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#35824 Unexpected foot drop after proximal ipack block
  1. Alessandro Ruggiero,
  2. Costa Fabio,
  3. Giuseppe Pascarella,
  4. Alessandro Strumia,
  5. Stefano Rizzo,
  6. Francesca Gargano,
  7. Massimiliano Carassiti and
  8. Felice Eugenio Agrò
  1. Campus Biomedico University Hospital Foundation, Rome, Italy


Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)

Background and Aims In our institution, a common practice for providing motor-sparing analgesia after total knee replacement (TKR) is by combining the distal IPACK with adductor canal block. These blocks are typically administered preoperatively after spinal anesthesia to enable pain-free early exercise or deambulation as the neuraxial block wears off. However, in this case report, we describe an inadvertent sciatic block following proximal IPACK block.

Methods Informed consent for publication was obtained. A 69-year-old woman scheduled for TKR, was admitted to the preoperative room with delay. Since the patient arrived late, we decided to proceed with spinal anesthesia and surgery, postponing the analgesic blocks to the recovery area. In order to avoid dressing manipulation and to maintain distance from the prosthesis, we performed the IPACK block postoperatively using the proximal technique, approximately two fingers above the patella in supine position. We injected 20 ml of 0.5% ropivacaine with dexamethasone 4 mg between the popliteal vessels and the femur.

Abstract #35824 Figure 1

Proximal IPACK block simulation: F = femur shaft; A = popliteal artery; SN = possible location of sciatic nerve. The technique does not permit optimal visualization and require the needle to point an area at risk for nerve involvement. Nerve stimulation is recommended

Results The first evaluation was postponed to the following morning since it was late afternoon when the block was performed. The patient presented with complete sensory and motor block below the knee, which resolved completely about 18 hours after the block.

Conclusions Proximal approach to IPACK may increase the risk of local anesthetic spreading toward the sciatic nerve and subsequent motor block. Therefore, we recommend performing this block with nerve stimulator or to chose alternative analgesic techniques for the posterior capsule of the knee, unless a clear US real-time visualization of the nerve structures during injection is possible.

  • knee replacement
  • motor sparing
  • fast track
  • adductor canal

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