Chapter 65

A 6-year-old child presents with a history of bilateral clubfoot. He has had previous nonsurgical treatment for clubfoot.

### PREOPERATIVE CONSIDERATIONS

Congenital clubfoot may be associated with congenital syndromes, such as diastrophic dwarfism and spina bifida. Syndrome-associated clubfoot may be less responsive to manual correction and casting. Idiopathic clubfoot is often unilateral, but 1 in 4 patients have bilateral disease. Idiopathic clubfoot is very responsive to manual correction and casting. If a parent has clubfoot, the incidence in the offspring will increase.

The incidence of clubfoot is about 1 in 800-1000. It is usually treated with massage, manual correction, a series of casts, and percutaneous Achilles tendon lengthening (Ponseti method). This is effective in about 95% of patients. Surgical interventions including anterior tibial tendon transfer or foot bone wedge resection are considered for cases that are unresponsive to conservative treatment.

The procedure is elective surgery, and the patient should have taken nothing by mouth and be free from any acute illnesses.

### ANESTHETIC MANAGEMENT

• Consider general anesthesia with mask induction and laryngeal mask anesthesia or endotracheal intubation.

• Use caudal epidural anesthesia or a combination of a popliteal nerve block and a saphenous nerve block. See coverage distribution in Fig. 65-1.

• The sciatic nerve bifurcates above the knee level into the common peroneal and tibial nerves. Both nerves can be blocked or block the sciatic nerve above the bifurcation (Figs. 65-2 and 65-3). The tibial nerve can be found right next to the popliteal artery at the knee crease. The common peroneal nerve runs laterally around the head of the fibula. Identify the two nerves at knee level and then trace up cephaladly to find the bifurcation level.

• The saphenous nerve is a branch of the femoral nerve. The nerve can be identified at mid-thigh, at the medial aspect of the thigh. At this level, the saphenous nerve is right next to the femoral artery. The nerve can be traced distally from this level, and the nerve will be running right deeper than the sartorius muscle. At the knee level, the nerve will pass behind the insertion site of the sartorius muscle. Below the knee level, the saphenous nerve will be running right next to the saphenous vein, and local anesthetic can be deposited next to the saphenous vein.

• Use caution with muscle relaxants; if planning to use a nerve stimulator for a nerve block, avoid muscle relaxants or use succinylcholine and confirm the recovery using a nerve stimulator.

• Usually a tourniquet is used and blood loss is expected to be limited.

• Indications for popliteal block: Procedures on the lower leg, ankle, and foot (with or without saphenous nerve block surgery of the anteromedial aspect of the lower leg or the medial aspect of the ankle or foot) 15-20 mL of local anesthetic are sufficient for adults; decrease volume according to ...

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