| Control Group |
femoral nerve block and sciatic nerve block |
20 mL of bupivacaine 0.25% |
15 min |
The ultrasound scan for femoral nerve by using linear transducer(13-6 MHz) mid-point inguinal ligament 2cm caudally, cephalic direction at 30–45° angle, the femoral nerve will be visualized in transverse section 1.5–2 cm lateral to the Common Femoral Artery (CFA), a hyperechoic triangle formed by the fascia iliaca superiorly, Common Femoral Artery and iliopsoas muscle will be demonstrated, where the femoral nerve fibers are located, inserting 22-gauge needle in plane technique till reach this triangle, lateral to the femoral artery.
For sciatic nerve block patients are turned to lateral position with the side to be blocked uppermost, with slightly flexion of the hip and knee, under all aseptic precautions, ultrasound scan will be performed using (5-2 MHz )curvilinear transducers. After identifying the greater trochanter and the ischial tuberosity, a line will be drawn between these two landmarks, and the ultrasound probe will be positioned parallel to the line previously drawn with directed laterally.
The sub-gluteal space will be seen as a hypoechoic area between the hyperechoic shadows of the gluteus maximus and quadratus femoris muscles. At this level, the sciatic nerve will be visualized as oval hyperechoic nodule within the subgluteal space. At this view spinal needle will be inserted in the plane of the ultrasound beam and will be advanced toward the sciatic nerve in real-time |
30 |
Active-Treatment of Control Group |
| Experimental Group |
ultrasound guided Adductor Canal and IPACK block |
20 mL of bupivacaine 0.25% |
15 min |
For adductor canal block: while patients in supine position with knee slightly flexed and leg externally rotated (frog-leg position), under all aseptic precautions. The ultrasound scan in ACB will be performed using linear transducer (13-6 MHz) at the mid-point between the inguinal crease and medial condyle. Identify the femur (usually at a depth of 3–5 cm) and sartorius muscle (trapezoid/ boat-shaped) the femoral artery lies under this muscle in the adductor canal. The saphenous nerve usually appears at this position lateral to the artery as a hyperechoic structure. The block needle will be inserted in the plane in a lateral-to-medial orientation and advanced towards the femoral artery from the lateral side of the transducer, through the sartorius muscle, with the tip of the needle placed lateral to the artery .
For IPACK block: patient in supine position with knee slightly flexed and leg externally rotated (frog-leg position), clean the area with alcohol swap then will scan the popliteal fossa using a linear (6 -13 MHz) US probe at or proximal to the popliteal crease until the femoral condyles visualized. The US probe then proximally aligned until the condyles disappear and the shaft of the femur visible (interrupted hyperechoic line of the condyles changes to a continuous, hyper-echoic silhouette of the femoral shaft just cranial to the condyles . At this level, the block needle will be inserted in plane in the medial thigh using an anteromedial to posterolateral direction between the popliteal artery and the femur until the needle tip 1 cm beyond the lateral edge of the popliteal artery(the needle tip not be pushed 2 cm beyond the lateral edge of the popliteal artery to avoid anesthetizing the common peroneal nerve and causing a foot-drop |
30 |
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