A 29-year-old man presented for arthroscopic-assisted repair of a torn right knee anterior cruciate ligament (ACL). The patient was discharged home after adequate analgesia was achieved with both a femoral nerve catheter and a sciatic block. He returned to the emergency department the following evening after falling when he got up to use the bathroom. An x-ray showed a fracture of the left fifth metatarsal. An open reduction and internal fixation (ORIF) of the fifth metatarsal is planned.
Describe the sensory innervation of the lower extremity.
Innervation of the lower extremity is derived from nerves of the lumbar and sacral plexuses, sometimes collectively referred to as the lumbosacral plexuses ( Figure 53-1 ). The lumbar plexus, which lies between the psoas major and quadratus lumborum fascias, is derived from the ventral rami of L1 to L4, with some contribution from T12, and branches into the iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous (also known as the lateral cutaneous nerve of the thigh), obturator, and femoral nerves. The saphenous nerve is the largest terminal branch of the femoral nerve. Sensory innervation of the lumbar plexus is shown in Table 53-1 .
|Iliohypogastric||L1||Superolateral buttock and thigh|
|Ilioinguinal||L1||Proximal anteromedial thigh|
|Genitofemoral||L1-L2||Inguinal region and proximal anteromedial thigh|
|Lateral femoral cutaneous||L2-L3||Lateral thigh from greater trochanter to proximal knee|
|Femoral||L2-L4||Anterior thigh, distal medial thigh |
Medial leg and foot
The sacral plexus is derived from the ventral rami of L4 to S4 and gives off the superior and inferior gluteal nerves, the posterior cutaneous nerve of the thigh, the pudendal nerve, and the sciatic nerve. The sciatic nerve is composed of two nerves, tibial and common fibular (formerly known as peroneal), bound together by a common sheath. The terminal branches of the tibial nerve include the medial and lateral plantar nerves. The terminal branches of the common fibular nerve include the deep and superficial fibular nerves. The union of branches from the common fibular and tibial nerves forms the sural nerve. Sensory innervation of the sacral plexus is shown in Table 53-2 .
|Posterior femoral cutaneous||S1-S3||Posterior thigh and popliteal fossa|
|Tibial||L4-S3||Lateral ankle and foot, posterior calf, heel and plantar surface of the foot (via medial and lateral plantar nerves)|
|Medial plantar||Plantar surface, medial to a line splitting the fourth toe|
|Lateral plantar||Plantar surface, lateral to a line splitting the fourth toe|
|Superficial fibular||Distal third of anterior leg and dorsum of foot|
|Deep fibular||Web space between first and second toes|
|Sural||S1-S2||Posterolateral leg and foot|
Which nerves are affected during anterior cruciate ligament surgery?
Postoperative pain after ACL repair originates from skin incisions, tibial periosteum at the bone tunnel site, inflammation and swelling within the knee joint, and the tendon harvest site (if an autograft is used). The nerves involved are the following:
Femoral nerve: skin incisions adjacent to the patellar tendon
Tibial nerve: tibial periosteum
Branches of femoral, obturator, sciatic nerves: internal knee joint
Femoral nerve: patellar tendon
Obturator nerve: gracilis tendon
Tibial nerve: semitendinosus tendon
What are the anesthetic options for anterior cruciate ligament surgery?
ACL surgery may be successfully performed under general anesthesia, neuraxial anesthesia, or peripheral nerve block. Although general anesthesia provides excellent operating conditions during surgery, it does not provide postoperative analgesia. Postoperative pain relief can be accomplished with either intravenous analgesic agents or femoral or lumbar plexus blocks or catheters placed perioperatively.
Spinal or epidural neuraxial anesthesia provides adequate analgesia for the procedure but limited postoperative pain relief. Although placement of an epidural catheter provides the potential for an extended period of postoperative analgesia, it is inappropriate for ambulatory procedures. For optimal postoperative pain control, a single-shot spinal technique should be combined with a femoral nerve catheter. The femoral nerve catheter provides extended postoperative analgesia without motor weakness in the nonoperative leg.
Peripheral nerve blocks alone can provide anesthesia, with or without the addition of sedation. They can also provide postoperative pain relief, either by continuous local anesthetic infusion via a catheter or by administration of a long-acting local anesthetic in the original block. Depending on the surgical plan, options include sciatic nerve block combined with either a lumbar plexus or fascia iliaca block.