Preoperative Lateral Popliteal Nerve Block for Intraoperative and Postoperative Pain Control in Elective Foot and Ankle Surgery: A Prospective Analysis

Background: Purpose of this study was to compare the effects of direct, continuous adductor canal block (ACB) and ultrasonography guided, continuous femoral nerve block (FNB) on postoperative pain control, strength of the knee extensor, walking ability, and related complications after primary total knee arthroplasty. Methods: Between November 2018 and February 2019, 107 patients underwent primary total knee arthroplasty under spinal anesthesia. Forty eight patients received ACB and the other 59 received FNB for postoperative pain control. After the surgery, the patients received adductor canal or femoral nerve block via a catheter. 10 mL of 0.75% ropivacaine was administered initially, followed by continuous injection of 4 mL per hour. ACB was done before capsule repair by orthopedic surgeon and FNB was performed after the surgery. Data were prospectively collected out from these 107 patients. To evaluate postoperative pain control, the numerical rating scale scores at rest and during range of motion were recorded. To evaluate quadriceps strength, motor grade by manual muscle testing was measured. Walking ability was assessed by first weight bearing day and walking distance (steps). We also evaluated analgesic consumption using morphine equivalent and recorded related complications of peripheral nerve block. Results: No significant intergroup difference was observed in the numerical rating scale scores at rest and during range of motion on postoperative days 1, 2, 3, 4, and 5. ACB group had significantly greater quadriceps strength than did the FNB group, as evaluated by manual muscle testing on postoperative days 1. However, there was no significant difference onpostoperative days 2, 3, 4, and 5. These two groups showed no differences in walking ability in terms of first weight bearing day and walking distance. No significant intergroup difference was observed in analgesic consumption. Conclusions: The groups showed no difference in postoperative pain control. ACB showed better motor grade on postoperative day one compared with femoral nerve block, but which was similar in days after postoperative day one.

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

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00228 ◽

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]

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Comparison of postoperative pain control methods after bony surgery in the foot and ankle

Foot and Ankle Surgery ◽

10.1016/j.fas.2017.06.006 ◽

2018 ◽

Vol 24 (6) ◽

pp. 521-524 ◽

Cited By ~ 3

Author(s):

Chan Kang ◽

Gi-Soo Lee ◽

Sang-Bum Kim ◽

You-Gun Won ◽

Jeong-Kil Lee ◽

...

Keyword(s):

Postoperative Pain ◽

Pain Control ◽

Control Methods ◽

Foot And Ankle ◽

Postoperative Pain Control

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Liposomal Bupivacaine versus Continuous Popliteal Nerve Block in Total Ankle Arthroplasty

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000301 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0003

Author(s):

Ryan Mulligan ◽

Joel Morash ◽

James DeOrio ◽

Selene Parekh

Keyword(s):

Postoperative Pain ◽

Sciatic Nerve ◽

Pain Score ◽

Nerve Block ◽

Total Ankle Arthroplasty ◽

Sciatic Nerve Block ◽

Foot And Ankle ◽

Ankle Arthroplasty ◽

Ankle Surgery ◽

Regional Anesthetic

Category: Ankle, Ankle Arthritis Introduction/Purpose: The use of liposomal bupivacaine (LB) has recently gained popularity in joint arthroplasty. Despite it’s proven safety and efficacy, there is little reported on the use of LB in foot and ankle surgery. Catheter placement for a continuous popliteal sciatic nerve block (CPSNB) has an excellent track record for pain relief, and is commonly used by our group for major foot and ankle reconstructions. The purpose of this study was to compare the use of intraoperative LB injection to CPSNB as a regional anesthetic for total ankle arthroplasty (TAA), with attention to postoperative pain scores, narcotic use, and complications. Methods: Retrospective review of TAA patients treated by two fellowship-trained orthopedic foot and ankle surgeons was performed. Patient demographic data, operative, and postoperative details were collected, including type of regional anesthetic used. Patient’s received either preoperative single-shot popliteal sciatic nerve block with 0.25% bupivacaine followed by intraoperative injection of LB, or preoperative CPSNB alone. Outcomes examined were VAS pain score at 8 hours, 24 hours, 1 week, and 3 weeks following surgery, need for opioid pain medication refill, physician office notification for pain issues or other adverse events, and complications within the first 90 days following surgery. Standard statistical analysis was performed and p < 0.05 was considered significant. Results: 75 patients were identified who underwent TAA and met inclusion criteria. 41 received LB and 34 received CPSNB. No statistical difference was seen between groups with regard to complications, emergency department visits, readmissions, reoperations, VAS pain score at any time point, physician office contacts, and narcotic refills. Mean VAS with LB use was 1.8, 3.5, 2.6, and 2.2 at 8 hours, 24 hours, 1 week, and 3 weeks respectively, compared with mean VAS 2.1, 3.2, 2.2, and 1.9 at similar time points for CPSNB (p=0.59, 0.65, 0.27, and 0.40, respectively). 16 of 41 LB patients needed narcotic refills, versus 12 of 34 CPSNB patients (p=0.81). 3 of 41 LB patients had a complication postoperatively, versus 4 of 34 CPSNB patients. Conclusion: This is the first study evaluating the use of LB for total ankle arthroplasty. LB was both safe and effective for postoperative pain control, with comparable results to CPSNB. As LB gains more widespread use in foot and ankle surgery, further investigation is warranted to determine potential unseen complications and cost-effectiveness.

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Postoperative pain control after the use of dexmedetomidine and propofol to sedate patients undergoing ankle surgery under spinal anesthesia: a randomized controlled trial

Journal of Pain Research ◽

10.2147/jpr.s195745 ◽

2019 ◽

Vol Volume 12 ◽

pp. 1479-1487 ◽

Cited By ~ 4

Author(s):

Doyeon Kim ◽

Ji Seon Jeong ◽

Huigyeong Park ◽

Ki-Sun Sung ◽

Soo Joo Choi ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Postoperative Pain ◽

Spinal Anesthesia ◽

Pain Control ◽

Controlled Trial ◽

Postoperative Pain Control ◽

Randomized Controlled ◽

Ankle Surgery

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Self-Reported Pain Tolerance and Opioid Pain Medication Use after Foot and Ankle Surgery

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00006 ◽

2019 ◽

Vol 4 (2) ◽

pp. 2473011419S0000

Author(s):

Laura E. Sokil ◽

Elizabeth McDonald ◽

Ryan G. Rogero ◽

Daniel J. Fuchs ◽

Steven M. Raikin ◽

...

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Pain Control ◽

Pain Threshold ◽

Postoperative Pain Management ◽

Pain Medication ◽

Pain Tolerance ◽

Foot And Ankle ◽

Ankle Surgery ◽

Perceived Pain

Category: Pain Management Introduction/Purpose: The opioid epidemic in the United States continues to take lives. As one of the top prescribing groups, orthopaedic surgeons must tailor post-surgical pain control to minimize the potential for harm from prescription opioid use. Patients often reference their own pain threshold as a benchmark for how they will tolerate the pain of surgery, but current literature suggests that there is not a significant correlation between an individual’s perceived pain threshold and their actual threshold for heat stimulus. The purpose of this study was to determine whether there is a correlation between a patient’s self- reported pain tolerance and their actual prescription narcotic medication usage after foot and ankle surgery. Methods: This was a prospective cohort study of adult patients that underwent outpatient foot and ankle surgeries performed by 5 fellowship-trained foot and ankle surgeons at a large, multispecialty orthopaedic practice over a one year period. Demographic data, procedural details and anesthesia type were collected. Narcotic usage data including number of pills dispensed and pill counts performed at the first postoperative visit were obtained. Patients were contacted via email or telephone between 7-19 months postoperatively, and asked to respond to the validated statement “Pain doesn’t bother me as much as it does most people” by choosing “strongly disagree”, “disagree”, “neither”, “agree” or “strongly agree”. Patients scored their pain threshold on a scale of 1- 100 with 0 being “pain intolerant” and 100 a ”high pain threshold" and ranked their expectations of the pain after surgery and satisfaction with pain management on respective five-point Likert scales. Data was analyzed using a Spearman’s correlation. Results: Of the 486 patients who completed surveys, average age was 51.24 years, 32.1% were male and 7.82% current smokers. After controlling for age and anesthesia type, both agreement with the validated statement and higher pain tolerance score had a weak negative correlation with pills taken (r=-0.13, p=0.004 and r=-0.14, p=0.002, respectively); patients with higher perceived pain thresholds took fewer opioid pills after surgery (Table 1). Correlation between high expectations of postoperative pain and pills taken was weakly negative (r=-0.28, p=<0.001) (Table 1). Patients who found surgery more painful than they expected took less pain medication. There was a small, positive correlation between pain tolerance and satisfaction with pain management (r=0.12, p=0.008), indicating that patients with a relatively high pain tolerance had more satisfaction (Table 1). Conclusion: Assessment of both subjective description and quantitative score of a patient’s pain threshold prior to surgery may assist the surgeon in tailoring postoperative pain control regimens. Unexpectedly, patients who found surgery less painful than expected actually took a greater number of opioid pills. This may highlight an educational opportunity regarding postoperative pain management in order to reduce narcotic requirement. Setting expectations on safe utilization of prescribed pain medications may also increase satisfaction. This study provides useful information for surgeons to customize pain management regimens and to perform effective preoperative education and counseling regarding postoperative pain management. [Table: see text]

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