A&A: The Efficacy of Skin Temperature for Block Assessment After Infraclavicular Brachial Plexus Block. A&A: Ultrasound-Guided Obturator Nerve Block: A Sonoanatomic Study of a New Methodologic Approach.
YouTube – Ultrasound-Guided Obturator Nerve Block
A nice video of an ultrasound-guided obturator nerve block. Importantly, they show the anterior and posterior divisions and demonstrate separate blockage of these nerves. As a reminder, always ensure a negative aspiration AND visualize spread of local anesthetic on ultrasound. The obturator artery and vein aren’t that far away….
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I am quite interested to know the indications for this block. After years of doing Nerve blocks for total knee replacement I have moved to Local Infiltration analgesia ( ref Dr Kerr , Sydney, Australia ). The results so far is very impressive . http://www.youtube.com/watch?v=Nq8Q2lpTJIU
For TKA, we usually place a femoral nerve catheter. Depending upon our surgeon, we may also perform single injection nerve blocks of the sciatic and obturator nerves. We’ve found that sciatic catheters may delay physical therapy participation.
Our most recent protocols involve FNC + single-injection obturator block, with PT starting on POD zero or early POD 1.
Of note, this is not our standard for the unicompartmental knee replacement seen on your video. For this procedure, we find that a femoral catheter alone is sufficient, and this is discontinued early on post-operative day 1.
Are you able to forward a description of the Kerr protocol? What I’ve found so far seems to describe continual intraarticular infusion of local anesthetic. While I’m unsure of the data at 24h, we’ve had considerable issues in the US with chrondromalacia following prolonged intraarticular local anesthetic infusion.
Continuous wound infiltration is an intersting alternative to continuous nerve blocks. The report in question Kerr DR, Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following hip and knee surgery: a case study of 325 patients. Acta Orthop 2008; 79:174-83., suggests an interesting alternative, but has considerable limitations. It is simply a case study, took place in a private practice setting which the authors admit represents a skewed patient population, and over half of the included patients were hip resurfacing procedures. Wound infiltration has been studied in a randomized fashion against placebo, but not against “gold standard” modalities such as continuous peripheral nerve block. Dr Tighe mentions concerns about cartlage effects, I would certainly add concerns re infection with a percutaneous catheter placed directly in aposition to an implanted prosthesis.
As for peripheral nerve block technique, there is a dearth of literature to guide us as far as “supplemental” blocks is concerned. I believe a well placed femoral catheter is by far the most important element and I reject the idea that this is time consuming or difficult in experienced hands. My personal practice is to supplement with single shot sciatic in TKA, I do not routinely perform obturator blocks.