Amputation of forefoot

[BLADEMDA]

Recently I did 2 popliteal blocks for amputation of the forefoot.
U/s guided blocks went perfectly. Yet, upon incision the patients had pain and required GA with LMA.

Solution:

Third patient presents for foot amputation.
Popliteal plus adductor canal block placed
High risk patient. INR of 2.3, Plavix, etc.
EF of 15. You get the idea

Result: perfect block. Only 1 mg of midazolam for the case.

Discussion: medial side of foot and ball of big toe has saphenous nerve innervation which can be clinically significant.

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[saratoga733]

simplier yet just as effective solution for would be a saphenous nerve block just below the knee, medial aspect. no u/s required, takes literally 10 seconds.

 

[BLADEMDA]

simplier yet just as effective solution for would be a saphenous nerve block just below the knee, medial aspect. no u/s required, takes literally 10 seconds.

Sure. That works just fine as would local infiltration around medial part of the ankle or just an ankle block entirely. Or, find the saphenous vein under u/s distal to the knee and place local around it.

My blocks last 30 hours when Placed around the nerve under direct vision. How long do your "field" blocks last? 8 hours? 12?

If I was getting an amputation of my foot I would prefer the block with the longest duration possible.

 

[BLADEMDA]

 

[BLADEMDA]

http://www.youtube.com/watch?v=q4nqd4aQYpo

5 minute video of saphenous nerve block at the tibial tuberosity (with needle moving medial) and saphenous nerve block at the level of the medial malleolus.

 

[Planktonmd]

Most people who get a foot amputation are diabetics and have advanced neuropathy to a point that you can probably amputate their foot with no anesthesia at all.
A General anesthetic with LMA (if you know how) would be enough ... but all the other masturbatory nerve blocks are not contraindicated.

 

[BLADEMDA]

Most people who get a foot amputation are diabetics and have advanced neuropathy to a point that you can probably amputate their foot with no anesthesia at all.
A General anesthetic with LMA (if you know how) would be enough ... but all the other masturbatory nerve blocks are not contraindicated.

Not all are diabetics and not all have a neuropathy.

 

[BLADEMDA]

 

[BLADEMDA]

 

[Planktonmd]

If you want to use a popliteal block for foot surgery without GA you should always add a form a saphenous nerve block because otherwise you will miss the medial aspect of the ankle and foot.
What you are describing above is the classic way to block the saphenous nerve that we learned before ultrasound.
It's simple and it works.
But in these cases most of the time it is an overkill.
LMA ... GA ... call it a day.

 

[BLADEMDA]

If you want to use a popliteal block for foot surgery without GA you should always add a form a saphenous nerve block because otherwise you will miss the medial aspect of the ankle and foot.
What you are describing above is the classic way to block the saphenous nerve that we learned before ultrasound.
It's simple and it works.
But in these cases most of the time it is an overkill.
LMA ... GA ... call it a day.

Slim,

You are wrong quite often. For postop pain relief the Popliteal block was sufficient in the first 2 patients. But, for surgical anesthesia the saphenous nerve block was required.

The podiatrists and surgeons report that my block duration exceeds any of their own field blocks (usually double the time) so I am getting more requests for Preop blocks.

While some patients have a significant neuropathy prior to surgery many are elderly with significant vascular disease as well. Again, about 1/2 my patients do NOT have any neuropathy or diabetes. On the other hand, many have severe COPD and peripheral vascular disease.

As usual, your posts have added absolutely nothing to this discussion other than the usual worthless commentary.

How about something clinical slim?

 

[Planktonmd]

Slim,

You are wrong quite often. For postop pain relief the Popliteal block was sufficient in the first 2 patients. But, for surgical anesthesia the saphenous nerve block was required.

The podiatrists and surgeons report that my block duration exceeds any of their own field blocks (usually double the time) so I am getting more requests for Preop blocks.

While some patients have a significant neuropathy prior to surgery many are elderly with significant vascular disease as well. Again, about 1/2 my patients do NOT have any neuropathy or diabetes. On the other hand, many have severe COPD and peripheral vascular disease.

As usual, your posts have added absolutely nothing to this discussion other than the usual worthless commentary.


How about something clinical slim?

I am glad that you finally recognize that I don't buy the BS that you sell to others around here .
I actually really suspect that you are demented and you attempt to cover your dementia with an endless flow of web searches and copied crap that is most of the time irrelevant but people dont have time to verify.
Did you try to see a specialist in aging or Alzheimer before???
But back to your silly thread: If you do a popliteal block without covering the saphenous you will skip the medial aspect of the foot and the ankle!
Any first year medical student knows this... but you don't... because of dementia!

 

[HollATme]

yeah, we always do a pop-saphenous block if not an ankle block for these amps.

not earth-shattering, but still good to know.

most times, though, we just end up doing GA and LMA - depends on how good the attending is with regional blocks. spinal is also doable if coags/plts are fine and pt not on anticoags.

many ways to skin a cat.

 

[Orin]

It's simple and it works.
But in these cases most of the time it is an overkill.
LMA ... GA ... call it a day.

Don't the data show shorter hospitalizations, less morbidity, and less mortality with regional techniques for extremity amputations as compared with GA/neuraxial?

I'm not sure what the discussion is though, as I am being taught to do a pop and a saph for foot/ankle surgery to cover the whole thing. Is there a school of thought that suggests the saphenous is unimportant?

 

[HollATme]

Don't the data show shorter hospitalizations, less morbidity, and less mortality with regional techniques for extremity amputations as compared with GA/neuraxial?

I'm not sure what the discussion is though, as I am being taught to do a pop and a saph for foot/ankle surgery to cover the whole thing. Is there a school of thought that suggests the saphenous is unimportant?

that's news to me.

 

[Jay K]

many ways to skin a cat.

This.

There's a time and place for all the different ways, and I like having 'em all under my belt.

Just cause I haven't had the ocassion, I'd love to do more adductor canal blocks.

 

[BLADEMDA]

that's news to me.

A lot of what is taught to Residents is Dogma. I'm of the camp that everything needs to be tested and confirmed in clinical practice.

1. Do you really need to add a Superficial Cervical Plexus Block for a Shoulder operation? No


2. If the Ortho Surgeon repairs the ankle fracture via an incision and ORIF only involving the lateral malleolus will a saphenous nerve block help in reducing post op pain? Yes.

3. Does Exparel really last 72 hours for a bilateral TAP block? No


Again, we should always question the Dogma even if our results just affirm it.

 

[BLADEMDA]

 

[BLADEMDA]

Injury to the saphenous nerve at the ankle has been described as a complication resulting from incision and dissection over the distal tibia and medial malleolus. However, the exact course and location of the distal saphenous nerve is not well described in the literature. The purpose of this study was to determine the distal limit of the saphenous nerve and its anatomic relationship to commonly identified orthopaedic landmarks and surgical incisions


A Study from 2011

 

[BLADEMDA]

that's news to me.

The most common depiction of the saphenous nerve is that there is a branch (usually the anterior branch) that extends to the first metatarsophalangeal joint and communicates at this level with branches of the superficial peroneal nerve.12-14 In our study, only one case of sixteen demonstrated an anterior branch of the saphenous nerve extending to the first metatarsophalangeal joint, similar to that depicted in major anatomic references. In Gray's Anatomy, the saphenous nerve is described as communicating with the superficial peroneal nerve. This communication was not observed in any of our specimens. It appears that the most common depiction of the distal saphenous nerve is more aptly described as an uncommon variation. The most common pattern is for the nerve to divide into two branches approximately those branches to terminate in the integument proximal to the tip of the medial malleolus.



http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215141/

 

[BLADEMDA]

Don't the data show shorter hospitalizations, less morbidity, and less mortality with regional techniques for extremity amputations as compared with GA/neuraxial?

I'm not sure what the discussion is though, as I am being taught to do a pop and a saph for foot/ankle surgery to cover the whole thing. Is there a school of thought that suggests the saphenous is unimportant?

Yes. For forefoot amputations there is a school of thought that only a solid Popliteal block is required.

 

[BLADEMDA]

Aust N Z J Surg. 1998 Aug;68(8):565-7.

Lumbar foot innervation of the medial foot and ankle region.

Williams RP, Sugars W.


Source

Department of Orthopaedics, Prince Charles Hospital, Brisbane, Queensland, Australia.


Abstract


BACKGROUND:

Differences in the dermatomal maps appearing in standard anatomic texts which are in common use may lead to diagnostic confusion in the assessment of patients who suffer from nerve root deficiency. This is particularly evident in the variable depiction of the L4 nerve root dermatome which is carried distally in the saphenous nerve. The purpose of this study is to establish the distal limit of L4 nerve root innervation in the foot by performing cadaveric dissection of the saphenous nerve.

METHODS:

Dissection of the dorsum of the medial foot and ankle was performed on 20 cadaveric specimens.

RESULTS:

The saphenous nerve was found to enter the dermis of the medial ankle region (mean = 14.75 mm) distal to the tip of the medial malleolus in the direction of the hallux. In three cases the nerve terminated proximal to the medical malleolus. In all cases the medial forefoot and hallux were supplied by the most medial branch of the superficial peroneal nerve.

CONCLUSIONS:

These findings suggest that the sensory component of the L4 nerve root terminates in most cases near the medical malleolus, well proximal to the bunion area of the forefoot.

 

[nap$ter]

personally i've found the saphenous block to be relatively unreliable - if i want to cover that distribution i drop a good ol' femoral block.

i used to work at the va - at least 80 percent of my patients coming for forefoot amps were neuropathic - they just need a blip of propofol and a field/ankle block.

if there was a compelling reason for regional in the remaining 20 percent they got fem/pop single shots with decadron/bupivicaine.

 

[Mman]

Slim,

You are wrong quite often. For postop pain relief the Popliteal block was sufficient in the first 2 patients. But, for surgical anesthesia the saphenous nerve block was required.

The podiatrists and surgeons report that my block duration exceeds any of their own field blocks (usually double the time) so I am getting more requests for Preop blocks.

While some patients have a significant neuropathy prior to surgery many are elderly with significant vascular disease as well. Again, about 1/2 my patients do NOT have any neuropathy or diabetes. On the other hand, many have severe COPD and peripheral vascular disease.

As usual, your posts have added absolutely nothing to this discussion other than the usual worthless commentary.

How about something clinical slim?

If your surgeons and podiatrists are so in love with the longer acting block, why don't you just hand them the vial of Exparel and tell them to use it for a field block of the saphenous nerve at the ankle and it will last even longer. Wouldn't that be even better?

 

[deleted9493]

I question the consistency/reliability of saphenous nerve field blocks at the level of the tibial tuberosity. I can't imagine I'll ever do one again unless I find myself without the help of ultrasound.

 

[BLADEMDA]

I question the consistency/reliability of saphenous nerve field blocks at the level of the tibial tuberosity. I can't imagine I'll ever do one again unless I find myself without the help of ultrasound.

Adductor canal block for the saphenous is almost 100'percent reliable. I can't speak as to the reliability of the field block starting at the tibual tuberosity as I have only done 2 of them.

Both are technically easy to do so I prefer the u/s guided adductor canal block

I guess we agree here.

 

[BLADEMDA]

If your surgeons and podiatrists are so in love with the longer acting block, why don't you just hand them the vial of Exparel and tell them to use it for a field block of the saphenous nerve at the ankle and it will last even longer. Wouldn't that be even better?

I'm spending a total of $3.00 to do the adductor canal and popliteal blocks both of which last for 30 hours. I see no need to spend $280 on Exparel as Medicare won't reimburse the hospital for that drug.

Also, I'm not keen to inject local around nerves with a 72 hour drug when you can't visualize the nerve under direct vision or ultrasound.

The surgeons are reporting to me that my 30 hour blocks are sufficient for postop pain control. I have offered to do Blocks utilizing Exparel for BKA and AKAs but so far nobody has requested it.

 

[Mman]

I'm spending a total of $3.00 to do the adductor canal and popliteal blocks both of which last for 30 hours. I see no need to spend $280 on Exparel as Medicare won't reimburse the hospital for that drug.

Also, I'm not keen to inject local around nerves with a 72 hour drug when you can't visualize the nerve under direct vision or ultrasound.

The surgeons are reporting to me that my 30 hour blocks are sufficient for postop pain control. I have offered to do Blocks utilizing Exparel for BKA and AKAs but so far nobody has requested it.

so now the cost matters???? Also, what is $3.00 total that you are spending the money on for your adductor canal block? Does that cover the local, the needle, the prep, the cost of ultrasound, etc? Seems like it should cost a lot more.

Also, I was suggesting you have the surgeons (or podiatrists) inject the Exparel as a field block. That's what it is FDA approved for. Local infiltration. Never said anything about you injecting it around a nerve.

 

[BLADEMDA]

so now the cost matters???? Also, what is $3.00 total that you are spending the money on for your adductor canal block? Does that cover the local, the needle, the prep, the cost of ultrasound, etc? Seems like it should cost a lot more.

Also, I was suggesting you have the surgeons (or podiatrists) inject the Exparel as a field block. That's what it is FDA approved for. Local infiltration. Never said anything about you injecting it around a nerve.

Fortunately, I don't answer to you or the FDA. Once a drug has been approved for use Physicians have always looked for other "off label" uses. Exparel has studies and Regional experts who would testify to such use.

Exparel costs $280 and as a "field block" last 24 hours. My Surgeons have used the Exparel for "local" and they report 24 hours of postop pain relief.

If the Podiatrist injects the Exparel around the specific nerves at the ankle then the injection becomes more concerning as it becomes a nerve block without the benefit of ultrasound.

My $3.00 vs $280 was simply the cost of the local plus decadron vs the local/Exparel. The other costs remain the same.

One final point is that the Exparel is only reimbursed by CMS for outpatient use. Hence, the hospital loses money with every bottle of Exparel if the patient stays overnight.

 

[Consigliere]

I'm spending a total of $3.00 to do the adductor canal and popliteal blocks both of which last for 30 hours. I see no need to spend $280 on Exparel as Medicare won't reimburse the hospital for that drug.

Also, I'm not keen to inject local around nerves with a 72 hour drug when you can't visualize the nerve under direct vision or ultrasound.

The surgeons are reporting to me that my 30 hour blocks are sufficient for postop pain control. I have offered to do Blocks utilizing Exparel for BKA and AKAs but so far nobody has requested it.

Once Medicare stops reimbursing for pre-op blocks, I wonder how many anesthesiologists will stop doing them. Not saying you will, Blade, but it will be interesting to see how this unfolds. It sounds like you are utilizing the block as the primary anesthetic and aren't getting paid anyway. Risk/benefit equation in the cases you describe favors regional and is the route I would go regardless.