BRIEF TECHNICAL REPORT
Ultrasound-Guided Ankle Block for Forefoot Surgery
The Contribution of the Saphenous Nerve
Ana M. López, MD, PhD,* Xavier Sala-Blanch, MD,* Marta Magaldi, MD,*
Daniel Poggio, MD,Þ Jordi Asuncion, MD,Þ and Carlo D. Franco, MDþ
Background: Ankle blocks typically include the block of 5 nerves, the
4 branches that trace their origin back to the sciatic nerve plus the sa-
phenous nerve (SaN). The sensory area of the SaN in the foot is variable.
Based on our clinical experience, we decided to study the sensory dis-
tribution of the SaN in the foot and determine whether the block of this
nerve is necessary as a component of an ultrasound-guided ankle block
for bunion surgery.
Methods: One hundred patients scheduled for bunion surgery under
ankle block were prospectively studied. We performed ultrasound-guided
individual blocks of the tibial, deep peroneal, superficial peroneal, and
sural nerves. After obtaining complete sensory block of these nerves, we
mapped the SaN sensory territory as such area without anesthesia on the
medial side of the foot.
Results: Every nerve block was successful within 10 minutes of in-
jection. The saphenous territory extended into the foot to 57 T 13 mm
distal to the medial malleolus. This distal margin was 22 T 11 mm
proximal to the first tarsometatarsal joint. The proximal end of the sur-
gical incision was located 1 cm distal to the first tarsometatarsal joint. In
only 3 patients (3%), the area of SaN innervation reached the proximal
end of the planned incision.
Conclusions: Ultrasound-guided ankle block is a highly effective
technique for bunion surgery. The sensory territory of the SaN in the foot
seems to extend only to the midfoot. According to our sample, 97% of the
patients undergoing bunion surgery under an ankle block would not
benefit from having a SaN block.
(Reg Anesth Pain Med 2012;37: 554Y557)
A nkle blocks are widely used for foot surgery. The technique
was originally described by Braun1 and Pauchet and Sourdat2
in 1914, and later by Labat.3 Different modifications have been
proposed to improve the results and to promote its use.4 Typically,
it includes the block of the 4 nerve branches that trace their
origins to the sciatic nerve plus the block of the saphenous
nerve (SaN), a branch of the femoral nerve. Recently, ultrasound
(US) has provided the means to identify and reliably block the
nerves at the ankle,5 improving success rate5Y8 and/or decreasing
onset time,9,10 as compared with conventional anatomical
landmark techniques. However, the evaluation of US-guided
blocks of every individual nerve at the ankle level has not been
addressed.
From the *Department of Anesthesiology and †Foot and Ankle Surgery Unit,
Department of Orthopedic Surgery, Hospital Clı́nic, Barcelona, Spain; and
‡Department Anesthesiology, JHS Hospital of Cook County, Chicago, IL.
Accepted for publication May 16, 2012.
Address correspondence to: Ana M. López, MD, PhD, Department of
Anesthesiology. Ambulatory Surgery Unit, Hospital Clı́nic, Villarroel 170,
08036 Barcelona, Spain (e-mail: analopez@clinic.ub.es).
The authors declare no conflict of interest.
Copyright * 2012 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0b013e3182611483
554 Regional Anesthesia and Pain Medicine
Copyright © 2012 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Based on our clinical experience, we believe that SaN block
might not be necessary as a component of ankle block used for
surgery of the forefoot. We decided to test the hypothesis that
an US-guided block of the remaining 4 nerves at the ankle
could provide complete anesthesia of the forefoot.
METHODS
This study was approved by the institutional review board
of the Hospital Clı́nic, Universitat de Barcelona. Written in-
formed consent was obtained for the anesthetic procedure, as it
is customary in our institution. Because the study involved a
standard anesthesia technique, the institutional review board
waived a specific consent. One hundred consecutive patients
scheduled for ambulatory hallux valgus (bunion) repair under
ankle block were prospectively recruited. Patient refusal to ankle
block, local skin disorders, and previous neuropathy were ex-
clusion criteria.
Patients were placed supine for the procedure and sedated
with midazolam 1 mg and fentanyl 50 Kg intravenously admin-
istered. The foot to be blocked was elevated by placing a small
pillow under the leg to facilitate probe manipulation. The ankle
area was disinfected with an iodine solution. The 4 nerves origi-
nated from the tibial, and common peroneal nerves (sciatic origin)
were identified using a linear US transducer 6Y13 MHz (Turbo
SonoSite; SonoSite, Bothell, Washington) and blocked consecu-
tively as follows (Fig. 1):
(1) The tibial nerve (TN) was identified between the medial
malleolus and the Achilles tendon as a hyperechoic oval-
shaped structure posterior to the posterior tibial artery and
veins. The trajectory of the nerve was traced proximally to
make sure it was blocked before giving off its terminal
branches.
(2) The deep peroneal nerve (DPN) was imaged on the ante-
rolateral aspect of the ankle as a small hyperechoic struc-
ture with hypoechoic dots next to the anterior tibial artery
and in between the tendons of the extensor hallucis longus
and tibialis anterior muscles. If the nerve was not seen,
local anesthetic was injected on both sides of the artery.
(3) The superficial peroneal nerve (SPN) was imaged 10 to
15 cm proximal to the lateral malleolus before it pierces
the deep fascia to become subcutaneous. The SPN appears
as 1 or 2 hypoechoic fusiform-shaped small structure deep
to the fascia. The nerve was tracked proximally to identify
potential variations.
(4) The sural nerve (SuN) was imaged subcutaneously between
the lateral malleolus and the Achilles tendon, in relation-
ship to the lesser saphenous vein. If the vein was not seen,
the nerve was scanned proximally on the surface of the
Achilles tendon.
Every block was performed using a 27-gauge, 4-cm, short-
bevel needle connected to a 30-cm tubing and injected with
2 to 3 mL of 1.5% plain mepivacaine. In addition, 3 to 5 mL of
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Regional Anesthesia and Pain Medicine & Volume 37, Number 5, September-October 2012
FIGURE 1. Probe position and US imaging of the nerves at the level of lower leg and ankle. MM indicates medial malleolus; PM:
peroneal muscles; AT: Achilles tendon.
0.5% levobupivacaine was injected around the TN and 2 mL
around the DPN to prolong postoperative analgesia.
The sensory blocks were assessed by pinprick every 5 min-
utes for 20 minutes in the following locations: TN: medial, lateral,
and calcaneal sole of foot; DPN: web space between the first
and second toes; SPN: dorsum of the foot; and SuN: lateral border
of the foot. The extent of sensory block was graded as follows:
2: normal sensation; 1: decreased sensation; and 0: no sensation
(complete block). If any of the blocks was incomplete after
20 minutes, the block was repeated with 2 mL of 1.5% mepi-
vacaine. After sensory block was complete in all territories, the
innervation area of the SaN in the foot was assessed by pin-
prick stimulation starting from the medial malleolus to the tip
of the great toe, and the limit of the area was marked on the
skin (Fig. 2). The location of the first tarsometatarsal joint was
determined by palpation and also marked on the skin. The dis-
tance from the distal limit of the SaN territory to the joints and
to the medial malleolus was measured, as well as the distances
between the tip of medial malleolus and the bunion. The prox-
imal end of the planned surgical incision was located 1 cm distal
to the first tarsometatarsal joint.
FIGURE 2. Assessment of the innervation area of the SaN (shadow
area) in relation to bony landmarks: 1: distance from medial
malleolus to the bunion area; 2: medial malleolus to the limit of
SaN innervation area; 3: limit of SaN innervation area to the
tarsometatarsal joint; 4: planned surgical incision.
* 2012 American Society of Regional Anesthesia and Pain Medicine
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US-Guided Ankle Block for Bunion Surgery
When the sensory block was incomplete at the level of the
first tarsometatarsal joint, the skin was infiltrated with 2 mL of
1% plain mepivacaine.
During the procedure, patients were asked to rate the quality
of block as good, fair, or poor.
Statistical Analysis
A descriptive study was performed. Measured distances are
expressed in median (25%Y75%). Comparison of measures be-
tween male and female was performed with a nonparametric test
Mann-Whitney/Wilcoxon test. The confidence interval of proba-
bility to require a SaN block was calculated based on binomial
proportion using the exact method.
RESULTS
Every recruited patient completed the study and was in-
cluded in the analysis. Anthropometric data and surgical details
are shown in Table 1. Complete sensory block of the 4 nerve
branches that can be traced back to the sciatic nerve was obtained
in all 100 patients within 10 minutes of the completion of the
injection. No patient needed rescue block.
Details of the innervation area of the SaN are shown in
Table 2 and Figure 3. The SaN innervated the medial malleolus
(100%), but not the base of the great toe (0%). In 97 patients, the
TABLE 1. Anthropometric Data and Surgical Details
Age, y 61 (11)
Weight, kg 67 (11)
Height, cm 159 (9)
Sex, male/female, n 12/88
Minimally invasive bunionectomies, n 75
Open procedures, n 25
Data are mean (SD), unless specified otherwise.
555
López et al Regional Anesthesia and Pain Medicine
limits of the area of innervation of the SaN did not reach the first
tarsometatarsal joint. In the remaining 3 patients, the limit of the
innervation area extended beyond this level by 5, 10, and 15 mm,
respectively. Only 2 of these patients required skin infiltration
of local anesthetic before incision. Therefore, the probability to
require a SaN block for forefoot surgery in our study is 3% (95%
confidence interval, 0.6%Y8%).
No correlation was observed between the extension of SaN
territory and gender. No patient required additional sedation or
analgesia during the procedure. Quality of block during the
surgery was rated as good (94%) and fair (6%).
DISCUSSION
An ankle block traditionally means to block 5 nerves in-
cluding the SaN. However, our results seem to indicate that the
SaN block might not contribute significantly to the anesthesia
of the forefoot. In fact, our study shows that the sensory territory
of the SaN in the foot does not reach distally to the level of
the first tarsometatarsal joint in 97% of cases. The clinical im-
plication is that the block of the SaN would be necessary in only
3% of patients undergoing forefoot surgery under ankle block.
Our results are in agreement with previous anatomical
findings. Williams and Sugars11 found that the SaN ended near
the medial malleolus in 20 dissections. In another study that
included the dissection of 229 feet, the SaN branches ex-
tended to the first tarsometatarsal joint or the great toe in only
2 cases.12 Anatomic variations in the distribution of the SaN,
including connections with the SPN in the foot, have been
reported.13 It is possible that these connections could account
for the 3 patients in which the SaN territory extended beyond
the first tarsometatarsal joint. However, our findings suggest
that, if these variations exist, they are rare.
On the other hand, the branches of the tibial and common
peroneal nerves present multiple anatomical variations12 and
frequent anastomosis between them. The SPN and the SuN,
for instance, are connected in the malleolar and lateral tarsal
regions producing different patterns of innervation with variable
frequency.14,15 Therefore, attempts to selectively block specific
nerves based on landmarks alone may result in inconsistent
and patchy anesthesia and may contribute to failed blocks.16
Ultrasound provides an invaluable tool to achieve targeted
and highly selective blocks.5 In our study, US guidance achieved
100% success rate for every nerve targeted within 10 minutes
of the injection. Only 2 of 3 patients in whom the proximal
part of the incision was within the distal saphenous distribu-
tion needed a small subcutaneous injection of local anesthetic,
whereas the surgical technique used on the third patient did
not make it necessary. No supplemental analgesia or sedation
was used in any patient.
In our study, we made the best effort to accurately deter-
mine the success rate for each individual nerve block, as op-
posed to the ‘‘no need for supplemental anesthesia,’’ usually
TABLE 2. Sensory Area of Saphenous Nerve
Distance, mm
Medial malleolus-bunion 13 (13Y14)
Medial malleolus-distal edge of SaN 55 (4.5Y6)
innervation area
Distal edge of SaN innervation 2 (1.5Y2.5)
areaYtarsometatarsal joint
Data are median (interquartile range [25%Y75%]).
556
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& Volume 37, Number 5, September-October 2012
FIGURE 3. Distribution of the distances from medial malleolus to
the distal limit of the sensory area of the SaN.
used in our literature. The lack of standardization in the testing
method and timing to assess the blocks may render comparisons
of techniques difficult.10,16,17
The main limitation of this study is anatomical. A sensory
nerve territory is formed by a nucleus or central area that belongs
only to that nerve (autonomous zone) and a peripheral area that
is shared with the surrounding nerve(s). Because we defined
the SaN territory by determining the area without anesthesia,
we did not take into account the peripheral area that the SaN
shares with the surrounding nerves. Had we blocked instead
the SaN to determine the resulting area of anesthesia, this area
would have been slightly different,18 but for the purpose of
ankle block for forefoot surgery, this difference would not
have been clinically relevant.
In conclusion, US-guided ankle block is a reliable and ac-
curate anesthesia technique. In the particular case of ankle block
for forefoot (eg, bunion) surgery, the block of the SaN would
only be needed in 3% of patients.
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