Where on the thigh do you do ACBs?

[IDGARA]

I remember reading an article around 2019 about ACBs in ACL surgery. They compared three injection locations based on the position of the femoral artery relative to the sartorius. The image below is what I remember about the three arms of the study:

If I remember correctly, the proximal group had the best outcomes (I think least morphine equivalents consumed with similar quad weakness.) Thus, I have been doing all my ACBs pretty high on the thigh, just distal to what would be considered a femoral block.

Then I went and watched the below video from Duke about ACBs. In it they talk about kinda doing two blocks: one is the saphenous, and the other is the nerve to the vastus medialis. The location seems to be mid thigh, which is more distal than what I'm used to.
.

So my question is, where do you people do your injection for ACBs? Is there specific anatomy you look for? Or do you just slap the probe on proximal to the knee and call it a day?

---

Members don't see this ad.

 

[PlayToWin]

I usually go mid thigh, aim right next to
Femoral artery below the Sartorius. You will feel two pops and local will spread around the artery and frequently you’ll the saphenous nerve floating in the pool of local.

 

[DrOwnage]

I usually go mid thigh, aim right next to
Femoral artery below the Sartorius. You will feel two pops and local will spread around the artery and frequently you’ll the saphenous nerve floating in the pool of local.

Second this

 

[Coffee PRN]

Do you guys like to follow along under the sartorius or just pop straight through? I’ve done both

 

[IDGARA]

Do you guys like to follow along under the sartorius or just pop straight through? I’ve done both

I pop through the sartorius at an angle.

 

[ranvier]

“60% of the time, it works every time!”

 

[Hoya11]

I remember reading an article around 2019 about ACBs in ACL surgery. They compared three injection locations based on the position of the femoral artery relative to the sartorius. The image below is what I remember about the three arms of the study:

View attachment 384281

If I remember correctly, the proximal group had the best outcomes (I think least morphine equivalents consumed with similar quad weakness.) Thus, I have been doing all my ACBs pretty high on the thigh, just distal to what would be considered a femoral block.

Then I went and watched the below video from Duke about ACBs. In it they talk about kinda doing two blocks: one is the saphenous, and the other is the nerve to the vastus medialis. The location seems to be mid thigh, which is more distal than what I'm used to.
.

So my question is, where do you people do your injection for ACBs? Is there specific anatomy you look for? Or do you just slap the probe on proximal to the knee and call it a day?

i would say i prefer more of a "mid" approach

i scan up and down the middle third of the thigh looking for the most convincing image of the saphenous nerve that i can find

i look for a little round distinct hyperechoic ball lateral to the artery - sometimes this becomes more visible after you start injecting local near it

 

[MirrorTodd]

Do you guys like to follow along under the sartorius or just pop straight through? I’ve done both

I was originally taught to follow the fascial plane of the sartorius, but recently heard that you will occasionally pierce the nerve to vastus medialus resulting in nerve injury by following the fascial plane. Majority of my AC blocks are done after induction nowadays so I just go straight through the sartorius.

 

[dannyboy1]

Wherever the dressing ends.

 

[Coffee PRN]

I was originally taught to follow the fascial plane of the sartorius, but recently heard that you will occasionally pierce the nerve to vastus medialus resulting in nerve injury by following the fascial plane. Majority of my AC blocks are done after induction nowadays so I just go straight through the sartorius.

When I follow the fascial plane, I try to inject along the way to isolate and avoid the VM

 

[anbuitachi]

mid thigh

 

[PlayToWin]

Wherever the dressing ends.

So youre doing blocks postoperatively? we usually do our knees and ACLs block preoperatively.

 

[banister]

I was originally taught to follow the fascial plane of the sartorius, but recently heard that you will occasionally pierce the nerve to vastus medialus resulting in nerve injury by following the fascial plane. Majority of my AC blocks are done after induction nowadays so I just go straight through the sartorius.

I would love to do more of my adductor canal blocks after induction, but most everyone in my group does it preop while they're awake citing medicolegal reasons. Has anyone personally had any bad outcomes from intraoperative ACB that might have been avoided if done awake?

 

[Simba1711]

I do my acb and ipack after induction. Mid thigh and I inject at about the 2 or 10 o clock position depending on side. I like to see the femoral artery move down with injection to confirm position in the adductor canal.

 

[GassYous]

I would love to do more of my adductor canal blocks after induction, but most everyone in my group does it preop while they're awake citing medicolegal reasons. Has anyone personally had any bad outcomes from intraoperative ACB that might have been avoided if done awake?

What bad outcome? That the patient can't feel the side of their big toe?

 

[JoelJoel84]

Why are so many not doing their adductor canal blocks in the preop area, as with an interscalene or supraclavicular block?

Seems like a waste of in OR time , when you could be blocked and ready to go for incision after induction.

 

[GassYous]

Why are so many not doing their adductor canal blocks in the preop area, as with an interscalene or supraclavicular block?

Seems like a waste of in OR time , when you could be blocked and ready to go for incision after induction.

It takes 2 minutes to do it in the OR. It takes longer to get the surgeon in the room.

 

[MirrorTodd]

Why are so many not doing their adductor canal blocks in the preop area, as with an interscalene or supraclavicular block?

Seems like a waste of in OR time , when you could be blocked and ready to go for incision after induction.

Most places aren't set up to actually do/monitor the pt following the block.

 

[PpfSuxTube]

A block for acl? Why?
Surely no meaningful benefit.

whats next? tap blocks for lap appys?

 

[GassYous]

A block for acl? Why?
Surely no meaningful benefit.

whats next? tap blocks for lap appys?

I have a bunch of patients in pacu being in 10/10 pain. Adductor/ipack ensures that they are comfortable and that I'm not getting phone calls for more dilaudid.

 

[PpfSuxTube]

I have a bunch of patients in pacu being in 10/10 pain. Adductor/ipack ensures that they are comfortable and that I'm not getting phone calls for more dilaudid.

Ok.
The evidence is pretty clear that there's only minor benefit for regional with acls but if that's what you find then that's good... and the minor benefit only lasts like 6 hours then nothing after 24hr
Maybe your surgeon is doing something differently or pacu rns are too quick to call.

 

[Hoya11]

Ok.
The evidence is pretty clear that there's only minor benefit for regional with acls but if that's what you find then that's good... and the minor benefit only lasts like 6 hours then nothing after 24hr
Maybe your surgeon is doing something differently or pacu rns are too quick to call.

Yeah blocks are pretty standard for ACLs everywhere I have ever practiced

 

[coffeebythelake]

A block for acl? Why?
Surely no meaningful benefit.

whats next? tap blocks for lap appys?

Yes ACL often get AC blocks. I wouldn't offer them for meniscus repairs though.

 

[Ronin786]

I would love to do more of my adductor canal blocks after induction, but most everyone in my group does it preop while they're awake citing medicolegal reasons. Has anyone personally had any bad outcomes from intraoperative ACB that might have been avoided if done awake?

Not only was the surgery unsuccessful but Floyd experienced a post-operation treatment that he says was unnecessary and that caused him irreparable injury. One of Andrews’s colleagues, Dr. Gregory Hickman, performed a “post-operative adductor-canal nerve block” on Floyd—a decision that Floyd insists was done without his consent. This post-op procedure entailed the administration of substances to numb Floyd’s pain. However, Floyd notes that the “post-operative adductor-canal nerve block carried the risk of career-ending complications” and was unwarranted in the circumstances. As Floyd notes, not only did he not offer consent to the nerve block—to that point, as an NFL player, Floyd is accustomed to dealing with pain and would seem less likely than the typical person to okay a procedure to blunt pain—but even if Floyd had consented, it would not have been a legally-binding, informed consent since he was heavily medicated at that time. Floyd stresses he “would have preferred to remain in pain rather than undergo such a non-essential procedure that gambled his entire career.”

Worse yet for Floyd, the nerve block was (as Floyd claims) “negligently misplaced” by Hickman. The misplacement allegedly caused “permanent injury” to Floyd by “destroying portions of Floyd’s femoral/saphenous nerves and attendant musculature (e.g. the quadriceps and vastus medialis muscles.)”

Diving Into Sharrif Floyd's $180M suit vs. Dr. Andrews

Sharrif Floyd's lawsuit against Dr. James Andrews won’t be an easy case to settle, riddled with challenges in proving $180 million in damages.

www.si.com

Obviously not the same situation, but always comes into mind when people talk about ACB. Moral of the story- don't operate on athletes.

 

[GassYous]

Not only was the surgery unsuccessful but Floyd experienced a post-operation treatment that he says was unnecessary and that caused him irreparable injury. One of Andrews’s colleagues, Dr. Gregory Hickman, performed a “post-operative adductor-canal nerve block” on Floyd—a decision that Floyd insists was done without his consent. This post-op procedure entailed the administration of substances to numb Floyd’s pain. However, Floyd notes that the “post-operative adductor-canal nerve block carried the risk of career-ending complications” and was unwarranted in the circumstances. As Floyd notes, not only did he not offer consent to the nerve block—to that point, as an NFL player, Floyd is accustomed to dealing with pain and would seem less likely than the typical person to okay a procedure to blunt pain—but even if Floyd had consented, it would not have been a legally-binding, informed consent since he was heavily medicated at that time. Floyd stresses he “would have preferred to remain in pain rather than undergo such a non-essential procedure that gambled his entire career.”

Worse yet for Floyd, the nerve block was (as Floyd claims) “negligently misplaced” by Hickman. The misplacement allegedly caused “permanent injury” to Floyd by “destroying portions of Floyd’s femoral/saphenous nerves and attendant musculature (e.g. the quadriceps and vastus medialis muscles.)”

Diving Into Sharrif Floyd's $180M suit vs. Dr. Andrews

Sharrif Floyd's lawsuit against Dr. James Andrews won’t be an easy case to settle, riddled with challenges in proving $180 million in damages.

www.si.com

Obviously not the same situation, but always comes into mind when people talk about ACB. Moral of the story- don't operate on athletes.

I never block professional athletes for this exact reason

 

[PlayToWin]

I also do a popliteal plexus block in addition to the ACB. most of our ACLs only require minimal dose of dilaudid and an oral opiod prior to discharge.

i also have done ACB after induction/ placement of spinal without any issues.

we never block any of the professional athletes and sometimes the high level collegiate athletes as well.

 

[neutro]

Ok.
The evidence is pretty clear that there's only minor benefit for regional with acls but if that's what you find then that's good... and the minor benefit only lasts like 6 hours then nothing after 24hr
Maybe your surgeon is doing something differently or pacu rns are too quick to call.

This.

 

[PlayToWin]

This.

So are you not blocking at all or doing femoral nerve block?

 

[neutro]

So are you not blocking at all or doing femoral nerve block?

No block generally unless patient or surgeon wants it

 

[NightyNight]

When I follow the fascial plane, I try to inject along the way to isolate and avoid the VM

Can always use nerve stim for patellar twitch if you don’t want the VM. But for TKA, it’s a good one to block too

 

[nimbus]

Can always use nerve stim for patellar twitch if you don’t want the VM. But for TKA, it’s a good one to block too

Yep. Getting the VM is necessary to cover the knee. Doesn’t matter for foot and ankle.

 

[nimbus]

I never block professional athletes for this exact reason

You guys do upper extremity blocks on surgeons? I’ve taken care of 2 surgeons for rotator cuff repairs. After discussion they both asked me to “do what you usually do.” So they both got ISBs.

 

[GassYous]

You guys do upper extremity blocks on surgeons? I’ve taken care of 2 surgeons for rotator cuff repairs. After discussion they both asked me to “do what you usually do.” So they both got ISBs.

I would as they probably have the best idea of the risks and benefits as they follow up on all the patients. And they probably chose you to do their anesthesia.

 

[2Fast2Des]

A block for acl? Why?
Surely no meaningful benefit.

whats next? tap blocks for lap appys?

Yes to both. TAP block for lap cases occasionally if pain not improving with Dilaudid, but we do TAP for all lap hernia repairs. ACL patients appreciate blocks, I would want a block myself if I were to get it

 

[nimbus]

I would as they probably have the best idea of the risks and benefits as they follow up on all the patients. And they probably chose you to do their anesthesia.

One of them is a bariatric surgeon 😂