Anaesthesia, 2010, 65 (Suppl. 1), pages 57–66
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Lower limb blocks
J. M. Murray,1 S. Derbyshire2 and M. O. Shields3
1 Consultant Anaesthetist, Department of Anaesthetics, Queen’s University, Belfast, UK
2 Research Nurse, Musgrave Park Hospital, Belfast, UK
3 Consultant Anaesthetist, Department of Anaesthetics, Royal Hospitals Trust, Belfast, UK
Summary
The advances in regional techniques for blocks of the lower limb have been driven primarily by the
need to produce effective analgesia in the postoperative period and beyond. These techniques are
commonly performed before or after central neuraxial blockade when this technique is used to
provide anaesthesia and analgesia for the surgical procedure. Increasingly, modern practice demands
a shorter hospital stay, improved patient expectations and early mobilisation. This article describes
the current methods and reasons for performing specific blocks to the lower limb and the man-
agement of these blocks particularly in the postoperative period.
. ......................................................................................................
Correspondence to: Dr James Murray
E-mail: james.murray@qub.ac.uk
Regional anaesthesia for major lower limb surgery such as
hip and knee arthroplasty is readily provided by central
neuraxial blockade, obviating the need for peripheral
blocks for the operative procedure itself. For this reason,
the advance of the popularity of peripheral nerve blocks
for lower limb surgery has been in the effective manage-
ment of pain and in accelerating postoperative mobility.
Pain management after lower limb surgery has a signif-
icant impact on overall postoperative outcome in terms of
faster mobilisation, less postoperative nausea and vomit-
ing, and decreased overall hospital stay. Both early
mobilisation and shorter hospital stay have been achieved
in large part by advances in anaesthesia, postoperative
rehabilitation and surgical technique [1]. Inadequate
control of pain prevents early mobilisation and militates
against these advances. Parenteral opioids still continue to
play a major role in postoperative pain control strategies
despite significant side effects such as nausea and vom-
iting, hypotension, confusion, constipation, urinary
retention, sedation, respiratory depression and pruritus
[2–6]. These side effects are undesirable for patients in
whom early mobilisation and hospital discharge are
planned. Capdevila et al. [7] highlighted the importance
of analgesia in optimising postoperative rehabilitation.
These authors insist on the need to develop techniques
that allow early functional recuperation, and they
emphasise the importance of integrating multimodal
analgesia into rehabilitation programmes.
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Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
doi:10.1111/j.1365-2044.2010.06240.
Singelyn et al. [8] reported that regional analgesic
techniques (epidural analgesia or ‘three-in-one’ blocks)
enhance early recovery after unilateral total knee replace-
ment. Nevertheless, there were no additional significant
differences between the groups at 6 weeks and 3 months
after surgery in term of knee flexion and mobility.
Capdevila et al. [7] also demonstrated a better early
quality of rehabilitation after major knee surgery by using
regional analgesia, but found no functional difference at
one or 3 months afterwards. More recently, Singelyn
et al. [9] also failed to demonstrate any advantage of
regional analgesia (epidural or femoral nerve block) over
morphine patient-controlled analgesia in terms of ambu-
lation, fatigue, patient activity, or hospital stay in a
classical program of rehabilitation after hip replacement.
However, even if there are no absolute, longer-term
advantages of regional analgesia, nerve blocks are still
important both for provision of good quality analgesia and
an excellent short-term side-effect profile. Progress in
anaesthetic techniques and drugs has led to a decrease in
the incidence of mortality and major morbidity to the
point at which it may be difficult to compare these
outcomes without huge, randomised controlled trials or
patient databases. This also includes the methods of
delivery of the local anaesthetic (LA) such as the use of
infusion devices that provide patient-controlled regional
anaesthesia [10]. Therefore, patient-orientated outcomes
such as satisfaction, quality of life and quality of recovery
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have become more prominent [11–13], reflecting numerous branches early in the proximal anterior thigh.
increased interest in patient-focussed assessments. All of Blockade of the femoral nerve (Figs. 1–3) provides
these new parameters are important to consider and are sensory anaesthesia of the anterior thigh, knee and medial
valid outcomes. aspect of the calf, ankle and foot. Femoral nerve block
One of the key drivers in modern practice is the need should be distinguished from the ‘three-in-one’ block and
to achieve a shorter length of hospital stay [14]. For this to the fascia iliaca block, techniques that hope to achieve
occur, changes to individual clinical practice are required, anaesthesia of the lateral femoral cutaneous and obturator
including admissions on the day of surgery and better nerves as well as the femoral nerve.
patient preparation, leading to improved expectations of Femoral nerve block can be used to provide peri-
patients and, most importantly, improved postoperative operative analgesia for femoral neck fractures or total hip
pain management leading to earlier mobilisation. The
postoperative management of nerve blocks is one of the
key factors in successful outcome. It requires multidis-
ciplinary input from anaesthetists, physiotherapists and,
most importantly, the nurses who are looking after the
patient. Before introducing the technique, considerable
effort must be invested in educating the nursing and phys-
iotherapy staff about anatomy, complications, trouble-
shooting and pump delivery systems.
The rest of this section will describe the important
aspects of some popular lower limb blocks.

Femoral nerve block

The femoral nerve arises from the lumbar plexus and has
the root value L2–L4. The nerve travels through the
substance of the psoas muscle behind the fascia iliaca, and
then passes anterior to the iliopsoas muscle under the
Figure 2 Ultrasound view of the anatomy of the left femoral
inguinal ligament before becoming more superficial in the triangle.
anterior thigh. The nerve lies deep to the fascia lata and
fascia iliaca. As the femoral artery and vein pass behind the
inguinal ligament, they become surrounded in a fascial
sheath. The femoral nerve lies posterior and lateral to this
sheath and not within it. The femoral nerve divides into

Figure 3 Ultrasound view of the anatomy of the left femoral

Figure 1 In-plane approach for ultrasound-guided block of the triangle after injection of local anaesthetic (LA). Note LA
femoral nerve. contained below fascia iliaca.

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58 Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65 (Suppl. 1), pages 57–66
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arthroplasty. When performed before surgery, it facilitates
patient positioning for placement of a neuraxial block.
Other indications for femoral nerve block include
providing pre-operative or postoperative analgesia for
femoral shaft fractures, surgical anaesthesia for day-case
saphenous vein stripping and knee arthroscopy, postoper-
ative analgesia for knee procedures or total knee arthro-
plasty, and surgical anaesthesia for femoropopliteal bypass
surgery [15–17]. It is important to remember that failure
to obtain an opioid-sparing effect in certain knee
procedures may be related to lack of blockade of sensory
fibres from the sciatic and obturator nerves, which can
provide a significant proportion of the sensory innerva-
tion of the knee.
The presence of a prosthetic femoral artery graft is a
relative contraindication to femoral nerve block. The
procedure, particularly when combined with sciatic
block, is also relatively contraindicated in situations where
a dense sensory block could mask the onset of lower
extremity compartment syndrome, e.g. fresh fractures of
the tibia and fibula, or traumatic and extensive elective
orthopedic procedures of the tibia and fibula. This
contraindication is not specific for the femoral nerve
block but rather applies to regional anaesthesia of the
lower extremity in general. Best practice suggests that
consultation with surgical colleagues should be sought as
to the likelihood of the development of compartment
syndrome.
Postoperative analgesia can be continued for a number
of days with a LA infusion when a catheter is placed close
to the femoral nerve. This technique has been shown to
reduce systemic opioid requirements significantly with a
minimum of complications after total knee arthroplasty.
Both ultrasound-guided and nerve stimulator techniques
can be modified for the placement of an indwelling
catheter for continuous femoral nerve block [18, 19].
Continuous techniques have the advantage of providing
high quality postoperative analgesia and minimising
systemic opioid requirements, without the disadvantages
of epidural analgesia such as urinary retention, orthostatic
hypotension and impaired mobilisation. Much has been
written about continuous femoral nerve blocks and their
advantages regarding earlier mobilisation and duration of
hospital stay [20–22]. Outpatient knee surgery has come
to involve increasingly complex procedures such as high
tibial osteotomy, multiple ligament reconstructions and
meniscal reconstruction. Many institutions, particularly in
the US, send patients home with a catheter and infusion
in place. This approach is particularly popular with
patients who have undergone total knee replacement.
Pain after knee replacement surgery can be intense,
especially during physiotherapy and rehabilitation, and
this is the one area in which good analgesia using a
 2010 The Authors
Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
J. M. Murray et al. Æ Lower limb blocks
continuous femoral nerve block really does make a
difference to postoperative outcome. This is not achieved
solely by the block itself but by input from a multidis-
ciplinary team comprising anaesthetists, nurses and phys-
iotherapists.
Continuous infusion was associated with significant
improvements in some functional outcomes in both
studies that compared continuous blockade with placebo
or no treatment. In their prospective study of 211
patients, Cuvillon et al. [23] found that continuous
femoral nerve catheters were effective for postoperative
analgesia but had a relatively high rate of bacterial
catheter colonisation. However, they found no serious
infections after short-term (2-day) infusion. Side effects
were few, but one nerve injury occurred. In a
retrospective study of patients having outpatient knee
surgery, Williams et al. [24] demonstrated that patients
undergoing complex surgery were significantly more
likely to be admitted to the hospital overnight than were
patients undergoing less invasive surgery, and that
patients undergoing complex surgery who were given
femoral or sciatic nerve blocks were significantly less
likely to require hospital admission than those patients
undergoing complex surgery and who were not given
nerve blocks.
Three-in-one block and fascia iliaca block
The three nerves referred to in this block are the femoral
nerve, the lateral cutaneous nerve of the thigh and the
obturator nerve. The ‘three-in-one’ block is indicated
when anaesthesia in the distributions of the obturator and
lateral femoral cutaneous nerves as well as the femoral
nerve is desired. It is essentially a variation of the femoral
nerve block and was first described by Winnie et al. [25].
This technique relies on a single injection of large
volumes of LA within the neurovascular ‘sheath’ with the
needle directed cranially, and the subsequent spread of
anaesthetic proximally, aided by pressure applied distal to
the sheath, to achieve anaesthesia in the desired location.
Dye injection studies in cadavers [26] have cast doubt on
whether LA spreads proximally to block the obturator
nerve, and there have been suggestions that when the
block is effective, it is because of lateral spread of LA.
Clinical studies have also demonstrated that failure to
obtain anaesthesia in the distribution of lateral femoral
cutaneous and obturator nerves is common even with
large volumes (40 ml) of LA [27].
The fascia iliaca compartment block is a hybrid anterior
lumbar plexus approach with a puncture point relatively
distant from the neurovascular sheath. A nerve stimulator
is not necessary for this procedure. It was described in
children in 1989 [28]. It is widely used for postoperative
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J. M. Murray et al. Æ Lower limb blocks Anaesthesia, 2010, 65 (Suppl. 1), pages 57–66
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analgesia after lower limb surgery in children and adults, 34]. When used in combination or as a sole technique, it
and provides effective postoperative analgesia after hip, has the distinct advantage of delivering superior postop-
femoral shaft or knee surgery [29]. Compared with the erative analgesia when compared to intravenous opioids
‘three-in-one’ block, it provides a faster and more or femoral nerve block [35]. In addition, it may be used in
consistent simultaneous blockade of the lateral femoral conjunction with a sciatic nerve block to provide
cutaneous nerve and femoral nerve [30]. complete analgesia of the lower limb when central
As a result of the low incidence of obturator nerve neuraxial block is contraindicated. The combination of
block, the ‘three-in-one’ technique is best reserved for general anaesthesia and lumbar plexus block is particularly
surgical procedures in the distribution of the femoral and useful in revision joint replacement where the surgery is
lateral cutaneous nerves. It is thus not ideal for patients likely to be prolonged.
undergoing femoral neck surgery and hip reduction or Numerous posterior approaches have been described
replacement. The fascia iliaca compartment block pro- and all tend to be variations on a theme [36]. Although
vides a faster and more consistent simultaneous blockade most anaesthetists currently use a nerve stimulator based
of the lateral cutaneous and femoral nerves than the technique, Karmakar et al. [37] recently described the
‘three-in-one’ block. Both blocks have value in the initial sono-anatomy relevant to posterior lumbar plexus block
management of patients with femoral neck fracture who and recommended its routine use. In their paper, they
need to be moved and positioned for X-ray examination describe a technique of ultrasound-guided lumbar plexus
or positioned for spinal anaesthesia. A sensory block of the block that was successfully used in conjunction with
internal part of the thigh is an early predictive sign of sciatic nerve block for anaesthesia in a series of patients
optimal pain relief [30]. undergoing emergency lower limb surgery. In the
resultant longitudinal ultrasound image, the acoustic
shadow of the transverse processes produces the so-called
Posterior lumbar plexus block or psoas
‘trident sign’. The lumbar plexus is seen through the
compartment block
acoustic window of the trident as multiple longitudinal
The lumbar plexus is formed from the anterior divisions hyperechoic striations against a hypoechoic background
of the first three and the greater part of the fourth lumbar typical of muscle (Fig. 4).
nerves; the first lumbar often receives a branch from the Continuous lumbar plexus techniques have the advan-
last thoracic nerve. It is situated in the posterior part of tage of providing high quality postoperative analgesia and
the psoas muscle, in front of the transverse processes of minimising systemic opioid requirements, without the
the lumbar vertebrae. From a practical point of view, the disadvantages of epidural analgesia such as urinary reten-
main nerves to consider when performing a lumbar tion, orthostatic hypotension and impaired ambulation
plexus block are the femoral nerve, lateral cutaneous [15, 36, 38, 39].
nerve of the thigh and the obturator nerve. Using a
posterior approach, the plexus as a whole is blocked as the
nerves enter the psoas muscle. It is therefore a reliable
method for anaesthesia and analgesia of hip, and the
anterior aspects of the inner and outer thigh as far as the
knee.
The lumbar plexus is contained in an anatomical space
called ‘the psoas compartment.’ Within the psoas muscle,
the branches of the plexus are close to each other at the
level of the transverse processes of the L4 and L5
vertebrae. Medially, the psoas compartment is continuous
with the intervertebral foramina of L4 and L5 [31]. This
explains why LA or a catheter inserted by the posterior
approach may reach the epidural space. The proximity of
the lumbar plexus to the retroperitoneum and peritoneal
cavity means that complications such as kidney and bowel
puncture may occur.
Lumbar plexus block is most commonly performed in Figure 4 Longitudinal ultrasound image of the lumbar spine,
with the acoustic shadows of the lumbar transverse processes
combination with either central neuraxial blockade or producing the ‘trident sign’. TPL2, TPL3, TPL4: Transverse
general anaesthesia to provide analgesia for hip replace- processes of second, third and fourth lumbar vertebrae.
ment or as a sole procedure for femoral neck surgery [32– Reproduced with permission [37].

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60 Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65 (Suppl. 1), pages 57–66 J. M. Murray et al. Æ Lower limb blocks
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with more postoperative pain than hip replacement, it

Intra-articular techniques
could be concluded that the knee patients accounted for
To minimise the side effects of parenteral opioids, an the differences seen.
analgesia protocol should ideally not only be multimodal, Anderson et al. [45] observed that after total hip
but it should block pain at its origin while maintaining replacement, LA wound infiltration as part of a multi-
maximum muscular control and optimising active modal analgesia regime decreased opioid consumption,
physiotherapy and rehabilitation. Peri-articular injection improved mobilisation and reduced hospital stay by 2 days
of LA may be a technique that can achieve these results. when compared to epidural analgesia. However, the
As such, intra-articular injection of LA has recently technique described included a postoperative intra-artic-
enjoyed considerable success as a simple and effective ular injection via a catheter. This, as previously mentioned,
method of providing postoperative analgesia for surgery not only raises concern over postoperative infection but
on the hip and knee. It is particularly useful after also makes blinding of the treatment groups difficult. In
arthroscopy, anterior cruciate ligament reconstruction addition, no details were given of the number of
and primary knee replacement. physiotherapists involved or whether objective guidelines
Infiltration of LA as part of a multimodal analgesia for assessment or grading of assistance were provided.
regime has recently been suggested to improve outcomes Kerr and Kohan [46] described a multimodal technique
after total hip and knee replacement [40, 41]. In contrast for the control of pain after knee and hip surgery called
to epidural analgesia and peripheral nerve blocks, LA ‘local infiltration analgesia’. It is based on the systematic
infiltration is simple, cheap and apparently safe. In infiltration of a mixture of ropivacaine, ketorolac and
essence, the technique includes an intra-operative infil- adrenaline into the tissues around the surgical field to
tration of the whole surgical area with 100–150 ml achieve satisfactory pain control with little physiological
levobupivacaine 0.1% or ropivacaine 0.2% with adrena- disturbance. The technique allows virtually immediate
line before wound closure. Most studies of this technique mobilisation and earlier discharge from hospital. In this
have been for total knee replacement and an indwelling approach, a mixture of ropivacaine, ketorolac and
catheter has been left in place, allowing repeated injec- adrenaline is injected around all structures subject to
tions or infusion. Concerns have been raised about surgical trauma, and is followed by top-ups via a catheter.
postoperative infection, and although studies to date have In contrast to conventional acute pain management,
not shown an increased infection rate, the study numbers opioid drugs are used only sparingly or not at all. Three
have been small and at least one study showed signifi- reports by others [40, 41, 47], involving 64, 44, and 41
cantly increased wound ooze. Certainly, the limited patients respectively, detailed limited but successful trials
evidence for total hip replacement shows an improve- of regimens based on this technique but without details of
ment in postoperative pain management and quicker the actual technique used, thereby precluding its thor-
rehabilitation, although the infiltration not only con- ough evaluation. Studies comparing outcomes obtained
tained bupivacaine and adrenaline but also included using this technique with those after continuous femoral
methylprednisolone and morphine [42]. A study by nerve block or placebo saline injection were subject to
Millington et al. [43] assessed a single intracapsular editorial comment that outlined the directions that
injection of LA for total hip replacement and found no research in this area should take [48]. Otte et al. [49]
significant improvement in outcomes. recently confirmed the analgesic efficacy and simplicity of
There has been considerably more published research the technique. However, they stress that more data are
into the outcomes after total knee replacement using a required from several centres regarding safety and the role
multimodal protocol with LA wound infiltration, but of incisional infusions of opioids, non-steroidal anti-
evidence with regard to total hip replacement is limited or inflammatory drugs and LAs. In addition, further detailed
presented in combination with total knee replacement. studies on the volume and concentration of LA used, the
Peters et al. [44] observed an improvement in pain scores type and location of catheter for drug administration (i.e.
and faster rehabilitation in patients undergoing total hip intra-articular or extra-articular administration) use of
and knee replacement who were given LA wound single or multihole catheters, and the requirement for and
infiltration as part of a multimodal peri-operative analge- type of additional systemic analgesic drugs are required.
sia regimen. However, the study was retrospective, the Subsequently, the optimised infiltration technique should
control group did not have a standardised analgesia be compared in blinded, randomised studies to the
protocol, and non-validated assessment tools were used. present gold standard of continuous peripheral nerve
The results for both hip and knee replacements were blocks and systemic analgesics, including its potential for
presented in combination rather than separately, and as it improving early rehabilitation, earlier achievement of
is generally accepted that knee replacement is associated discharge criteria and reduction of hospital stay.

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J. M. Murray et al. Æ Lower limb blocks Anaesthesia, 2010, 65 (Suppl. 1), pages 57–66
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anterior approach with the posterior subgluteal approach

Proximal sciatic nerve block
under ultrasound guidance in patients undergoing minor
The sciatic nerve is the largest peripheral nerve in the knee surgery. They showed that there were no differ-
human body. Its anatomy has been well described in ences in the onset of sensory and motor blockade of the
classical textbooks. However, as with much anatomy, sciatic nerve after the block between the two approaches
there are many variations from normal that may lead to and argued that either the anterior or posterior approach
subsequent failure of a regional anaesthetic technique. can be used interchangeably for minor knee surgery.
The sciatic nerve divides into two large terminal Sensory block of the posterior femoral cutaneous nerve,
branches. Although this typically happens approximately which runs parallel to the sciatic nerve in the gluteal
6.6 cm proximal to the popliteal crease [50], the division region, is rarely achieved after the anterior approach.
may occur at any level below the greater sciatic foramen, However, this does not appear to constitute a disadvan-
and such high divisions may be a cause of incomplete or tage for knee surgery in which a thigh tourniquet is
failed blocks if unrecognised [51]. A sciatic nerve block used.
can be used to provide peri-operative analgesia for hip, Continuous sciatic nerve block using a perineural
ankle and foot surgery, and is particularly useful in catheter has been described for many of the approaches
providing postoperative analgesia for lower limb ampu- described above [62–66]. Few differences have been
tation, especially when a continuous catheter technique is reported between each of these techniques, with similar
used. rates of catheter dislodgement and occlusion. It may be
There are at least four broad approaches to blocking that fewer attempts are required for successful catheter
the sciatic nerve, including the classic posterior approach placement with a subgluteal approach [62]. Major neu-
of Labat [52], anterior approaches, lateral approaches, rological complications related to catheter techniques are
and the supine lithotomy approach of Raj et al. [53]. few. However, minor complications may be more
The anterior, lateral, and lithotomy approaches have the common. These include local inflammation at the skin
advantage of keeping the patient supine during the site, infection and infection requiring surgical drainage
performance of the block. The Labat approach requires [67, 68]. In canine sciatic nerves, injections requiring high
the placement of the patient in the lateral position, pressures were associated with intrafascicular injections
which may be painful in the acutely injured patient and and were predictive of nerve damage when compared
may be contraindicated in the presence of spinal injury. with injecting against low resistance [69]. Local bleeding
Another classification of the approaches to blocking the and extensive haematoma formation have been reported
sciatic nerve can be described as the transgluteal, in two patients with sciatic catheters in situ who were
subgluteal ⁄ mid-femoral and popliteal blocks. Of the given low molecular weight heparins on the first
transgluteal blocks, the most proximal approach is the postoperative day [70]. These resolved with conservative
parasacral technique that aims to block the sciatic nerve management.
at its exit from the greater sciatic foramen [54]. This Various mechanisms for pain related to the use of a
block has been shown to be quicker to perform than tourniquet have been proposed. These include neuro-
other transgluteal approaches. However, it can have a pathic pain due to mechanical compression of Ad fibres
slow onset time [55]. leaving C fibres functioning to conduct pain, direct pain
Ultrasound-guided sciatic nerve block is rapidly from compression of skin and muscle and finally pain due
gaining popularity and has been described in both adults to ischaemia [71]. For lower limb surgery under nerve
and children [56–58]. Kamarkar et al. [59] found the block, one controversy that remains is the role of the
‘subgluteal space’ to be an effective site for LA injection posterior cutaneous nerve of the thigh in tourniquet pain.
or catheter insertion during ultrasound-guided sciatic Proximal posterior approaches to block the sciatic nerve,
nerve block. Using ultrasound, the sciatic nerve can be especially the parasacral approach, were initially advo-
identified and followed using a posterior approach as it cated when use of a tourniquet was planned as these have
passes distally from the subgluteal region. In lean a higher likelihood of blocking the posterior cutaneous
volunteers, the sciatic nerve is sufficiently thick and nerve of thigh [72]. However, more recent studies have
close to the skin to make demonstration with ultrasound shown similar rates of tourniquet pain when comparing a
optimal between 5.4 and 10.8 cm along its subgluteal femoral and proximal sciatic nerve block with a femoral
course [60]. Ultrasound can be used to identify the and posterior popliteal sciatic nerve block, and also when
sciatic nerve using an anterior approach. Ota et al. [61] a posterior approach to the sciatic nerve was compared to
described the clinical use of an ultrasound-guided an anterior approach that consistently failed to provide
anterior approach to sciatic nerve block and compared sensory block in the distribution of the posterior cutane-
the quality of the block and execution time of the ous nerve of thigh [61].

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Anaesthesia, 2010, 65 (Suppl. 1), pages 57–66
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Popliteal sciatic nerve block
Various approaches to block the sciatic nerve in the
popliteal fossa have been described. These involve one or
two injections, and lateral or posterior approaches [73, 74].
Some controversy exists about the advantages of two
injections to block both the posterior tibial nerve and the
common peroneal nerve over a single injection to block
only the posterior tibial nerve with both posterior and
lateral approaches, similar rates of success being reported
with each when higher volumes of LA are used [75, 76].
Ultrasound has been shown to increase success rates at this
level when used alone or in combination with peripheral
nerve stimulation [77, 78]. This may in part be due to the
ability to demonstrate anatomical variation at this level [51,
58]. Effective LA volumes can also be decreased with the
use of ultrasound. This may make ultrasound a useful tool
when multiple lower limb blocks are being used in the same
patient. The success rate when using a lateral popliteal block
may be lower compared to the transgluteal approaches,
with significantly longer onset times compared to both
transgluteal and mid-femoral approaches. However, pos-
terior popliteal blocks are associated with much less
procedure-related pain when compared to transgluteal
blocks, with no difference in the time taken to perform the
block, the onset time or the duration of action [75].
Summary
Simple decreases in postoperative pain scores do not
necessarily translate to clinically meaningful improved
pain relief or outcomes for the patient and, as such, use of
a regional anesthetic or analgesic technique by itself does
not automatically confer clinical advantage to the patient
if overall management is not optimal and is not adapted to
the individual patient’s needs. Having said this, there is
good evidence that lower limb regional anesthesia
provides superior postoperative analgesia that in itself
may contribute to an improvement in patient-related
outcomes. The benefits of a regional anesthesia technique
are increased when adapted to a particular patient’s
requirements. Obvious benefits such as the quality of
postoperative analgesia and a decrease in hospital stay or
in hospital costs are easy to demonstrate, but conclusive
proof that regional anesthesia improves the outcome from
surgery is still lacking. The ultimate goal will be to
demonstrate that regional analgesia can contribute to
improvements in long-term functional recovery and to a
decrease in the incidence of chronic pain.
Conflicts of interest
The authors declare no conflicts of interest.
 2010 The Authors
Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
J. M. Murray et al. Æ Lower limb blocks
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