‘4 in 1’ block – expanding the horizon in post-op analgesia for below knee surgeries

Abstract

We have read the article by Roy et al.1 on “ultrasound guided 4 in 1 block – a newer, single injection technique for complete postoperative analgesia for knee and below knee surgeries.” With utmost enthusiasm, we want to congratulate and thank the authors for their detailed description of this promising approach. We are also using this block for various surgeries around and below the knee joint at distal part of adductor canal or adductor hiatus (Table 1). We believe, this block has more application in distal lower limb surgeries where sciatic nerve block is needed for adequate analgesia. But directly blocking the sciatic nerve in popliteal fossa could be a doubleedged sword – as it might prevent early mobilisation especially in day-care surgeries and chances of needle trauma or intraneural injection is also a possibility. In addition to this, some patients are very apprehensive about numbness and mobilisation whereas the surgeons dread the delay in detection of compartment syndrome due to the nerve block. It is still a debatable issue whether regional anaesthesia masks or facilitates timely diagnosis of acute compartment syndrome. But, according to literature, diagnosis of compartment syndrome is possible even in the presence of continuous low dose local anaesthetic infusion.2