| Experimental Group |
Anterior Femoral Cutaneous Nerve Block in Combination with Femoral Triangle Block |
20 ml volume of 0.25% bupivacaine divided upon two 10 ml syringes one for each block |
single injection after administration of spinal anesthesia |
Anterior femoral cutaneous nerve block (AFCNB): Ultrasound-guided AFCNB will be performed by placing the transducer along the upper to middle third of the thigh. After identifying the position of the superficial femoral artery (SFA) beneath the sartorius muscle (SM) in the ultrasound image, the transducer will be moved slightly cephalad to identify the optimal position of the SFA beneath the medial border of the SM in the ultrasound (Abdallah et al., 2019). After administration of 1−2 ml of 1% lidocaine to anesthetize the skin, an echogenic B-bevel needle will be inserted from the lateral-to-medial direction using an “in-plane technique” and then the needle will be advanced until the needle tip will be superficial to the fascia lata at the junction of the sartorius and rectus femoris muscles (Sogbein et al., 2017). Thereafter, 5 ml of Bupivacaine 0.25% will be slowly injected after careful aspiration while the needle is being advanced superficial to the fascia lata covering the SM until it reaches the medial border of the SM to block the intermediate cutaneous nerve of the thigh (ICNT) (Johnston et al., 2018). The needle will be then redirected to pierce the fascia lata and another 5 ml of bupivacaine 0.25% will be slowly injected after careful aspiration between the fascia lata and SM until the tip of the needle reaches the medial border of the SM to block the medial cutaneous nerve of the thigh (MCNT) (Bjorn et al., 2020).
-Femoral triangle block (FTB):
The saphenous nerve will be identified by ultrasound and will be seen anterolateral and adjacent to the femoral artery in a short-axis view, approximately ten cm distal to the midpoint of the inguinal ligament inside the femoral triangle and deep to the sartorius muscle. The needle will be inserted in plane with the ultrasound beam through the sartorius muscle. The end point of injection will be peri-arterial spread of local anesthetic around the anterolateral part of the femoral artery to anesthetize the saphenous nerve, the medial vastus muscle nerve, and the medial femoral cutaneous nerve. A 10 ml of bupivacaine 0.25% will be injected incrementally via the needle after careful aspiration. The solution will be seen peri-arterially spreading around the femoral artery (Runge et al., 2020).
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30 |
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| Control Group |
Adductor Canal Block |
20 ml of 0.25% bupivacaine |
single injection after administration of spinal anesthesia |
With the patient supine, and the knee externally rotated and slightly flexed, the ultrasound probe is positioned axially at mid-thigh and femoral artery is visualised. The probe is then moved medially and distally to identify a point between the middle and distal third of the thigh where the artery lies deep to the sartorius and proximal to the adductor hiatus where the saphenous nerve is anterolateral to the artery. The needle is inserted in-plane from lateral to medial till the tip lies superficial to the femoral artery afterward, a 20 ml of 0.25% bupivacaine will be injected (Sogbein et al., 2017). |
30 |
Active-Treatment of Control Group |