Saphenous Nerve Block From Within the Knee Is Feasible for TKA: MRI and Cadaveric Study

Abstract

Background: Surgeon-performed periarticular injections and anesthesiologist-performed femoral nerve or adductor canal blocks with local anesthetic are in common use as part of multimodal pain management regimens for patients undergoing TKA. However, femoral nerve blocks risk causing quadriceps weakness and falls, and anesthesiologist-performed adductor canal blocks are costly in time and resources and may be unreliable. We investigated the feasibility of a surgeon-performed saphenous nerve ("adductor canal") block from within the knee at the time of TKA.

Questions/purposes: (1) Can the saphenous nerve consistently be identified distally on MRI studies, and is there a consistent relationship between the width of the femoral transepicondylar axis (TEA) and the proximal (cephalad) location where the saphenous nerve emerges from the adductor canal? With these MRI data, we asked the second question: (2) Can we utilize this anatomic relationship to simulate a surgeon-performed intraoperative block of the distal saphenous nerve from within the knee with injections of dyes after implantation of trial TKA components in cadaveric lower extremity specimens?

Methods: A retrospective analysis of 94 thigh-knee MRI studies was performed to determine the relationship between the width of the distal femur at the epicondylar axis and the proximal location of the saphenous nerve after its exit from the adductor canal and separation from the superficial femoral artery. These studies, obtained from one hospital's MRI library, had to depict the saphenous nerve in the distal thigh and the femoral epicondyles and excluded patients younger than 18 years of age or with metal implants. These studies were performed to evaluate thigh and knee trauma or unexplained pain, and 55 had some degree of osteoarthritis. After obtaining these data, TKA resections and trial component implantation were performed, using a medial parapatellar approach, in 11 fresh cadaveric lower extremity specimens. There were six male and five female limbs from cadavers with a mean age of 70 years (range, 57-80 years) and mean body mass index of 20 kg/m (range, 15-26 kg/m) without known knee arthritis. Using a blunt-tipped 1.5-cm needle, we injected 10 mL each of two different colored solutions from inside the knee at two different locations and, after 30 minutes, dissected the femoral and saphenous nerves and femoral artery from the hip to the knee. Our endpoints were whether the saphenous nerve was bathed in dye and if the dye or needle was located in the femoral artery or vein.

Results: Based on the MRI analysis, the mean ± SD TEA was 75 ± 4 mm in females and 87 ± 4 mm in males. The saphenous nerve exited the adductor canal and was located at a mean of 1.5 ± 0.16 times the TEA width in females and a mean of 1.3 ± 0.13 times the TEA width in males proximal to the medial epicondyle. After placement of TKA trial components and injection, the proximal injection site solution bathed the saphenous nerve in eight of 11 specimens. In two cachectic female cadaver limbs, the dye was located posteriorly to the nerve in hamstring muscle. The proximal blunt needle and colored solution were directly adjacent to but did not penetrate the femoral artery in only one specimen.

Conclusions: This study indicates, based on MRI measurements, cadaveric injections, and dissections, that a surgeon-performed injection of the saphenous nerve from within the knee after it exits from the adductor canal seems to be a feasible procedure.

Clinical relevance: This technique may be a useful alternative to an ultrasound-guided block. A trial comparing surgeon- and anesthesiologist-performed nerve block should be considered to determine the clinical efficacy of this procedure.

Fig. 1

A-B (A) Sagittal and (B) axial MRI demonstrate the location of the saphenous nerve as it exits the adductor canal. The red arrow (B) points to the location of the saphenous nerve.

Fig. 2

This is a photograph of the two different intraarticular injections with the knee in extension. The more proximal injection is the pink latex with slightly more medial angulation of the syringe. The injection is performed after trial knee arthroplasty components have been inserted.

Fig. 3

This is a photograph of a typical specimen with dissection of the femoral nerve from the hip to the knee. The sartorius muscle is mobilized anteriorly to show the distal saphenous nerve and other branches of the femoral nerve. The pink latex dye is present about the distal aspect of the adductor canal.

Fig. 4

This is a photograph of another specimen after the sartorius muscle has been mobilized anteriorly to demonstrate the saphenous nerve. In this specimen, both the proximal pink latex and the distal green dye injections bathe the saphenous nerve.