Korean J Pain.  2024 Apr;37(2):132-140. 10.3344/kjp.23292.

New insight into the vasto-adductor membrane for safer adductor canal blockade

• Heo Y
• Yang M
• Nam SM
• Lee HS
• Kim YD
• Won HS

• KMID: 2554953
• DOI: http://doi.org/10.3344/kjp.23292

Abstract

Background
This study aimed to identify exact anatomical landmarks and ideal injection volumes for safe adductor canal blocks (ACB).
Methods
Fifty thighs from 25 embalmed adult Korean cadavers were used. The measurement baseline was the line connecting the anterior superior iliac spine (ASIS) to the midpoint of the patellar base. All target points were measured perpendicular to the baseline. The relevant cadaveric structures were observed using ultrasound (US) and confirmed in living individuals. US-guided dye injection was performed to determine the ideal volume.
Results
The apex of the femoral triangle was 25.3 ± 2.2 cm distal to the ASIS on the baseline and 5.3 ± 1.0 cm perpendicular to that point. The midpoint of the superior border of the vasto-adductor membrane (VAM) was 27.4 ± 2.0 cm distal to the ASIS on the baseline and 5.0 ± 1.1 cm perpendicular to that point. The VAM had a trapezoidal shape and was connected as an aponeurosis between the medial edge of the vastus medialis muscle and lateral edge of the adductor magnus muscle. The nerve to the vastus medialis penetrated the muscle proximal to the superior border of the VAM in 70% of specimens. The VAM appeared on US as a hyperechoic area connecting the vastus medialis and adductor magnus muscles between the sartorius muscle and femoral artery.
Conclusions
Confirming the crucial landmark, the VAM, is beneficial when performing ACB. It is advisable to insert the needle obliquely below the superior VAM border, and a 5 mL injection is considered sufficient.

Keyword

Anatomy; Cadaver; Injections; Membranes; Nerve Block; Pain; Quadriceps Muscle; Thigh; Ultrasonography

Figure

• 

  Fig. 1 A schematic drawing showing each target point. The baseline is the red line connecting the anterior superior iliac spine (ASIS) to the midpoint of the patellar base (PB). Points a, b, c, and d indicate the apex of the femoral triangle, the midpoint of the superior border of the VAM, the anterior foramen of the adductor canal, and the uppermost point of the adductor hiatus, respectively. VAM: vasto-adductor membrane.

• 

  Fig. 2 The VAM exposed by fine dissection. The asterisk indicates the VAM. NVM: nerve to vastus medialis, SN: saphenous nerve, FA: femoral artery, S: sartorius muscle, VMe: vastus medialis muscle, FL: fascia lata, VAM: vasto-adductor membrane, Cra: cranial side, Cau: caudal side, Med: medial side, Lat: lateral side.

• 

  Fig. 3 Relationship between the NVM and superior border of VAM (SB). The red lines indicate the SB. NVM: nerve to the vastus medialis, VAM: vasto-adductor membrane, Med: medial side, Lat: lateral side.

• 

  Fig. 4 Relationships between the femoral artery and saphenous nerve at the superior border of the VAM (SB). The horizontal line in the circle indicates the SB, and the vertical line is a line passing through the midpoint of the SB. VAM: vasto-adductor membrane, Med: medial side, Lat: lateral side.

• 

  Fig. 5 The VAM shown on US images of a cadaver (A) and living individual (B). The yellow asterisk indicates the VAM. S: sartorius muscle, AMg: adductor magnus muscle, FA: femoral artery, FV: femoral vein, VMe: vastus medialis muscle, VAM: vasto-adductor membrane, US: ultrasound, Med: medial side, Lat: lateral side.

• 

  Fig. 6 Photographs showing the thigh injected with 10 mL (A) and 5 mL (B) of the mixture. The asterisks indicate the VAM. SN: saphenous nerve, FA: femoral artery, S: sartorius muscle, VMe: vastus medialis muscle, NVM: nerve to the vastus medialis, AL: adductor longus muscle, G: gracilis muscle, AMg: adductor magnus muscle, VAM: vasto-adductor membrane, Cra: cranial side, Cau: caudal side, Med: medial side, Lat: lateral side.

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