Comparison of the Three-in-One and Fascia lliaca Compartment Blocks in Adults: Clinical and Radiographic Analysis X. Capdevila, MD, MSc, Ph. Biboulet, MD, M. Bouregba, MD, Y. Barthelet, MD, J. Rubenovitch, MD, BSc, and F. d’Athis, MD Department of Anesthesiology, Lapeyronie University Hospital, Montpellier, France The 3-in-1 (Group 1) and fascia iliaca compartment (Group 2) blocks, two single-injection, anterior ap- proach procedures used to simultaneously block the femoral, obturator, and lateral femoral cutaneous (LFC) nerves, were compared in 100 adults after lower limb surgery. Pain control, sensory and motor blockades, and radiographically visualized spread of local anes- thetic solution were studied prospectively. Both ap- proaches provided efficient pain control using 30 mL of 2% lidocaine with 1:200,000 epinephrine and 0.5% bu- pivacaine and 5 mL of contrast media (iopamidol). Complete lumbar plexus blockade was achieved in 18 (38%) Group 1 and 17 (34%) Group 2 patients (n = 50 patients per group). Sensory block of the femoral, obtu- rator, genitofemoral, and LFC nerves was obtained in 90% and 88%, 52% and 38%, 38% and 34%‘ and 62% and 90% of the patients in Groups 1 and 2, respectively (P < 0.05). Sensory LFC blockade was obtained more rapidly for the patients in Group 2 (P < 0.05). Concurrent inter- nal and external spread of the local anesthetic solution under the fascia iliaca and between the iliacus and psoas muscles was noted in 62 of the 92 block procedures analyzed radiographically. Isolated exter- nal spreads under the fascia iliaca and over the iliacus muscle were noted in 10% and 36% of the patients in Groups 1 and 2, respectively (P < 0.05). The local anes- thetic solution reached the lumbar plexus in only five radiographs. We conclude that the fascia iliaca com- partment block is more effective than the 3-in-1 block in producing simultaneous blockade of the LFC and fem- oral nerves in adults. After both procedures, blockade was obtained primarily by the spread of local anesthetic under the fascia iliaca and only rarely by contact with the lumbar plexus. Implications: In adults, the two an- terior approaches, 3-in-1 and fascia iliaca compartment blocks, provide effective postoperative analgesia. The fascia iliaca compartment technique provides faster and more consistent simultaneous blockade of the lat- eral femoral cutaneous and femoral nerves. Sensory block is caused by the spread of local anesthetic solu- tion under the fascia iliaca and only rarely to the lumbar plexus. (Anesth Analg 1998;86:103944) A fter hip, femoral shaft, and knee surgery, the lumbar plexus block provides high-quality an- algesia (l-3). It is superior to that obtained from the systemic administration of morphine (4,5) and has fewer side effects than epidural anesthesia (6). Although various approaches to the lumbar plexus have been studied, Winnie (7) described a multiple nerve block of the lumbar plexus nerve supplying the thigh that could be obtained with a single injection of 20 mL or more of local anesthetic. While reducing the number of peripheral blocks required to provide ade- quate anesthesia, this 3-in-1 technique was shown to be inconsistent in producing blockade of both the Accepted for publication January 28, 1997. Address correspondence to X. Capdevila, MD, Department of Anesthesiology, Lapeyronie University Hospital, 292 Av du Doyen Gaston Giraud, 34295 Montpellier, France. lateral femoral cutaneous (LFC) nerve of the thigh and the obturator nerve (8-10). Neither the use of neuro- stimulators (8) nor increasing the administered doses of local anesthetic (9) improved the global success rate of the 3-in-1 block. The report of a fortuitous 3-in-1 blockade resulting from a LFC nerve of the thigh block (ll), and the consideration of the anatomical configuration of the fascia iliaca covering the femoral nerve and its branches (7,12) led to the identification of the fascia iliaca compartment. Dalens et al. (10) developed a new procedure, the fascia iliaca compartment block, and compared it with the classical 3-in-1 block in a study including 120 children. The new technique was re- ported to provide a higher success rate, with blockade of the three main lumbar plexus nerves supplying the thigh in more than 90% of procedures. Furthermore, neither expensive equipment (i.e., neurostimulators) 01998 by the International Anesthesia Research Society 0003-2999/98/$5.00 An&h Analg 1998;86:103944 1039