Ultrasound-Guided Saphenous (Adductor Canal)

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• Indications: saphenous vein stripping or harvesting; supplementation for medial

foot/ankle surgery in combination with a sciatic nerve block, and analgesia for knee
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surgery in combination with multimodal analgesia.

• Transducer position: transverse on the anteromedial thigh at the junction between the
middle and distal third of the thigh or below the knee at the level of the tibial tuberosity,

depending on the approach chosen (proximal or distal) (Figure 1)

• Goal: local anesthetic spread lateral to the femoral artery and deep to the sartorius

muscle or more distal, below the knee, adjacent to the saphenous vein.

• Local anesthetic: 5–10 mL

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FIGURE 1. Transducer position and needle insertion to block the saphenous nerve (A) at the level of the lower third of
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The saphenous nerve is a terminal sensory branch of the femoral nerve. It supplies Research Seminar
SCI Caparello, Beach Cala
innervation to the medial aspect of the leg down to the ankle and foot. It also sends Rossa, Corsica, France

infrapatellar branches to the knee joint. A saphenous nerve block is useful as a Advanced Ultrasound-
supplement to sciatic block for foot and ankle procedures that involve the medial aspect Guided Techniques
San Diego, CA
of the malleolus and the foot. The block has also been reported as a supplement to
Building Blocks of
multimodal analgesia protocols in patients having knee arthroplasty. Typically, a more
Ultrasound-Guided
proximal (mid-thigh) approach and a larger volume of local anesthetic is used for this Regional Anesthesia
San Diego, CA, USA
“adductor canal block”. Several approaches have been described to block the saphenous
nerve along its route from the inguinal area to the medial malleolus (Figure 2). The use of
ultrasound (US) guidance has improved the success rates of the saphenous blocks
compared with field blocks below the knee and blind trans-sartorial approaches.

FIGURE 2. Various approaches to the saphenous nerve block: the

perifemoral typically targets the nerve to the vastus medialis muscle with
nerve stimulation; the subsartorial at the femoral riangle; subsartorial at the
adductor canal; at the medial femoral condyle, between the tendons of the
sartorius and the gracilis muscle; once the femoral vessels have crossed the
 adductor hiatus to become the popliteal vessels; the paravenous approach
using the saphenous vein as a landmark at the level of the tibial tuberosity;
and at the level of the medial malleolus.

ULTRASOUND ANATOMY
The sartorius muscle descends in a lateral to the medial direction across the anterior
thigh and forms a “roof ” over the adductor canal in the lower half of the thigh. The

muscle appears as a trapezoid shape beneath the subcutaneous layer of adipose tissue.

The sides of the triangular canal are formed by the vastus medialis laterally and the
adductor longus or magnus medially (depending on how proximal or distal the scan is).
The saphenous nerve is typically imaged by ultrasound as a small, round, hyperechoic
structure anterior to the artery. The femoral vein accompanies the artery and saphenous
nerve, which all can be identified at a depth of 2–3 cm (Figure 3).

FIGURE 3. (A) Cross-sectional anatomy of the saphenous nerve at the level of the thigh. The saphenous nerve (SaN)
is positioned between the sartorius muscle (SM) and the vastus medialis muscle (VM), anterolateral to the femoral artery
(FA) and vein (FV). AMM, adductor magnus muscles; GM, gracilis muscle; MRN, medial retinacular nerve. (B) US
anatomy of the subsartorial space at the midthigh.

When attempting to identify the saphenous nerve on US image, the following anatomical
considerations should be kept in mind:

Above the knee: The saphenous nerve pierces the fascia lata between the tendons
of the sartorius and gracilis muscles before becoming a subcutaneous nerve.
The saphenous nerve lies in close proximity to several vessels along its trajectory: the
femoral artery above the knee, the descending genicular artery and its saphenous
branch at the knee, and the great saphenous vein in the lower leg and ankle.
Below the knee, the saphenous nerve passes along the tibial side of the leg,
adjacent to the great saphenous vein subcutaneously (Figure 4).
At the ankle, branches of the saphenous nerve are located medially, next to the
subcutaneously positioned saphenous vein.
FIGURE 4. (A) Cross-sectional anatomy of the saphenous nerve (SaN) at the level of the tibial tuberosity. (B) US
image of the SaN below the knee. The SaN is seen within the immediate vicinity of the great saphenous vein (SV). The
transducer should be applied lightly to avoid compression of the SV because the vein serves as an important landmark
for the technique.

DISTRIBUTION OF ANESTHESIA
The saphenous nerve block results in anesthesia of the skin on the medial leg and foot
(Figure 5). For a more comprehensive review of the femoral and saphenous nerve
distributions, see Functional Regional Anesthesia Anatomy. Of note, although the
saphenous nerve block is a sensory block, an injection of a large volume of local
anesthetic into the subsartorial space can result in a partial motor block of the vastus
medialis due to the block of the femoral nerve branch to this muscle, often contained in
the canal. For this reason, caution must be taken when advising patients regarding the
safety of unsupported ambulation after undergoing a proximal saphenous block.

FIGURE 5. Expected distribution of

analgesia after saphenous nerve block at
the level of midthigh.

EQUIPMENT
Ultrasound machine with a linear transducer (8–14 MHz), sterile sleeve, and gel
Standard nerve block tray
One 10-mL syringe containing local anesthetic
An 80 mm 22-25 gauge needle
Peripheral nerve stimulator to elicit paresthesia
Sterile gloves

LANDMARKS AND PATIENT POSITIONING

FOR THE PROXIMAL APPROACH
The patient is placed in any position that allows for comfortable placement of the US
transducer and needle advancement. This block typically is performed with the patient in
the supine position, with the thigh abducted and externally rotated to allow access to the
medial thigh (see Figure 1a).

GOAL
The goal is to place the needle tip just anterior to the femoral artery, deep to the sartorius
muscle, and to deposit 5–10 mL (or up to 20 mL for the adductor canal block) of local
anesthetic until its spread around the artery is confirmed with US visualization. Block of
the nerve at other, more distal and superficial locations consists of a simple
subcutaneous infiltration of the tissues within the immediate vicinity of the nerve under
US guidance.

TECHNIQUE
The skin is disinfected and the transducer is placed anteromedially, approximately at the
junction between the middle and distal third of the thigh or somewhat lower. If the artery
is not immediately obvious, several maneuvers can be used to identify it, including color
Doppler scanning to trace the femoral artery caudally from the inguinal crease. Once the
femoral artery has been identified, the probe is moved distally to trace the artery until it
passes through the adductor hiatus to become the popliteal artery.

The saphenous nerve block should be performed at the most distal level where the artery
still lies immediately deep to the sartorius muscle, thus minimizing the amount of motor
block of the vastus medialis; an adductor canal block is typically performed more
proximally, around the mid-thigh level. The needle is inserted in-plane in a lateral-to-
medial orientation and advanced toward the femoral artery (Figure 1a and 6). If nerve
stimulation is used (1 mA, 1 msec), the passage of the needle through the sartorius and/or
adductor muscles and into the adductor canal is usually associated with paresthesia in
the saphenous nerve distribution. Once the needle tip is visualized anterior to the artery
and after careful aspiration, 1–2 mL of local anesthetic is injected to confirm the proper
injection site (Figure 6). When injection of local anesthetic does not appear to result in its
spread around the femoral artery, additional needle repositions and injections may be
necessary.

FIGURE 6. Simulated needle path, needle tip

position and local anesthetic initial distribution (blue-
shaded area) to anesthetize the Saphenous nerve
(SaN) at the level of the thigh. FA, femoral artery:
FV, femoral vein.

Color Doppler can be used to locate the peri-saphenous branch of the descending
 geniculate artery in order to avoid puncturing it. Because the saphenous nerve is a purely
sensory nerve, high concentrations of local anesthetic are not required and in fact may
delay patient ambulation should local anesthetic spread to one of the motor branches of
the femoral nerve innervating the quadriceps muscle.

TIPS
An out-of-plane technique can also be used through the belly of the sartorius
muscle. Because the needle tip may not be seen throughout the procedure, small
boluses of local anesthetic are administered (0.5–1 mL) as the needle is advanced
toward the adductor canal to confirm the location of the needle tip.
Visualization of the nerve is not necessary for this block, as the saphenous nerve is
not always well imaged. Administration of 5–10 mL of local anesthetic next to the
artery in the plane between the sartorius and vastus medialis muscles should suffice
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without confirming nerve position.
Practitioners should be aware of the potential for partial quadriceps weakness
following a more proximal approach along the subsartorial space and/or injection of
a large volume (20-30 mL) of local anesthetic. Patient education and assistance with
ambulation should be encouraged. For that reason, it is recommended to perform
this block as distally as practically possible.

Additional reading Ultrasound-Guided Femoral Nerve Block.

Learn ultrasound anatomy of Adductor/Saphenous Canal Block Simulator on NYSORA

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 Saphenous nerve block at the adductor canal
Analgesia for knee surgery, skin anesthesia of the medial aspect of the leg below the
knee

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REFERENCES
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nerve block. Acta Anaesthesiol Scand 2011;55:1030–1031.
Bendtsen TF, Moriggl B, Chan V, Børglum J. Basic Topography of the Saphenous
Nerve in the Femoral Triangle and the Adductor Canal. Reg Anesth Pain Med.
2015;40(4):391–2.
Davis JJ, Bond TS, Swenson JD: Adductor canal block: more than just the saphenous
nerve? Reg Anesth Pain Med 2009;34:618–619.
Goffin P, Lecoq JP, Ninane V, Brichant JF, Sala-Blanch X, Gautier PE et al. Interfascial
Spread of Injectate After Adductor Canal Injection in Fresh Human Cadavers. Anesth
Analg. 2016 Aug;123(2):501–3.
Gray AT, Collins AB: Ultrasound-guided saphenous nerve block. Reg Anesth Pain
Med 2003;28:148.
Head SJ, Leung RC, Hackman GP, Seib R, Rondi K, Schwarz SK: Ultrasound-guided
saphenous nerve block–within versus distal to the adductor canal: a proof-of-
principle randomized trial. Can J Anaesth 2015;62:37–44.
Horn JL, Pitsch T, Salinas F, Benninger B: Anatomic basis to the ultrasound-guided
approach for saphenous nerve blockade. Reg Anesth Pain Med 2009;34:486–489.
Kapoor R, Adhikary SD, Siefring C, McQuillan PM: The saphenous nerve and its
relationship to the nerve to the vastus medialis in and around the adductor canal: an
anatomical study. Acta Anaesthesiol Scand 2012;56: 365–367.
Kirkpatrick JD, Sites BD, Antonakakis JG: Preliminary experience with a new
approach to performing an ultrasound-guided saphenous nerve block in the mid- to
proximal femur. Reg Anesth Pain Med 2010;35:222–223.
Krombach J, Gray AT: Sonography for saphenous nerve block near the adductor
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Lundblad M, Kapral S, Marhofer P, et al: Ultrasound-guided infrapatellar nerve block
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Manickam B, Perlas A, Duggan E, Brull R, Chan VW, Ramlogan R: Feasibility and
efficacy of ultrasound-guided block of the saphenous nerve in the adductor canal.
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Marsland D, Dray A, Little NJ, Solan MC: The saphenous nerve in foot and ankle
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Miller BR: Ultrasound-guided proximal tibial paravenous saphenous nerve block in
pediatric patients. Paediatr Anaesth 2010;20:1059–1060.
Pannell WC, Wisco JJ: A novel saphenous nerve plexus with important clinical
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Sahin L, Sahin M, Isikay N: A different approach to an ultrasound-guided saphenous
nerve block. Acta Anaesthesiol Scand 2011;55:1030–1031.
Saranteas T, Anagnostis G, Paraskeuopoulos T, et al: Anatomy and clinical
implications of the ultrasound-guided subsartorial saphenous nerve block. Reg
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Tsai PB, Karnwal A, Kakazu C, Tokhner V, Julka IS: Efficacy of an ultrasound-guided
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 Tsui BC, Ozelsel T: Ultrasound-guided transsartorial perifemoral artery approach for
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