scholarly journals Prescribing Fewer Opioid Pills to Patients Undergoing Foot and Ankle Surgery: A Prospective Comparative Study

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0002
Author(s):  
Kristin C. Caolo ◽  
Jonathan Day ◽  
Celia Marion ◽  
Gabrielle S. Ray ◽  
A. Holly Johnson
Keyword(s):  
Pain Management ◽  
Prospective Study ◽  
Senior Author ◽  
The Novel ◽  
Foot And Ankle ◽  
Opioid Prescribing ◽  
Ankle Surgery ◽  
Significant Difference ◽  
Sliding Scale ◽  
Established Group

Category: Ankle; Ankle Arthritis; Arthroscopy; Basic Sciences/Biologics; Bunion; Diabetes; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports; Trauma; Other Introduction/Purpose: This study aims to compare a novel opioid prescribing protocol aimed at reducing the number of opioid pills prescribed and consumed with an established, previously published protocol for foot and ankle surgery. We hypothesized that patients in the novel group would consume fewer opioids and report similar satisfaction with pain management compared with the established group. Methods: This study is a single center prospective study of 59 patients undergoing foot and ankle surgery who received a novel opioid prescribing protocol used by the senior author. Preoperatively, patients were counseled on the expectations of pain after surgery, received a take home pamphlet, and were prescribed opioids based on a sliding scale of procedures designated as minor (0-5 pills), moderate (5-10 pills) or major (15-20 pills). These patients were then compared to 84 patients from a previous prospective study from the same institution who received an opioid prescribing protocol with a maximum of 40-60 opioid pills. Patients were excluded if they used opioids or muscle relaxants preoperatively or had a known history of a substance use disorder. Patients completed surveys postoperatively for eight weeks reporting pain level, number of opioid pills consumed, refill requests, and satisfaction with their pain management plan. Results: There was a significant difference (p< 0.001) in mean pills consumed between the novel and established prescribing protocols at all time points (Table 1). During the entire postoperative period patients in the novel group had taken 21% of their prescribed pills compared to 40% in the established group (p=0.03). Patients had comparable levels of pain throughout the study (p>0.05 at POD 3, POD 7 and POD 14) and only differed significantly at POD 56 (p=0.005). Patients in the novel group did not request any refills, whereas patients in the established group requested a total of 9 refills over the course of the study. Conclusion: Patients receiving fewer opioid medications, along with preoperative coaching and take home materials, achieved equivalent analgesic effect when compared to patients receiving approximately double the amount of opioids. This study demonstrates that a sliding scale protocol with a maximum prescription of 20 opioid pills provides appropriate pain relief for most patients. This study confirms that patients on average take far fewer opioid pills than prescribed, and likely an even more limited prescribing protocol would be adequate for the majority of patients. This novel prescribing protocol ensures less opioids are both consumed and leftover for potential diversion in the community. [Table: see text]

Postoperative Opioid Prescribing Practice in Foot and Ankle Surgery

2021 ◽  
Author(s):  
Brandon M Brooks ◽  
Bradley M Brooks ◽  
Brady M Brooks ◽  
Adam E Fleischer ◽  
Robert G Smith ◽  
...  
Keyword(s):  
United States ◽  
Online Survey ◽  
The United States ◽  
Practice Variation ◽  
Foot And Ankle ◽  
Linear Regression Models ◽  
Time Of Surgery ◽  
Opioid Prescribing ◽  
Ankle Surgery ◽  
Prescribing Practice

Background: Clinicians, governmental agencies, patients, and pharmaceutical companies all contribute to the United States' opioid epidemic. These same stakeholders can make meaningful contributions to resolve the epidemic by identifying ineffective habits and encouraging change. The purpose of this study was to determine if postoperative opioid prescribing practice variation exists in foot and ankle surgery. We also aimed to identify if demographic characteristics of podiatric foot and ankle surgeons were associated with their postoperative opioid prescribing practices. Methods: We administered an open, voluntary, anonymous, online questionnaire distributed on the internet via Qualtrics, an online survey platform. The questionnaire consisted of six foot and ankle surgery scenarios followed by a demographics section. We invited Podiatric foot and ankle surgeons practicing in the United States to complete the questionnaire via email from the American Podiatric Medical Association's membership list. Respondents selected the postoperative opioid(s) that they would prescribe at the time of surgery, as well as the dose, frequency, and number of "pills" (dosage units). We developed multiple linear regression models to identify associations between prescriber characteristics and two measures of opioid quantity: dosage units and MME. Results: Eight hundred and sixty podiatric foot and ankle surgeons completed the survey. The median number of dosage units never exceeded 30 regardless of the foot and ankle surgery. Years in practice correlated with reduction in opioid dosage units prescribed at the time of surgery. Conclusions: Postoperative opioid prescribing practice variation exists in foot and ankle surgery. In comparison to the orthopedic community, podiatric foot and ankle surgeons prescribe approximately 25% fewer opioids at the time of surgery than orthopedic foot and ankle surgeons. Further research is warranted to determine if additional education is needed for young surgeons.

scholarly journals Outcome Following Lower Extremity Nerve Block during Foot and Ankle Surgery: A Systematic Review

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0022
Author(s):  
Arianna L. Gianakos ◽  
Filippo Romanelli ◽  
Malaka Badri ◽  
Naina Rao ◽  
Bart Lubberts ◽  
...  
Keyword(s):  
Systematic Review ◽  
Pain Management ◽  
Postoperative Pain ◽  
Continuous Infusion ◽  
Nerve Block ◽  
Opioid Consumption ◽  
Foot And Ankle ◽  
Complication Risk ◽  
Prospective Comparison ◽  
Ankle Surgery

Category: Ankle; Other Introduction/Purpose: The purpose of this study was to perform a systematic review of the current literature assessing the management of pain with various block techniques in the perioperative period during elective foot and ankle surgery. Methods: A review of the literature was performed according to the PRISMA guidelines. Medline, Embase, and Cochrane databases were searched on October 1, 2019. Studies were identified by using synonyms for ‘foot’, ‘ankle’, ‘pain management’, ‘opioid’ and ‘nerve block’. Inclusion criteria were studies that 1) reported and compared the outcomes following various types of peripheral nerve blocks in in foot and ankle surgery, 2) were published in the English language, and 3) were published within the last 10 years. Results: Twenty-four articles evaluating 4,640 patients were included. Sixty-seven percent were randomized controlled trials, 17% were prospective comparison studies, and 17% were retrospective comparison studies. Nerve block techniques included: femoral, adductor canal, sciatic, popliteal, saphenous, and ankle. Ropivacaine and bupivacaine were most commonly utilized. Postoperative opioid consumption and postoperative pain levels were reduced with use of PNB when compared with systemic/local anesthesia, in patients receiving combined popliteal/femoral block, and in patients receiving continuous infusion popliteal block [Table 1, Table 2]. Studies demonstrated higher satisfaction with PNB, continuous infusion, and dual injections [Table 3]. One study reported 7% neurologic related complication risk and demonstrated a higher complication rate when with popliteal versus ankle block. All other studies were equivocal or failed to mention complications. Conclusion: Optimal pain management for elective foot and ankle surgery remains controversial and an ideal protocol from a risk-benefit perspective regarding use of PNB has yet to be established. Our study demonstrates improvements in postoperative pain levels, opioid consumption, and length of stay in patients receiving a PNB when compared with systemic anesthesia. Combined PNB and dual catheter administration may improve outcomes. Unfortunately, little data has been published on risks and tradeoffs in order to help guide patients and surgeons with a well informed shared decision making model. Future studies are needed to better clarify any respective tradeoffs to these options. [Table: see text]

Use of Prophylaxis for Prevention of Venous Thromboembolism in Patients with Isolated Foot or Ankle Surgery: A Systematic Review and Meta-Analysis

2019 ◽  
Vol 119 (10) ◽  
pp. 1686-1694 ◽  
Author(s):  
Bavand Bikdeli ◽  
Renuka Visvanathan ◽  
David Jimenez ◽  
Manuel Monreal ◽  
Samuel Z. Goldhaber ◽  
...  
Keyword(s):  
Systematic Review ◽  
Venous Thromboembolism ◽  
Meta Analysis ◽  
Evidence Base ◽  
Controlled Trials ◽  
Cochrane Central Register ◽  
Foot And Ankle ◽  
Vte Prophylaxis ◽  
Ankle Surgery ◽  
Significant Difference

AbstractAlthough prophylaxis for venous thromboembolism (VTE) is recommended after many surgeries, evidence base for use of VTE prophylaxis after foot or ankle surgery has been elusive, leading into varying guidelines recommendations and notable practice variations. We conducted a systematic review of the literature to determine if use of VTE prophylaxis decreased the frequency of subsequent VTE, including deep vein thrombosis (DVT) or pulmonary embolism (PE), compared with control. We searched PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov through May 2018, for randomized controlled trials (RCTs) or prospective controlled observational studies of VTE prophylaxis in patients undergoing foot and ankle surgery. Our search retrieved 263 studies, of which 6 were finally included comprising 1,600 patients. Patients receiving VTE prophylaxis had lower risk for subsequent DVT (risk ratio [RR]: 0.72; 95% confidence interval [CI]: 0.55–0.94) and subsequent VTE (RR: 0.72; 95% CI: 0.55–0.94). There was only one case of nonfatal PE, no cases of fatal PE, and no change in all-cause mortality (RR: 3.51; 95% CI: 0.14–84.84). There was no significant difference in the risk for bleeding (RR: 2.12; 95% CI: 0.53–8.56). Very few RCTs exist regarding the efficacy and safety of VTE prophylaxis in foot and ankle surgery. Prophylaxis appears to reduce the risk of subsequent VTE, but the event rates are low and symptomatic events are rare. Future studies should determine the subgroups of patients undergoing foot or ankle surgery in whom prophylaxis may be most useful.

Factors associated with patient satisfaction with foot and ankle surgery in a large prospective study

The Foot ◽  
2012 ◽  
Vol 22 (3) ◽  
pp. 211-218 ◽  
Author(s):  
Jill Dawson ◽  
Irene Boller ◽  
Helen Doll ◽  
Grahame Lavis ◽  
Robert J. Sharp ◽  
...  
Keyword(s):  
Patient Satisfaction ◽  
Prospective Study ◽  
Foot And Ankle ◽  
Large Prospective Study ◽  
Factors Associated ◽  
Ankle Surgery

Bone grafting in foot and ankle surgery. A review of 300 cases

1998 ◽  
Vol 88 (3) ◽  
pp. 109-118 ◽  
Author(s):  
KT Mahan ◽  
HJ Hillstrom
Keyword(s):  
Complication Rates ◽  
Allogeneic Bone ◽  
Graft Material ◽  
Foot And Ankle ◽  
First Metatarsal ◽  
Ankle Surgery ◽  
Significant Difference ◽  
Lower Complication ◽  
Lower Complication Rate ◽  
Bone Complications

Three hundred foot and ankle bone grafts were reviewed in three separate series of 100 consecutive grafts from two institutions. The series represent a period from 1977 to 1990 and demonstrate treatment patterns that varied over time and between institutions in indications, graft material, and perioperative management. Over 42% of the 300 grafts were for calcaneal osteotomies; most were Evans calcaneal osteotomies. Over 72% of the grafts were allogeneic bone-bank bone, which performed well in calcaneal osteotomies and for packing of defects. Upon review of the incidence of bone complications, no significant differences were observed between surgical procedures that used autogenous versus allogeneic grafts. However, four out of six failures of first metatarsal repair were with allogeneic bone. There was a significant difference in complication rates for the major indications for bone-graft surgery. Nonunions and arthrodeses resulted in higher complication rates than expected, whereas calcaneal osteotomies resulted in a lower complication rate than expected.

scholarly journals Preoperative and Postoperative PROMIS and FFI Scores Based on Region of Foot Pathology and Surgery

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0038
Author(s):  
Charles C. Pitts ◽  
Bradley Alexander ◽  
Elise M. Greco ◽  
Benjamin B. Cage ◽  
Spaulding F. Solar ◽  
...  
Keyword(s):  
Physical Function ◽  
Surgical Intervention ◽  
Activity Limitation ◽  
Foot And Ankle ◽  
Tertiary Referral Center ◽  
Pain Disability ◽  
Ankle Surgery ◽  
Significant Difference ◽  
Patient Reported ◽  
The Mean

Category: Other; Ankle; Ankle Arthritis; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot Introduction/Purpose: The Patient-Reported Outcomes Measurement Instrumentation System (PROMIS) has become increasingly utilized in orthopaedic foot and ankle surgery to assess outcomes and better understand patient function, pain, and disability. Similarly, the Foot Function Index (FFI) is used to assess pain, disability, and activity limitation. PROMIS scores have been shown to predict, preoperatively, which patients will benefit most from foot and ankle surgery from a general perspective. It is currently unknown, with regard to chronic foot pathology, which region of the foot has the greatest effect on PROMIS and FFI scores and which region is affected the most by surgical intervention. Methods: PROMIS physical function, pain index, and depression scores along with FFI scoring subsets of pain, disability, and activity limitation were retrospectively reviewed for patients at a tertiary referral center with chronic pathology in either the hindfoot, midfoot, or forefoot that underwent surgery. Scores were obtained preoperatively and at 6 weeks postoperatively, and a preoperative to postoperative difference was calculated. Once the mean of each subcategory was obtained, an analysis of variance (ANOVA) was conducted in order to compare the means and identify statistically significant differences. Significance was set at p < 0.05 and p < 0.10. Results: There was no statistically significant difference between the mean preoperative PROMIS or FFI scores in the forefoot, midfoot, or hindfoot regions. There was also no statistically significant difference between means of PROMIS or FFI categories at 6 weeks postoperatively. However, the mean pre- to postoperative differences between PROMIS physical function scores of the forefoot, midfoot, and hindfoot were statistically significantly different at 9.12, 8.16, and 2.88, respectively (p=0.037). There was no statistically significant difference between the remaining scoring categories. Conclusion: Physical function, pain, depression, disability, and activity limitation are not affected disparately by the location of chronic pathology within the foot. Surgical intervention for problems in the forefoot, midfoot, and hindfoot does not provide differences in outcomes with regard to pain, disability, depression, or activity limitation based on region. Patients who have undergone surgical intervention for forefoot or midfoot pathology may experience greater improvements in physical function postoperatively when compared to patients who have undergone hindfoot surgery. [Table: see text]

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