![]() Finally, we also block the nerve to vastus intermedius, as it lies on the anterior surface of the femur just proximal to the patella, making it an easy additional target. We omit the inferolateral genicular nerve because it runs in close proximity to the common peroneal nerve, and blockade at this site may result in temporary foot drop. Our genicular nerve block technique involves blockade of three of the genicular nerves (superolateral, superomedial, and inferomedial) as they travel around the femur and tibia toward the anterior capsule. ILGN, inferolateral genicular nerve IMGN, inferomedial genicular nerve NVI, nerve to vastus intermedius NVL, nerve to vastus lateralis NVM, nerve to vastus medialis RPN, recurrent peroneal nerve SaN, saphenous nerve SLGN, superolateral genicular nerve SMGN, superomedial genicular nerve. Schematic diagram showing posterior (A) and anterior (B) innervation of the knee capsule and joint. The three genicular targets are the SMGN, SLGN and IMGN. ![]() Some cadaveric sources describe the superomedial genicular nerve as originating from a branch of the femoral nerve while interindividual variation exists, the upstream origin of this branch is not important from a clinical perspective, as its eventual location just proximal to the medial epicondyle is consistent.įigure 1. These genicular nerves “wrap around” from behind to the anterior aspect of the knee, and their consistent proximity to the metaphysis of the femur and tibia make them easy targets for blockade. The cardinal genicular nerves are named for their position relative to the knee joint: the superomedial genicular nerve (SMGN), the superolateral genicular nerve (SLGN), and the inferomedial (IMGN) and inferolateral (ILGN) genicular nerves. The anterior knee joint and capsule are supplied by four branches of the femoral nerve (the saphenous nerve and articular branches of the nerves to the three vasti), as well as multiple branches from the sciatic nerve. The posterior knee is innervated largely by the popliteal plexus, derived from the tibial and obturator nerves. ![]() AnatomyĪn overview of knee innervation is presented in Figure 1. 3 Recently, it was shown that the addition of genicular nerve blockade for TKA patients can significantly reduce postoperative opioid requirement, 4 and since these blocks are simple and quick to perform, they are an impactful addition to our block pathway for knee arthroplasty patients. Targeted genicular nerve blocks (or ablative procedures) have been a standard chronic pain intervention for arthritic pain in the past. Only two of these nerves (the saphenous and nerve to vastus medialis) are covered by a standard adductor canal block. This is not surprising, as the anterior knee is innervated by the saphenous nerve, articular branches of the nerves to the three vastus muscles (medialis, intermedius, and lateralis), and at least four genicular nerves. 1,2 However, many patients continue to experience significant pain after TKA, even when these two blocks are performed. Targeted, motor-sparing regional techniques such as adductor canal blocks and posterior capsule infiltration (aka IPACK) provide good pain control while facilitating early ambulation and rehab. Regional analgesia is a foundational component of multimodal postoperative pain management following knee replacement surgery (TKA). How I do it: genicular nerve blocks for acute pain.
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