1. 2015;18;E899-E904Accuracy of Ultrasound-Guided Genicular Nerve Block: A Cadaveric Study
   Cadaveric Study
   Arif Kenan Tan, MD, Fatih Yazar, MD, Ümüt Güzelküçük, MD, Cenk Kilic, MD, Serdar Kesikburun, MD, and Evren Yasar, MD.

BACKGROUND: Genicular nerve block has recently emerged as a novel alternative treatment in chronic knee pain. The needle placement for genicular nerve injection is made  under fluoroscopic guidance with reference to bony landmarks.
OBJECTIVE: To investigate the anatomic landmarks for medial genicular nerve branches and to determine the accuracy of ultrasound-guided genicular nerve block in a cadaveric model.
STUDY DESIGN: Cadaveric accuracy study.
SETTING: University hospital anatomy laboratory.
METHODS: Ten cadaveric knee specimens without surgery or major procedures were used in the study. The anatomic location of the superior medial genicular nerve (SMGN) and the inferior medial genicular nerve (IMGN) was examined using 4 knee dissections. The determined anatomical sites of the genicular nerves in the remaining  6 knee specimens were injected with 0.5 mL red ink under ultrasound guidance. The knee specimens were subsequently dissected to assess for accuracy. If the nerve was dyed with red ink, it was considered accurate placement. All other locations were considered inaccurate.
RESULTS: The course of the SMGN is that it curves around the femur shaft and passes between the adductor magnus tendon and the femoral medial epicondyle, then descends approximately one cm anterior to the adductor tubercle. The IMGN is situated horizontally around the tibial medial epicondyle and passes beneath the medial collateral ligament at the midpoint between the tibial medial epicondyle and the tibial insertion of the medial collateral ligament. The adductor tubercle for the SMGN and the medial collateral ligament for the IMGN were determined as anatomic landmarks for ultrasound. The bony cortex one cm anterior to the peak of the adductor tubercle and the bony cortex at the midpoint between the peak of the tibial medial epicondyle and the initial fibers inserting on the tibia of the medial collateral ligament were the target points for the injections of SMGN and IMGN, respectively. In the cadaver dissections both genicular nerves were seen to be dyed with red ink in all the injections of the 6 knees.
LIMITATIONS: The small number of cadavers might have led to some anatomic variations of genicular nerves being overlooked.
CONCLUSIONS:  The result of this cadaveric study suggests that ultrasound-guided medial genicular nerve branch block can be performed accurately using the above-stated anatomic landmarks.