514039
research-article2013
FAIXXX10.1177/1071100713514039Foot & Ankle InternationalGucev et al
Case Report
Midcalf Continuous Peripheral Nerve Block Anesthesia for Hallux Valgus Surgery: Case Report
Foot & Ankle International 2014, Vol. 35(2) 175–177 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100713514039 fai.sagepub.com
Gligor Gucev, MD, EdD1, Kalyani Karandikar, MD1, and Timothy Charlton, MD2 Level of Evidence: Level V, expert opinion. Keywords: hallux disorders, forefoot disorders Ankle block anesthesia is a well-established and safe technique of analgesia for forefoot and hallux valgus surgery.1,7 However, even with the use of long-acting anesthetics and corticosteroids, ankle block technique will last no longer than 24 hours.2 Popliteal block catheters are effective for postoperative pain,3-6,8 but the subsequent loss of motor function necessitates the use of immobilization at the level of the ankle, either in the form of a short leg cast or cam walker, to avoid falls associated with foot drop. Single-injection peripheral nerve blocks of the tibial, superficial, and deep peroneal nerves with and without ultrasound guidance have been described.1 We describe selective continuous superficial peroneal nerve block, deep peroneal nerve block, and tibial nerve block (SPDPT), allowing for 3 days of continuous analgesia without loss of motor function. This allowed for retention of protective motor function, the use of hard shoe immobilization, and no restriction of ankle range of motion.
Case Description A 44-year-old female physician presented for right hallux valgus correction. The patient was scheduled for right modified McBride procedure and right scarf osteotomy. Patient’s medical history was significant only for factor 5—Leiden coagulopathy and aspirin allergy. The patient requested a long-acting analgesia technique, but the restriction of ankle range of motion associated with a cast or cam walker immobilization was a relative contraindication secondary to deep vein thrombosis (DVT) risk associated with factor 5 Leiden coagulopathy. The anesthetic management was planned for propofol sedation along with SPDPT continuous peripheral nerve blocks. With the patient in supine position, a PLT 1204BT 7-14 MHz probe on Aplio MX 500 (Toshiba America Medical Systems, Inc, Tustin, CA) ultrasound machine was used to trace all 3 nerves from the ankle to the midcalf (Figures 1, 2, and 3). The skin point of puncture was infiltrated with 1 ml of 2% lidocaine. With real-time ultrasound guidance, a
20 Ga. Tuohy needle (Perifix, B. Braun Medical Inc, Bethlehem, PA) was advanced in the proximity of each of the nerves. Once the structures were identified, 5 ml of 0.5% Bupivacaine was injected in close proximity to each nerve. After the injection, 24 gauge pediatric epidural catheters (Perifix One, B. Braun Medical Inc, Bethlehem, PA) were advanced 3 cm past the needle tip in close proximity to the nerves. The patient did not receive any sedatives during the placement of the 3 nerve blocks and tolerated the procedure well. Careful attention was made to allow for adequate exposure of the leg in sterile surgical preparation, as well as use of a sterile ankle tourniquet. After the blocks were in place, the patient was taken to the operating room. The patient received propofol to maintain sedation throughout the entire 1.5 hour procedure along with a single dose of 25 micrograms of fentanyl when the propofol infusion was started. A medial incision was used for medial eminence resection and scarf osteotomy, and a dorsal incision was used for adductor tendon release and modified McBride procedure. The patient was placed in a postoperative dressing, hard shoe, and was non-weightbearing, as per the protocol of the operative surgeon. All 3 catheters were then attached to a single On-Q elastomeric pump (Triple-Site, I-flow LLC, Lake Forest, CA) supplying 0.2% Ropivacaine at 2 ml/hr to each catheter. The patient was discharged home after an hour of recovery in the postanesthesia care unit and followed for the next 3 days of her recovery. Wong–Baker VAS analog scale scores 1
Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA 2 Department of Orthopaedics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA Corresponding Author: Gligor Gucev, MD, EdD, Department of Anesthesiology, Keck School of Medicine, University of Southern California, 1500 San Pablo St, 4th Fl, Los Angeles, CA 90033, USA. Email: [email protected]
Downloaded from fai.sagepub.com at University of Bath - The Library on June 11, 2015
176
Foot & Ankle International 35(2)
Figure 1. Illustration of axial section through the midcalf. 1, transducer position for Figure 2; 2, transducer position for Figure 3; AT, tibialis anterior muscle; ATA, tibialis anterior artery; DPN, peroneus profundus nerve; EDL, extensor digitorum longus; FDL, flexor digitorum longus; Fib, fibula; GCL, gastrocnemius muscle—lateral head; GCM, gastrocnemius muscle—medial head; PB, peroneus brevis muscle; PL, peroneus longus muscle; PT, tibialis posterior muscle; PTA, tibialis posterior artery; Sol, soleus muscle; SPN, peroneus superficialis nerve; Tib, tibia; TN, tibialis nerve.
Figure 2. Axial ultrasound image of the lateral midcalf. A, anterior; FDL, flexor digitorum longus; GCM, gastrocnemius muscle—medial head; L, lateral; M, medial; P, posterior; PTA, tibialis posterior artery; Tib, tibia; TN, tibialis nerve.
and narcotic diary were obtained via phone interview. VAS score was 0 over the first 3 postoperative days and the patient did not require any further narcotic pain medications or NSAIDs while the peripheral nerve block catheters were in place. The patient did not have any motor weakness of the operative extremity and was able to perform unrestricted dorsiflexion and plantarflexion of the ankle. The patient did not experience any falls, difficulty with ambulation during the postoperative period, or DVT.
Figure 3. Axial ultrasound image of the medial midcalf. A, anterior; AT, tibialis anterior muscle; ATA, tibialis anterior artery; DPN, peroneus profundus nerve; Fib, fibula; L, lateral; M, medial; P, posterior; PB, peroneus brevis muscle; SPN, peroneus superficialis nerve; Tib, tibia.
Discussion The popliteal nerve block has proven to be a valuable tool for a multimodal postoperative pain control for patients undergoing foot and ankle surgery.2-5,6,8 To avoid the foot drop, which is 1 of the major side effects of the popliteal nerve block, we approached the tibial nerve at midcalf to preserve the motor branches supplying the gastrocnemius muscle and allowing for extension of the ankle. Approaching the deep peroneal nerve at midcalf preserved the motor branches supplying the tibialis anterior, extensor digitorum longus and extensor hallucis longus muscles that provide dorsiflexion of the ankle. Finally, approaching the superficial peroneal nerve at midcalf spared the peroneus longus and peroneus brevis muscles, allowing for foot eversion. Use of this selective technique provided adequate anesthesia and analgesia without major functional impairment. The concept of selective blockade may offer more physiologic postoperative recovery with particular effect on early physical therapy. Similar effects can be achieved with an ankle block1,7 that also accesses the nerves distal to the motor branch takeoffs; however, placing catheters at this level will raise concerns about the sterility of the operative field as the catheters will have to be prepped into it. Placement of the SPDPT catheters at midcalf also allows for ankle tourniquet placement below the block entry points. Use of 20 Ga needle and 24 Ga catheters was important for these blocks since the nerve diameter at the midcalf is comparable to the 20 Ga needle. Needles of 17 and 18 Ga, ubiquitous in many continuous nerve block sets, would have more than twice the diameter of the nerves and may have been more difficult to control. Further controlled studies are under way to compare the effectiveness and safety of the midcalf block of the SPDPT nerves versus the standard sciatic nerve block at the popliteal fossa.
Downloaded from fai.sagepub.com at University of Bath - The Library on June 11, 2015
177
Gucev et al
Summary We describe a novel technique of continuous SPDPT blocks performed at the midcalf level for operative treatment of hallux valgus. This technique allowed for retention of protective motor function and avoidance of ankle immobilization, while providing excellent continuous pain relief and patient satisfaction. The technique was well tolerated and had minimal additional cost compared to standard continuous analgesia techniques. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Degado-Martinez AD, Marchal JM. Supramalleolar ankle block anesthesia and ankle tourniquet for foot surgery. Foot Ankle. 2001;22:836-838.
2. Elliot R, Pearce C, Seifert C. Continuous infusion versus single bolus popliteal block following major ankle and hindfoot surgery: a prospective, randomized trial. Foot Ankle Int. 2010;31:1043-1047. 3. Gallardo J, Lagos L, Bastias C, Henriquez H, Carcuro G, Paleo M. Continuous popliteal block for postoperative analgesia in total ankle arthroplasty. Foot Ankle Int. 2012;33:208212. 4. Grosser DM, Herr MJ, Claridge RJ, Barker LG. Preoperative lateral popliteal nerve block for intraoperative and postoperative pain control in elective foot and ankle surgery: a prospective analysis. Foot Ankle Int. 2007; 28:1271-1275. 5. Rodriguez J, Taboada M, Carceller J, Lagunilla J, Barcena M, Alvarez J. Stimulating popliteal catheters for postoperative analgesia after hallux valgus repair. Anesth Analg. 2006;102:258-262. 6. Rongstad K, Mann RA, Prieskorn D. Popliteal sciatic nerve block for postoperative analgesia. Foot Ankle Int. 1996;17:378382. 7. Serrafian SK, Ibrahim IN, Breihan JH. Ankle-foot peripheral nerve block for mid and forefoot surgery. Foot Ankle Int. 1983;4:86-90. 8. Singelyn FJ, Aye F, Gouverneur JM. Continuous popliteal sciatic nerve block: an original technique to provide postoperative analgesia after foot surgery. Anesth Analg. 1997;84:383-386.
Downloaded from fai.sagepub.com at University of Bath - The Library on June 11, 2015
research-article2013
FAIXXX10.1177/1071100713514039Foot & Ankle InternationalGucev et al
Case Report
Midcalf Continuous Peripheral Nerve Block Anesthesia for Hallux Valgus Surgery: Case Report
Foot & Ankle International 2014, Vol. 35(2) 175–177 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100713514039 fai.sagepub.com
Gligor Gucev, MD, EdD1, Kalyani Karandikar, MD1, and Timothy Charlton, MD2 Level of Evidence: Level V, expert opinion. Keywords: hallux disorders, forefoot disorders Ankle block anesthesia is a well-established and safe technique of analgesia for forefoot and hallux valgus surgery.1,7 However, even with the use of long-acting anesthetics and corticosteroids, ankle block technique will last no longer than 24 hours.2 Popliteal block catheters are effective for postoperative pain,3-6,8 but the subsequent loss of motor function necessitates the use of immobilization at the level of the ankle, either in the form of a short leg cast or cam walker, to avoid falls associated with foot drop. Single-injection peripheral nerve blocks of the tibial, superficial, and deep peroneal nerves with and without ultrasound guidance have been described.1 We describe selective continuous superficial peroneal nerve block, deep peroneal nerve block, and tibial nerve block (SPDPT), allowing for 3 days of continuous analgesia without loss of motor function. This allowed for retention of protective motor function, the use of hard shoe immobilization, and no restriction of ankle range of motion.
Case Description A 44-year-old female physician presented for right hallux valgus correction. The patient was scheduled for right modified McBride procedure and right scarf osteotomy. Patient’s medical history was significant only for factor 5—Leiden coagulopathy and aspirin allergy. The patient requested a long-acting analgesia technique, but the restriction of ankle range of motion associated with a cast or cam walker immobilization was a relative contraindication secondary to deep vein thrombosis (DVT) risk associated with factor 5 Leiden coagulopathy. The anesthetic management was planned for propofol sedation along with SPDPT continuous peripheral nerve blocks. With the patient in supine position, a PLT 1204BT 7-14 MHz probe on Aplio MX 500 (Toshiba America Medical Systems, Inc, Tustin, CA) ultrasound machine was used to trace all 3 nerves from the ankle to the midcalf (Figures 1, 2, and 3). The skin point of puncture was infiltrated with 1 ml of 2% lidocaine. With real-time ultrasound guidance, a
20 Ga. Tuohy needle (Perifix, B. Braun Medical Inc, Bethlehem, PA) was advanced in the proximity of each of the nerves. Once the structures were identified, 5 ml of 0.5% Bupivacaine was injected in close proximity to each nerve. After the injection, 24 gauge pediatric epidural catheters (Perifix One, B. Braun Medical Inc, Bethlehem, PA) were advanced 3 cm past the needle tip in close proximity to the nerves. The patient did not receive any sedatives during the placement of the 3 nerve blocks and tolerated the procedure well. Careful attention was made to allow for adequate exposure of the leg in sterile surgical preparation, as well as use of a sterile ankle tourniquet. After the blocks were in place, the patient was taken to the operating room. The patient received propofol to maintain sedation throughout the entire 1.5 hour procedure along with a single dose of 25 micrograms of fentanyl when the propofol infusion was started. A medial incision was used for medial eminence resection and scarf osteotomy, and a dorsal incision was used for adductor tendon release and modified McBride procedure. The patient was placed in a postoperative dressing, hard shoe, and was non-weightbearing, as per the protocol of the operative surgeon. All 3 catheters were then attached to a single On-Q elastomeric pump (Triple-Site, I-flow LLC, Lake Forest, CA) supplying 0.2% Ropivacaine at 2 ml/hr to each catheter. The patient was discharged home after an hour of recovery in the postanesthesia care unit and followed for the next 3 days of her recovery. Wong–Baker VAS analog scale scores 1
Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA 2 Department of Orthopaedics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA Corresponding Author: Gligor Gucev, MD, EdD, Department of Anesthesiology, Keck School of Medicine, University of Southern California, 1500 San Pablo St, 4th Fl, Los Angeles, CA 90033, USA. Email: [email protected]
Downloaded from fai.sagepub.com at University of Bath - The Library on June 11, 2015
176
Foot & Ankle International 35(2)
Figure 1. Illustration of axial section through the midcalf. 1, transducer position for Figure 2; 2, transducer position for Figure 3; AT, tibialis anterior muscle; ATA, tibialis anterior artery; DPN, peroneus profundus nerve; EDL, extensor digitorum longus; FDL, flexor digitorum longus; Fib, fibula; GCL, gastrocnemius muscle—lateral head; GCM, gastrocnemius muscle—medial head; PB, peroneus brevis muscle; PL, peroneus longus muscle; PT, tibialis posterior muscle; PTA, tibialis posterior artery; Sol, soleus muscle; SPN, peroneus superficialis nerve; Tib, tibia; TN, tibialis nerve.
Figure 2. Axial ultrasound image of the lateral midcalf. A, anterior; FDL, flexor digitorum longus; GCM, gastrocnemius muscle—medial head; L, lateral; M, medial; P, posterior; PTA, tibialis posterior artery; Tib, tibia; TN, tibialis nerve.
and narcotic diary were obtained via phone interview. VAS score was 0 over the first 3 postoperative days and the patient did not require any further narcotic pain medications or NSAIDs while the peripheral nerve block catheters were in place. The patient did not have any motor weakness of the operative extremity and was able to perform unrestricted dorsiflexion and plantarflexion of the ankle. The patient did not experience any falls, difficulty with ambulation during the postoperative period, or DVT.
Figure 3. Axial ultrasound image of the medial midcalf. A, anterior; AT, tibialis anterior muscle; ATA, tibialis anterior artery; DPN, peroneus profundus nerve; Fib, fibula; L, lateral; M, medial; P, posterior; PB, peroneus brevis muscle; SPN, peroneus superficialis nerve; Tib, tibia.
Discussion The popliteal nerve block has proven to be a valuable tool for a multimodal postoperative pain control for patients undergoing foot and ankle surgery.2-5,6,8 To avoid the foot drop, which is 1 of the major side effects of the popliteal nerve block, we approached the tibial nerve at midcalf to preserve the motor branches supplying the gastrocnemius muscle and allowing for extension of the ankle. Approaching the deep peroneal nerve at midcalf preserved the motor branches supplying the tibialis anterior, extensor digitorum longus and extensor hallucis longus muscles that provide dorsiflexion of the ankle. Finally, approaching the superficial peroneal nerve at midcalf spared the peroneus longus and peroneus brevis muscles, allowing for foot eversion. Use of this selective technique provided adequate anesthesia and analgesia without major functional impairment. The concept of selective blockade may offer more physiologic postoperative recovery with particular effect on early physical therapy. Similar effects can be achieved with an ankle block1,7 that also accesses the nerves distal to the motor branch takeoffs; however, placing catheters at this level will raise concerns about the sterility of the operative field as the catheters will have to be prepped into it. Placement of the SPDPT catheters at midcalf also allows for ankle tourniquet placement below the block entry points. Use of 20 Ga needle and 24 Ga catheters was important for these blocks since the nerve diameter at the midcalf is comparable to the 20 Ga needle. Needles of 17 and 18 Ga, ubiquitous in many continuous nerve block sets, would have more than twice the diameter of the nerves and may have been more difficult to control. Further controlled studies are under way to compare the effectiveness and safety of the midcalf block of the SPDPT nerves versus the standard sciatic nerve block at the popliteal fossa.
Downloaded from fai.sagepub.com at University of Bath - The Library on June 11, 2015
177
Gucev et al
Summary We describe a novel technique of continuous SPDPT blocks performed at the midcalf level for operative treatment of hallux valgus. This technique allowed for retention of protective motor function and avoidance of ankle immobilization, while providing excellent continuous pain relief and patient satisfaction. The technique was well tolerated and had minimal additional cost compared to standard continuous analgesia techniques. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Degado-Martinez AD, Marchal JM. Supramalleolar ankle block anesthesia and ankle tourniquet for foot surgery. Foot Ankle. 2001;22:836-838.
2. Elliot R, Pearce C, Seifert C. Continuous infusion versus single bolus popliteal block following major ankle and hindfoot surgery: a prospective, randomized trial. Foot Ankle Int. 2010;31:1043-1047. 3. Gallardo J, Lagos L, Bastias C, Henriquez H, Carcuro G, Paleo M. Continuous popliteal block for postoperative analgesia in total ankle arthroplasty. Foot Ankle Int. 2012;33:208212. 4. Grosser DM, Herr MJ, Claridge RJ, Barker LG. Preoperative lateral popliteal nerve block for intraoperative and postoperative pain control in elective foot and ankle surgery: a prospective analysis. Foot Ankle Int. 2007; 28:1271-1275. 5. Rodriguez J, Taboada M, Carceller J, Lagunilla J, Barcena M, Alvarez J. Stimulating popliteal catheters for postoperative analgesia after hallux valgus repair. Anesth Analg. 2006;102:258-262. 6. Rongstad K, Mann RA, Prieskorn D. Popliteal sciatic nerve block for postoperative analgesia. Foot Ankle Int. 1996;17:378382. 7. Serrafian SK, Ibrahim IN, Breihan JH. Ankle-foot peripheral nerve block for mid and forefoot surgery. Foot Ankle Int. 1983;4:86-90. 8. Singelyn FJ, Aye F, Gouverneur JM. Continuous popliteal sciatic nerve block: an original technique to provide postoperative analgesia after foot surgery. Anesth Analg. 1997;84:383-386.
Downloaded from fai.sagepub.com at University of Bath - The Library on June 11, 2015
