What regional blocks are recommended for Achilles tendon repair?

Regional Blocks for Achilles Tendon Repair

Single-shot or continuous peripheral nerve blocks using lower concentrations of local anesthetic without adjuncts are recommended for Achilles tendon repair, as they provide effective analgesia without delaying diagnosis of potential complications like acute compartment syndrome. 1

Recommended Regional Block Techniques

• Popliteal sciatic nerve block is the primary regional technique for Achilles tendon repair, providing excellent analgesia for the posterior aspect of the ankle and heel 2
• Adductor canal block can be combined with popliteal block for comprehensive analgesia of the lower extremity 3
• Single-shot blocks should use lower concentrations of local anesthetic (bupivacaine or ropivacaine 0.1-0.25%) to maintain some sensory function 1
• For continuous techniques, use dilute solutions (ropivacaine 0.2%) to avoid dense motor blockade that could mask compartment syndrome 2

Administration Recommendations

• Programmed intermittent bolus (PIB) and continuous infusion (CI) techniques both provide excellent analgesia for continuous blocks, though PIB may result in more profound motor block 2
• If using continuous techniques, consider ropivacaine 0.2% at 5 mL/hour with patient-controlled boluses (5 mL every 30 minutes as needed) 2
• Avoid dense blocks of long duration that significantly exceed the duration of surgery 1
• Amide local anesthetics (lidocaine, bupivacaine, ropivacaine) are preferable to ester types for regional blocks 1

Adjuncts to Local Anesthetics

• Use caution with adjuncts as they can increase block density and duration 1
• The combination of dexmedetomidine and dexamethasone may provide extended pain relief but should be used judiciously due to potential for prolonged sensory blockade 3
• If prolonged analgesia is required, consider lower concentration continuous techniques rather than dense single-shot blocks with adjuncts 1

Special Considerations

Risk of Acute Compartment Syndrome (ACS)

• Achilles tendon repair carries risk of ACS, which requires vigilant monitoring 1
• Post-injury and postoperative surveillance should include regular assessment for signs and symptoms of ACS by trained healthcare staff 1
• Use objective scoring charts to monitor for ACS 1
• Equipment for measuring intracompartmental pressure should be available on wards caring for these patients 1

Pediatric Considerations

• In children, low concentrations of local anesthetic (bupivacaine or ropivacaine 0.1-0.25% for single shot and 0.1% for continuous nerve blocks) can be used safely 1
• Proper monitoring systems should be in place to recognize ACS in children 1

Clinical Pearls and Pitfalls

• Obtain informed consent specifically addressing the choice of analgesic technique 1
• Avoid neuraxial blocks (spinal, epidural) as they may exacerbate hemodynamic instability and carry risks of coagulopathy in trauma patients 1
• If neuraxial techniques are used, they should be based on local anesthetics only, without opioid additives, to minimize respiratory depression 1
• Military experience suggests that continuous peripheral nerve blocks with low-dose local anesthetic solutions can be used safely even in high-energy injuries at risk of ACS 1
• Ensure proper ventilation and oxygenation monitoring during the surgical procedure regardless of anesthetic technique 1

By following these recommendations, effective pain control can be achieved while maintaining the ability to monitor for potential complications after Achilles tendon repair.