title: Femoral nerve block with selective tibial nerve block provides effective analgesia without foot drop after total knee arthroplasty: a prospective, randomized, observer-blinded study.
abstract: BACKGROUND
  Sciatic nerve block when combined with femoral nerve block for total knee arthroplasty may provide superior analgesia but can produce footdrop, which may mask surgically induced peroneal nerve injury. In this prospective, randomized, observer-blinded study, we evaluated whether performing a selective tibial nerve block in the popliteal fossa would avoid complete peroneal motor block.
  
  
  METHODS
  Eighty patients scheduled for primary total knee arthroplasty were randomized to receive either a tibial nerve block in the popliteal fossa or a sciatic nerve block proximal to its bifurcation in combination with femoral nerve block as part of a multimodal analgesia regimen. Local anesthetic solution of sufficient volume to encircle the target nerve was administered for the block, up to a maximum of 20 mL. General anesthesia was administered for surgery. After emergence from anesthesia, in the recovery room, the presence or absence of peroneal sensory and motor block was noted. Pain scores and opioid consumption were recorded for 24 hours after surgery.
  
  
  RESULTS
  The tibial nerve block and sciatic nerve block were performed 1.7 cm (99% CI, 1.3 to 2.1) and 9.4 cm (99% CI, 8.3 to 10.5) proximal to the popliteal crease, respectively (99% CI for difference between means: 6.4 to 9.0; P < 0.001). A lower volume of ropivacaine 0.5% was used for the tibial nerve block, 8.7 mL (99% CI, 7.9 to 9.4) versus 15.2 mL (99% CI, 14.9 to 15.5), respectively (99% CI for difference between means, 5.6 to 7.3; P < 0.001). No patient receiving a tibial nerve block developed complete peroneal motor block compared to 82.5% of patients with sciatic nerve block (P < 0.001). There were no significant differences in the pain scores and opioid consumption between the groups.
  
  
  CONCLUSIONS
  Tibial nerve block performed in the popliteal fossa in close proximity to the popliteal crease avoided complete peroneal motor block and provided similar postoperative analgesia compared to sciatic nerve block when combined with femoral nerve block for patients undergoing total knee arthroplasty.
authors.affiliation: St. Francis Hospital and Medical Center, Department of Anesthesiology, 114 Woodland Street, Hartford, CT 06105, USA. sanjaysinha@comcast.net
authors.forename: Sanjay K
authors.initials: SK
authors.lastname: Sinha
authors.forename: Jonathan H
authors.initials: JH
authors.lastname: Abrams
authors.forename: Sivasenthil
authors.initials: S
authors.lastname: Arumugam
authors.forename: John
authors.initials: J
authors.lastname: D'Alessio
authors.forename: David G
authors.initials: DG
authors.lastname: Freitas
authors.forename: John T
authors.initials: JT
authors.lastname: Barnett
authors.forename: Robert S
authors.initials: RS
authors.lastname: Weller
mesh_terms: D000368:Aged; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects; D016009:Chi-Square Distribution; D003237:Connecticut; D005260:Female; D005267:Femoral Nerve / Q000000981:diagnostic imaging; D020233:Gait Disorders, Neurologic / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009043:Motor Activity / Q000187:drug effects; D009407:Nerve Block / Q000009:adverse effects / Q000379:methods*; D010147:Pain Measurement; D017288:Pain Threshold / Q000187:drug effects; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D010543:Peroneal Nerve / Q000000981:diagnostic imaging; D011446:Prospective Studies; D013979:Tibial Nerve / Q000000981:diagnostic imaging; D013997:Time Factors; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional