Ultrasound-guided fascia iliaca compartment block in pediatric patients using a long-axis, in-plane needle technique: a report of three cases

Ultrasound guided fascia iliaca compartment block (FICB) has not been previously described in pediatric patients. Reported here is an ultrasound guided long axis, in-plane needle technique used to perform FICB in three pediatric patients undergoing hip or femur surgery. Postoperative assessment revealed nerve blockade of the lateral femoral cutaneous, femoral, and obturator nerves or no requirement for narcotics in the PACU. FICB using this ultrasound guided technique was easy to perform and provided postoperative analgesia for hip and femur surgical procedures within the presumed distribution of the lateral femoral cutaneous, femoral, and obturator nerves.     

Effects of using the posterior or anterior approaches to the lumbar plexus on the minimum effective anesthetic concentration (MEAC) of mepivacaine required to block the femoral nerve: a prospective, randomized, up-and-down study

BACKGROUND AND OBJECTIVES: To evaluate if psoas compartment block requires a larger concentration of mepivacaine to block the femoral nerve than does an anterior 3-in-1 femoral nerve block. METHODS: Forty eight patients undergoing anterior cruciate ligament repair were randomly allocated to receive an anterior 3-in-1 femoral block (femoral group, n = 24) or a posterior psoas compartment block (psoas group, n = 24) with 30 mL of mepivacaine. The concentration of the injected solution was varied for consecutive patients using an up-and-down staircase method (initial concentration: 1%; up-and-down steps: 0.1%). RESULTS: The minimum effective anesthetic concentration of mepivacaine blocking the femoral nerve in 50% of cases (ED(50)) was 1.06% +/- 0.31% (95% confidence interval [CI], 0.45%-1.68%) in the femoral group and 1.03% +/- 0.21% (95% CI, 0.6%-1.45%) in the psoas group (P = .83). The lateral femoral cutaneous and obturator nerves were blocked in 4 (16%) and 5 (20%) femoral group patients as compared with 20 (83%) and 19 (80%) psoas group patients (P = .005 and P = .0005, respectively). Intraoperative analgesic supplementation was required by 15 (60%) and 5 (20%) patients in the femoral and psoas groups, respectively (P = .01). CONCLUSIONS: Using a posterior psoas compartment approach to the lumbar plexus does not increase the minimum effective anesthetic concentration of mepivacaine required to block the femoral nerve as compared with the anterior 3-in-1 approach, and provides better quality of intraoperative anesthesia due to the more reliable block of the lateral femoral cutaneous and obturator nerves.     

A review of approaches and techniques for lower extremity nerve blocks

PURPOSE: The purpose of this narrative review is to summarize the evidence derived from randomized controlled trials (RCTs) regarding approaches and techniques for lower extremity nerve blocks. SOURCE: Using the MEDLINE (January 1966 to April 2007) and EMBASE (January 1980 to April 2007) databases, medical subject heading (MeSH) terms "lumbosacral plexus", "femoral nerve", "obturator nerve", "saphenous nerve", "sciatic nerve", "peroneal nerve" and "tibial nerve" were searched and combined with the MESH term "nerve block" using the operator "and". Keywords "lumbar plexus", "psoas compartment", "psoas sheath", "sacral plexus", "fascia iliaca", "three-in-one", "3-in-1", "lateral femoral cutaneous", "posterior femoral cutaneous", "ankle" and "ankle block" were also queried and combined with the MESH term "nerve block". The search was limited to RCTs involving human subjects and published in the English language. Forty-six RCTs were identified. PRINCIPAL FINDINGS: Compared to its anterior counterpart (3-in-1 block), the posterior approach to the lumbar plexus is more reliable when anesthesia of the obturator nerve is required. The fascia iliaca compartment block may also represent a better alternative than the 3-in-1 block because of improved efficacy and efficiency (quicker performance time, lower cost). For blockade of the sciatic nerve, the classic transgluteal approach constitutes a reliable method. Due to a potentially shorter time for sciatic nerve electrolocation and catheter placement than for the transgluteal approach, the subgluteal approach should also be considered. Compared to electrolocation of the peroneal nerve, electrostimulation of the tibial nerve may offer a higher success rate especially with the transgluteal and lateral popliteal approaches. Furthermore, when performing sciatic and femoral blocks with low volumes of local anesthetics, a multiple-injection technique should be used. CONCLUSIONS: Published reports of RCTs provide evidence to formulate limited recommendations regarding optimal approaches and techniques for lower limb anesthesia. Further well-designed and meticulously executed RCTs are warranted, particularly in light of new techniques involving ultrasonographic guidance.     

Fascia iliaca compartment block for femoral bone fractures in prehospital care

BACKGROUND AND OBJECTIVES: The fascia iliaca compartment block provides a faster and more consistent simultaneous blockade of the lateral cutaneous and femoral nerves than the "3 in 1" block. We studied the effectiveness of this technique for analgesia after a femoral bone fracture in pre-hospital care. METHODS: Patients with an isolated femoral shaft fracture were included. A fascia iliaca compartment block was performed on all of them. Twenty milliliters of lidocaine 1.5 % with epinephrine were injected under the fascia iliaca. The intensity of pain was measured using a simplified verbal scale (SVS) from 0 (no pain) to 4 (extreme pain). The SVS was noted before the block was performed, 10 minutes later, and then on admission to the trauma care center. Sensory blockade was evaluated using cold perception in the lateral, medial, and internal part of the thigh 10 minutes after block performance and on arrival at the trauma care center. RESULTS: Twenty-seven patients were enrolled in this study. The SVS was 3 (3-4) before the block, 1 (0-2) 10 minutes after the block, and 0 (0-1) when arriving at the trauma care center (P <.05). The SVS was lower when the internal part of the thigh was blocked. CONCLUSION: The fascia iliaca compartment block is a simple, inexpensive, and effective method of prehospital analgesia for femoral shaft fracture. A sensory block of the internal part of the thigh is an early predictive sign of optimal pain relief.     

The analgesic efficacy of continuous fascia iliaca block vs. continuous psoas compartment block after hip surgery: A comparative study

BackgroundBoth psoas compartment block and fascia iliaca compartment block have been shown to be reliable blocks for postoperative pain relief for procedures involving the hip joint. This study evaluated the efficacy of continuous psoas compartment block with continuous fascia iliaca block for postoperative analgesia after hip surgery.MethodsIn randomized blinded study Forty, ASA I–III patients aged 30–75 years, with BMI less than 40, scheduled for hip surgery, were divided to one of two groups. Group P: continuous psoas compartment block (n = 18) and group F: continuous fascia iliaca block (n = 19). Standard general anesthesia was induced after finishing the block technique. After recovery 30 ml of 0.125% levobupivacaine was injected through the catheter to all patients. Postoperative 24 h meperidine consumption, patient satisfaction, visual analogue scale pain scores at (1, 6, 12, 18, and 24 h) postoperative, postoperative hemodynamics (HR and MAp), evidence of sensory and motor blockades, and incidence of adverse effects were recorded.ResultsThere was no significant difference between the two groups in 24 h postoperative meperidine requirements, postoperative VAS, patient satisfaction, postoperative hemodynamics, and distribution of sensory and motor block of (femoral, lateral femoral cutaneous, and obturator nerves). The epidural anesthesia occurred in two patients in psoas group (11%).ConclusionBoth continuous fascia iliaca block and continuous psoas compartment block were comparable in providing safe and effective analgesia after hip surgery.     

Magnetic resonance imaging of the distribution of local anesthetic during the three-in-one block

The three-in-one technique of simultaneously blocking the femoral, the lateral femoral cutaneous (LFC), and the obturator nerves by a single injection of a local anesthetic was first described in 1973, and it was suggested that the underlying mechanism was one of cephalad spread resulting in a blockade of the lumbar plexus. Today, the technique is widely used in surgery and pain management of the lower limb. Many investigators have, however, reported suboptimal analgesia levels, particularly in the obturator nerve. The purpose of this prospective study was to trace the distribution of a local anesthetic during a three-in-one block by means of magnetic resonance imaging (MRI). Seven patients scheduled for surgery of the lower limb were analyzed with the aid of a primary MRI and then received three-in-one blocks using 30 mL of bupivacaine 0.5% under the guidance of a nerve stimulator. A secondary MRI was performed to determine the distribution pattern of the local anesthetic. It emerged that the local anesthetic blocks the femoral nerve directly, the LFC nerve through lateral spread, and the anterior branch of the obturator nerve by slightly spreading in a medial direction. No involvement of the proximal and posterior portions of the obturator nerve was observed, nor was there any cephalad spread that could have resulted in a lumbar plexus blockade. We therefore conclude that the basis of the three-in-one block is confined to lateral, medial, and caudal spread of the local anesthetic, which effectively blocks the femoral and LFC nerves, as well as the distal anterior branch of the obturator nerve. IMPLICATIONS: We demonstrate by using magnetic resonance imaging that the mechanism of a three-in-one block is one of lateral, caudal, and slight medial spread of a local anesthetic with subsequent blockade of the femoral, the lateral femoral cutaneous, and the anterior branch of the obturator nerves. It does not involve cephalad spread of the local anesthetic with blockade of the lumbar plexus.     

Continuous three-in-one block for postoperative pain after lower limb orthopedic surgery: where do the catheters go?

Continuous three-in-one block is widely used for postoperative analgesia after proximal lower limb surgery, but location of the catheter has not been well addressed in the literature. We prospectively studied, in 100 patients, the characteristics of catheter threading under the iliac fascia and the correlations between catheter tip location and effective sensory and motor blockade of the three principal nerves of the lumbar plexus. Postoperatively, in conscious patients, 16 to 20 cm of a catheter was placed in the fascial sheath after femoral nerve location with a nerve stimulator. Contrast media (3 mL Iopamidol 390) was injected, and the catheter tip was located by means of an anteroposterior pelvic radiograph. An equal-volume mixture of 0.5% bupivacaine/2% lidocaine with epinephrine (30 mL) was injected through the catheter. Patient and catheter-insertion characteristics were noted. Thirty minutes after injection, sensory blockade was evaluated in the cutaneous territories of the lateral femoral cutaneous, femoral, and obturator nerves, along with motor blockade of the last two nerves. Pain scores at 30 min were also recorded. Seven block failures were noted. The tip of the catheter reached the lumbar plexus (Group 1) in 23% of the patients and lay deep to the medial (Group 2) or lateral (Group 3) part of the fascia iliaca in 33% and 37% of the patients, respectively. Demographic data and catheter threading characteristics were comparable among the groups. A three-in-one block was noted in 91% of Group 1 patients, but in only 52% and 27% of Group 2 and 3 patients, respectively (P < 0.05). Comparing Group 2 and 3 patients, sensory block was achieved in respectively 100% and 94% for the femoral nerve, 52% and 94% for the lateral femoral cutaneous nerve (P < 0.05), and 82% and 27% for the obturator nerve (P < 0.05). Visual analog scale pain scores on movement were significantly lower in Group 1 patients (P < 0.05). We conclude that during a continuous three-in-one block, the threaded catheter rarely reached the lumbar plexus. The quality of sensory and motor blockade and initial pain relief depend on the location of the catheter tip under the fascia iliaca. IMPLICATIONS: The course of a continuous three-in-one block catheter is unpredictable. Only 23% of the catheters lie near the lumbar plexus. The success of sensory and motor blocks, as well as postoperative analgesia, depend on the position of the catheter under the fascia iliaca.     

Comparison of continuous 3-in-1 and fascia Iliaca compartment blocks for postoperative analgesia: feasibility,catheter migration,distribution of sensory block,and analgesic efficacy

BACKGROUND AND OBJECTIVES: Efficacy and technical aspects of continuous 3-in-1 and fascia iliaca compartment blocks were compared. METHODS: Forty-four patients scheduled for cruciate ligament repair or femur surgery were randomly divided into 2 groups. After surgery with the patient anesthetized, catheters were placed for continuous 3-in-1 blocks by means of a nerve stimulator (group 1). In group 2, the catheter was inserted for continuous fascia iliaca compartment block without the use of a nerve stimulator. In both groups, a 5-mg/kg bolus of 0.5% ropivacaine was administered followed by continuous infusion of 0.1 mL/kg/h of 0.2% ropivacaine for 48 hours. In the postoperative period, all the patients received parenteral propacetamol (6 g daily) and ketoprofen (200 mg daily) and 0.1 mg/kg of subcutaneous morphine as rescue analgesia if the visual analog scale (VAS) pain values were greater than 30 mm. We evaluated the technical difficulties relative to catheter placement, the location of the catheter, the analgesic efficacy, and the distribution of the sensory block at 1 hour, 24 hours, and 48 hours. RESULTS: Catheter placement was faster in group 2, and the absence of nerve stimulation decreased material costs (P <.05). No significant difference was observed between groups concerning location of the catheter tip under the fascia iliaca. In both groups, the distribution of the sensory block and its course were similar except for those of the obturator nerve (more sensory blocks in group 1, P <.05). No significant difference was noted between the groups regarding median VAS pain values and consumption of morphine during the 48-hour period. No major side effect was observed. CONCLUSIONS: The authors conclude that a catheter for continuous lumbar plexus block can be placed more quickly and at lesser cost using the fascia iliaca technique than the perivascular technique with equivalent postoperative analgesic efficacy.     

Extent of blockade with various approaches to the lumbar plexus

The extent of blockade when four different techniques were used for blocking the lumbar plexus was prospectively evaluated in 80 adult patients. The extent of blockade was measured by testing motor function of all nerves except the lateral and posterior femoral cutaneous nerves, which were evaluated by pinprick response. The posterior approaches of Dekrey at L3 (n = 20) and Chayen at L4-5 (n = 20) proved similarly effective in producing blockade of the femoral, obturator, and lateral femoral cutaneous nerves, as well as the nerves to the psoas muscle. The anterior approach of Winnie (femoral sheath or 3-in-1 block) using paresthesia (n = 20) or peripheral nerve stimulation (n = 20) proved effective in producing blockade of the femoral and lateral femoral cutaneous nerves, but ineffective for obturator nerve blockade. None of the four techniques produced blockade of the sacral plexus. Perhaps our means of assessing blockade (motor) is what produced the difference between our findings and those of others.     

改良髂筋膜间隙联合腘窝坐骨神经阻滞在单侧大隐静脉曲张手术中的应用

目的观察改良髂筋膜间隙联合腘窝坐骨神经阻滞在单侧大隐静脉曲张手术中的麻醉效果。方法选择择期行单侧大隐静脉高位结扎加抽剥术患者60例,男32例,女28例,年龄42~76岁,ASAⅠ或Ⅱ级,采用随机数字表法将其分为改良髂筋膜间隙联合腘窝坐骨神经阻滞组(N组)和硬膜外阻滞组(E组),每组30例。N组先行腘窝坐骨神经阻滞,再在超声图像上确认髂筋膜和股神经位置,先行股神经阻滞,再在同一穿刺点从缝匠肌内侧缘开始,由外向内沿髂筋膜下给1%利多卡因10ml和0.5%罗哌卡因10ml,同时超声探头在腹股沟韧带水平向内移动,内侧达股动脉上方;E组采用L2~3间隙行硬膜外阻滞。记录两组阻滞前(T0)、阻滞后10min(T1)、30min(T2)、60min(T3)的SBP、DBP及HR;记录两组阻滞完成时间、感觉阻滞起效时间、术中麻黄碱使用情况、麻醉效果及术后48h恶心呕吐、头痛及尿潴留发生情况。结果与T0时比较,T2时E组的SBP和DBP明显降低(P0.05),T2时N组SBP和DBP明显高于E组(P0.05);N组感觉阻滞起效时间明显短于E组、术中麻黄碱使用率明显低于E组(P0.05);E组整体麻醉效果优于N组(P0.05),但两组麻醉效果优良率差异无统计学意义;术后48hN组尿潴留发生率明显低于E组(P0.05)。结论改良髂筋膜间隙联合腘窝坐骨神经阻滞用于单侧大隐静脉高位结扎加抽剥术中,麻醉效果良好,较硬膜外阻滞具有血流动力学影响小、术后并发症少及适应证更广等优点。     

A comparison of pre‐operative nerve stimulator‐guided femoral nerve block and fascia iliaca compartment block in patients with a femoral neck fracture

We undertook a randomised, controlled trial to compare the analgesic efficacy and opioid sparing effect of nerve stimulator‐guided femoral nerve block with fascia iliaca compartment block in patients awaiting surgery for fractured neck of femur. Ten‐centimetre visual analogue pain scores were measured before and 2 h after the block and opioid consumption was recorded in the 12‐h period after the block. One hundred and ten patients were randomly assigned. Femoral nerve block provided superior pre‐operative analgesia for fractured neck of femur compared with fascia iliaca compartment block. The difference in the mean reduction of pain score after the block was 0.9 (95% CI 0–1.8); p = 0.047. Patients receiving a femoral nerve block required less morphine after the block than those receiving fascia iliaca compartment block (p = 0.041).     

Editorial Commentary: The Truth about Peripheral Nerve Blocks and Hip Arthroscopy

Peripheral nerve blocks targeting the fascia iliaca compartment have been used in attempts to improve postoperative pain after hip arthroscopy surgery. Recent level I evidence from randomized controlled trials have revealed injection of local anesthetic into the fascia iliaca compartment to be no better than sham injection for postoperative pain control, while contributing to decreased patient quadriceps strength and increased fall risk after surgery. The fascia iliaca compartment block is also inferior to local anesthetic injection at the surgery site for pain control. Results of these high-level studies show that routine preoperative use of the fascia iliaca compartment block is not recommended for hip arthroscopy.     

An evaluation of the cutaneous distribution after obturator nerve block.

In 1973, Winnie et al. introduced the inguinal paravascular three-in-one block, which allegedly provides anesthesia of three nerves--the femoral, lateral cutaneous femoral, and obturator nerves--with a single injection. This concept was undisputed until the success of the obturator nerve block was reassessed by using evidence of adductor weakness rather than cutaneous sensory blockade, the latter being variable in its distribution and often absent. We performed this study, therefore, to evaluate the area of sensory loss produced by direct injection of local anesthetic around the obturator nerve. A selective obturator nerve block with 7 mL of 0.75% ropivacaine was performed in 30 patients scheduled for knee surgery. Sensory deficit and adductor strength were evaluated for 30 min by using sensory tests (cold and light-touch perception) and the pressure generated by the patient's squeezing a blood pressure cuff placed between the knees. Subsequently, a three-in-one block was performed, and the sensory deficit was reassessed. The obturator nerve block was successful in 100% of cases. The strength of adductors decreased by 77% +/- 17% (mean +/- SD). In 17 patients (57%), there was no cutaneous contribution of the obturator nerve. The remaining 7 patients (23%) had an area of hypoesthesia (cold sensation was blunt but still present) on the superior part of the popliteal fossa, and the other 6 (20%) had sensory deficit located at the medial aspect of the thigh. The three-in-one block resulted in blockade of the lateral aspect of the thigh in 87% of cases, whereas the anteromedial aspect was always anesthetized. By use of magnetic resonance imaging in eight volunteers, we demonstrated that the obturator nerve has already divided into its two branches at the site of local anesthetic injection. However, the injection of blue dye after having simulated the technique in five cadavers showed that the fluid regularly spread to both branches. We conclude that after three-in-one block, a femoral nerve block may have been assessed as an obturator nerve block in 100% of cases when testing the cutaneous distribution of the obturator nerve on the medial aspect of the thigh. IMPLICATIONS: Previous studies reporting an incidence of obturator nerve block after three-in-one block may have mistaken a femoral nerve block for an obturator nerve block in 100% of cases when the cutaneous distribution of the obturator nerve was assessed on the medial aspect of the thigh. The only way to effectively evaluate obturator nerve function is to assess adductor strength.     

Iliac compartment block following ilioinguinal iliohypogastric nerve block

Transient femoral nerve palsy is a known complication associated with percutaneous ilioinguinal iliohypogastric nerve block. Excess volume and higher concentrations of local anesthetic have been implicated for transient femoral nerve palsy. We encountered partial iliac compartment block involving lateral cutaneous nerve of the thigh and femoral nerve with a lower concentration (0.25%) of bupivacaine administered in the smallest indicated volume of 0.25 ml.kg-1 using a double-shot technique.     

Analgesia before a spinal block for femoral neck fracture: fascia iliaca compartment block

Background: In this prospective randomized study, the authors compared the analgesic effect of a fascia iliaca compartment (FIC) block with that of intravenous (i.v.) alfentanil when administered to facilitate positioning for spinal anaesthesia in elderly patients undergoing surgery for a femoral neck fracture.
Methods: The 40 patients were randomly assigned to one of two groups, namely, the FIC group (fascia iliaca compartment block, n =20) and the IVA group (intravenous analgesia with alfentanil, n =20). Group IVA patients received a bolus dose of i.v. alfentanil 10 μg/kg, followed by a continuous infusion of alfentanil 0.25 μg/kg/min starting 2 min before the spinal block, and group FIC patients received a FIC block with 30 ml of ropivacaine 3.75 mg/ml (112.5 mg) 20 min before the spinal block. Visual analogue pain scale (VAS) scores, time to achieve spinal anaesthesia, quality of patient positioning, and patient acceptance were compared.
Results: VAS scores during positioning (mean and range) were lower in the FIC group than in the IVA group [2.0 (1–4) vs. 3.5 (2–6), P =0.001], and the mean (± SD) time to achieve spinal anaesthesia was shorter in the FIC group (6.9 ± 2.7 min vs. 10.8 ± 5.6 min; P =0.009). Patient acceptance (yes/no) was also better in the FIC group (19/1) than in the IVA group (12/8)( P =0.008).
Conclusions: An FIC block is more efficacious than i.v. alfentanil in terms of facilitating the lateral position for spinal anaesthesia in elderly patients undergoing surgery for femoral neck fractures.     

Evaluation of a new fenestrated needle for ultrasound-guided fascia iliaca block

STUDY OBJECTIVE: To evaluate a new 20-gauge (G) fenestrated needle designed to be used with ultrasound guidance to deliver local anesthetic into the tissue plane of the fascia iliaca without immediate proximity to the femoral nerve. DESIGN: Prospective study. SETTING: University hospital. PATIENTS: 15 male volunteers. INTERVENTIONS: To determine the onset of motor and sensory block after ultrasound-guided injection of 1% lidocaine and iopamidol, fluoroscopy was performed during and after injection to discover the pattern of local anesthetic distribution. The buckling strength of the new needle was compared using a standard mechanical testing protocol to a conventional 22-G needle (Quincke type). MEASUREMENTS AND MAIN RESULTS: Injection through the fenestrated needle consistently produced sensory block in the anterior, medial, and lateral aspects of the thigh. All subjects were also observed to have loss of motor function in the quadriceps muscle. No subject experienced motor effect in the adductor muscles of the thigh. The fenestrated 20-G needle yielded at significantly larger compressive forces than did the standard 22-G needle (P < 0.001). CONCLUSION: The needle is novel in that it does not require immediate proximity to the femoral nerve or precise placement of the needle tip in the plane of the fascia iliaca. The 20-G fenestrated needle is stronger under compressive force than existing 22-G needles.     

Comparison of sciatic psoas compartment block and sciatic femoral 3-in-1 block for knee arthroscopy

STUDY OBJECTIVES: To compare the clinical effectiveness of two peripheral nerve block techniques combined with sciatic nerve block: sciatic psoas compartment (SPC) and sciatic femoral 3-in-1 (SF 3-in-1) block. DESIGN: Prospective, randomized study. SETTING: Military medical academy hospital. PATIENTS: Thirty-six ASA physical status I patients, aged 20 to 33 years, undergoing elective knee arthroscopy. INTERVENTIONS: Patients having SPC block (n = 19) or SF 3-in-1 block (n = 17) received 40 mL of a mixture of solution containing 15 mL of 0.5% bupivacaine, 15 mL of 2.0% prilocaine, and 10 mL of 0.9% sodium chloride. In both groups, the sciatic nerve was blocked with 20 mL of the same solution. An intravenous bolus injection of fentanyl 0.1 mg was used if patients complained of pain. MEASUREMENTS AND MAIN RESULTS: None of the patients in the SPC group experienced pain owing to the applied tourniquet during the operation, whereas 7 patients from the SF 3-in-1 group (41.2 %) reported tourniquet pain. All SF 3-in-1 group patients but only 5 patients (26.3 %) in the SPC group required fentanyl during the operation. In addition, 7 patients in the SF 3-in-1 group required second doses of fentanyl. Patient satisfaction was significantly higher in the SPC group than in the SF 3-in-1 block group (P < 0.0001). CONCLUSIONS: Both SPC and SF 3-in-1 provided sufficient anesthetic efficacy for knee arthroscopy. However, SPC may be preferable to SF 3-in-1 block owing to better patient satisfaction and less requirement for opioid analgesics.     

Bloc ≪ 3 en 1 ≫ ou bloc femoral. Que faut-il faire et comment le faire ?

The “3 in 1” block and the femoral nerve block are widely used for lower limb surgery and postoperative analgesia. Whether these blocks are in fact a same regional block with two different names or represent definitively two different blocks remains controversial. A large number of anatomical as well as functional variations of the lumbar plexus have been described and complicate a rational analysis of the spread of local anaesthetics following these blocks. Anatomical, radiological and especially clinical data seem to confirm that these blocks are to be distinguished from one another. Femoral nerve block requires the use of a nerve stimulator and has a high success rate in the territory of the femoral nerve; a spread towards other lumbar nerves, especially the lateral femoral cutaneous nerve, is sometimes observed. The “3 in 1” block is supported by the idea of diffusion within a space that is located after going through two fascial layers. Even in experienced hands, the success predictive value is not high. However, once the “3 in 1” block is well performed, a complete anaesthesia covering the territories of the femoral nerve, the lateral femoral cutaneous nerve, and the obturator nerve occurs. Specific indications of each technique are different: major knee surgery and postoperative analgesia for the “3-in-1” block and leg surgery for femoral nerve block. The best approach for knee arthroscopy remains open for discussion.     

A modified fascia iliaca compartment block has significant morphine-sparing effect after total hip arthroplasty

We assessed whether a modified fascia iliaca compartment block in unilateral total hip arthroplasty provides a morphine-sparing effect in the first 24 hours. This involved a randomised, double blind study of 44 patients. Both groups received a modified fascia iliaca block with the trial group receiving 30 ml 0.5% bupivacaine with 1:200,000 adrenaline, 150 microg clonidine and 9 ml 0.9% saline and the control group receiving 40 ml 0.9% saline. Otherwise both groups received identical care with a subarachnoid block for operative anaesthesia. Patient-controlled morphine analgesia was commenced postoperatively and data were collected at three, six, 12 and 24 hours post commencement of surgery. We found that the trial group used less morphine at 12 and 24 hours (P < 0.001). The median morphine usage at 24 hours was 37.5 mg in the control patients and 22 mg in the trial patients. Pain scores were similar between groups. We conclude that a modified fascia iliaca compartment block has a significant morphine-sparing effect in unilateral total hip arthroplasty.