Peritibial fascial infiltration block for postoperative analgesia management: Two case reports

Abstract

Fascial plane blocks have become increasingly popular for postoperative analgesia. Recently, Ekinci et al. have defined the peritibial fascial infiltration block (PFIB) for ankle fractures. This report discusses two cases where PFIB was utilized as part of a multimodal analgesic strategy. The first case involved a 13-year-old male with a lateral malleolus fracture following a bicycle accident. The second case concerned a 27-year-old male with bilateral malleolus fractures sustained in a motorcycle accident. In both cases, PFIB was administered preoperatively, and neither patient required supplemental analgesics postoperatively. The PFIB appears to be a promising adjunct in multimodal analgesia for ankle fractures. Further research is warranted to validate its efficacy and broader applications.

Introduction

Since the integration of ultrasound (US) into our clinical practice, interfascial plane blocks have become increasingly popular for postoperative analgesia.[1] According to the PROSPECT guidelines for analgesic management in hallux valgus repair, the ankle block is recommended as the preferred technique.[2] An ankle block is a commonly used technique for surgical procedures of the foot and ankle. However, in surgical procedures directly involving the ankle joint, this approach may not provide optimal conditions due to the intersection of the blocked region with the surgical field. In 2021, Ekinci et al.[3] introduced the peritibial fascial infiltration block (PFIB) as a novel fascial plane block for lower extremity analgesia. This report aims to present the application of PFIB as a postoperative analgesic technique in two cases: a 13-year-old male with a lateral malleolus fracture sustained in a bicycle accident and a 27-year-old male with bilateral malleolar fractures resulting from a motorcycle accident.

Case 1

The patient, a 13-year-old boy weighing 75 kg with a BMI of 29.3, presented with a lateral malleolus fracture sustained from a bicycle accident. The orthopedic surgeon planned to treat the fracture with a plate fixation. The patient, with no significant medical history, was classified as American Society of Anesthesiologists (ASA) physical status I. After obtaining informed consent from the family, the patient was taken to the operating room for the procedure.

Standard ASA monitoring, including electrocardiogram (ECG), non-invasive blood pressure, pulse oximetry, and end-tidal carbon dioxide (ETCO₂), was initiated.

Before surgery, PFIB was performed. Under sterile conditions, a linear ultrasound probe (GE ML6-15-D Matrix Linear) was positioned proximal to the fracture line of the ankle [Figure 1]. The periosteum of the tibia and fascia cruris was visualized using ultrasound guidance. A 22 G, 50 mm needle (Stimuplex Ultra®, Braun, Melsungen, Germany) was then directed between the tibia periosteum and fascia cruris using an ultrasound in-plane approach. After negative aspiration, 2 mL of saline solution was injected to confirm needle placement. Subsequently, 40 mL of 0.25% bupivacaine was administered between the fascia cruris and periosteum from medial to lateral [Figure 2]. No complications or side effects were observed following the procedure. General anesthesia was induced via intravenous propofol (2 mg/kg), fentanyl (1.5 μg/kg), and rocuronium bromide (0.6 mg/kg). Anesthesia was maintained with 2% sevoflurane. The surgical procedure started following PFIB. The fracture was successfully reduced and fixed with a plate. The surgery lasted approximately 60 minutes, and no complications were observed. For multimodal analgesia, paracetamol (10 mg/kg) and ibuprofen 400 mg were administered intravenously during the final 30 minutes of the surgery. After the surgery, the patient was extubated without any problems and transferred to the recovery ward for postoperative monitoring. Pain was assessed using the Visual Analog Scale (VAS) at 3, 6, 12, and 24 hours, with scores of 2, 2, 3, and 3, respectively. The patient received paracetamol 1000 mg every 8 hours and did not require rescue analgesia. No nausea or vomiting was observed during the postoperative follow-up period.

Figure 1.

Linear US view of the ankle proximal to the fracture line

Figure 2.

Needle view between tibia and fascia cruris

Case 2

A 27-year-old male weighing 82 kg with a BMI of 25.4 presented with bilateral malleolus fractures following a motorcycle accident. The orthopedic surgeon planned to treat the medial malleolus fracture with screws and the lateral malleolus fracture with plate fixation. The patient, a smoker with no other significant medical history, was classified an ASA physical status II. After obtaining informed consent, the patient was taken to the operating room.

Standard ASA monitoring was performed. Before spinal anesthesia, PFIB was performed as described in case 1. The pre-procedure VAS score of 8/10 decreased to 3/10 at the 20-minute post-procedure evaluation. Following PFIB, the sensory dermatome level was determined using the pin-prick test [Figure 3]. Subsequently, the patient was positioned in a sitting position for spinal anesthesia, and after antisepsis, a 27G Quincke spinal anesthesia needle (QPen®, Egemen, İzmir, Turkey) was inserted into the subarachnoid space at the L3-4 level. The presence of cerebrospinal fluid confirmed the correct placement of the needle. A total of 15 mg (3 mL) of 0.5% hyperbaric bupivacaine (Bupivon®, Onfarma, Samsun, Turkey) was administered into the subarachnoid space to perform spinal anesthesia. The surgery lasted approximately 75 minutes without any complications. For multimodal analgesia, paracetamol (1000 mg) and tenoxicam (20 mg) were administered intravenously during the last 30 minutes of the surgery. Three hours postoperatively, following the resolution of the spinal block and the sensory function returned to baseline, postoperative pain was assessed using the Visual Analog Scale (VAS) at 4, 6, 12, and 24 hours, with scores of 2, 2, 2, and 3, respectively. The patient received 1000 mg of paracetamol every 8 hours and 20 mg of tenoxicam every 12 hours, and no rescue analgesia was required. No nausea or vomiting was observed during the postoperative period.

Figure 3.

Sensory dermatome level following PFIB

Discussion

US-guided interfascial plane blocks involve the injection of local anesthetics into the fascial planes between muscles for regional anesthesia.[4] Nerve endings are present in the perifascial area and analgesia may be more effective when local anesthetic is injected into this area. In surgery below the ankle, the ankle block is a well-established regional anesthesia technique.[5]

Unfortunately, it is not suitable for surgery around the ankle itself because the corresponding nerve fibers leave their nerve roots 5–10 cm above the ankle joint. PFIB, as defined by Ekinci et al.,[3] involves injecting local anesthesia between the fascia cruris in the deep fascia of the leg and the periosteum of the tibia [Figure 4]. A cadaver study was reported by Çiftçi et al.[6] in 2022 demonstrated that higher volumes of 0.25% bupivacaine (30–40 mL) resulted in a wider spread to deeper compartments, including both the tibial and saphenous nerves. In our cases, we administered 40 mL of 0.25% bupivacaine.

Figure 4.

The anatomical illustration of the block mechanism (The anatomical illustration of the block mechanism. Fascia cruris, tibia, deep peroneal nerve, tibial nerve, blood vessels, and muscles are depicted)

In 2014, Lee et al.[7] found femoral and sciatic nerve blocks effective for postoperative pain control in ankle fractures. The sciatic nerve (L4-S3) provides motor/sensory innervation to the posterior aspect of the leg (via tibial and peroneal nerves).[8] The saphenous nerve (terminal branch of the femoral nerve) innervates the medial aspect of the lower leg and the medial malleolus.[9] Although the sciatic block provides analgesia in deep muscles, the medial malleolus skin, innervated by the saphenous nerve, remains largely unaffected. Therefore, a saphenous block may be effective in medial ankle fractures or medial incisions. In bimalleolar/trimalleolar fractures, saphenous and sciatic blocks are necessary for effective pain control. PFIB, on the other hand, is successful with a single needle insertion.

The tibial, saphenous, and deep peroneal nerves have their nerve endings in the peritibial area. The tibial nerve is the principal peripheral nerve of the lower extremity. It provides both sensory and motor innervation to the leg and foot. The sensory innervation areas are the skin of the posterolateral leg, the lateral part of the foot, and the sole of the foot. Motor innervation areas are the posterior compartment of the leg and the majority of the intrinsic foot muscles. The deep fibular nerve (deep peroneal nerve) is a nerve of the leg. It is one of the terminal branches of the common fibular nerve, ınnervates the muscles in the anterior compartment of the leg, as well as some of the intrinsic muscles of the foot, and provides sensory innervation of the triangular skin area between the 1^st and 2^nd toes.

The block can be performed in the supine position and anatomical landmarks are evident. For this reason, PFIB is an alternative regional analgesia technique that is easily applied primarily in distal tibia and fibula fractures. We believe that US-guided PFIB, which has very little data in the literature, can be safely used as a part of multimodal analgesia for postoperative analgesia in foot surgery. Further studies are needed to investigate its effectiveness.

Patient/Parent consent

Written informed consent for the procedure and future publishing was obtained from the patient.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.