Health education
Ultrasound-guided ankle block: An attractive anaesthetic technique for foot surgery
Bloqueo de tobillo guiado por ultrasonido: una técnica anestésica atractiva para cirugía de pie
Laura Girón-Arangoa,
, María Isabel Vásquez-Sadderb, María Patricia González-Obregónc, Carlos Enrique Gamero-Fajardoa
Corresponding author
laura_giron55@hotmail.com
Corresponding author at: Clínica Universidad CES, Calle 58 N° 50C-2 Prado Centro, Medellín, Colombia.
Corresponding author at: Clínica Universidad CES, Calle 58 N° 50C-2 Prado Centro, Medellín, Colombia.
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"nombre" => "María Isabel" "apellidos" => "Vásquez-Sadder" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "María Patricia" "apellidos" => "González-Obregón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Carlos Enrique" "apellidos" => "Gamero-Fajardo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Anaesthesia Resident, Universidad CES, Medellín, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Anaesthetist, Clínica CES; Regional Anaesthesia Committee Coordinator, S.C.A.R.E.; Secretary, LASRA International, Medellín, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Anaesthetist, Clínica CES; Pain and Palliative Care Specialist, Universidad CES, Medellín, Colombia" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author at</span>: Clínica Universidad CES, Calle 58 N° 50C-2 Prado Centro, Medellín, Colombia." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueo de tobillo guiado por ultrasonido: una técnica anestésica atractiva para cirugía de pie" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 980 "Ancho" => 1583 "Tamanyo" => 104196 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Sensory innervation of the foot and ankle.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Regional anaesthesia has become increasingly popular in ambulatory surgery because it has been shown to offer excellent pain control in the immediate postoperative period, with shorter length of stay in the post-anaesthetic care unit, and perioperative opioid sparing.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Ankle blockade consists of blocking the five nerves that provide sensory innervation to the region distal to the malleoli. It is used alone as anaesthetic technique in foot surgery provided no pneumatic tourniquet is used during the procedure, or it can also be used together with general or neuroaxial anaesthesia in order to provide adequate post-operative analgesia.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> Whenever a tourniquet is required, we propose its use at ankle level, with good tolerance when the ankle block is used as the only anaesthetic technique.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Its main advantage over the simultaneous sciatic and femoral nerve block is the absence of motor blockade above the ankle. This allows for rapid mobilization of the patient, which is important in the outpatient context or when bilateral procedures are required.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Migues et al.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a> conducted a prospective randomized study in 51 patients, comparing the quality of surgical anaesthesia, postoperative analgesia and postoperative complications of the sciatic nerve block at the popliteal level with the ankle block in foot surgery. In their study, they used the anatomic landmark technique for the ankle block, and the peripheral nerve stimulator for the popliteal sciatic block. The authors did not find a significant difference in terms of block efficacy and the quality of postoperative analgesia. No complications were reported in this study.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although high rates of success have been reported with the anatomical landmark technique (89–100%),<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">9,10</span></a> it has been perceived as technically challenging and not very reliable.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Regarding the ultrasound technique, Chin et al.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> conducted a six-year retrospective cohort study comparing the ultrasound technique with the anatomical landmark technique for ankle blocks and found that the use of ultrasound increases clinical efficacy with improved surgical anaesthesia, a lower need for rescue systemic opioids, and smaller postoperative opioid doses.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The objective of this article is to review the relevant anatomy and sonoanatomy in ankle blocks and to provide anaesthetists with a tool for localization and successful blockade of the nerves involved.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Ankle innervation</span><p id="par0040" class="elsevierStylePara elsevierViewall">Innervation distal to the malleoli comprises the tibial, superficial and deep peroneal, sural and saphenous nerves.</p><p id="par0045" class="elsevierStylePara elsevierViewall">All of these nerves are branches of the sciatic nerve except for the saphenous, which is a branch of the femoral nerve. The deep peroneal, posterior tibial and sural nerves are accompanied by blood vessels, which are useful anatomical landmarks for the ultrasound approach. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the regions corresponding to the sensory innervation of each of the nerves of the foot.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Although it has been suggested that saphenous nerve block is only necessary in 3% of patients taken to foot surgery,<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> a complete rather than a selective block is recommended regardless of the type of surgery, because nerve territories are often superimposed.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Tibial nerve</span>: A nerve with mixed characteristics (sensory and motor), it arises from the terminal branches of the sciatic nerve. As it crosses the popliteal fossa it receives the name of tibial nerve, and becomes superficial in the region that lies posterior to the medial malleolus. It is the largest of the group of five nerves innervating the foot and provides sensation to the sole and the heel. At the ankle, it divides into its medial, lateral and calcaneal branches.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">14,15</span></a> With the knee in flexion and the hip in external rotation, the transducer is placed cross-wise between the medial malleolus and the Achilles tendon (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Blood vessels in this area are identified with the help of the sonanatomy, including the posterior tibial artery which runs posterior to the medial malleolus, and two accompanying veins. The tibial nerve appears as a hyperechoic structure adjacent to the posterior tibial artery (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The tibial nerve is most often found posterior to the artery, although sometimes it may be anterior to it. It is recommended to perform this block proximal to the eminence of the medial malleolus to ensure blockade of the calcaneal branch.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> Finally, it is important to bear in mind the flexor hallucis longus tendon deep to the tibial nerve; because of its sonoanatomic characteristics, it may be mistaken occasionally for a nerve structure.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Redborg et al.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> conducted a prospective randomized study with 18 healthy volunteers comparing the anatomical landmark technique with the ultrasound-guided technique for tibial nerve blockade and showed a higher proportion of complete blocks after 30 minutes when ultrasound was used (72% vs. 22%).</p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Superficial peroneal nerve</span>: The superficial peroneal nerve is the superficial branch of the common peroneal nerve. It arises at the level of the fibular neck and courses down the lateral compartment of the leg providing sensation to the dorsum of the foot and the toes.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> With the knee in flexion and hip in internal rotation, the transducer is placed across the middle third of the lateral aspect of the leg (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The anatomical landmark used is the fibula, which generates a rectangular-shaped echo. Superficial to it are the peroneous brevis and extensor digitorum longus muscles. The intermuscular septum and the superficial peroneal nerve are usually visualized at this level between the two muscles, deep to the crural fascia (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">As the transducer is advanced distally, the nerve becomes more superficial until it crosses the crural fascia. At this point, the nerve branches into the intermediate dorsal and medial cutaneous nerves, which innervate the dorsum of the foot.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">17,18</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Regarding the superficial peroneal nerve in particular, no studies were found comparing the success of the ultrasound-guided technique with that of the anatomical landmark technique.</p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Deep peroneal nerve</span>: The deep peroneal nerve is a branch of the common peroneal nerve and, like the superficial branch, it emerges at the level of the fibular neck. It courses deep to the extensor hallucis longus and becomes more superficial until it comes to the anterior aspect of the interosseous membrane where it is localized lateral to the anterior tibial artery, although anatomical variants have been reported.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">19,20</span></a> It provides sensation to the region between the first and the second rays, the lateral aspect of the first ray, and the medial aspect of the second ray. The transducer is placed cross-wise over the intermalleolar region (<a class="elsevierStyleCrossRef" href="#fig6">Fig. 6</a>), where the anterior tibial artery is visualized as the main anatomical landmark, which is of great use in cases where it is difficult to visualize the nerve because just by surrounding the artery with local anaesthetic the nerve block is assured (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>).<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="fig6"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Care must be exercised not to press too hard on the transducer because this could occlude the artery and impair adequate visualization.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Antonakakis et al. conducted a prospective randomized controlled study with 18 healthy volunteers comparing the anatomical landmark approach with the ultrasound-guided technique for deep peroneal nerve blockade. At the end of the study, the authors concluded that although the use of ultrasound for deep peroneal nerve blockade reduced latency times, it did not improve the quality of the final block when compared to the conventional anatomical landmark technique.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sural nerve</span>: This nerve arises from branches of the tibial and common peroneal nerves where the gastrocnemii come together in the upper third of the calf. It reaches the ankle in a posterolateral position in contact with the lesser saphenous vein and lateral to the Achilles tendon, branching into two terminal portions referred to a lateral calcaneal and lateral dorsal.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> It provides sensory innervation to the lateral aspect of the heel and to the proximal lateral third of the foot in the majority of cases, and may extend to the lateral aspect of the fifth ray. The patient is positioned with the knee in flexion and the hip in internal rotation, and the transducer is placed across the space between the lateral malleolus and the Achilles tendon (<a class="elsevierStyleCrossRef" href="#fig8">Fig. 8</a>). A hyperechoic image is observed lateral to the lesser saphenous vein along the same subcutaneous plane, but in the event it is not possible to visualize it, localizing the peroneal sheath helps localize the nerve outside and anterior to it (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>).</p><elsevierMultimedia ident="fig8"></elsevierMultimedia><elsevierMultimedia ident="fig0045"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Another way to make visualization of the sural nerve easier is by placing a tourniquet in the upper third of the leg in order to provoke distension of the lesser saphenous vein to help with the anatomic localization of the nerve.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> In the event the nerve is not visible, local anaesthetic may be injected around the vein.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Redborg et al.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> conducted a prospective blinded randomized study with 18 healthy volunteers divided into two groups. In one group, ultrasound guidance was used to block the sural nerve, and in the second group they made the blockade under landmark guidance. They concluded that the use of ultrasound results in a more prolonged and complete block.</p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Saphenous nerve</span>: This is the only nerve arising from the lumbar plexus as it is the terminal branch of the femoral nerve. It courses alongside the greater saphenous vein down to the medial malleolus. It provides sensory innervation to the medial aspect of the ankle and to the heel. There are reports of the saphenous nerve extending deep down to the periostium of the distal tibia, the medial malleolus capsule in the ankle joint and, in some cases, to the capsule of the talocalcaneonavicular joint medially.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The patient is positioned with the hip in external rotation and the transducer is placed proximal to the medial malleolus (<a class="elsevierStyleCrossRef" href="#fig0050">Fig. 10</a>).</p><elsevierMultimedia ident="fig0050"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">The anatomical landmark is the greater saphenous vein. In the event it is not possible to visualize it, a tourniquet may be placed around the calf in order to promote venous filling. The saphenous nerve may be visualized as a small superficial hyperechoic structure posterior to the greater saphenous vein. However, it is not always visible and the block may require infiltration of local anaesthetic around the vein.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">We did not find studies comparing the use of ultrasound with the anatomical landmark technique for blocking this nerve in particular (<a class="elsevierStyleCrossRef" href="#fig0055">Fig. 11</a>).</p><elsevierMultimedia ident="fig0055"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ultrasound approach and local anaesthetic volume</span><p id="par0145" class="elsevierStylePara elsevierViewall">The linear transducer is recommended for ankle nerve blocks considering that nerves are superficial, and 50<span class="elsevierStyleHsp" style=""></span>mm short bevel needles or 25-27G hypodermic needles may be used.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In terms of the approach, both the in-plane or the out-of-plane technique may be used for the five nerves; recommendations regarding the use of one over the other vary in the literature and depend on the authors’ own experience.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">4,7,14</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">As to the volume of local anaesthetic, it is recommended to use 5<span class="elsevierStyleHsp" style=""></span>mL for every nerve, except the tibial nerve which requires between 5 and 10<span class="elsevierStyleHsp" style=""></span>mL because of its larger size. There is general agreement in the literature regarding the use of a total volume ranging between 30 and 40<span class="elsevierStyleHsp" style=""></span>mL.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">4,7,12,13</span></a> This total volume is not significantly different from the volume used for ankle blocks with the anatomical landmark technique. Fredrickson et al.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a> assessed 72 patients taken to foot surgery in whom the ankle block was used. The patients were divided into two groups: in the first group, a low volume of local anaesthetic was used (approximately 16<span class="elsevierStyleHsp" style=""></span>mL), while the total conventional volume (30<span class="elsevierStyleHsp" style=""></span>mL) was used in the second group. The authors concluded that, despite a high success rate with the block when low volumes are used, the duration of postoperative analgesia may be compromised.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0160" class="elsevierStylePara elsevierViewall">Ankle blockade is an effective regional anaesthesia technique when used alone or as analgesic adjuvant in foot surgery. In outpatients, it offers the advantage of reduced motor blockade with similar analgesic effectiveness when compared to the sciatic block.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a> It may be considered an alternative for patients with heart or pulmonary disease in order to avoid side effects from general anaesthesia and highly potent systemic analgesics such as opioids.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Although the use of ultrasound to guide the blockade of these five nerves is relatively recent, there are studies in the literature that favour its use over the traditional landmark-guided technique.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">12,13</span></a> Moreover, when the two techniques have been compared in terms of the quality and latency of the blockade for each separate nerve, the literature favours ultrasound for tibial<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> and sural<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> nerve blocks and does not show any difference in block quality for the deep peroneal nerve.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> No studies were found comparing the two techniques for the superficial peroneal or the saphenous nerves.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Funding</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors did not receive sponsorship to undertake this article.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres573633" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec590569" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres573634" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec590568" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Ankle innervation" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Ultrasound approach and local anaesthetic volume" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:3 [ "identificador" => "sec0035" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-05-18" "fechaAceptado" => "2015-07-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec590569" "palabras" => array:5 [ 0 => "Anesthesia, conduction" 1 => "Ultrasonography" 2 => "Nerve block" 3 => "Ankle" 4 => "General surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec590568" "palabras" => array:5 [ 0 => "Anestesia de conducción" 1 => "Ultrasonografía" 2 => "Bloqueo nervioso" 3 => "Tobillo" 4 => "Cirugía general" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Foot innervation, defined as distal to the tibial and fibular malleoli, is provided by five nerves, namely the tibial, peroneal (deep and superficial), sural and saphenous nerves. Blockade of these nerves is referred to as ankle block. The main advantage of using this block in foot surgery over other regional techniques is the absence of motor blockade above the ankle, which allows faster mobility after surgery. The use of ultrasound for this block has been shown to be of higher clinical efficacy when compared to a landmark approach. The purpose of this continuing education article is not only to detail the anatomy and sonoanatomy of the five nerves innervating the foot, but the ultrasound technique as well. The ultrasound-guided ankle block can be used alone as anaesthetic technique or as adjuvant for analgesia in foot surgery.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La inervación del pie, definida como aquella distal a los maléolos tibial y peroneal es dada por cinco nervios: tibial, peroneal (superficial y profundo), sural y safeno. El bloqueo de estos nervios se conoce como el bloqueo de tobillo. Su principal ventaja en la cirugía de pie comparado con otras técnicas regionales es la ausencia de bloqueo motor por encima del tobillo, que permite una rápida movilización posterior a la cirugía. El uso del ultrasonido para este bloqueo ha mostrado mayor eficacia clínica cuando se compara con la técnica por reparos anatómicos. El objetivo de este artículo de educación continua no es sólo detallar la anatomía y sonoanatomía de estos cinco nervios sino también describir la técnica guiada por ultrasonido. El bloqueo de tobillo guiado por ultrasonido puede ser usado como una técnica anestésica única o como coadyuvante analgésica en la cirugía de pie.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Girón-Arango L, Vásquez-Sadder MI, González-Obregón MP, Gamero-Fajardo CE. Bloqueo de tobillo guiado por ultrasonido: una técnica anestésica atractiva para cirugía de pie. Rev Colomb Anestesiol. 2015;43:283–289.</p>" ] ] "multimedia" => array:11 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 980 "Ancho" => 1583 "Tamanyo" => 104196 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Sensory innervation of the foot and ankle.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 578 "Ancho" => 850 "Tamanyo" => 57758 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patient and transducer positioning for tibial nerve block.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 595 "Ancho" => 1600 "Tamanyo" => 91860 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Ultrasound imaging of the tibial nerve. PTN: posterior tibial nerve; PTA: posterior tibial artery; MM: medial malleolus; FHLT: flexor hallucis longus tendon.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 610 "Ancho" => 900 "Tamanyo" => 63346 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Patient and transducer positioning for superficial peroneal nerve block.</p>" ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 597 "Ancho" => 1600 "Tamanyo" => 84710 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ultrasound imaging of the superficial peroneal nerve. SPN: superficial peroneal nerve; EDL: extensor digitorum longus; PL: peroneus longus; F: fibula.</p>" ] ] 5 => array:8 [ "identificador" => "fig6" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 554 "Ancho" => 900 "Tamanyo" => 57489 ] ] "descripcion" => array:1 [ "en" => "<p id="spar9015" class="elsevierStyleSimplePara elsevierViewall">Patient and transducer positioning for deep peroneal nerve block.</p>" ] ] 6 => array:8 [ "identificador" => "fig0035" "etiqueta" => "Fig. 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 595 "Ancho" => 1600 "Tamanyo" => 78453 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Ultrasound imaging of the deep peroneal nerve. DPN: deep peroneal nerve; ATA: anterior tibial artery; EDL: extensor digitorum longus; T: tibia.</p>" ] ] 7 => array:8 [ "identificador" => "fig8" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 675 "Ancho" => 900 "Tamanyo" => 63091 ] ] "descripcion" => array:1 [ "en" => "<p id="spar9020" class="elsevierStyleSimplePara elsevierViewall">Patient and transducer positioning for sural nerve block.</p>" ] ] 8 => array:8 [ "identificador" => "fig0045" "etiqueta" => "Fig. 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 596 "Ancho" => 1600 "Tamanyo" => 94405 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Ultrasound imaging of the sural nerve. SN: sural nerve; LSV: lesser saphenous vein; F: fibula; PS: peroneal sheath.</p>" ] ] 9 => array:8 [ "identificador" => "fig0050" "etiqueta" => "Fig. 10" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr10.jpeg" "Alto" => 644 "Ancho" => 900 "Tamanyo" => 66388 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patient and transducer positioning for saphenous nerve block.</p>" ] ] 10 => array:8 [ "identificador" => "fig0055" "etiqueta" => "Fig. 11" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr11.jpeg" "Alto" => 600 "Ancho" => 1600 "Tamanyo" => 81725 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Ultrasound imaging of the saphenous nerve. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 31 | 5 | 36 |
| 2024 October | 221 | 14 | 235 |
| 2024 September | 272 | 28 | 300 |
| 2024 August | 187 | 20 | 207 |
| 2024 July | 192 | 14 | 206 |
| 2024 June | 207 | 13 | 220 |
| 2024 May | 271 | 13 | 284 |
| 2024 April | 191 | 14 | 205 |
| 2024 March | 262 | 11 | 273 |
| 2024 February | 408 | 20 | 428 |
| 2024 January | 459 | 18 | 477 |
| 2023 December | 468 | 32 | 500 |
| 2023 November | 606 | 43 | 649 |
| 2023 October | 527 | 27 | 554 |
| 2023 September | 372 | 20 | 392 |
| 2023 August | 262 | 21 | 283 |
| 2023 July | 257 | 19 | 276 |
| 2023 June | 241 | 18 | 259 |
| 2023 May | 351 | 47 | 398 |
| 2023 April | 307 | 45 | 352 |
| 2023 March | 299 | 18 | 317 |
| 2023 February | 243 | 15 | 258 |
| 2023 January | 270 | 32 | 302 |
| 2022 December | 335 | 38 | 373 |
| 2022 November | 273 | 35 | 308 |
| 2022 October | 241 | 23 | 264 |
| 2022 September | 256 | 39 | 295 |
| 2022 August | 268 | 44 | 312 |
| 2022 July | 292 | 35 | 327 |
| 2022 June | 280 | 33 | 313 |
| 2022 May | 335 | 33 | 368 |
| 2022 April | 259 | 33 | 292 |
| 2022 March | 305 | 51 | 356 |
| 2022 February | 293 | 35 | 328 |
| 2022 January | 408 | 53 | 461 |
| 2021 December | 305 | 41 | 346 |
| 2021 November | 347 | 53 | 400 |
| 2021 October | 461 | 62 | 523 |
| 2021 September | 358 | 45 | 403 |
| 2021 August | 443 | 59 | 502 |
| 2021 July | 392 | 38 | 430 |
| 2021 June | 250 | 17 | 267 |
| 2021 May | 243 | 37 | 280 |
| 2021 April | 637 | 177 | 814 |
| 2021 March | 293 | 61 | 354 |
| 2021 February | 177 | 15 | 192 |
| 2021 January | 192 | 38 | 230 |
| 2020 December | 148 | 24 | 172 |
| 2020 November | 127 | 13 | 140 |
| 2020 October | 84 | 23 | 107 |
| 2020 September | 108 | 17 | 125 |
| 2020 August | 134 | 30 | 164 |
| 2020 July | 100 | 22 | 122 |
| 2020 June | 81 | 8 | 89 |
| 2020 May | 58 | 28 | 86 |
| 2020 April | 55 | 20 | 75 |
| 2020 March | 57 | 16 | 73 |
| 2020 February | 63 | 21 | 84 |
| 2020 January | 49 | 24 | 73 |
| 2019 December | 49 | 23 | 72 |
| 2019 November | 24 | 12 | 36 |
| 2019 October | 3 | 6 | 9 |
| 2019 September | 6 | 10 | 16 |
| 2019 August | 1 | 3 | 4 |
| 2019 July | 0 | 8 | 8 |
| 2019 June | 3 | 2 | 5 |
| 2019 May | 1 | 11 | 12 |
| 2018 September | 1 | 0 | 1 |
| 2018 June | 42 | 2 | 44 |
| 2018 May | 285 | 7 | 292 |
| 2018 April | 211 | 7 | 218 |
| 2018 March | 252 | 9 | 261 |
| 2018 February | 113 | 4 | 117 |
| 2018 January | 147 | 5 | 152 |
| 2017 December | 108 | 5 | 113 |
| 2017 November | 127 | 7 | 134 |
| 2017 October | 102 | 8 | 110 |
| 2017 September | 99 | 18 | 117 |
| 2017 August | 96 | 6 | 102 |
| 2017 July | 95 | 5 | 100 |
| 2017 June | 121 | 6 | 127 |
| 2017 May | 131 | 13 | 144 |
| 2017 April | 134 | 19 | 153 |
| 2017 March | 98 | 7 | 105 |
| 2017 February | 83 | 5 | 88 |
| 2017 January | 68 | 8 | 76 |
| 2016 December | 137 | 11 | 148 |
| 2016 November | 171 | 9 | 180 |
| 2016 October | 210 | 7 | 217 |
| 2016 September | 261 | 9 | 270 |
| 2016 August | 251 | 14 | 265 |
| 2016 July | 116 | 14 | 130 |
| 2016 June | 6 | 0 | 6 |
| 2016 May | 7 | 0 | 7 |
| 2016 April | 5 | 0 | 5 |
| 2016 March | 4 | 0 | 4 |
| 2016 February | 12 | 33 | 45 |
| 2016 January | 2 | 0 | 2 |
| 2015 December | 18 | 23 | 41 |
| 2015 November | 56 | 18 | 74 |
| 2015 October | 4 | 3 | 7 |
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