The Spread of Ultrasound-Guided Injectate From the Adductor Canal to the Genicular Branch of the Posterior Obturator Nerve and the Popliteal Plexus

Runge, Charlotte; Moriggl, Bernhard; Børglum, Jens; Bendtsen, Thomas Fichtner

doi:10.1097/aap.0000000000000675

Cited by 80 publications

(74 citation statements)

References 35 publications

(47 reference statements)

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“…The contribution of PON innervation is important and was reported in 82% of specimens (n=9/11) by Gardner,8 in 100% of specimens (n=10/10) by Runge et al ,18 and 100% of specimens (n=15/15) in the current study. Additionally, in the current study, the PON was found to course through the adductor hiatus consistent with previous studies 9 10.…”

Section: Discussionsupporting

confidence: 54%

Anatomical study of the innervation of posterior knee joint capsule: implication for image-guided intervention

Tran

Peng

Gofeld

et al. 2019

Regional Anesthesia &Amp; Pain Medicine

102

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Background and objectivesPeripheral nerve block is an important component of the multimodal analgesia for total knee arthroplasty. Novel interventional techniques of ultrasound-guided nerve block supplying the posterior knee joint capsule require knowledge of the innervation of the posterior capsule. The objectives of this cadaveric study were to determine the course, frequency, and distribution of the articular branches innervating the posterior knee joint capsule and their relationships to anatomical landmarks.MethodsFifteen lightly embalmed specimens were meticulously dissected. The origin of articular branches was identified, their frequency recorded, and the course documented in relation to anatomical landmarks. The capsular distribution of articular branches was documented and a frequency map generated.ResultsIn all specimens, articular branches from the posterior division of the obturator and tibial nerves were found to supply the posterior capsule. Additionally, articular branches from common fibular nerve and sciatic nerve were found in eight (53%) and three (20%) specimens, respectively. The capsular distribution of tibial nerve spanned the entire posterior capsule. The posterior division of obturator nerve supplied the superomedial aspect of the posterior capsule overlapping with the tibial nerve. The superolateral aspect of the posterior capsule was innervated by the tibial nerve and, when present, the common fibular/sciatic nerves.ConclusionsFrequency map of the course and distribution of the articular branches and their relationship to anatomical landmarks form an anatomical basis for peripheral nerve block approaches that provide analgesia to the posterior knee joint capsule.

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Section: Discussionsupporting

confidence: 54%

Anatomical study of the innervation of posterior knee joint capsule: implication for image-guided intervention

Tran

Peng

Gofeld

et al. 2019

Regional Anesthesia &Amp; Pain Medicine

102

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“…Choosing the proximal or midpoints of the AC may not have given the same contrasting results. One potential drawback of the distal AC location is the observation of injectate spread into the popliteal fossa via the adductor hiatus which has been previously described 24. Despite attempts to maintain motor sparing effects by placing distal AC injections, motor nerve involvement may still occur due to spread toward the popliteal fossa.…”

Section: Discussionmentioning

confidence: 99%

Spread of dye injectate in the distal femoral triangle versus the distal adductor canal: a cadaveric study

Johnston

Black

Cowden

et al. 2019

Regional Anesthesia &Amp; Pain Medicine

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Background and objectivesThe nerve to vastus medialis (NVM) supplies sensation to important structures relevant to total knee arthroplasty via a medial parapatellar approach. There are opposing findings in the literature about the presence of the NVM within the adductor canal (AC). The objective of this cadaveric study is to compare the effect of injection site (distal femoral triangle (FT) vs distal AC) on injectate spread to the saphenous nerve (SN) and the NVM.MethodsFour unembalmed fresh-frozen cadavers acted as their own control with one thigh receiving 20 mL of dye injected via an ultrasound-guided injection in the distal FT while the other thigh received an ultrasound-guided injection in the distal AC. A standardized dissection took place 1 hour later to observe the extent of staining to the NVM and SN in all cadaver thigh specimens.ResultsIn all specimens where the injectate was introduced into the distal FT, both the SN and NVM were stained. In contrast, when the dye was administered in the distal AC only the SN was stained.ConclusionsOur findings suggest that an injection in the distal AC may be suboptimal for knee analgesia as it may spare the NVM, while an injection in the distal FT could provide greater analgesia to the knee but may result in undesirable motor blockade from spread to the nerve to vastus intermedius.

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“…The second case may support this theory that the adductor canal and the popliteal area is connected. Tran et al found that the dye injected from a medial IPACK approach tracked into the adductor canal and Runge et al found that dye injected in the adductor canal tracks in the popliteal area [7] [8]. If the nerve to the vastus medialis can be blocked with this same injection, it would avoid having to do a second block at the femoral triangle [27] or adductor canal [6] [11].…”

Section: Casementioning

confidence: 99%

“…The recent technique of ultrasound guided local anesthetic infiltration of the interspace between the popliteal artery and the capsule of posterior knee (IPACK) has shown promising results [3] [5] [6]. The technique involves a very selective block of the terminal sensory branches of the posterior aspect of the knee without the involvement of motor branches of the tibial and peroneal nerves leading to reduced pain without motor weakness [7] [8]. This leads to earlier ambulation, rehabilitation and recovery in various knee surgeries [6].…”

Section: Introductionmentioning

confidence: 99%

“…There are postulations that the popliteal plexus (end articular nerves) may be blocked with 15 mls of local anaesthesia given in the caudal end of the adductor canal [8] [25]. The dye is shown in cadaveric studies to spread via the adductor hiatus into the popliteal region[8]. A single injection at the distal adductor canal may be able to block both the saphenous nerve and the popliteal plexus within the popliteal fossa.…”

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confidence: 99%

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Interspace between the Popliteal Artery and the Capsule of the Knee (IPACK) Block for Anterior Cruciate Ligament Reconstruction Surgery: A Two Case Series

Huang¹,

Singh²,

Woon³

2020

OJAnes

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This case series describes the use of Interspace between the Popliteal Artery and the Capsule of the Knee (IPACK) block to provide motor-sparing analgesia for two consecutive patients undergoing anterior cruciate ligament reconstruction (ACLR) by the same surgeon. Case 1 demonstrates the use of a proximal IPACK block as a post-operative rescue block for a patient who still experienced severe pain despite having received a femoral nerve block and parenteral opioids. Case 2 describes the use of a modified IPACK block as part of a multimodal approach with opioid and motor sparing effects. In both cases, the IPACK block provided satisfactory pain relief in the immediate postoperative period without motor weakness, making it an effective analgesic method for day surgery. With the IPACK block shown to be an effective nerve block for ACLR, we explore other advantages, limitations and further research required to better define the role of this block.

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The Spread of Ultrasound-Guided Injectate From the Adductor Canal to the Genicular Branch of the Posterior Obturator Nerve and the Popliteal Plexus

Abstract: Injection of 10 mL of dye into the distal part of the AC spreads into the popliteal fossa and colors the popliteal plexus and the genicular branch of the posterior obturator nerve.

Cited by 80 publications

References 35 publications

Anatomical study of the innervation of posterior knee joint capsule: implication for image-guided intervention

Anatomical study of the innervation of posterior knee joint capsule: implication for image-guided intervention

Spread of dye injectate in the distal femoral triangle versus the distal adductor canal: a cadaveric study

Interspace between the Popliteal Artery and the Capsule of the Knee (IPACK) Block for Anterior Cruciate Ligament Reconstruction Surgery: A Two Case Series

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