Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know

Table 3 Summary of lower extremity peripheral nerve blocks

Block	Clinical application	Nerves blocked	Anatomical landmarks	Advantages	Disadvantages	Complications
Femoral nerve(Femoral nerve block)	Surgeries involving anterior aspect of the thigh and medial aspect of the leg below the knee	Femoral nerve	Inguinal crease; located lateral to femoral artery	(1) Broad coverage; and (2) Easily identifiable landmarks	Causes quadriceps weakness which may lead to falls	(1) LE weakness and falls; (2) Bleeding; (3) Infection; and (4) Nerve damage
Femoral nerve (Fascia Iliaca block)	Surgeries involving anterior aspect of the thigh and medial aspect of the leg below the knee	(1) Femoral nerve; and (2) Lateral femoral cutaneous nerve of the thigh	Inguinal crease, LA injected under fascia iliaca	(1) Easily identifiable landmarks; and (2) Assist in optimal patient positioning for spinal anesthesia	(1) Causes quadriceps weakness which may lead to falls; and (2) Large volume of local anesthetic required	(1) LE weakness and falls; (2) Bleeding; (3) Infection; and (4) Nerve damage
Sciatic nerve (Anterior, transgluteal, and subgluteal approaches)	Surgeries involving foot, ankle, and posterior knee	Sciatic nerve	Variable, based on injection site	(1) Broad lower extremity coverage; and (2) Easilyidentifiable landmarks	Motor blockade	(1) Bleeding; (2) Infection; and (3) Nerve damage, persistent foot drop and heel ulcers
Sciatic nerve (Popliteal Block)	Surgeries involving foot, ankle, posterior knee	Sciatic nerve	Popliteal fossa, located cephalad to the knee near popliteal artery	(1) Broad lower extremity coverage; and (2) Easilyidentifiable landmarks	Motor blockade	(1) Bleeding; (2) Infection; and (3) Nerve damage, persistent foot drop and heel ulcers
Saphenous nerve (Femoral triangle, medial femoral condyle, tibial tuberosity approaches)	Surgeries involving medial aspect of knee, foot, and ankle	Saphenous nerve	Variable, based on injection site	Motor-sparing	Does not provide anesthesia and analgesia to the posterior capsule of knee	(1) Bleeding; (2) Infection; and (3) Nerve damage - Potential lower extremity weakness at high doses
Saphenous nerve (Adductor Canal block)	Surgeries involving medial aspect of knee, foot, and ankle	(1) Saphenous nerve; and (2) Nerve to vastus medialis (branch of femoral nerve)	Medial thigh, located deep to the sartorius muscle, adjacent to the femoral artery and vein.	Motor-sparing	(1) Does not provide anesthesia and analgesia to the posterior capsule of knee; and (2) Compared to femoral nerve block, it is less efficacious for analgesia after ACL reconstruction surgery	(1) Bleeding; (2) Infection; (3) Nerve damage; and (4) Potential lower extremity weakness at high doses
iPACK	Surgeries involving the posterior knee capsule	Articular branches of the tibial, common peroneal, and obturator nerve to the posterior aspect of the knee	Popliteal crease, located cephalad to femoral condyles	Motor-sparing, increased posterior knee coverage	Coverage only to posterior knee; useful as an adjunct to alternative blocks	Inadvertent motor block due to local anesthetic spread to sciatic nerve branches
Ankle	Foot surgery	Saphenous, sural, posterior tibial, superficial peroneal, and deep peroneal nerves	Ankle and foot bony landmarks	Injection based on surface landmarks, no requirement for ultrasound	Limited efficacy for surgery proximal to the foot, potential higher failure rate due to blind technique	(1) Bleeding; (2) Infection; and (3) Nerve damage
Lumbar plexus	Hip surgery	Lumbar plexus, providing blockade to femoral, obturator, and lateral femoral cutaneous nerves	Lateral to lumbar spine, located cephalad to iliac crest	Coverage of multiple nerves with a single block	High potential for complications and block failure, technically challenging block to perform	(1) Bleeding and hematoma; (2) Infection; (3) Nerve damage; (4) Epidural spread resulting in high neuraxial anesthesia; (5) Hypotension, and (6) LAST

ACL: anterior cruciate ligament; LAST: local anesthetic systemic toxicity.