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C OPYRIGHT 2013

BY

T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

Nerve Block of the Infrapatellar Branch of the

Saphenous Nerve in Knee Arthroscopy
A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial
Lawrence P. Hsu, MD, Sanders Oh, BS, Gordon W. Nuber, MD, Robert Doty Jr., MD, Mark C. Kendall, MD,
Stephen Gryzlo, MD, and Antoun Nader, MD
Investigation performed at the Departments of Orthopaedic Surgery and Anesthesiology,
Northwestern University, Feinberg School of Medicine, Chicago, Illinois

Background: With the rising use of outpatient knee arthroscopy over the past decade, interest in peripheral nerve blocks
during arthroscopy has increased. Femoral nerve blocks are effective but are associated with an inherent risk of the
patient falling postoperatively because of quadriceps weakness. We studied blocks of the infrapatellar branch of the
saphenous nerve, which produce analgesia in the knee that is similar to that resulting from a femoral nerve block but
without associated quadriceps weakness.
Methods: Thirty-four patients were enrolled into each arm of this prospective, randomized, double-blinded trial comparing 10 mL of 0.25% bupivacaine used as a block of the infrapatellar branch of the saphenous nerve with a placebo
during simple knee arthroscopy. Immediate outcome measures included Numeric Rating Scale (NRS) pain scores (0 to
10 points), mobility and discharge times, opioid usage, subjective adverse side effects, and forty-eight-hour anesthesia
recovery surveys. Short-term measures included one-week and twelve-week Lysholm knee scores.
Results: No adverse effects or increased quadriceps weakness were observed following use of the nerve block. Improvement in early NRS scores and subjective nausea (p = 0.03) were detected. Patients for whom the block was
successful also had improved twelve-week Lysholm knee scores (p = 0.04). No differences in opioid usage, mobility time,
forty-eight-hour anesthesia recovery scores, or one-week Lysholm knee scores were found.
Conclusions: No significant adverse effect or disadvantage was identified for blocks of the infrapatellar branch of
the saphenous nerve used in simple knee arthroscopy. In addition to decreased early NRS scores and nausea, blocks of
the infrapatellar branch of the saphenous nerve demonstrated potential benefit at twelve weeks after simple knee
arthroscopy.
Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

nee arthroscopy is one of the most common orthopaedic procedures performed in the United States.
An estimated 690,000 meniscectomies were performed in 2006, which represent a 50% increase over a
single decade. Peripheral nerve blocks were used in 9.8% of
these 690,000 cases1. With the shift towards surgical procedures being performed more often in the ambulatory
setting, effective pain management to hasten recovery is
important 2. Interest in peripheral nerve blocks has in-

creased due to their ability to provide analgesia beyond the

duration of the surgical procedure3,4 and their low overall
risk. Nerve blocks expedite discharge from the hospital and
improve the immediate recovery profile following outpatient knee arthroscopy5.
Although femoral nerve blocks have provided effective
analgesia for knee arthroscopy6,7, the associated quadriceps
weakness carries an inherent risk of injury from falls8-10. For
this reason, femoral nerve blocks seldom are employed for

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this
work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what
is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the
article.

J Bone Joint Surg Am. 2013;95:1465-72

http://dx.doi.org/10.2106/JBJS.L.01534

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TABLE I Group Characteristics

Age* (yr)
BMI*

(kg/m2)

ASA score (1, 2, or 3)

Sex (no.)
Male
Female
Airway (no.)
Laryngeal mask
General endotracheal
anesthesia
Duration of surgery* (min)
Preoperative NRS pain
score* (0-10)
Type of procedure (no.)
Soft-tissue
Single osseous
Multiple osseous

Group I (Placebo)

Group II (0.25% Bupivacaine)

P Value

49.6 14.1

51.7 12.1

0.51

29.9 7.5

30.6 9.4

0.75

1.7 (1-3)

1.9 (1-3)

0.47

18
16

15
19

33
1

31
3

34.1 10.4

36.4 12.3

0.41

0.9 1.9

1.4 2.6

0.23

30
9
4

29
9
12

0.92
0.99
0.07

0.63

0.30

*The values are given as the mean and standard deviation. The values are given as the mean with the range in parentheses. Soft-tissue
procedures include meniscectomy, meniscal repair, and synovial debridement. Osseous procedures include chondroplasty and microfracture.

simple knee arthroscopy at our institution. Likewise, concerns

about chondrocyte injury are associated with intra-articular
injection of local anesthetic11-14.
The infrapatellar branch of the saphenous nerve arises
from the saphenous nerve in the adductor hiatus before
piercing the fascia lata to become subcutaneous15. The infrapatellar branch of the saphenous nerve is purely sensory and
innervates both the anteromedial aspect of the knee and the
anterior-inferior portion of the knee capsule16,17. Blockade of
this nerve provides the advantage of the sensory analgesia
to the knee provided by a femoral nerve block, without the
concomitant quadriceps weakness. In the past, anatomic variation of the nerve made landmark-based techniques of nerve
block inconsistent at best. However, the advent of ultrasoundguided techniques has made targeted blockade of the infrapatellar branch of the saphenous nerve more feasible and
reliable16,18.
We hypothesized that the analgesic benefit of a block of
the infrapatellar branch of the saphenous nerve improves the
postoperative quality of recovery, decreases narcotic use and
the inherent side effects of narcotics, and improves mobility
immediately following knee arthroscopy. We secondarily attempted to study whether an improvement in these factors led
to an improvement in short-term outcomes. Thus, our primary outcomes were early postoperative measures, including
pain scores, analgesic requirements, side effects, time to discharge and mobilization, and Quality of Recovery (QoR)
scores. Our secondary outcomes included short-term Lysholm
knee scores.

Materials and Methods

Participants

pproval was obtained from our institutional review board, and the study
was registered with ClinicalTrials.gov (NCT01279447). All patients signed
an approved informed-consent form in order to participate.

Fig. 1

An ultrasound scan of the saphenous nerve and the infrapatellar branch

of the saphenous nerve. The infrapatellar branch of the saphenous nerve
lies superficial and lateral to the femoral artery. IBSN = infrapatellar branch
of the saphenous nerve, SN = saphenous nerve, A = femoral artery, VM =
vastus medialis, and S = sartorius.

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TABLE II NRS Pain Scores

Postoperatively

Group I (Placebo)*

Group II (0.25% Bupivacaine)*

P Value

5.5 2.6 (n = 34)

3.9 3.3 (n = 34)

0.02

1 hour

4.5 2.4 (n = 34)

3.3 2.6 (n = 34)

0.046

2 hours

3.6 2.0 (n = 22)

2.6 1.7 (n = 19)

0.07

3 hours

3.0 0.8 (n = 4)

2.0 2.5 (n = 4)

0.49

4 hours

3.0 1.4 (n = 2)

4.0 1.4 (n = 2)

0.55

At discharge

3.0 1.7

2.4 1.7

0.14

On arrival at home

3.4 2.3

2.3 1.8

0.03

0-6 hours

3.5 2.5

2.5 1.9

0.08

6-12 hours

3.2 2.1

2.8 2.5

0.49

12-24 hours

3.2 2.1

2.4 2.2

0.15

*The values are given as the mean and standard deviation. Self-reported surveys.

From January to November 2011, adult patients undergoing simple

knee arthroscopy at an ambulatory surgery center were prospectively enrolled.
Simple knee arthroscopy included all soft-tissue procedures (e.g., meniscectomy,
meniscal repair, and synovial debridement) and osseous procedures no more
substantial than microfracture or chondroplasty. Arthroscopic procedures involving osseous resection more substantial than microfracture (e.g., ligament
reconstruction and osteochondral autograft transfer) were excluded. Patients
with risk factors for block-related complications (e.g., coagulopathy, neuropathy, allergy to local anesthetics, and type-1 diabetes mellitus) were excluded.

Randomization
Randomization was performed with the use of a random-number generator, and
then each assignment was placed into a sealed envelope. Upon each patients
enrollment into the study, the next sealed envelope was opened and the patient
was assigned to group I (saline-solution placebo) or group II (0.25% bupivacaine). Thirty-four patients were assigned to each group. The patient and surgeon
were blinded to the study-arm assignment. There was no significant difference
between the two groups with regard to patient age, body mass index (BMI), ASA
(American Society of Anesthesiologists) score, sex, duration of the procedure,
preoperative pain scores, or surgical procedures performed (p > 0.05) (Table I).

Procedure
A nerve block was performed prior to the surgical procedure, under the supervision of an anesthesiologist experienced in administering regional anesthesia.

Patients received 2 mg of midazolam and/or fentanyl as premedication prior to

the performance of the nerve block. The nerve block was performed under
ultrasound guidance (SonoSite M-Turbo; SonoSite, Bothell, Washington) in
19
accordance with the technique described by Lundblad and colleagues . The
ultrasound probe was placed transverse to the axis of the thigh 10 to 15 cm
proximal to the joint line and directly over the vastus medialis. With the femoral
artery as a reference, the saphenous nerve was identified as lying superficial and
medial to the artery. The saphenous nerve was then traced cranially and caudally until its infrapatellar branch could be seen branching and lying superficial
and lateral to the femoral artery (Fig. 1). Under sterile technique, a needle then
was advanced under ultrasound visualization to the infrapatellar branch of the
saphenous nerve. A small amount of saline solution was injected to confirm the
position of the needle, and 10 mL of the study agent was injected while infiltration around the nerve was observed (see Appendix). In cases in which the
infrapatellar branch of the saphenous nerve could not be distinguished clearly
from the parent saphenous nerve, both nerves were blocked.
On removal of the needle used to administer the nerve block, an independent observer who was not involved in the clinical care of the patient performed
all sensory assessments every minute until the plateau of sensory anesthesia was
reached. Both the time of onset of sensory changes and the time until maximum
sensory anesthesia were documented. The sensory block assessments were performed with a 21-gauge needle, and the distribution of anesthesia was recorded.
Blocks were deemed effective if there was dense sensory anesthesia in the cutaneous
territories of either the saphenous nerve or the infrapatellar branch of the saphenous

TABLE III Analgesic Usage

Group I (Placebo)*
Ketorolac, intravenous (mg)
Fentanyl, intravenous (mg)

Group II
(0.25% Bupivacaine)*

P Value

17.3 15.1

12.4 14.5

0.18

136.7 74.8

119.9 61.2

0.32

0.6 0.7

0.7 0.6

0.38

Hydrocodone, oral: 0-24 hours (mg)

47.7 38.0

35.3 31.7

0.16

Hydrocodone, oral: 24-48 hours at home (mg)

20.3 22.6

19.1 22.0

0.83

Total morphine, oral equivalent: 0-24 hours

74.9 38.3

64.4 36.1

0.27

Hydromorphone, intravenous (mg)

*The values are given as the mean and standard deviation. Fentanyl, hydromorphone, and hydrocodone from zero to twenty-four hours.

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TABLE IV Results of Self-Reported Surveys

Modified QoR (QoR-40)

Lysholm knee scale
1 week
12 weeks

Group I (Placebo)*

Group II
(0.25% Bupivacaine)*

P Value

125.7 14.1

128.3 9.6

0.38

53.5 23.1
66.8 23.8

54.9 17.4
77.4 18.2

0.79
0.053

*The values are given as the mean and standard deviation.

nerve. Anesthesia of the infrapatellar branch of the saphenous nerve was defined as a
nerve block occurring in the region within 5 cm superior, 8 cm medial, 10 cm
18
inferior, and 3 cm lateral to the tibial tubercle . Anesthesia of the saphenous nerve
was defined as a nerve block occurring in a region distal to the cutaneous boundaries
of the infrapatellar branch of the saphenous nerve, along the medial aspect of the
20
gastrocnemius and extending distally to the medial malleolus . Following plateau of
21
anesthesia, quadriceps strength was graded .
Intraoperatively, all patients received general anesthesia. Opioid usage
during anesthesia induction was controlled in order to avoid confounding the
results. Fentanyl was titrated to a respiratory rate of fourteen to twenty breaths
per minute. The surgeon was blinded to the randomization and performed
the knee arthroscopy as planned. At the conclusion of the procedure, no local
anesthetic was injected at the portal sites or intra-articularly.

Data Collection
Postoperatively, the subjects rating of pain with use of a Numeric Rating Scale
(NRS, 0 to 10 points) was assessed at one-hour intervals until discharge.

Intravenous ketorolac was administered as a rescue medication for substantial breakthrough pain only as needed. During phase I of the recovery of the
patient, intravenous hydromorphone was administered as needed to titrate to
a NRS score of 4 points. Criteria at our institution for transition to phase
22
II of recovery included stable vital signs, nausea control, an Aldrete score
of 10 points, and an NRS score of <5 points. In phase II of recovery, oral
Norco (hydrocodone bitartrate/acetaminophen; 10/325 mg) was administered as the analgesic to again titrate pain scores with the goal of 4 points.
Total usage of both the opioid and the ketorolac was recorded. At the time
of discharge, the patients subjective ratings of nausea and dizziness were
recorded.
At discharge, home opioid usage was standardized to Norco 10/325 mg
to be self-administered as needed. Patients recorded the number of pills taken at
intervals from zero to twenty-four hours and from twenty-four to forty-eight
hours postoperatively. Pain was self-reported with use of the NRS at intervals
immediately on arrival home and from zero to six hours, six to twelve hours,
and twelve to twenty-four hours after arrival home. The time until the patient

Fig. 2

CONSORT (Consolidated Standards of Reporting

Trials) diagram.

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began standing and walking to the bathroom were self-reported, and the severity
of pain experienced during these events was reported with use of the NRS.
At forty-eight hours postoperatively, the patients completed the mod23
ified QoR scale. This validated survey evaluates postanesthesia recovery,
including categories such as comfort, emotions, patient independence, and
support required based on a 145-point scale. A higher score denotes a superior
outcome. At one week and at twelve weeks, the Lysholm knee scale was completed. The Lysholm knee scale is an instrument used to assess a variety of knee
conditions, and has been validated for use in assessment of chondral, liga24,25
mentous, and meniscal conditions of the knee
.

Statistical Analysis
A power analysis estimated that a total of sixty patients was required to detect
a 15-point difference in the modified QoR score with a power of 80% and a
significance level of p = 0.05. Sixty-eight patients were thus recruited to account
for anticipated dropout.
Opioids were converted to morphine oral equivalents for comparison.
Continuous data were analyzed with use of the unpaired Student t test. The
Fisher exact test was used to analyze categorical data (e.g., quadriceps strength,
sex, and airway type). The Mann-Whitney U test was used to compare adverse
effects. Statistical analysis was performed with use of SAS (SAS Institute, Cary,
North Carolina) and Excel (Microsoft, Redmond, Washington) software. A
value of p < 0.05 was considered significant.

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(p = 1.0). Strength was graded 4/5 in the remaining patients.

No adverse reactions to the nerve block were reported.
Postoperative Outcomes
In the recovery room, the NRS scores in group II were significantly lower than those in group I immediately postoperatively
and at one hour. A trend toward less pain in group II was seen at
two hours. However, at two hours and beyond, data were incomplete due to patient discharge. The self-reported surveys
indicated significantly less pain in group II immediately on
arrival home. A trend toward less pain was observed at zero to
six hours after arrival home (Table II).
Group II required less fentanyl, hydrocodone, and rescue
ketorolac; however, these differences were not significant.
Group II also had less, but not significantly less, total narcotic
use over the first twenty-four hours (Table III).
No major complications were observed in either group.
When surveyed at the time of discharge, patients who received
the nerve block reported less subjective nausea (p = 0.03).
However, we found no differences in reported subjective dizziness (p = 0.68).

Funding
No external funding was received for this study.

Results
hirty-four patients were recruited into each study arm.
Two patients from group I and one patient from group II
were lost to follow-up. One additional patient in group I failed
to return the twelve-week surveys. The follow-up rate was 96%
(sixty-five of sixty-eight patients) at forty-eight hours and at
one week and 94% (sixty-four of sixty-eight patients) at twelve
weeks (Fig. 2)

Nerve Block Characteristics

In group II, the mean time (and standard deviation) of onset of
anesthesia was 159.7 173.2 seconds following needle withdrawal. Complete anesthesia occurred at a mean of 497.7
190.4 seconds. The nerve block was successful in 85% (twentynine) of the thirty-four cases. Isolated sensory anesthesia in
the nerve distribution of the infrapatellar branch of the saphenous nerve was observed in six patients (18%) and in the
saphenous nerve in nine patients (26%). Anesthesia of both
nerves was observed in the remaining fourteen patients (41%).
In group I, partial sensory anesthesia was observed in the
infrapatellar branch of the saphenous nerve in three patients
and in both the saphenous nerve and the infrapatellar branch
of the saphenous nerve in one patient. Subjective partial anesthesia of the entire leg was observed in two patients. No patient
reported dense sensory anesthesia suggestive of a complete block
of the infrapatellar branch of the saphenous nerve.
Under ultrasound guidance, the infrapatellar branch of
the saphenous nerve was clearly distinguished from the parent
saphenous nerve in 47% (thirty-two) of the sixty-eight patients
participating in the study.
Quadriceps strength was full (5/5 motor) in 91% (thirtyone) of the thirty-four patients in both group I and group II

Recovery Time and Mobility

The patients in groups I and II transitioned to phase II of
recovery at 61.3 41.0 and 55.1 21.6 minutes, respectively
(p = 0.43). Discharge occurred at 144.0 82.3 and 134.3 44.3
minutes, respectively (p = 0.55).
The time until the patient was able to initially stand was
3.6 2.7 hours in group I and 2.9 2.6 hours in group II (p = 0.36).
The NRS scores during standing were 3.6 2.8 and 3.0 2.3,
respectively (p = 0.35). The time until the patient was able to walk
to the bathroom was 7.5 13.0 hours in group I and 4.0 2.9 hours
in group II (p = 0.15). The NRS scores while the patient walked to
the bathroom were 3.7 2.8 and 2.9 2.3, respectively (p = 0.22).
Self-Reported Surveys
The modified QoR survey was returned forty-eight hours after
the surgery and showed no significant difference between the
groups (Table IV). Subcategory analysis of comfort, emotion,
patient support, and physical independence likewise yielded no
significant difference between groups (p 0.15).
At one week postoperatively, Lysholm knee scores demonstrated no significant difference between groups. However,
at twelve weeks after the surgery, we identified a trend toward
improved Lysholm knee scores in group II (Table IV) and a
significant improvement in those scores for the group-II patients for whom the block was successful (p = 0.04).
Discussion
o our knowledge, the current study is the first to evaluate
the efficacy of a nerve block of the infrapatellar branch
of the saphenous nerve with regard to short-term outcome
measures following simple knee arthroscopy. The important
finding of the present study was an improvement in Lysholm
knee scores at twelve weeks for the patients who had had a
successful block of the infrapatellar branch of the saphenous

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nerve. However, our early outcome measures only demonstrated improvements in early NRS scores and nausea.
We observed no adverse reactions to the nerve block,
a finding that is in agreement with those of prior studies19,26.
Quadriceps weakness was found in three patients in each arm
of the study, which was believed to be effort-dependent as a
result of the premedication. Thus, one advantage of this nerve
block is that there is no increased concern about postoperative
falls as a result of quadriceps weakness. Patients can potentially
avoid the knee immobilization in the perioperative period that
is necessary with a femoral nerve block.
Anesthesia in the cutaneous territory of the infrapatellar
branch of the saphenous nerve was observed in 69% of the
patients for whom the nerve block was successful. This rate is
lower than that reported by Lundblad and colleagues18, who
successfully anesthetized the infrapatellar branch of the saphenous nerve in 90% of their patients. In our experience,
body habitus was the major challenge while performing the
nerve block, and our overall population was overweight (BMI =
29.6 kg/m2), whereas their population of healthy volunteers
had a BMI within the normal range (24.9 kg/m2). We were able
to differentiate clearly the infrapatellar branch of the saphenous nerve from the parent saphenous nerve on ultrasound in
only 47% of the patients. This rate is inferior to that reported by
Le Corroller and colleagues16, who visualized the nerve in 100%
of their group of healthy volunteers who had an average BMI of
21.6 kg/m2. The performance of an accurate block in our more
typical population was more difficult than it is in a healthy
volunteer population. Poor visualization, however, did not
preclude an effective nerve block altogether because blockade
of the infrapatellar branch of the saphenous nerve or of the
saphenous nerve was still successful in 85% of the cases. There
is also no apparent problem with spillover block of the saphenous nerve because this is a purely sensory nerve.
Pain reported with use of the NRS scale was substantially
less in group II immediately postoperatively and at one hour in
the postoperative anesthesia recovery unit, and immediately on
arrival home as indicated by the self-reported surveys. Lundblad
and colleagues19 studied nerve blocks of the infrapatellar branch
of the saphenous nerve used in surgical procedures for the anterior cruciate ligament (ACL) and found improved pain scores
up to twenty-four hours following surgery. Akkaya and colleagues26 studied saphenous nerve blocks during arthroscopic
medial meniscectomies and monitored subjects as inpatients for
twenty-four hours. At all time intervals up to twenty-four hours,
they found decreased NRS scores at rest. Whereas we suspect
that our nerve block of the infrapatellar branch of the saphenous
nerve was effective beyond six hours due to the known long halflife of bupivacaine7,27, home self-reporting of NRS scores may
have obscured differences after longer time intervals. We also
chose to include all simple knee arthroscopy procedures rather
than selecting for medially based procedures because this is more
generalizable to the clinical setting. However, the lateral aspect of
the knee is differently innervated, and pain in this region would
not be covered with use of our nerve block, which may have
additionally confounded our results. Lundblad and colleagues19

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reported improved sleep at thirteen to twenty-four hours with

the use of a nerve block of the infrapatellar branch of the saphenous nerve for ACL reconstructions. We found no difference
between groups with regard to the modified QoR score at fortyeight hours postoperatively. Simple knee arthroscopy is likely less
painful than ACL reconstruction because no osseous tunnels are
drilled, and the reduction in pain in the group that received the
block may have been too small to translate to an improvement in
postanesthesia recovery scores. The minimum clinically important difference in NRS scores has been suggested to be 1.4 to 2.0
points28-30. Although we found significant differences between
groups with regard to pain scores, these differences did not reach
this clinically relevant threshold, likely because a knee arthroscopy procedure is not extremely painful for most patients.
We attempted to demonstrate decreased narcotic requirements and reduced opioid side effects with the use of the
nerve block. Akkaya and colleagues26 found that saphenous
nerve blocks during arthroscopic medial meniscectomy reduced the amount of tramadol required as patient-controlled
analgesia. We did observe a decrease in side effects, specifically
subjective nausea, but we were unable to demonstrate a decreased analgesic requirement as an explanation for this finding. We believe that the outpatient nature of our study and the
self-administration and self-reporting of medication use introduced error into our results. The patients took an average of
three and five tablets (10 mg hydrocodone plus acetaminophen) in group I and group II, respectively, suggesting that the
difference in opioid requirement is small.
The ultimate goal of any intervention is to improve patient outcomes. The Lysholm knee scale surveys walking, pain,
swelling, and functional activities, all of which are important
outcome measures following knee arthroscopy. We hypothesized
that improved early pain control would promote improved early
rehabilitation, which would improve these outcomes. Although
we observed no difference between groups with regard to the
Lysholm knee scores at one week, the patients who had had a
successful nerve block had superior scores at twelve weeks. At
one week, the residual swelling and disability from the surgical
procedure likely masked any functional difference. Once the
short-term sequelae from the surgical procedure resolved, the
difference appeared to become evident. Early postoperative
walking decreases complications such as deep venous thrombosis following knee arthroplasty31-33, and we expected to find an
improvement in mobility to explain the improved twelve-week
Lysholm knee score. However, we were unable to demonstrate
whether there was a difference in early mobilization times because of a large variation in those times. The difference in the
twelve-week Lysholm knee score between our groups exceeds the
minimum clinically important difference suggested by Briggs
and colleagues34. However, we acknowledge the possibility that
these differences may be the results of a statistical anomaly because we failed to demonstrate early mobility as an etiology and
also required post-hoc analysis to show a difference. We cannot
recommend routine use of a nerve block of the infrapatellar
branch of the saphenous nerve based on improved twelve-week
Lysholm knee scores.

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Regional anesthesia used in the lower extremity decreases

pain and postoperative narcotic use requirements, facilitates
readiness for discharge, improves tolerance of physical therapy,
and improves functional outcomes35,36. Other authors have demonstrated that regional anesthesia may facilitate discharge after
painful joint surgery5. Some of the benefits after a femoral nerve
block are attributed to the interruption of quadriceps spasm
following a surgical procedure on the knee and the resulting pain
cycle. However, quadriceps weakness requires additional precautions against the patient falling that may delay postoperative
discharge. Performing a pure sensory blockade such as the block
of the saphenous nerve or the infrapatellar branch of the saphenous nerve may provide the analgesic benefit of a femoral nerve
block without the quadriceps weakness. We demonstrated the
efficacy of a block of the infrapatellar branch of the saphenous
nerve for pain reduction, with no apparent detrimental effect, in
the immediate postoperative period after a common outpatient
procedure. Although our results are not strong enough to suggest
routine preoperative use, a block of the infrapatellar branch of the
saphenous nerve can be considered postoperatively as a rescue
block for patients experiencing severe pain. The infrapatellar
branch of the saphenous nerve may ultimately be more effective
in more painful procedures such as ligament reconstruction or
total knee arthroplasty, after which early mobility is vital and the
commonly used femoral nerve block inhibits mobilization.
The major limitation of this study was its outpatient nature. The self-reporting of a number of outcomes and the selfadministration of opioid medication introduced error, which
limited statistical power. This was unavoidable, however, because knee arthroscopy is typically an outpatient procedure,
and the performance of the present study in a controlled inpatient setting would be impractical. Knee arthroscopy inherently leads to minimal pain and uneventful recovery in most
cases. Thus, the benefits in terms of reduced pain and narcotic
use and increased mobility may be minimal, and this type
of block may be better applied more selectively to patients
experiencing active postoperative pain.
Our study did not include the collection of preoperative
Lysholm knee scores. Improvement of the postoperative scores
compared with the preoperative values would have served as a
better short-term measure and would have resulted in stronger
conclusions with regard to this short-term outcome. Although
the number of subjects who had undergone multiple osseous
procedures did not differ significantly between groups, that
number was three times higher in the group that received a
nerve block of the infrapatellar branch of the saphenous nerve.
This difference may have influenced pain and opioid use and

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diminished our ability to observe a difference between groups

with regard to those outcomes. Finally, we lacked a comparison
group of patients who had undergone a simple injection of
local anesthetic into the arthroscopic portals, which is a more
common practice and a better control group.
In conclusion, we present the results of a prospective,
randomized, double-blinded study evaluating the short-term
outcomes following a knee arthroscopy that included a block
of the infrapatellar branch of the saphenous nerve. No adverse
reactions to the nerve block occurred. We observed decreased
early NRS pain scores and nausea. We found no difference in
opioid consumption, mobility times, or forty-eight-hour postanesthesia recovery scores. Our most interesting finding was
improvement in Lysholm knee scores for patients with a successful nerve block. However, we do not think that a firm conclusion with regard to that short-term outcome can be made
without a larger study. With the shift toward outpatient procedures, ultrasound-guided blocks of the infrapatellar branch of
the saphenous nerve represent a safe adjunct to knee arthroscopy, with the potential to improve short-term outcomes.
Appendix
A video showing the procedure for identifying the infrapatellar branch of the saphenous nerve and applying the
nerve block is available with the online version of this article as
a data supplement at jbjs.org. n

Lawrence P. Hsu, MD
Gordon W. Nuber, MD
Stephen Gryzlo, MD
Department of Orthopaedic Surgery,
Northwestern University Feinberg School of Medicine,
676 North St. Claire Avenue, Suite 1350,
Chicago, IL 60611
Sanders Oh, BS
Northwestern University Feinberg School of Medicine,
420 East Superior Street,
Chicago, IL 60611
Robert Doty Jr., MD
Mark C. Kendall, MD
Antoun Nader, MD
Department of Anesthesiology,
Northwestern University Feinberg School of Medicine,
251 East Huron Street, Feinberg 5-704,
Chicago, IL 60611

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