The Anatomic Relationship of the Tibial Nerve to the Common Peroneal Nerve in the Popliteal Fossa: Implications for Selective Tibial Nerve Block in Total Knee Arthroplasty

Eric R Silverman, Amaresh Vydyanathan, Karina Gritsenko, Naum Shaparin, Nair Singh, Sherry A Downie, Boleslav Kosharskyy, Eric R Silverman, Amaresh Vydyanathan, Karina Gritsenko, Naum Shaparin, Nair Singh, Sherry A Downie, Boleslav Kosharskyy

Abstract

Background. A recently described selective tibial nerve block at the popliteal crease presents a viable alternative to sciatic nerve block for patients undergoing total knee arthroplasty. In this two-part investigation, we describe the effects of a tibial nerve block at the popliteal crease. Methods. In embalmed cadavers, after the ultrasound-guided dye injection the dissection revealed proximal spread of dye within the paraneural sheath. Consequentially, in the clinical study twenty patients scheduled for total knee arthroplasty received the ultrasound-guided selective tibial nerve block at the popliteal crease, which also resulted in proximal spread of local anesthetic. A sensorimotor exam was performed to monitor the effect on the peroneal nerve. Results. In the cadaver study, dye was observed to spread proximal in the paraneural sheath to reach the sciatic nerve. In the clinical observational study, local anesthetic was observed to spread a mean of 4.7 + 1.9 (SD) cm proximal to popliteal crease. A negative correlation was found between the excess spread of local anesthetic and bifurcation distance. Conclusions. There is significant proximal spread of local anesthetic following tibial nerve block at the popliteal crease with possibility of the undesirable motor blocks of the peroneal nerve.

Conflict of interest statement

The authors do not report any relevant conflict of interests.

Figures

Figure 1
Figure 1
Blue dye injected around the tibial nerve at the popliteal crease. (a) Spread of blue dye is observed with significant extension proximal to the bifurcation point of the sciatic nerve. Complete sparing of the common peroneal nerve is observed at the level of the popliteal crease, (b) MSN = medial sural nerve; TN = tibial nerve; CPN = common peroneal nerve; SN = sciatic nerve.
Figure 2
Figure 2
Ultrasound image of the common peroneal nerve and tibial nerve at the popliteal crease after selective tibial nerve block. Local anesthetic was observed around the tibial nerve but not the common peroneal nerve. (a) Local anesthetic could be traced proximally toward the bifurcation which was observed to encircle the sciatic nerve proximal to the bifurcation, (b) CPN = common peroneal nerve; TN = tibial nerve; LA = local anesthetic; SN = sciatic nerve; PA = popliteal artery.
Figure 3
Figure 3
Scatter plot showing the relationship between bifurcation length and excess spread of local anesthetic. Excess spread was measured as the distance between the bifurcation point and maximal spread of local anesthetic proximal to the bifurcation. A negative correlation was found between the excess spread of local anesthetic and bifurcation length, r = −0.5605, p = 0.01.

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