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Evaluation of the iPACK block injectate spread: a cadaveric study
  1. John Tran1,
  2. Laura Giron Arango2,
  3. Philip Peng3,
  4. Sanjay Kumar Sinha4,
  5. Anne Agur1 and
  6. Vincent Chan2
  1. 1 Division of Anatomy, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  2. 2 Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
  3. 3 Department of Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
  4. 4 Anesthesiology, St Francis Hospital and Medical Center, Hartford, Connecticut, USA
  1. Correspondence to Professor Vincent Chan, Department of Anesthesia, University of Toronto, Toronto, ON M5G 1E2, Canada; mail2vincechan{at}


Background and objectives Ultrasound-guided infiltration of the interspace between the popliteal artery and capsule of the knee (iPACK) block, a new regional analgesic technique, is believed to relieve posterior knee pain, after total knee arthroplasty, by targeting the articular branches innervating posterior aspect of the joint. The extent of injectate spread and the number of articular branches affected is currently unknown. This cadaveric study aimed to compare the area of dye spread and frequency of articular branches staining following a proximal versus distal injection technique.

Methods An ultrasound-guided iPACK injection (10 mL of methylene blue dye solution) was performed in 14 lightly embalmed specimens: 7 injected using a proximal injection technique (1 fingerbreadth above base of patella) and 7 using a distal injection technique (at the superior border of the femoral condyles). Following injection, dissection, digitization, and 3D modeling were performed to map the area of dye spread and determine the frequency of nerve staining.

Results Both injection techniques achieved a similar mean area of injectate spread. Of the four articular branches supplying the posterior knee joint capsule, the genicular branch of posterior division of obturator nerve was stained in all specimens. The proximal injection resulted in staining of superior medial genicular nerve, due to dye spread through the adductor hiatus, whereas superior lateral genicular nerve and anterior branch of common fibular nerve were consistently stained following distal injection. Other articular branches were stained with variable frequency.

Conclusions Both proximal and distal iPACK injection techniques provided a similar area of dye spread in the popliteal region and extensive staining of the articular branches supplying the posterior capsule. The proximal injection technique promoted greater anteromedial dye spread, while the distal injection had more anterolateral spread. Further clinical study is required to confirm our cadaveric findings.

  • anatomy
  • joint innervation
  • knee joint
  • nerve blocks
  • iPACK

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  • Presented at This work has been previously presented in part at the 2018 World Congress on Regional Anesthesia and Pain Medicine, 19-21 April 2018, New York, NY, USA.

  • Contributors JT, PP, AA, and VC contributed to the experimental design, data acquisition, data analysis, drafting and revising the manuscript critically for important intellectual content. LGA contributed to acquisition, analysis of data and drafting of the manuscript. SKS contributed to the experimental design and drafting of the manuscript.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests AA: Anatomy Faculty, Allergan Academy of Excellence. VC has received honorarium from Aspen Pharma, BBraun, Smiths Medical and SonoSite. PP received equipment support from SonoSite Fujifilm Canada. SKS has received honorarium from Pacira Pharmaceutical and Flexion Therapeutics.

  • Patient consent for publication Not required.

  • Ethics approval This cadaveric study was approved by the University of Toronto Health Sciences Research Ethics Board (No 27210).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data relevant to the study are included in the article or uploaded as supplementary information.