Chung O T in Lower Limb Reconstruction and Amputation 978197

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Operative Techniques in Lower Limb Reconstruction and Amputation

Published May 2019

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When you have to be right

Operative Techniques in Lower Limb Reconstruction and Amputation, 1e

ISBN 978-1-9751-2734-3 Price £195.00/ €220.00

Part of the best-selling Operative Techniques series, Operative Techniques in Plastic Surgery provides superbly illustrated, authoritative guidance on operative techniques along with a thorough understanding of how to select the best procedure, how to avoid complications and what outcomes to expect. This stand-alone book offers focused, easy-to-follow coverage of lower limb reconstruction and amputation, all taken directly from the larger text. It covers nearly all plastic surgery operations for these specific areas that are in current use, and is ideal for residents and physicians in daily practice.

Features include:

Comprehensively covers anesthesia and emergency procedures; foot, ankle, and lower leg; knee; thigh; amputation and replantation; lymphedema; and burns. Perfect for a quick preoperative review of the steps of a procedure.

Hundreds of full-color intraoperative photographs and illustrations, as well as numerous high- quality videos, capture procedures step by step and help you immediately apply your knowledge.

Succinct text, bulleted points, and quick-reference tables allow you to review information quickly and understand best practices and potential problems for each procedure.

Published May 2019 Sample Chapter Preview

When you have to be right

Contributors

Deepak M. Gupta, MD Clinical Assistant Professor of Plastic Surgery Santa Clara Valley Medical Center and Stanford University School of Medicine San Jose, California Martin Halle, MD, PhD Karolinska Institutet Department of Reconstructive Plastic Surgery Karolinska University Hospital Stockholm, Sweden Scott L. Hansen, MD Associate Professor of Surgery Division of Plastic and Reconstructive Surgery University of California, San Francisco Chief, Hand and Microvascular Surgery University of California, San Francisco Chief, Plastic and Reconstructive Surgery Zuckerberg San Francisco General Hospital San Francisco, California Rachel Hein, MD Resident Durham, North Carolina Michael C. Holland, MD Resident Physician Division of Plastic and Reconstructive Surgery University of California, San Francisco San Francisco, California Scott T. Hollenbeck, MD, FACS Associate Professor, Plastic and Reconstructive Surgery Director of Microsurgery Training Medical Student and Physician Assistant Clerkship Director—Plastic Surgery Duke University Medical Center Durham, North Carolina Jean-Louis Horn, MD, PhD Professor, Anesthesiology, Regional Anesthesia and Acute Pain Medicine Department of Plastic Surgery Duke University Medical Center

Loretta Chou, MD Professor of Orthopaedic Surgery Stanford University Redwood City, California Catherine Curtin, MD Associate Professor Division of Plastic Surgery Stanford University Palo Alto, California Gabrielle B. Davis, MD, MS Resident Physician Division of Plastic & Reconstructive Surgery Department of Surgery Stanford, California Sahitya K. Denduluri, MD Resident Physician Department of Orthopaedic Surgery

Derek F. Amanatullah, MD, PhD Assistant Professor Orthopedic Surgery Stanford Hospital and Clinics Redwood City, California Raffi S. Avedian, MD Assistant Professor of Orthopaedic Surgery Stanford University Medical Center Department of Orthopaedic Surgery Resident Physician School of Medicine Stanford University Palo Alto, California Michael Bellino, MD Assistant Professor Department of Orthopaedic Surgery Stanford University School of Medicine Palo Alto, California Julius Bishop, MD Assistant Professor and Associate Residency Director Department of Orthopaedic Surgery Stanford University School of Medicine Palo Alto, California David W. Chang, MD, FACS Chief of Plastic and Reconstructive Surgery Director of Microsurgery Fellowship Professor of Surgery The University of Chicago Medicine & Biological Sciences Chicago, Illinois Vishwanath R. Chegireddy, MD General Surgery Resident Department of Surgery Houston Methodist Hospital Houston, Texas Michael J. Chen, MD Current Orthopaedic Resident Department of Orthopaedic Surgery Charlotte and George Schultz Orthopaedic Tumor Center Palo Alto, California Joseph Baylan, MD

Stanford University Stanford, California Anahita Dua, MD, MS, MBA Vascular Surgery Fellow Division of Vascular Surgery Department of Surgery Stanford Hospital and Clinics

Palo Alto, California Anthony Echo, MD

Assistant Professor of Plastic Surgery Houston Methodist Hospital Research Institute Assistant Professor of Plastic Surgery Weill Cornell Medicine Assistant Clinical Professor of Surgery Texas A&M University Houston, Texas Michael W. Findlay, MBBS, PhD, FRACS, FACS Program Director—Plastic Surgery The Peter MacCallum Cancer Centre Plastic, Reconstructive and Hand Surgeon The Canberra Hospital Surgical Lead Plastic, Reconstructive and Hand Surgery Australasian Clinical Trials Network Director Program for Molecular and Cellular Innovation in Surgery Senior Lecturer The University of Melbourne Department of Surgery Royal Melbourne Hospital Melbourne, Australia

School of Medicine Stanford University Stanford, California

Stanford University Stanford, California

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vii

Contributors

Sean S. Li, MD Resident Division of Plastic and Reconstructive Surgery University of California, San Diego San Diego, California Xiangxia Liu, MD, PhD Associate Professor and Associate Chief Division of Plastic Surgery First Affiliated Hospital Sun Yat-sen University Guangzhou, Guangdong, China David W. Lowenberg, MD Clinical Professor Department of Orthopaedic Surgery Clinical Instructor and Fellow Regional Anesthesia Division Department of Anesthesiology, Perioperative and Pain Medicine Stanford University Medical Center Palo Alto, California Sarah Madison, MD Anesthesiologist Veterans Affairs Long Beach Healthcare System Long Beach, California Graeme E. McFarland, MD Assistant Professor Division of Vascular Surgery and Endovascular Therapy Department of Surgery University of Alabama at Birmingham Birmingham, Alabama Fred G. Mihm, MD Professor Division Chief, Critical Care Medicine Department of Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine Associate Medical Director, Intensive Care Units Department of Anesthesiology, Perioperative and Pain Medicine Stanford University Medical Center School of Medicine Stanford University Palo Alto, California Andrew Lyons, MD

Michael J. A. Klebuc, MD Associate Clinical Professor of Plastic and Neurosurgery Weill Medical College Cornell University Director Center for Facial Reanimation and Functional Restoration Houston Methodist Hospital Houston, Texas Ulrich Kneser, MD Professor of Plastic and Hand Surgery University of Heidelberg Medical School Director, Department of Hand, Plastic and Reconstructive Surgery Burn Unit BG Trauma Center Ludwigshafen Ludwigshafen, Germany Thomas Kremer, MD Professor of Plastic and Aesthetic Surgery, Hand Surgeon Department of Plastic and Hand Surgery Burn Center

Patrick Horrigan, MD Assistant Professor, University of Minnesota Department of Orthopaedic Surgery Regions Hospital Saint Paul, Minnesota James I. Huddleston III, MD Associate Professor of Orthopaedic Surgery Adult Reconstruction Service Chief Department of Orthopaedic Surgery Stanford University Medical Center Stanford, California Kenneth Hunt, MD Associate Professor and Chief, Foot and Ankle Surgery Department of Orthopaedic Surgery School of Medicine University of Colorado NYU Langone Health New York, New York Peter Johannet, MD Chief of Plastic Surgery Veterans Affairs Palo Alto Palo Alto, California Associate Clinical Professor of Plastic & Reconstructive Surgery Division of Plastic & Reconstructive Surgery Stanford University Stanford, California Yvonne L. Karanas, MD Chief of Plastic Surgery and Director Burn Center Santa Clara Valley Medical Center Associate Clinical Professor School of Medicine Stanford University San Jose, California Rohit Khosla, MD Assistant Professor of Plastic Surgery Division of Plastic Surgery Stanford University Medical Center Palo Alto, California So Young Kim, MD, PhD Assistant Professor Department of Plastic and Reconstructive Surgery Inje University Sanggye Paik Hospital Inje University School of Medicine Seoul, South Korea Aurora, Colorado Adam Jacoby, MD

Leipzig, Germany Brock Lanier, MD

Clinical Instructor in Microsurgery Division of Plastic and Reconstructive Surgery

Stanford University Stanford, California Kedar S. Lavingia, MD Fellow Division of Vascular Surgery Stanford University Menlo Park, California Jason T. Lee, MD Professor of Vascular Surgery

Director of Endovascular Surgery Program Director, Vascular Surgery Residency/Fellowship Stanford University Medical Center

Stanford, California Amber R. Leis, MD

Assistant Clinical Professor Director of Hand Surgery Assistant Program Director University of California—Irvine Orange, California L. Scott Levin, MD, FACS Paul B. Magnuson Professor of Bone and Joint Surgery Chairman, Department of Orthopaedic Surgery Professor of Surgery

Stanford, California Arash Momeni, MD Assistant Professor of Surgery

Director, Clinical Outcomes Research Ryan-Upson Scholar in Plastic and Reconstructive Surgery Division of Plastic & Reconstructive Surgery Stanford University Medical Center Palo Alto, California

Division of Plastic Surgery University of Pennsylvania Philadelphia, Pennsylvania

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viii

Contributors

Robert J. Steffner, MD Assistant Clinical Professor Musculoskeletal Tumor Surgery Department of Orthopaedic Surgery School of Medicine Stanford University Redwood City, California John T. Stranix, MD Chief Resident Hansjörg Wyss Department of Plastic Surgery Associate Professor, University of California San Diego, California Section Chief, Veterans Healthcare Administration Division of Plastic & Reconstructive Surgery University of California San Diego Section of Plastic & Reconstructive Surgery Veterans Healthcare Administration University of California, San Diego Medical Center Veterans Healthcare Administration, San Diego San Diego, California Alex Wong, MD, FACS Associate Professor of Surgery Director, Basic, Translational, and Clinical Research Director, Microsurgery Fellowship and Medical Student Education Division of Plastic and Reconstructive Surgery Keck School of Medicine of USC Los Angeles, California Kyong-Je Woo, MD, PhD Assistant Professor Department of Plastic Surgery College of Medicine Ewha Womans University Ewha Womans University Medical Center Seoul, Korea Ming Zhuo-Stine, MD NYU Langone Health New York, New York Ahmed Suliman, MD

Pierre Saadeh, MD Vice Chair of Education Residency Program Director Chief of Plastic and Hand Surgery Bellevue Hospital Department of Plastic Surgery School of Medicine New York University New York, New York Hani Sbitany, MD, FACS Associate Professor of Surgery Division of Plastic and Reconstructive Surgery University of California, San Francisco San Francisco, California Subhro K. Sen, MD Clinical Associate Professor Plastic and Reconstructive Surgery

Shawn Moshrefi, MD Plastic Surgery Resident Stanford University Medical Center Palo Alto, California Goo-Hyun Mun, MD, PhD Professor Department of Plastic Surgery Samsung Medical Center Sungkyunkwan University Seoul, South Korea Rahim Nazerali, MD, MHS, FACS Clinical Assistant Professor of Surgery Division of Plastic & Reconstructive Surgery Stanford University Palo Alto, California Hunter S. Oliver-Allen, MD Resident Physician Division of Plastic and Reconstructive Surgery Department of Surgery University of California, San Francisco San Francisco, California Adrian S. H. Ooi, MBBS, MMed (Surgery), MRCS, FAMS (Plastic Surgery) Consultant Plastic Surgeon Department of Plastic, Reconstructive and Aesthetic Surgery Singapore General Hospital SingHealth Head & Neck Disease Center SingHealth Stanford Healthcare Palo Alto, California Dung Nguyen, MD, PharmD Clinical Associate Professor

Stanford University Palo Alto, California Michael D. Sgroi, MD

Assistant Professor of Vascular Surgery Assistant Program Director of Vascular Surgery

Stanford University Stanford, California

Ashkaun Shaterian, MD Plastic Surgery Resident

Department of Plastic Surgery University of California, Irvine Orange, California Clifford C. Sheckter, MD Chief Resident Division of Plastic and Reconstructive Surgery Department of Surgery Stanford University Stanford, California Ann-Charlott Docherty Skogh, MD, PhD Senior Consultant in Plastic Surgery Breast Cancer Center Department of Surgery Stockholm South General Hospital and Karolinska Institute Stockholm, Sweden Rachel C. Steckelberg, MD, MPH Clinical Instructor Regional Anesthesia Fellow Department of Anesthesiology, Perioperative, and Pain Medicine Stanford University Hospital Palo Alto, California

Singapore, Singapore Paulo Piccolo, MD Microsurgey Fellow Division of Plastic Surgery Department of Surgery

University of Pennsylvania Philadelphia, Pennsylvania Lee L. Q. Pu, MD, PhD, FACS Professor of Surgery Division of Plastic Surgery University of California Davis Medical Center Sacramento, California

Clinical Instructor and Fellow Department of Anesthesiology Stanford University Hospitals Stanford, California

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Preface

of lower extremities so that a holistic approach can yield the most elegant and definitive treatment for the whole spectrum of lower extremity problems. I applaud the leadership of LWW for their commitment to education in promoting this text- book, and I very much appreciate the readers for continuing to embrace these operative technique textbooks that strive to provide expedient guidance in the care of patients with lower extremity injuries and conditions. Kevin C. Chung, MD, MS Chief of Hand Surgery, Michigan Medicine Director, University of Michigan Comprehensive Hand Center Charles B. G. de Nancrede Professor of Surgery Professor of Plastic Surgery and Orthopaedic Surgery Assistant Dean for Faculty Affairs

Lower extremity reconstruction leverages the expertise of vari- ous specialties in the total care of patients with diseases and trauma afflicting the lower extremity. These conditions can include traumatic injuries that require bone, nerve, muscle, tendon, and flap coverage. Similarly, the oncologic consid- eration mandates a comprehensive collaborative approach among various specialties for not only the resection of the tumor but also vascular reconstruction and possible soft tissue coverage. This book on lower extremity reconstruction and amputa- tion incorporates the expertise of orthopedic surgery, vascular surgery, and plastic surgery in the care of the lower extremi- ties. The organization of the textbook is technique based to illustrate various possibilities of reconstructive options as well as time-honored procedures that have proven to be effective. As the Editor-in-Chief, I have read every word in this volume to impart my personal guidance. This book is not geared to a particular specialty but is inclusive of all needs in the care

Associate Director of Global REACH University of Michigan Medical School Ann Arbor, Michigan

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Contents

13 The Medial Plantar Flap 65

Contributors vi Preface ix

Arash Momeni and Subhro K. Sen 14 Reconstruction of Heel and Plantar Defects: Free Flap 70 Goo-Hyun Mun and Kyong-Je Woo 15 The Reverse Sural Artery Flap for Lower Extremity Reconstruction 80 Ashkaun Shaterian and Amber R. Leis 16 Ankle Reconstruction With Free Flap 84 Sean S. Li, Ahmed Suliman, and Deepak M. Gupta 17 Vascular Reconstruction of Lower Extremity, Foot, and Ankle 92 Michael D. Sgroi and Jason T. Lee 18 Management of Diabetic Foot Ulcers 99 Rahim Nazerali 19 Nerve Repair and Reconstruction—Peroneal Nerve 102 Shawn Moshrefi and Catherine Curtin 20 Achilles Tendon Reconstruction 108 Hani Sbitany 21 Excision of Soft Tissue Tumors of the Lower Leg 112 Raffi S. Avedian and Robert J. Steffner 22 Excision of Bone Tumors of the Lower Leg 115 Raffi S. Avedian and Rohit Khosla 23 Debridement of Soft Tissue Infections of the Lower Leg 119 L. Scott Levin and Paulo Piccolo 24 Tibial Reconstruction 123 Vishwanath R. Chegireddy, Michael J. A. Klebuc, and Anthony Echo 25 Soft Tissue Coverage of Lower Leg—Free Flap 130 Goo-Hyun Mun and Kyong-Je Woo 26 Soft Tissue Coverage of Lower Leg—Soleus Flap 138 Rahim Nazerali and Lee L. Q. Pu

SECTION I ANESTHESIA AND EMERGENCY PROCEDURES 1 Femoral and Adductor Canal Blocks 2 Sarah Madison and Jean-Louis Horn 2 Popliteal Nerve Blocks 7 Ming Zhuo-Stine and Sarah Madison 3 Ankle Block 14 Andrew Lyons and Fred G. Mihm 4 Epidural Anesthesia 18 Rachel C. Steckelberg, Jean-Louis Horn, and Sarah Madison

SECTION II FOOT, ANKLE, AND LOWER LEG 5 Fasciotomy of the Thigh, Lower Leg, and Foot 23 Graeme E. McFarland and Jason T. Lee 6 Drainage of Abscesses of Lower Leg and Foot 27 Michael C. Holland and Scott L. Hansen 7 Excision of Soft Tissue Tumors of the Foot and Ankle 30 Raffi S. Avedian, Robert J. Steffner, and Subhro K. Sen 8 Ankle and Foot Bone Tumors 34 Robert J. Steffner, Raffi S. Avedian, and Sahitya K. Denduluri 9 Debridement of Soft Tissue Infections of the Foot and Ankle 41 Hunter S. Oliver-Allen, Michael C. Holland, and Scott L. Hansen 10 Debridement of Infected Bone of the Foot and Ankle 44 Michael C. Holland and Scott L. Hansen 11 Bony Reconstruction of Foot and Ankle (Bone Grafts) 47 Kenneth Hunt and Loretta Chou 12 Reconstruction of the Forefoot 55 Rachel Hein and Scott T. Hollenbeck

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Contents

41 Nerve Repair and Reconstruction—Sciatic Nerve and Femoral Nerve 221 Gabrielle B. Davis and Catherine Curtin 42 Keystone and Related Perforator Flaps 229 Michael W. Findlay SECTION V AMPUTATION AND REPLANTATION 43 Amputation of the Lower Extremity: Toes, Foot, Ankle 236 Kedar S. Lavingia and Jason T. Lee 44 Amputation of the Lower Extremity: Above-Knee Amputation, Below-Knee Amputation, Through-Knee Amputation 240 Anahita Dua and Jason T. Lee Ann-Charlott Docherty Skogh and Martin Halle 46 Lymphedema: Lymph Node Transfer 249 Adrian S. H. Ooi and David W. Chang 47 Fasciocutaneous Debulking of Extremity Lymphedema: The Charles Procedure 259 Clifford C. Sheckter and Peter Johannet 48 Liposuction for Treatment of Lymphedema 263 Dung Nguyen and Joseph Baylan SECTION VI LYMPHEDEMA 45 Lymphaticovenous Anastomosis 243

SECTION III KNEE 27 Nerve Repair and Reconstruction—Tibial Nerve 143 Shawn Moshrefi and Catherine Curtin 28 Excision of Soft Tissue Tumors of the Knee 148 Raffi S. Avedian 29 Excision of Bone Tumors of the Knee 152 Raffi S. Avedian 30 Bony and Soft Tissue Debridement Around the Knee 157 Derek F. Amanatullah, Michael J. Chen, Sahitya K. Denduluri, and James I. Huddleston 31 Bone Reconstruction of the Knee 165 Robert J. Steffner and Raffi S. Avedian 32 Soft Tissue Coverage of the Knee: Gastrocnemius Muscle Flap 174 Hani Sbitany 33 Soft Tissue Coverage of the Knee: Free Flaps 178 Goo-Hyun Mun and So Young Kim 34 Repair of Patella Tendon 185 Patrick Horrigan, Michael Bellino, and Julius Bishop SECTION IV THIGH 35 Excision of Soft Tissue Tumors of the Thigh 189 Raffi S. Avedian 36 Excision of Bone Tumors of the Femur 194 Raffi S. Avedian 37 Femoral Bone Debridement 198 Robert J. Steffner, David W. Lowenberg, and Sahitya K. Denduluri 38 Reconstruction of Femur 202 Vishwanath R. Chegireddy, Michael J. A. Klebuc, and Anthony Echo 39 Soft Tissue Coverage of the Thigh—Pedicled Rectus Flap 209 Brock Lanier and Alex Wong 40 Soft Tissue Coverage of Thigh—Free Flaps 214 Ulrich Kneser and Thomas Kremer

SECTION VII BURNS 49 Acute Management: Tangential Excision and Skin Grafting 267 Yvonne L. Karanas 50 Reconstruction of Contractures: Z-Plasty, Skin Grafting, and Flaps 272 Xiangxia Liu 51 Soft Tissue Reconstruction With Propeller Flaps 282

Adam Jacoby, John T. Stranix, and Pierre Saadeh

Index 287

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Video Clips

Chapter 14 Reconstruction of Heel and Plantar Defects: Free Flap Chapter 25 Soft Tissue Coverage of Lower Leg— Free Flap Chapter 31 Bony Reconstruction of the Knee Chapter 40 Soft Tissue Coverage of Thigh— Free Flaps

Chapter 45 ICG Lymphography Chapter 48 Liposuction for Lymphedema Chapter 49 Tangential Excision, Part 1

Tangential Excision, Part 2 Tangential Excision, Part 3

xii

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Section I: Anesthesia and Emergency Procedures Femoral and Adductor Canal Blocks

C H A P T E R

Sarah Madison and Jean-Louis Horn

DEFINITION

■ Any local infections, masses, previous surgeries, or other irregularities at the site of injection should be identified. IMAGING ■■ Ultrasound imaging confers efficiency and increases the suc- cess rate of most peripheral nerve blocks. ■ Using a high-frequency linear transducer, scan in a trans- verse orientation at the level of the inguinal crease. The femoral artery and femoral nerve should be easily identified in cross-section ( FIG 1 ). ■ The adductor canal block is often performed in a location that is proximal to the true adductor canal, near the point at which the sartorius muscle covers the femoral vessels. The nerve can be visualized next to the femoral artery, just deep to the sartorius muscle ( FIG 2 ). NONOPERATIVE MANAGEMENT ■ The balance of risks and benefits must be considered before any nerve block. Sometimes, it is more appropriate to only employ systemic medications for pain control. ■ Opioids and nonopioid adjuvant medications may be used when medically appropriate, with or without a nerve block. SURGICAL MANAGEMENT ■ Femoral nerve block is indicated for postoperative analgesia of the anterior thigh, knee, medial leg, or medial ankle, or for surgical anesthesia of the anterior thigh. ■ When combined with a sciatic block, it can be used for surgical anesthesia of the foot/ankle. ■ Local anesthetics will affect both motor and sensory nerves. Blocking the femoral nerve at the level of the inguinal crease results in quadriceps weakness. ■ Adductor canal block is indicated for postoperative analge- sia of the knee, medial leg, or medial ankle. ■ It can be used as a surgical anesthetic in conjunction with a sciatic block for procedures on the foot/ankle.

■■ A peripheral nerve block is an analgesic technique in which local anesthetics are injected percutaneously in proximity to a sensory nerve. ■■ The location of the injection determines the distribution of analgesia. ■■ Femoral nerve block may be used for postoperative analge- sia for procedures on the anterior thigh, knee, medial leg, or medial ankle. ■■ Adductor canal block may be used for postoperative analge- sia for procedures on the knee or medial leg. ■■ A continuous infusion of local anesthetic via a perineural catheter can provide analgesia for several days after surgery. ■■ Nerve blocks are often part of a multimodal regimen that also includes systemic medications. ■■ Nerve blocks can reduce pain and opioid consumption and enhance satisfaction and recovery. 1 ■■ Depending on the location and extent of surgery, nerve blocks may be used for surgical anesthesia. ■■ The femoral nerve arises from the lumbar plexus and is formed by the ventral rami of L2-L4. ■■ In the area of the femoral triangle, the femoral nerve lies deep to the fascia iliaca, lateral to the femoral artery, and superficial to the iliacus muscle. ■■ The femoral nerve divides into anterior and posterior divi- sions and descends as the saphenous nerve to the medial leg. ■■ The posterior branch provides motor innervation to the quadriceps muscles as well as sensory articular branches to the knee joint. ■■ The saphenous nerve, obturator nerve (posterior division), and the nerve to the vastus medialis lie within the adductor canal. ■■ The adductor canal is bounded by the sartorius and the vasto- adductor membrane medially, the vastus medialis anteriorly, and adductor longus and magnus muscles posteriorly. ■■ The adductor canal also contains the femoral artery and vein. ■■ The saphenous nerve and the nerve to the vastus medialis supply sensory branches to the knee. 2 PATIENT HISTORY AND PHYSICAL FINDINGS ■■ A preoperative history and physical must be performed prior to any anesthetic technique. ■■ A thorough history and physical exam will include anes- thetic history, exercise tolerance, cardiopulmonary exami- nation, and airway examination. ■■ Any pre-existing neuropathies in the distribution of the block should be defined and documented. ANATOMY

FIG 1 • Ultrasound image of femoral nerve block. FN, femoral nerve; A, femoral artery.

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Chapter 1 Femoral and Adductor Canal Blocks

■ Crutch training, if appropriate, should take place prior to surgery. ■ Inpatients should be labeled as a “fall risk” and should not get out of bed without assistance. ■ Femoral nerve blocks for outpatients should be carefully considered and only performed with close follow-up and an otherwise low risk of falls. ■ The use of crutches and a knee immobilizer may attenu- ate fall risk with ambulation after a femoral nerve block. Positioning ■ The patient should be positioned supine with the opera- tive leg slightly externally rotated. ■ The bed should be flat with hips extended. ■ The patient’s ipsilateral hand may be kept out of the ster- ile field by lightly taping it to the chest. ■ The operator should stand on the side to be blocked, with the ultrasound machine on the other side of the patient. Approach ■■ With the use of ultrasound, the nerve may be approached either in-plane (needle parallel to transducer surface) or out- of-plane (needle perpendicular to transducer surface) with the ultrasound probe placed in a transverse orientation. ■ When a nerve stimulator technique is used, the needle approach is generally with the long axis of the nerve, at a 45-degree angle to the skin.

FIG 2 • Ultrasound image of adductor canal block. SN, saphenous nerve; SM, sartorius muscle; A, femoral artery; V, femoral vein.

■■ A nerve block in the adductor canal is less likely to cause quadriceps weakness than a femoral nerve block; how- ever, local anesthetic may spread proximally and affect motor nerves. ■■ The nerve to the vastus medialis is reliably anesthe- tized with an adductor canal block, but the overall effect on quadriceps function is minimal. 3 Preoperative Planning ■■ Surgical site, extent of incision, anticipated degree of pain, and any pre-existing conditions that increase risk of complications should be considered before offering the patient a nerve block. ■■ Postoperative ambulatory status should be determined to optimize dosing. ■ Femoral Block: Ultrasound-Guided Technique ■■ Position the patient as described above, with ASA (American Society of Anesthesiologists) standard moni- tors and supplemental oxygen applied. ■■ IV sedation, usually with fentanyl and midazolam, may be titrated to patient comfort. ■■ Using a high-frequency linear transducer, scan at the level of the inguinal crease in a transverse orientation to visualize the femoral artery and nerve in cross-section. ■■ The best image may be obtained in a location proxi- mal to the bifurcation of the femoral artery where the neurovascular bundle is closest to the skin. ■■ Identify the fascia lata, fascia iliaca, femoral nerve, and iliacus muscle. ■■ Slowly tilt the ultrasound transducer to optimize nerve imaging. ■■ Estimate the depth of the nerve in the ultrasound image. ■■ After sterile skin preparation, place a skin wheal just lat- eral to the ultrasound probe. ■ The depth of the nerve should guide the insertion site; start closer to the probe for more superficial tar- gets, and farther away if the target is deeper. ■■ Insert the block needle in the plane of the ultrasound image, visualizing the tip of the needle in real-time as the target is approached ( TECH FIG 1 ). ■■ The needle should pass through the fascia iliaca just lateral to the nerve. ■■ Tactile feedback through the needle may include a “pop” as the needle traverses fascial layers.

T E C H N I Q U E S

TECH FIG 1 • Positioning and approach for ultrasound-guided in- plane femoral nerve block.

■ Take care to avoid the lateral edge of the nerve. The patient may experience a paresthesia if the nerve is contacted directly. ■ The lateral circumflex femoral artery or one of its branches may be in the needle path or pass through the nerve, and should be avoided. ■ After careful aspiration, inject a small amount of local anesthetic. ■ Local anesthetic spread should appear as hypoechoic fluid filling the space deep to fascia iliaca and sur- rounding the nerve. ■ The needle may be advanced closer to the nerve as a local anesthetic pocket is formed (hydrodissection); this reduces the risk of needle-nerve contact. ■ When the needle is positioned in close proximity to the nerve, and local anesthetic spread is confirmed around the nerve, an additional 10 to 15 mL of local anes- thetic can be injected.

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T E C H N I Q U E S 4 Operative Techniques in Plastic Surgery: Lower Limb Reconstruction and Amputation ■■ Local anesthetic selection and volume of injection depend on the goals of the block. ■■

■ A catheter may be placed for continuous local anesthetic infusion. ■ Use 0.2% ropivacaine or 0.125% of bupivacaine at 4 to 6 mL/h for continuous infusion, with a patient- controlled bolus of 2 to 4 mL every 30 minutes. ■ Infusions are generally continued for 2 to 3 days fol- lowing surgery.

For a surgical block, use 20 to 30 mL of 1.5% mepi- vacaine, 2% lidocaine, 0.5% bupivacaine, or 0.5% ropivacaine. ■■ For an analgesic block, use 15 to 20 mL of 0.25% bupivacaine or 0.25% ropivacaine.

■ Femoral Block: Nerve Stimulator Technique

■ Adductor Canal Block: Ultrasound- Guided Technique ■■ Position and prepare the patient as for a femoral block. Externally rotating the leg may facilitate access to the adductor canal. ■■ Place a high-frequency linear transducer in a trans- verse orientation over the medial thigh at the midpoint between ASIS and the superior pole of the patella. ■■ Identify the sartorius, vastus medialis, and adductor longus muscles. ■■ The femoral artery and vein lie within the adductor canal. ■■ The saphenous nerve may be visualized just lateral to the artery, beneath the sartorius muscle and the vasto- adductor membrane. ■■ Estimate the depth of the nerve in the ultrasound image. ■■ After sterile skin preparation, place a skin wheal just lat- eral to the ultrasound probe. ■■ The depth of the nerve should guide the insertion site. ■■ Insert the block needle in the plane of the ultrasound image, visualizing the tip of the needle in real-time as the target is approached ( TECH FIG 3 ). ■■ Traverse the sartorius muscle to position the needle tip just lateral to the femoral artery. ■■ A “pop” may be felt as the needle passes through fas- cial layers. ■■ Following patient positioning and preparation described above, identify and mark the inguinal crease. ■■ Standing near the patient’s hip and facing the head, pal- pate the femoral pulse along the crease. ■■ After sterile prep, place a local anesthetic skin wheal 2 cm lateral to the femoral artery pulse. ■■ Insert a stimulating block needle at a 45 to 60 degree angle to the skin in a cephalad direction ( TECH FIG 2 ). ■■ A quadriceps twitch (“patellar snap”) should be elic- ited at a current of 0.2 to 0.5 mA. Redirect the needle until the appropriate stimulation is observed. ■■ Sartorius contraction indicates a needle placement on the anterior division of the femoral nerve. Further advancement of the needle toward the posterior divi- sion of the nerve will usually solve this. ■■ Aspiration of blood indicates intravascular placement. Reposition the needle. ■■ Muscle contraction at a current of greater than 0.5 mA usually indicates inadequate needle-nerve proximity and may result in an incomplete or failed block.

TECH FIG 2 • Positioning and approach for stimulator-guided fem- oral nerve block.

■ Muscle contraction at a current of less than 0.2 mA may indicate intraneural needle placement. Withdraw the needle slightly before injecting, carefully noting injection pressure. ■ Avoid high-pressure injection (greater than 15 psi), indicative of an intraneural needle placement. ■ Once an acceptable motor response is elicited, inject local anesthetic as above. The motor response should terminate with injection (Raj test).

TECH FIG 3 • Positioning and approach for ultrasound-guided adductor canal block.

■ Take care to avoid the femoral vein, which often lies deep and lateral to the artery, and may not be visible when pressure is applied to the ultrasound transducer. ■ After careful aspiration, inject a small amount of local anesthetic. ■ Observe local anesthetic spread in the ultrasound image. This should appear as hypoechoic fluid fill- ing the space deep to sartorius and lateral to femoral artery. ■ Ensure that local anesthetic is not tracking back along the sartorius muscle, but rather staying contained in the adductor canal while partially surrounding the femoral artery.

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Notes:

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