Do them routinely for total knees. Patient supine, knee in reasonable flexion. Transducer in pop fossa directed anterior (towards ceiling). In most (obese) patients, have to move transducer quite lateral in the pop fossa to visualize needle entry, then follow medially towards pop artery. We just inject 5mL at 3 equidistant points medial, infra-arterial, and lateral. I have not seen much difference in pain control with the addition of these blocks beyond what we get from an adductor canal w/ catheter, N ~12.
I have to agree with repitionition, very little benefit.
I don’t do them for TKAs but I do them for ACLs. I was finding that most of my ACL patients were reporting significant posterior pain after ACL with only an adductor block, so I started doing both the ipack and adductor. I have done about a dozen of these and it works very well. I would say the majority didn’t require narcotics in pacu and only got a small dose of narcotic during the case.
My needle approach for iPACK is from the medial side of the posterior knee. I find it gives better visualization of the artery, is a shorter distance to travel, and avoids inadvertent injury to the common peroneal nerve.
Great overview of the block is on this site, read all the tabs on the left.
Great overview of the block is on this site, read all the tabs on the left.
I turn the patient on the side operated leg up and inject from latetal to medial between the artery and the femur.
If the patient is skinny i'll leave him supine with the leg bent.
Works great for post pain.
Some surgeons don't generate posterior knee pain for some reason so if your patient don't usually report post knee pain of course you won't see much of a difference.
If the patient is skinny i'll leave him supine with the leg bent.
Works great for post pain.
Some surgeons don't generate posterior knee pain for some reason so if your patient don't usually report post knee pain of course you won't see much of a difference.
Hip abducted 20 deg, then do the adductor canal block then the iPack without moving the lower extremity from that position. Transducer position: Medial aspect of the distal femur/medial condyle transverse transducer position to the femur. Visualize the femur/condyle, then look for the popliteal artery. Needle placement if pop artery is not easily visualized: anterior edge of transducer and contact the posterior femur, then walk off the femur and advance 1cm. If condyle: walk off the posterior condyle and advance 3cm. If pop artery can be visualized, then advance half way between the femur and pop artery. Results: vastly improved pain control in PACU and afterwards over a solitary adductor canal block.
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So do you place the transducer on the medial knee and use a steep angle approach? Or place the transducer almost like yoj were do a popliteal block and come in flat with the needle?
Steeper angle...
I’m doing it as originally described with a curvilinear probe on the medial lower leg, use color to verify artery then insert needle close to probe trying to just miss the femur and end up in the capsule and not out more posterior where the tibial nerve is. Using a probe cover for these as I’m worried about seeding bacteria into the knee. Using 20ml of local. Position of the leg is as done for adductor. Younger partners use same position with a high frequency probe as with pop/sci block but approaching from medial to avoid peroneal. Don’t go too high in the leg: either at the condyles or just above. Works quite well in most patients.
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My group does single shot tibial nerve block under ultrasound after completing the adductor catheter, seems to work well, haven't really seen patients complaining of posterior pain. Anyone else do this?
Alternative to frog leg technique.
USRA - iPACK Block
USRA - iPACK Block
Our surgeons want the patients to ambulate immediately after PACU, so motor nerve blocks are not an option. If you can't do an iPACK, you can do geniculate nerve blocks instead to preserve motor function.
I just joined a new group where apparently a lot of the ortho surgeons are liking this. I’m having a hard time visualizing anatomy. Only done a few. First one was skinny and easy to see everything so easy enough. Second one I tried to do the steep angle approach and had a hard time. Last one just now an obese lady and I went popliteal. My needle must’ve been like five cm from the probe! Tough picture...I just found artery and injected but not easy to see. Maybe I needed curvilinear ? I have decent hand probe needle coordination skills overall, but I need to still find the picture.
I have tried this and I’m not getting this result. Probably me fault.
I have had them work amazingly well... like chronic pain patient say it’s the best they have felt for years BEFORE induction. I think I may be hitting very low CP, TN and some genicular branches. Volume is key.
That being said, at this level it is very hard to visualize any nerve structures. Inherently it is not like a BP/sciatic/femoral nerve block as far as reproducibility.
But when you get it, you know.
My N is still under 50.... so it is low.
But when you get it, you know.
My N is still under 50.... so it is low.
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Several passes increases success rate. Lateral, medial and intracondylar.
