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Korean J Anesthesiol > Epub ahead of print
DOI: https://doi.org/10.4097/kja.19060    [Epub ahead of print]
Published online April 30, 2019.
Optimal location of local anesthetic injection into the interspace between the popliteal artery and posterior capsule of the knee (iPACK) for posterior knee pain after total knee arthroplasty: an anatomical and clinical study
Wirinaree Kampitak1, Tanvaa Tansatit2, Aree Tanavalee3, Srihatach Ngarmukos3
1Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
2Department of Anatomy, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
3Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
Corresponding author:  Wirinaree Kampitak,
Email: nutong127@yahoo.com
Received: 16 February 2019   • Revised: 1 April 2019   • Accepted: 30 April 2019
Abstract
Background
This study aimed to determine the optimal location of local anesthetic injection into the interspace between the popliteal artery and posterior capsule of the knee (iPACK) by using the anatomical pattern of the articular branch of tibial nerve (ABTN). We hypothesized that injection at the position of the ABTN, forming a popliteal plexus would spread mainly throughout the popliteal fossa without contacting tibial or peroneal nerves.
Methods
Anatomical study included 30 soft cadavers. After identifying the position of the ABTN and surrounding structures, ultrasound-guided dye injection was performed in 10 legs, followed by dissection to assess its spread. Clinical study was conducted in 15 patients undergoing total knee arthroplasty (TKA) with ultrasound-guided iPACK. All patients also received continuous adductor canal block (CACB). Sensorimotor function of the tibial and common peroneal nerves was determined.
Results
At the distal portion of popliteal fossa, the tibial nerve and popliteal vessels ran most superficially and closely together. The trajectory of ABTN ran laterally with the popliteal vasculature and formed a plexus distributed toward the posterior capsule of the knee below the medial side of the upper edge of lateral femoral condyle. In cadavers, the ABTN and surrounding area of the popliteal plexus were stained with dye after injection. In clinical study, no patients experienced complete motor and sensory blocks.
Conclusions
We describe a modified iPACK technique via injection at the level of the ABTN that forms the popliteal plexus. This technique may constitute an optional anesthetic regimen to promote early ambulation following TKA.
Key Words: Pain, postoperative; Arthroplasty, Replacement, Knee; Tibial nerve; Popliteal artery
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