Femoral vs Sciatic Blocks for High Tibial Osteotomy

[Mr Wizard]

I imagine that doing both a femoral and sciatic block would be best for post-operative analgesia in patients undergoing this surgery.

Does anyone have any experience with which block works better when choosing only one?
Is the proximal bone pain from the tibial osteotomy still in the intra-articular femoral distribution in most patients?

Plan to offer these blocks post-op since there is a higher incidence of peroneal nerve damage.

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[TrustMe]

Mostly sciatic coverage. You will get little to no help from a femoral block for tibial work. I learned this the hard way as a young resident working with an attending that didn't do much regional. We did pre-op femoral. Pt woke up in a ton of pain. Did a rescue sciatic (popliteal) and they had immediate relief. And then went back to read more about osteotomal coverage. Don't waste your time with a femoral for this one.

 

[Oggg]

How about adductor canal plus popliteal sciatic?

 

[Tuohy]

May want to review your anatomy-I did a regional fellowship and HTO pain can be covered well with femoral block (see attachment for anterior tibial coverage-L3-L4 which is femoral in nature). I would also perform a selective tibial component (of sciatic nerve) block to avoid getting blame for peroneal issues (ie drop foot/weak dorsiflexion and/or eversion after surgery).

 

[BLADEMDA]

May want to review your anatomy-I did a regional fellowship and HTO pain can be covered well with femoral block (see attachment for anterior tibial coverage-L3-L4 which is femoral in nature). I would also perform a selective tibial component (of sciatic nerve) block to avoid getting blame for peroneal issues (ie drop foot/weak dorsiflexion and/or eversion after surgery).

I agree with you. You get at least 60-70 percent pain relief with a femoral block. The other 30 percent is popliteal/sciatic.

I have tried adductor canal and popliteal with good results. I would like to try an adductor canal and selective tibial nerve block in the future. I could always do a femoral block in pacu if the adductor canal wasn't sufficient.

 

[BLADEMDA]

http://en.wikipedia.org/wiki/File:Gray826and831.svg

I think adductor canal and popliteal are required for excellent postop pain control. I've used this combo for high tibial plateau fracture and tibial osteotomy with excellent results.

I think the common peroneal is required to get good coverage of surgical incision and bone pain.
That said, perhaps a selective tibial nerve block is sufficient without blocking the common peroneal nerve.

I do agree that a complete popliteal block preop leaves you open to be blamed if the Ortho surgeon injures the common peroneal nerve during the surgery.


http://m.youtube.com/#/watch?v=qcuK2vHh4Ak&desktop_uri=/watch?v=qcuK2vHh4Ak

 

[BLADEMDA]

http://en.wikipedia.org/wiki/File:TibPlateauF.PNG

The common peroneal nerve may be injured at the knee with a fracture of the tibia or fibula, especially at the proximal fibula. There is an approximately 1% incidence of peroneal nerve injury with tibial plateau fracture. Also, this can occur with knee arthrodesis and is a rare complication of total knee arthroplasty, realignment of the knee extensor mechanism, and arthroscopic meniscal repair. Stretch injury of the peroneal nerve can occur after treatment of knee flexion contracture. Utilizing a posterolateral incision and placing a retractor to protect the nerve from traction can help to prevent common peroneal nerve injury during arthroscopic knee surgery [7].

 

[Oggg]

Does this bring back the question of should you do a high sciatic + adductor canal saphenous?

 

[BLADEMDA]

Does this bring back the question of should you do a high sciatic + adductor canal saphenous?

I've never tried an adductor canal and selective tibial block for a high tibial plateau fracture or tibial osteotomy. That said, I'm planning on trying it with my next patient.

So far, the selective tibial blocks are working quite well for those patients getting a total knee replacements along with a femoral block.