The Anatomic Relationship of the Tibial Nerve to the Common Peroneal Nerve in the Popliteal Fossa: Implications for Selective Tibial Nerve Block in Total Knee Arthroplasty.

Eric R Silverman,Karina Gritsenko,Nair Singh,Sherry A Downie,Amaresh Vydyanathan,Boleslav Kosharskyy,Naum Shaparin

doi:10.1155/2017/7250181

Abstract

Background. A recently described selective tibial nerve block at the popliteal crease presents a viable alternative to sciatic nerve block for patients undergoing total knee arthroplasty. In this two-part investigation, we describe the effects of a tibial nerve block at the popliteal crease. Methods. In embalmed cadavers, after the ultrasound-guided dye injection the dissection revealed proximal spread of dye within the paraneural sheath. Consequentially, in the clinical study twenty patients scheduled for total knee arthroplasty received the ultrasound-guided selective tibial nerve block at the popliteal crease, which also resulted in proximal spread of local anesthetic. A sensorimotor exam was performed to monitor the effect on the peroneal nerve. Results. In the cadaver study, dye was observed to spread proximal in the paraneural sheath to reach the sciatic nerve. In the clinical observational study, local anesthetic was observed to spread a mean of 4.7 + 1.9 (SD) cm proximal to popliteal crease. A negative correlation was found between the excess spread of local anesthetic and bifurcation distance. Conclusions. There is significant proximal spread of local anesthetic following tibial nerve block at the popliteal crease with possibility of the undesirable motor blocks of the peroneal nerve.

Highlights

Arthroplasty of the knee is associated with moderate to severe postoperative pain [1]
Subparaneural spread of local anesthetic was achieved using a technique similar to that described by Andersen et al (2012) but at the level of the popliteal crease [17]
Blue dye was observed to be contained within the paraneural sheath of the tibial nerve with only minimal extravasation to adjacent structures, Figure 1(a)

Summary

Introduction

Arthroplasty of the knee is associated with moderate to severe postoperative pain [1]. Peripheral nerve blocks for total knee arthroplasty (TKA) are effective for postoperative pain management and may hasten the recovery process [2]. A recently described selective tibial nerve block at the popliteal crease presents a viable alternative to sciatic nerve block for patients undergoing total knee arthroplasty. In this two-part investigation, we describe the effects of a tibial nerve block at the popliteal crease. In the clinical study twenty patients scheduled for total knee arthroplasty received the ultrasound-guided selective tibial nerve block at the popliteal crease, which resulted in proximal spread of local anesthetic. There is significant proximal spread of local anesthetic following tibial nerve block at the popliteal crease with possibility of the undesirable motor blocks of the peroneal nerve

Objectives

Methods

Results

Conclusion