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extremity: Newdevelopments
Transcript of extremity: Newdevelopments
US guided blocks of the lower limb extremity:
New developments
Luc Mercadal Sébas/en Bloc
France
SARA 2014
HP Claude Galien
2013: 1500 catheters 2014: 10 catheters
2013: 6000 blocks
Orthopedic Rehabilita/on
Orthopedic Rehabilita/on
Post-‐opera/ve rehabilita/on: Pa/ent being out of the bed early Ambula/ng full weight-‐bearing progressing from a walker to a cane Speedily return to his ac/ve lifestyle
Brian M. Ilfeld, Admir Hadzic. Anesthesiology 2013
Minimize post-‐opera/ve pain Preserved muscle func/on
Adductor Canal Block or Femoral Block ?
Femoral Block: The Gold standard
Adductor canal Block: The challenger?
INNERVATION OF THE KNEE
Hadzic's Peripheral Nerve Blocks. The McGraw-‐Hill Companies;2012
Rami ar/culares Femoral n.
Rami ar/culares Tibial n.
Peroneus comm n. Tibial n.
Obturator n. Tibial n. Peroneus comm n.
ADDUCTOR CANAL: ANATOMY
Subsartorial
Aponeuro/c intermuscular tunnel the middle third of the /ght
15 cm
Sartorius croses Adductor longus
End at the adductor hiatus in the tendon of adductor magnus
ADDUCTOR CANAL: BOUNDARY
Anteriorly: Sartorius m.
Posteriomedially: Adductor Longus m. Adductor Magnus m.
Laterally: Vaste medialis m.
ADDUCTOR CANAL: CONTENT
Horner G, Lee Dellon A. Innerva/on of the human knee joint and implica/ons for surgery Clinical Orthopaedics and Related Research. 1994
Femoral artery
Femoral vein
Saphenous nerve
Medial femoral cutaneous nerve
Ar/cular branches from the obturator nerve
Medial re/nacular nerve
Branches of the vaste medialis
ADDUCTOR CANAL: CROSS SECTION
Sagi`al sec/on mid-‐thigh
ADDUCTOR CANAL: MRI
Con/nuous adductor-‐canal-‐blockade for adjuvant post-‐opera/ve analgesia aaer major knee surgery: preliminary results. J. Lund, MT. Jenstrup, P. Jaeger. Acta Anaesthesiol Scand 2011
ADDUCTOR CANAL :US
Sartorius m
Vasta medialis m Adductor Longus m
FA
FV
SN Lateral Medial
Sonoanatomy: The right place just before the artery dives
Céph.
Caud. Lat.
Méd.
D’après Manuel Pra/que d’Anesthésie LocoRégionale Echoguidée. éd Elsevier-‐ Masson, Paris, 2014
ADDUCTOR CANAL BLOCK: SUPERFICIAL BLOCK
Hight frequency linear probe
OOP: Trans-‐sartorial Needle 5 cm
IP: Lateral to medial Needle 8 cm
The /p of the needle: Under the sartorius fascia close the artery lateral posi/on
Volume: 15 cc to 20 cc
Adductor Canal Block
Which Indica/ons ?
Analgesia: ACL repair Medial menisectomy Knee arthroplasty
HP Claude Galien: unicompartmental knee prosthesis Hight Volume Local Infiltra/on Analgesia Adductor Canal Block
New developement for Foot surgery
Short Ac/ng Product Popliteal Scia/c nerve Block
Long Ac/ng Product Ankle nerves blocks
US make the difference
Out Pa/ent
Tibial nerve at the ankle
Tibia
Anterior Posterior
TP a T n.
A
B AT
Landmark = Artery
DEEP PERONEAL NERVE BLOCK Latéral Médial
A
B
DP a DP n.
Bone
Landmark = Artery
SUPERFICIAL PERONEAL NERVE BLOCK Antérieur
C
SP n.
Postérieur
D Fibula
Landmark =
nerve is above the fascia
SURAL NERVE BLOCK
Antérieur
A
B
Postérieur
S n. S v
Landmark = Vein