1. Regional Anesthesia
Selene G. Parekh, MD, MBA
Associate Professor of Surgery
Partner, North Carolina Orthopaedic Clinic
Department of Orthopaedic Surgery
Adjunct Faculty Fuqua Business School
Duke University
Durham, NC
919.471.9622
http://seleneparekhmd.com
Twitter: @seleneparekhmd

2. Peripheral Nerves
• Saphenous
• Common peroneal (CPN)
• SPN
• 10-12cm proximal to the distal fibula
• Medial, intermediate, lateral branches
• DPN
• Tibial
• Medial plantar
• Lateral plantar
• Sural
• Branches from CPN & tibial nerves

3. Nerves of the Leg

4. Nerves of the Leg

5. Nerves of the Foot

6. Orthopaedist vs
Anesthesiologist
• General, Spinal/Epidural, popliteal:
anesthesiologist
• Ankle block, digital block: orthopaedist

7. Efficiency
• Local (no sedation): minor procedure room or
office
• No anesthesiologist
• Less controlled, less sterlie
• Popliteal or ankle block:
• Block room?

8. Local Anesthetic w Sedation
• Short cases w minimal expected post-op pain
• Medical comorbidities making other
anesthesia unsafe

9. Spinal versus General
• Spinal (epidural for long case)
• + quick acting, less overall sedation
• - Risk of spinal leak/headache
• General (LMA)
• + Avoids risk of spinal headache
• - Risks of aspiration and other CV complications,
more nausea

10. Regional Blocks
• Can be used with general/spinal
• Can be also be used in isolation

11. Regional Blocks
• Afford good post-op pain relief
• Duration depends on block
• Allows return to home before pain
• Decreases need for sedation/anesthesia
• Sets good early course for post-op pain control

12. Regional Blocks
• High satisfaction
• Low complication
• Decreased time in hospital  decreased costs

13. Regional Blocks: principles
• Type of block depends on:
• Location of surgery
• Magnitude of surgery (expected post-op pain)
• Complications (general)
• Infection
• Hematoma
• Nerve Injury
• Systemic Toxicity

14. Regional Blocks: Awake or
Asleep?
• Awake: patient can report pain to avoid intra-
neural injection
• Asleep: avoids uncontrolled movement by
patient
• Literature: nothing to support either way

15. Digital Block: Technique
• 0.5% marcaine (1%
lidocaine w/o epi)
• Insert needle dorsally
at medial and lateral
base of toe adjacent
to proximal phalanx
• Advance to plantar
skin

16. Digital Block: Indications
• Ideal cases:
• Corn or callus removal
• Flexor tenotomy
• Simple hardware removal

17. Digital Block: Complications
• Rare
• Infection
• Nerve injury
• Inadequate analgesia

18. Ankle Block: Technique
• Meds
• 30cc - 0.5% marcaine w/o epi
• 10cc - 1% lidocaine w/o epi
• Syringes
• 20cc x 1
• 10cc x 2
• 21 gauge needle

19. Ankle Block: Technique
• Posterior tibial nerve
• Level of ankle, 1 cm behind medial mal
• Superficial peroneal nerve (SPN)
• Immediately under skin, many branches
• “Fourth Toe Flexion Sign”
• Find 10 cm proximal to ankle where it exits fascia

20. Fourth Toe Flexion Sign

21. Ankle Block: Technique
• Deep Peroneal Nerve (DPN)
• In line with 1st webspace, just distal to ankle
• Saphenous nerve
• Superficial, adjacent to saphenous vein, anterior
medial mal
• Sural
• Superficial, ½ way b/t Achilles and fibula

22. Ankle Block: Technique

23. Ankle Block: Problems
• Usually does not control pain of thigh tourniquet
• Ankle tourniquet binds tendons
• Complications
• Dysesthesias
• Skin sloughing or breakdown

24. Ankle Block: Indications
• Forefoot surgery
• Hammertoes
• Sesamoid excision
• Neuroma excision
• Some bunions
• Pain relief: 6 to 12 hours after surgery
• Does allow for early WBAT

25. Ankle Block: Combination
• Can use for postop pain at same time as spinal
• “Spin-ankle”
• Spinal sets up quick, ankle blocks lasts
longer

26. Popliteal Block
• Lateral approach
• Patient supine
• Posterior approach
• Patient prone or lateral decubitus
• Aspirate before administering: popliteal vessels
• Injection peri-neurally

27. Popliteal Block: Stimulator
• Look for muscle twitch (motor response)
• Proximity of needle to nerve judged by current at
which response disappears: ideal 0.5mA.
• Inversion of foot best predicts sensory blockade
• Plantar-flexion better than dorsiflexion

28. Popliteal Block: Ultrasound
• Identify neurovascular structures before placing
needle
• Can also visualize needle movement
• Ultrasound may allow ↑ visualization
• No evidence to determine ↑success of block.

29. Popliteal Block: Benefits
• Can take a while to set up
• Given along with spinal or general
• Role for block room and use in isolation?
• Long lasting pain relief: 13 to 18 hours
• Clonidine: may prolong block
• Decadron: on rare occasion, 24 to 72 hours

30. Dexamethasone
• Analgesia avg 24 hours, some > 72 hrs
• Doses larger than 4 mg/40 ml have not been shown to
have a greater duration
• Suggestion that 1 mg/30 ml is as effective
• Suggestion that 8 – 10 mg IV results in less post-op pain
(?prolonged block)
• No known side effects

31. Popliteal Block: Drawbacks
• Patient satisfaction not shown to be better than
ankle block despite longer duration
• Does not get saphenous

32. Popliteal Block:
Complications
• Can not put weight on until block wears off
• Fracture ankle
• Nerve Injury: intraneural injection
• Foot drop
• Intravascular injection

33. Popliteal Indwelling Catheter
• Allows for continuous infusion of anesthetic after
surgery
• Usually removed 2 days after surgery
• Strong evidence showing:
• Reduced need for opiates and reduced postop pain

34. Popliteal Indwelling Catheter
• Discharge home with catheter?
• Our experience:
• Hard to find right patient
• Long acting popliteal block without catether allows for
discharge home and good pain relief

35. Summary
The foot hurts: safe and reliable analgesia is crucial
Regional anesthesia is safe
Few complications, most transient
High patient satisfaction
Make good friends with your anesthesia team

36. Video

37. Summary
• Mandatory technique for Foot and Ankle surgeons
• Adds to efficiency
• Anatomy
• USG technique for popliteal block

38. RE
ECT
the ankle
the foot