He received oral paracetamol 1 g and etoricoxib 120 mg 1 hour prior to surgery for preemptive analgesia. Plantar flexion and extension of bilateral feet were tested to be equal and full.Ī 25 year old ASA physical status 1 male (173 cm, 73 kg, BMI 24) who underwent a left knee ACLR with hamstring autograft and lateral meniscus repair. His pain score decreased to 0/10 within 5 minutes of the block. Ultrasound scan confirmed that the local anesthetic agent did not spread to the sciatic nerve ( Figure 1). After negative aspiration, 25 ml of 0.5% Ropivacaine was injected as the needle was gradually withdrawn. The needle was advanced 1 - 2 cm lateral to the popliteal artery in close proximity to the femoral shaft. Braun) was inserted in an anteromedial-posterolateral direction to the space between the popliteal artery and the femoral shaft. Under ultrasound guidance using the curvilinear probe, we traced the femoral artery caudally beginning under the sartorius muscle to where it dives deep at the adductor hiatus. As the knee was bandaged, we used the proximal approach to avoid the surgical dressing. The patient had a pain score of 7/10 over the posterior knee 1 hour after the end of surgery whilst in the post anesthesia care unit (PACU). Intraoperative analgesia comprised of fentanyl 100 mcg, ketamine 50 mg and oxycodone 10 mg. GA was maintained with nitrous oxide and desflurane. He received a general anesthetic (GA) with a supraglottic airway for the surgery.
A femoral nerve block was performed preoperatively under ultrasound guidance with 15 ml of 0.5% Ropivacaine as per our hospital pathway. He received oral paracetamol 1 g one hour prior to surgery for preemptive analgesia. We present a 29 year old ASA physical status 1 male (186 cm, 110 Kg, BMI 32), with allergy to non-steroidal anti-inflammatory drugs, who underwent a left knee ACLR with hamstring autograft, medial meniscus repair and extra-articular tenodesis. Written informed consent was provided by all patients for inclusion in this report. The IPACK block was offered to reduce pain, opioid consumption and facilitate early rehabilitation and discharge. These 2 patients were selected as they were under the care of the same surgeon and anesthetist. We describe our experience with the proximal approach of the IPACK block for ACLR. We aim to block the popliteal plexus, saphenous nerve and nerve to vastus medialis with a single injection by redirecting the needle after a single puncture. The transducer is then slid caudally to trace the artery as it dives into the popliteal fossa through the adductor hiatus to become the popliteal artery. In the supine position, the transducer is placed in the medial lower third aspect of the thigh to observe the femoral artery under the sartorius muscle. The IPACK block has evolved from being performed in a prone position where the injection occurs at the popliteal crease at the level of the femoral condyles, to being done with the patient supine. This leads to earlier ambulation, rehabilitation and recovery in various knee surgeries. The technique involves a very selective block of the terminal sensory branches of the posterior aspect of the knee without the involvement of motor branches of the tibial and peroneal nerves leading to reduced pain without motor weakness.
The recent technique of ultrasound guided local anesthetic infiltration of the interspace between the popliteal artery and the capsule of posterior knee (IPACK) has shown promising results. Given the multiple innervations of the knee, complete pain relief would not be expected from either the femoral nerve block (FNB) or the saphenous nerve block alone.
There are various choices of PNBs available either as a single injection or in combination. A multimodal analgesia regime with peripheral nerve blocks (PNB) is therefore recommended for this procedure. Anterior cruciate ligament reconstruction (ACLR) surgery is associated with moderate to severe postoperative pain which can be attributed to both arthroscopic surgery and the graft donor site.
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