfaction
Make good friends with your anesthesia team
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Video
SummaryMandatory technique for Foot and Ankle surgeonsAdds to
efficiencyAnatomyUSG technique for popliteal block
RE ECT
the anklethe foot
