Evaluation of the iPACK block injectate spread: a cadaveric study

John Tran; Laura Giron Arango; Philip Peng; Sanjay Kumar Sinha; Anne Agur; Vincent Chan

doi:10.1136/rapm-2018-100355

Evaluation of the iPACK block injectate spread: a cadaveric study

Reg Anesth Pain Med. 2019 May 6:rapm-2018-100355. doi: 10.1136/rapm-2018-100355. Online ahead of print.

Authors

John Tran¹, Laura Giron Arango², Philip Peng³, Sanjay Kumar Sinha⁴, Anne Agur¹, Vincent Chan⁵

Affiliations

¹ Division of Anatomy, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
² Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.
³ Department of Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
⁴ Anesthesiology, St Francis Hospital and Medical Center, Hartford, Connecticut, USA.
⁵ Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada mail2vincechan@aol.com.

PMID: 31061110
DOI: 10.1136/rapm-2018-100355

Abstract

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. .

Keywords: anatomy; iPACK; joint innervation; knee joint; nerve blocks.