Preoperative lateral popliteal nerve block for intraoperative and postoperative pain control in elective foot and ankle surgery: a prospective analysis

Effect of liposomal bupivacaine for sciatic nerve block on opioid use in patients undergoing maxillofacial reconstruction with free fibular flap: a randomized, controlled trial

Background

We investigated the efficacy and safety of preoperative popliteal sciatic nerve block (PSNB) using liposomal bupivacaine (LB) to reduce perioperative opioid consumption and improve recovery quality in patients undergoing maxillofacial reconstruction with a free fibular flap.

Methods

A total of 74 patients were randomly allocated into two groups. The PSNB group received ultrasound guided PSNB using 133 mg of LB after anesthesia induction. In the control group, patients underwent nerve block preparation procedures without puncture or drug injection. The primary endpoint was cumulative opioid consumption during the perioperative period (from anesthesia induction to 48 h post-surgery). The secondary endpoints were the total incidence of moderate to severe pain during the 48 h postoperative period; the incidence of moderate to severe pain during different time periods after surgery; the incidence of PONV within 48 h after surgery; subjective sleep quality within 2 days after surgery; the length of post-surgical hospital stay; all-cause in-hospital mortality; and the incidence of other complications during hospitalization.

Results

There was no significant difference in cumulative opioid consumption between the control group (3020.0 [2163.0, 3569.5] µg of remifentanil equivalents) and the PSNB group (2856.0 [2204.0, 3771.0] µg; p  = 0.863). The incidence of moderate to severe pain at the donor site within 48 h after surgery was significantly lower in the PSNB group (3 [8.1%] of 37 patients) than in the control group (18 [48.6%] of 37 patients; p  < 0.001). The consumption of rescue opioids was significantly reduced in the PSNB group (0 [0, 50]) compared with that in the control group (50 [0, 100]; p  = 0.007). The subjective sleep quality numeric rating scale score was significantly lower in the PSNB group than in the control group (day of surgery: 6.0 [5.0, 8.0] vs. 8.0 [6.0, 9.0], p  = 0.029; postoperative day 1: 5.0 [4.0, 5.0] vs. 7.0 [5.5, 7.5], p  < 0.001; postoperative day 2: 5.0 [4.0, 5.5] vs. 6.0 [5.0, 7.5], p  = 0.001). The incidence of postoperative nausea and vomiting was significantly lower in the PSNB group (0 [0.0%]) compared with that in the control group (5 [13.5%]; p  = 0.021). There was no significant difference in the incidence of adverse events between the two groups.

Conclusion

Preoperative administration of PSNB by LB did not spare opioids during the intraoperative period, but significantly relieved postoperative pain at the donor site, reduced rescue opioid consumption, and improved postoperative sleep quality, without additional adverse events.

Trial registration

Clinicaltrials.gov. Identifier ChiCTR2400080944, 19 February 2024.

Neurological injury following peripheral nerve blocks: a narrative review of estimates of risks and the influence of ultrasound guidance

BACKGROUND

Peripheral nerve injury or post-block neurological dysfunction (PBND) are uncommon but a recognized complications of peripheral nerve blocks (PNB). A broad range of its incidence is noted in the literature and hence a critical appraisal of its occurrence is needed.

OBJECTIVE

In this review, we wanted to know the pooled estimates of PBND and further, determine its pooled estimates following various PNB over time. Additionally, we also sought to estimate the incidence of PBND with or without US guidance.

EVIDENCE REVIEW

A literature search was conducted in six databases. For the purposes of the review, we defined PBND as any new-onset sensorimotor disturbances in the distribution of the performed PNB either attributable to the PNB (when reported) or reported in the context of the PNB (when association with a PNB was not mentioned). Both prospective and retrospective studies which provided incidence of PBND at timepoints of interest (>48 hours to <2 weeks; >2 weeks to 6 weeks, 7 weeks to 5 months, 6 months to 1 year and >1 year durations) were included for review. Incidence data were used to provide pooled estimates (with 95% CI) of PBND at these time periods. Similar estimates were obtained to know the incidence of PBND with or without the use of US guidance. Additionally, PBND associated with individual PNB were obtained in a similar fashion with upper and lower limb PNB classified based on the anatomical location of needle insertion.

FINDINGS

The overall incidence of PBND decreased with time, with the incidence being approximately 1% at <2 weeks' time (Incidence per thousand (95% CI)= 9 (8; to 11)) to approximately 3/10 000 at 1 year (Incidence per thousand (95% CI)= 0. 3 (0.1; to 0.5)). Incidence of PBND differed for individual PNB with the highest incidence noted for interscalene block.

CONCLUSIONS

Our review adds information to existing literature that the neurological complications are rarer but seem to display a higher incidence for some blocks more than others. Use of US guidance may be associated with a lower incidence of PBND especially in those PNBs reporting a higher pooled estimates. Future studies need to standardize the reporting of PBND at various timepoints and its association to PNB.

Techniques and complications of popliteal nerve blocks

BACKGROUND

Use of popliteal nerve blocks (PNBs) as an alternative or adjunctive therapy to traditional methods of pain control (e.g., systemic or spinal anesthesia and opioids) is increasingly popular in foot and ankle surgery.

METHODS

We reviewed online databases for literature on PNBs in foot and ankle surgery to analyze the various techniques and positioning used, the influence of drugs on their efficacy, and possible complications associated with their use. Thirty articles were identified with a predefined search criteria, followed by a review process for relevance.

RESULTS

Patient demographics, procedure specifics, and block techniques, such as anesthetic used, can impact the duration and success of a PNB. Administration with ultrasound guidance proved superior to nerve stimulation, and preoperative administration was superior to postoperative administration.

CONCLUSIONS

PNBs are an effective method to control postoperative pain with minimal complications, leading to decreased analgesic use, earlier discharge, and higher patient satisfaction.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

The effect of regional anesthesia blocks on post-operative pain after ambulatory orthopedic trauma surgery

PURPOSE

To determine if regional anesthesia had added benefit to general anesthesia, with or without local anesthesia, in controlling post-operative pain in outpatient orthopedic trauma surgery.

METHODS

A retrospective review was performed of prospectively gathered data on 71 patients undergoing outpatient orthopedic trauma surgery. All patients received general anesthesia and an addition 52 patients received additional regional anesthesia. Regional vs. no regional anesthesia groups were compared in terms of post-anesthesia care unit (PACU) pain visual analog scores (VAS), PACU length of stay (LOS), opioid use, and pain control at two weeks.

RESULTS

The regional anesthesia group not differ in demographics or proportion of patients receiving local anesthesia, but was less likely to be undergoing major procedures (13% vs. 37%, proportional difference (PD) - 23%; 95% confidence interval (CI) - 46% to - 0.4%). There were no detectable differences in PACU opioid requirements (median difference (MD) - 7.5 mg, CI - 8 to 0), PACU LOS (MD - 13 min, CI - 63 to 24), discharge pain VAS (MD 0, CI - 1 to 1), post-discharge pain VAS (MD 0, CI - 1 to 1), opioid refills (PD - 6%, CI - 31% to 18%), or patient-perceived pain control (PD - 24%, CI - 41% to 0%). On multivariate analysis, regional anesthesia was the only variable negatively associated with patient-perceived pain control at two weeks (Odds Ratio 0.15; 95% CI 0.03 to 0.8).

CONCLUSIONS

Regional anesthesia did not improve post-operative opioid requirements, PACU LOS, or patient-reported pain in the immediate or short-term post-operative period.

Clinical analyses of ultrasound-guided nerve block in lower-extremity surgery: A retrospective study

PURPOSE

The purpose of this study is to examine the clinical effects and results of lower-extremity surgery under ultrasound-guided nerve block; time required for nerve block, anesthesia onset time, duration of anesthesia, duration of analgesia, tolerable tourniquet time, visual analog scale (VAS) satisfaction score, and anesthetic-related complications.

METHODS

A total of 3312 cases (2597 patients) from January 2010 to April 2015 were analyzed retrospectively. A senior author performed ultrasound-guided nerve block of the lateral femoral cutaneous nerve (LFCN, 630 cases), femoral nerve (FN, 2503 cases), obturator nerve (ON, 366 cases), sciatic nerve (SN, 3271 cases), or posterior femoral cutaneous nerve (PFCN, 222 cases) depending on the type of surgery. Time required for nerve block, anesthesia onset time, duration of anesthesia, duration of analgesia, tolerable tourniquet time, VAS satisfaction score, and anesthetic-related complications were analyzed.

RESULTS

The mean times required were 1.1 min for SN block, 2.5 min for FN/SN block (1762 cases), and 4.8 min for FN/SN/LFCN/ON block. The mean anesthesia onset time was 48 min. The mean durations of anesthesia were 4.5 h for FN dermatome and 5.6 h for SN dermatome. The mean duration of analgesia was 11.5 h. The mean tolerable tourniquet times after were 35, 51, and 84 min after SN block, FN/SN block, and FN/SN/LFCN/ON block, respectively. The mean VAS satisfaction score was 9.3. There were no anesthetic-related complications, such as infection, hematoma, paralysis, or nerve irritation.

CONCLUSION

Selective block of the LFCN, FN, ON, SN, and PFCN based on the locations of lesions and type of surgery showed favorable clinical results with high efficacy. Ultrasound-guided nerve block may be a good option for anesthesia and analgesia in lower-extremity surgery.

Ultrasound-Guided Popliteal Nerve Block with Short-Acting Lidocaine in the Surgical Treatment of Ingrown Toenails

Background: Digital nerve block (DB) is a commonly utilized anesthetic procedure in ingrown toenail surgery. However, severe procedure-related pain has been reported. Although the popliteal sciatic nerve block (PB) is widely accepted in foot and ankle surgery, its use in ingrown toenail surgery has not been reported. Therefore, this study aimed to investigate the safety and effectiveness of PB in the surgical treatment of ingrown toenails. Methods: One-hundred-ten patients surgically treated for an ingrown toenail were enrolled. Sixty-six patients underwent DB, and 44 underwent PB. PB was performed under ultrasound-guidance via a 22-gauge needle with 15 mL of 1% lidocaine in the popliteal region. The visual analogue scale was used to assess pain at two-time points: pain with skin penetration and pain with the solution injection. Time to sensory block, duration of sensory block, need for additional injections, and adverse events were recorded. Results: PB group demonstrated significantly lower procedure-related pain than the DB group. Time to sensory block was significantly longer in the PB group (20.8 ± 4.6 versus 6.5 ± 1.6 minutes). The sensory block duration was significantly longer in the PB group (187.9 ± 22.0 versus 106.5 ± 19.1 minutes). Additional injections were required in 16 (24.2%) DB cases, while no additional injections were required in PB cases. Four adverse events occurred in the DB group and two in the PB group. Conclusion: PB was a less painful anesthetic procedure associated with a longer sensory block duration and fewer repeat injections compared with DB. The result of this study implicates that PB can be an alternative anesthetic option in the surgical treatment of ingrown toenails.

Local Ketorolac Injection vs Popliteal Sciatic Nerve Blockade as an Adjuvant to a Spinal Block in Hindfoot Arthrodesis

BACKGROUND

Popliteal nerve blocks reduce pain and markedly improve postoperative outcomes during foot and ankle surgery; however, several potential complications may arise from nerve block procedures. The purpose of this study was to investigate local infiltration analgesia with ketorolac as a convenient alternative for pain relief.

METHODS

A total of 80 patients scheduled for hindfoot arthrodesis were randomly allocated to one of 2 anesthetic groups: a spinal block augmented with either a popliteal nerve block (n = 40) or local ketorolac and Marcaine infiltration (n = 40). Clinical assessment included postoperative visual analog scale (VAS) pain scores at 4, 8, 12, 24, and 48 hours, total morphine consumption, time to incision (time in operating room to incision), operative time, length of hospital stay, and complications.

RESULTS

Despite similar morphine consumption between groups (P = .28), VAS scores were significantly lower at 24 hours (1.6 ± 2.2 cm vs 2.7 ± 3.0 cm, P = .01) and 48 hours (0.2 ± 0.7 cm vs 1.0 ± 1.5 cm, P < .01) after surgery using local ketorolac injection. Although time from entry into the operating room to incision was also reduced after local ketorolac injection (19.0 ± 5.3 minutes vs 31.4 ± 14.6 minutes, P < .001), the length of operative time (P = .38), hospital stay (P = .43), and number of complications (P = .24) were similar between groups.

CONCLUSION

Ketorolac local injection provided effective pain control in hindfoot arthrodesis and markedly reduced VAS pain scores up to 48 hours after surgery compared with popliteal nerve block. In addition, ketorolac local injection also reduced time in the operating room compared with popliteal nerve blockade.

LEVEL OF EVIDENCE

Level 1, randomized controlled trial.

Peripheral nerve block anaesthesia and postoperative pain in acute ankle fracture surgery: the AnAnkle randomised trial

BACKGROUND

Peripheral nerve blocks (PNBs) are increasingly popular in acute ankle fracture surgery but rebound pain may outweigh the benefits. The AnAnkle Trial was designed to assess the postoperative pain profile of PNB anaesthesia compared with spinal anaesthesia (SA).

METHODS

The AnAnkle Trial was a randomised, two-centre, blinded outcome analysis trial. Eligible adults booked for primary ankle fracture surgery were randomised to PNB or SA. The PNBs were ultrasound-guided popliteal sciatic and saphenous blocks with ropivacaine and SAs were with hyperbaric bupivacaine. Postoperatively, all subjects received paracetamol, ibuprofen, and patient-controlled i.v. morphine for pain. The primary endpoint was 27 h Pain Intensity and Opioid Consumption (PIOC) score. Secondary endpoints included longitudinal pain scores and morphine consumption separately, and questionnaires on quality of recovery.

RESULTS

This study enrolled 150 subjects, and the PNB success rate was >94%. PIOC was lower with PNB anaesthesia (median, -26.5% vs +54.3%; P<0.001) and the probability of a better PIOC score with PNB than with SA was 74.8% (95% confidence interval, 67.0-82.6). Pain scores and morphine consumption analysed separately also yielded a clear benefit with PNB, despite substantial rebound pain when PNBs subsided. Quality of recovery scores were similar between groups, but 99% having PNB vs 90% having SA would choose the same anaesthesia form again (P=0.03).

CONCLUSIONS

PNB anaesthesia was efficient and provided a superior postoperative pain profile compared with SA for acute ankle fracture surgery, despite potentially intense rebound pain after PNB.

CLINICAL TRIAL REGISTRATION

Clinicaltrialsregister.eu, EudraCT number: 2015-001108-76.

Lateral popliteal block in foot and ankle surgery: Comparing ultrasound guidance to nerve stimulation. A prospective randomized trial

BACKGROUND

The popliteal block has several benefits in foot and ankle surgery. It reduces postoperative pain, limits the use of narcotics and facilitates early discharge. The aim of this prospective randomized trial was to evaluate whether ultrasound guidance improves block characteristics compared to the nerve stimulation technique in lateral popliteal blocks.

METHODS

Patients were randomized to receive either a lateral popliteal block using neurostimulation or ultrasound guidance. Block performance time, number of needle pricks, number of redirections were recorded. Pain upon admission to and discharge from post anesthesia care unit (PACU) was recorded. Block duration, patient satisfaction, pain at block site and amount of opioids used in PACU and between subsequent followup visits was recorded. Patients were followed for 12 weeks postoperatively.

RESULTS

There was no statistically significant difference between the two groups in terms of number of pricks, time for the block to wean, pain upon admission to PACU, amount of opioids received in PACU, pain upon discharge from PACU, pain at the operative site, pain at the block site, toe motor function and toe sensation. There was a statistically significant difference in the block procedure performance time between the two groups, with the control group being faster (P<0.0001). A significantly larger number of patients in the control group required more than three needle redirections (P=0.0060).

CONCLUSIONS

The lateral sciatic popliteal block using nerve stimulation had similar block characteristics and patient satisfaction with a significantly faster performance time compared to the ultrasound guided technique.

LEVEL OF EVIDENCE

Level I, prospective randomized study.

Comparative Evaluation of Two Different Post-Operative Analgesia after Hallux Valgus Correction in Day Surgery Patients

Introduction

The aim of this study was the evaluation of two different techniques on post-operative analgesia and motor recovery after hallux valgus correction in one-day surgery patients.

Material and Methods

We enrolled 26 patients scheduled for hallux valgus surgery and treated with the same surgical technique (SCARF osteotomy). After subgluteal sciatic nerve block with a short acting local anaesthetic (Mepivacaine 1.5%, 15ml), each patient received an ultrasound-guided Posterior Tibialis Nerve Block (PTNB) with Levobupivacaine 0.5% (7-8ml). We measured the postoperative intensity of pain using a Visual Analogue Scale (VAS), the consumption of oxycodone after operative treatment and the motor recovery. VAS was detected at baseline (time 0, before the surgery) and at 3, 6, 12 and 24 hours after the operative procedure (T1, T2, T3, T4 respectively). Control group of 26 patients were treated with another post-operative analgesia technique: local infiltration (Local Infiltration Anaesthesia, LIA) with Levobupivacaine 0.5% (15ml) performed by the surgeon.

Results

PTNB group showed a significant reduction of VAS score from the sixth hour after surgery compared to LIA group (p<0.028 at T2, p<0.05 at T3 and p<0.002 at T4, respectively). Instead, no significant differences were found in terms of post-operative oxycodone consumption and motor recovery after surgery.Conclusions: PTNB resulted in a valid alternative to LIA approach for post-operative pain control due to its better control of post-operative pain along the first 24 hours. In a multimodal pain management according to ERAS protocol, both PTNB and LIA should be considered as clinically effective analgesic techniques.

Regional Nerve Block Complication Analysis Following Peripheral Nerve Block During Foot and Ankle Surgical Procedures

Background

Foot and ankle surgeries are frequently accompanied by a peripheral nerve block in order to reduce postoperative pain. Higher than expected complication rates with peripheral nerve blocks have led to increased concern among surgeons and patients. To our knowledge, no study conducted by the treating surgeon has identified risk factors that may predispose a patient to complications. Our goal was to attempt to identify those risk factors.

Methods

We reviewed patient charts of those who underwent an orthopedic foot and ankle procedure between 2013 and 2018, as performed by the senior author. This yielded 992 procedures performed across four surgical locations. Of these procedures, 137 procedures were removed because no block was used. The remaining cases were analyzed for nerve complications, defined as sensory or motor deficits along the distribution of a nerve. The patients were divided into those with and without complications and were evaluated for differences. Statistical analysis was performed using the SAS^® software (SAS Institute Inc., Cary, North Carolina, USA).

Results

The overall short-term complication rate was 10.1% and the long-term complication rate was 4.3%, with a total of 855 blocks given. Electromyographies (EMGs) were performed on 24.4% of the patients with a complication. Of the EMGs, 95.2% confirmed nerve complications in the distribution of the blocked nerve. The significant factors associated with complications were age, BMI, location, and smoking status. A regression analysis was performed to determine the odds ratio for individual factors. Those with significantly higher odds ratio were between 40 and 65 years of age, had normal or underweight BMI, underwent surgery at an outpatient surgery center, and were current smokers.

Conclusions

Our study suggests that there are significant epidemiological factors in predicting postoperative complications related to a peripheral nerve block. The study also shows a similar short-term complication rate but a higher long-term complication rate than other studies. This data are important because it allows for an informed decision to be made between a surgeon, anesthesiologist, and the patient regarding the safety and necessity of delivering a preoperative peripheral nerve block based on patient risk factors.

Current Trends in Anesthesia Management in Hallux Valgus

Anesthesia management during hallux valgus surgery trends toward multimodal pain control. Locoregional anesthesia with peripheral nerve blocks and wound instillation increase pain control. Peripheral nerve blocks as first-line analgesia are effective with minimal side effects. Local wound instillation has a variable but positive effect with minimal negative side effects. Nonsteroidal anti-inflammatory drugs in bone-to-bone healing remain controversial; however, they reduce opiate requirements and enhance patient satisfaction. Opiate agonists remain the mainstay for postoperative pain; long-acting formulations minimize pain crises. Multimodal analgesia with locoregional anesthesia facilitate the progress of hallux valgus surgery as an outpatient procedure.

Popliteal Versus Local Field Block for Pain-Related Postoperative Unplanned Emergency Room Visits After Foot and Ankle Surgery

Ultrasound-guided popliteal blocks for postoperative pain management have grown in popularity within foot and ankle surgery. The purpose of this study was to evaluate the efficacy of popliteal block in preventing postoperative emergency department visits after foot and ankle surgery. We compared rates of presentation to the emergency department for pain following foot and ankle surgery between surgeries with a popliteal block and those with local field block alone. We identified 101 charts, of which 26 presented to the emergency department for postoperative pain following popliteal block. Our results demonstrated that popliteal blocks did not perform better than local blocks, and that there is no statistically significant difference between the 2 methods of postoperative pain control in terms of rates of presentation to the emergency department for pain. Levels of Evidence: Level III, All statistical analyses were carried out using the R statistical package by the primary author (NS) (R Developmental, Core Team. R: A Language and Environment for Statistical Computing, 2012. http://www.R-project.org ).

Mini-invasive methods of treatment of diabetic foot pain

Neuropathic pain occurs with diabetic polyneuropathy more often than with all polyneuropathies of another etiology. Because the cause of pain can rarely be cured, treatment is usually symptomatic. Neuropathic pain is usually poorly controlled by analgesics. Management of neuropathic pain is started with conservative pharmacotherapy before invasive pain management is applied. Although there are many drugs that can be used in patients with diabetic pain syndrome, pain syndrome can not be surely stoped with monotherapy. In addition, the patient may not tolerate the full therapeutic dose of the drug. All this dictates the need for combination therapy. It is believed that regional anesthesia as an independent type of analgesia or a component of combined anesthesia is the method of choice for the elderly and senile patients. The main reasons for this choice, when comparing regional anesthesia with narcosis, are less stressful response of the organism, absence of depression of the central nervous system, stable reliable analgesia with complete blockade of nociceptive reflexes with the provision of adequate muscle relaxation, prevention of neurovegetative reactions, which ultimately helps to reduce the incidence of postoperative complications and mortality. Clinicians have accumulated considerable experience demonstrating the need for regional analgesia in the management of diabetic foot pain.

Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery: An exploratory pilot study

BACKGROUND

Peripheral nerve blocks (PNB) are increasingly used for anaesthesia and postoperative pain control in acute orthopaedic limb surgery but rebound pain upon cessation of PNBs may challenge the benefits on the pain profile. We aimed to explore the pain profile following acute ankle fracture surgery under PNB anaesthesia and investigate if rebound pain could pose a clinical problem.

METHODS

Exploratory, observational study of adults scheduled for acute primary internal fixation of an ankle fracture under ultrasound-guided popliteal sciatic and saphenous ropivacaine block anaesthesia. Postoperatively, patients regularly registered pain scores while receiving a fixed analgesics regimen and patient controlled morphine on-demand. We analysed morphine consumption and depicted the detailed pain profiles as graphs allowing for visual analysis of pain courses, including rebound pain. Secondly, we compared the area under the curve and peak pain between relevant age-subgroups.

RESULTS

We included 21 patients aged 20-83. Depicted pain profiles reveal that PNB supplied effective and long lasting postoperative pain control, but cessation of the PNB led to intense rises in pain scores with six out of nine 20-60-year-olds reaching severe pain levels. The rebound was less pronounced in patients >60 years old, but nearly all reached moderate pain levels. Morphine consumption rates were high during the rebound.

CONCLUSIONS

This study thoroughly analyses the post-PNB pain profile and suggests rebound pain is a clinically relevant and problematic issue with the potential to outweigh the PNB benefits, especially for younger patients. The conclusions are tentative, and a randomised study is pending.

Complications After Multiple-Site Peripheral Nerve Blocks for Foot and Ankle Surgery Compared With Popliteal Sciatic Nerve Block Alone

BACKGROUND

Single or combined multiple-site peripheral nerve blocks (PNBs) are becoming popular for patients undergoing surgery on their feet or ankles. These procedures are known to be generally safe in surgical settings compared with other forms of anesthesia, such as spinal block. The purposes of this study were to assess the incidence of complications after the administration of multiple PNBs for foot and ankle surgery and to compare the rates of complications between patients who received a single PNB and those who received multiple blocks.

METHODS

Charts were reviewed retrospectively to assess peri- and postoperative complications possibly related to the PNBs. The records of 827 patients who had received sciatic nerve blocks, femoral nerve blocks adductor canal blocks, or combinations of these for foot and/or ankle surgery were analyzed for complications. The collected data consisted of age, sex, body mass index, presence of diabetes mellitus, smoking history, tourniquet time, and complications both immediately postoperatively and 1 year later.

RESULTS

Of these 827 patients, 92 (11.1%) developed neurologic symptoms after surgery; 22 (2.7%) of these likely resulted from the nerve blocks, and 7 (0.8%) of these were unresolved after the patients' last follow-up visits. There were no differences in complication rates between combined blocks and single sciatic nerve blocks.

CONCLUSION

There were more complications, both transient and long term, after anesthetic PNBs than previous literature has reported. Combined multiple-site blocks did not increase the rate of neurologic complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Liposomal Bupivacaine Versus Continuous Popliteal Sciatic Nerve Block in Total Ankle Arthroplasty

BACKGROUND

Liposomal bupivacaine (LB) is widely used in joint arthroplasty, but there is little reported on the use of LB in foot and ankle surgery. Continuous popliteal sciatic nerve block (CPSNB) is more commonly used for major foot and ankle reconstructions. The purpose of this study was to compare 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 of 2 fellowship-trained orthopedic foot and ankle surgeons was performed. Patients received either preoperative single-shot popliteal sciatic nerve block with 0.2% ropivacaine followed by intraoperative injection of LB or preoperative CPSNB alone. Outcomes examined were visual analog scale (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 < .05 was considered significant. Seventy-five patients were identified who underwent TAA and met inclusion criteria. Forty-one received LB, and 34 received CPSNB.

RESULTS

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. Sixteen of 41 (39%) LB patients had narcotic refills, versus 12 of 34 (35%) CPSNB patients ( P = .81). Two of 41 (5%) LB patients had a complication postoperatively, versus 4 of 34 (12%) CPSNB patients. There were no complications specific to the anesthetic used in either group.

CONCLUSION

This is the first study evaluating the use of LB for total ankle arthroplasty. Liposomal bupivacaine was safe and effective as an option for regional anesthetic and postoperative pain control, with comparable results to CPSNB.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Ankle Block vs Single-Shot Popliteal Fossa Block as Primary Anesthesia for Forefoot Operative Procedures: Prospective, Randomized Comparison

BACKGROUND

Postoperative pain is often difficult to control with oral medications, requiring large doses of opioid analgesia. Regional anesthesia may be used for primary anesthesia, reducing the need for general anesthetic and postoperative pain medication requirements in the immediate postoperative period. The purpose of this study was to compare the analgesic effects of an ankle block (AB) to a single-shot popliteal fossa block (PFB) for patients undergoing orthopedic forefoot procedures.

METHODS

All patients having elective outpatient orthopedic forefoot procedures were invited to participate in the study. Patients were prospectively randomized to receive either an ultrasound-guided AB or PFB by a board-certified anesthesiologist prior to their procedure. Intraoperative conversion to general anesthesia and postanesthesia care unit (PACU) opioid requirements were recorded. Postoperative pain was assessed using the visual analog scale (VAS) at regular time intervals until 8 am on postoperative day (POD) 2. Patients rated the effectiveness of the block on a 1 to 5 scale, with 5 being very effective. A total of 167 patients participated in the study with 88 patients (53%) receiving an AB and 79 (47%) receiving a single-shot PFB.

RESULTS

There was no significant difference in the rate of conversion to general anesthesia between the 2 groups (13.6% [12/88] AB vs 12.7% [10/79] PFB). PACU morphine requirements and doses were significantly reduced in the PFB group ( P = .004) when compared to the AB group. The VAS was also significantly lower for the PFB patients at 10 pm on POD 0 (4.6 vs 1.6, P < .001), 8 am on POD 1 (5.9 vs 4.2, P = .003), and 12 pm on POD 1 (5.4 vs 4.1, P = .01). Overall complication rates were similar between the groups (AB 9% vs PFB 10.1%, P = .51) and there were no significant differences in residual sensory paresthesias (AB 2.3% [2/88] vs PFB 5.1% [4/79], P = .29), motor loss (0% vs 0%), or block site pain and/or erythema (AB 6.9% [6/88] vs PFB 5.1% [4/79], P = .44). The analgesic effect of the PFB lasted significantly longer when compared to the ankle block (AB 14.5 hours vs PFB 20.9 hours, P < .001). There was no significant difference in patient-perceived effectiveness of the block between the 2 groups, with both blocks being highly effective (AB 4.79/5 vs PFB 4.82/5, P = .68).

CONCLUSION

Regional anesthesia was a safe and reliable adjunct to perioperative pain management and highly effective in patients undergoing elective orthopedic forefoot procedures. However, patients who received a PFB had significantly better pain management and decreased opioid requirements in the immediate perioperative period than patients who received an ankle block.

LEVEL OF EVIDENCE

Level I, prospective randomized study.

Peripheral Nerve Blocks in Foot and Ankle Surgery

Postoperative pain is one of the most important factors in regard to patient outcomes. It has been linked with patient satisfaction, length of stay, and overall hospital costs. Peripheral nerve blocks have provided a safe, effective method to control early postoperative pain when symptoms are most severe. Peripheral nerve blocks, whether used intraoperatively or postoperatively, provide an alternative or adjunct to conventional pain management methods for patients who may not tolerate heavy narcotics or general anesthesia, in particular the elderly and those with cardiopulmonary disease.

AnAnkle Trial study protocol: a randomised trial comparing pain profiles after peripheral nerve block or spinal anaesthesia for ankle fracture surgery

INTRODUCTION

Ankle fracture surgery is a common procedure, but the influence of anaesthesia choice on postoperative pain and quality of recovery is poorly understood. Some authors suggest a benefit of peripheral nerve block (PNB) in elective procedures, but the different pain profile following acute fracture surgery and the rebound pain on cessation of the PNB both remain unexplored. We present an ongoing randomised study aiming to compare primary PNB anaesthesia with spinal anaesthesia for ankle fracture surgery regarding postoperative pain profiles and quality of recovery.

METHODS AND ANALYSIS

AnAnkle Trial is a randomised, dual-centre, open-label, blinded analysis trial of 150 adult patients undergoing primary internal fixation of an ankle fracture. Main exclusion criteria are habitual opioid use, impaired pain sensation, other painful injuries or cognitive impairment. The intervention is ultrasound-guided popliteal sciatic (20 mL) and saphenal nerve (8 mL) PNB with ropivacaine 7.5 mg/mL, and controls receive spinal anaesthesia (2 mL) with hyperbaric bupivacaine 5 mg/mL. Postoperatively all receive paracetamol, ibuprofen and patient-controlled intravenous morphine on demand. Morphine consumption and pain scores are registered in the first 27 hours and reported as an integrated pain score as the primary endpoint. Pain score intervals are 3 hours and we will use the area under curve to get a longitudinal measure of pain. Secondary outcomes include rebound pain on cessation of anaesthesia, opioid side effects (Opioid-Related Symptom Distress Scale), quality of recovery (Danish Quality of Recovery-15 score) and pain scores and medication days 1-7 (diary).

ETHICS AND DISSEMINATION

The study has been approved by the Regional Ethics Committees in the Capital Region of Denmark, the Danish Data Protection Agency and the Danish Health and Medical Authority. We will publish the results in international peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

AnAnkle Trial is registered in the European Clinical Trials Database (EudraCT 2015-001108-76).

Complications After Popliteal Block for Foot and Ankle Surgery

BACKGROUND

A popliteal nerve block is a common analgesic procedure for patients undergoing surgery on their knee, foot, or ankle. This procedure carries less risk in a surgical setting compared with other forms of anesthesia such as a spinal block. Previous reports demonstrated few to no complications with the use of this nerve block, but it is unclear whether these data are consistent with the recent increase in use of this analgesic procedure for lower extremity surgery.

METHODS

Retrospectively, a busy orthopedic foot and ankle practice performed a chart review examining for postoperative neuropathic complications possibly related to the popliteal nerve block. The 1014 patients who had undergone a popliteal block for foot and/or ankle orthopedic surgery were analyzed for short and long-term neuropathic complications. The collected data consisted of tourniquet time, pressure, and location as well as the method of finding the fossa nerve, adjuncts used, and patient medical history. Data were analyzed using chi-square, Fisher's exact, and t tests for analysis with a significance value of P < .05.

RESULT

Of these 1014 patients, 52 patients (5%) developed deleterious symptoms likely resulting from their popliteal block, and 7 (0.7%) of these were unresolved after their last follow-up. No immediately apparent underlying causes were determined for these complications.

CONCLUSION

The frequency of a neuropathic complication following a popliteal nerve block was notably higher in the early postoperative period than indicated in the past. The proportion of patients with unresolved neuropathic symptoms at last follow-up is comparable to that previously reported in the literature.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Postoperative pain and preemptive local anesthetic infiltration in hallux valgus surgery

BACKGROUND

Several techniques of anesthesia are used in foot surgery. Preemptive analgesia helps to prevent the development of hypersensitivity in the perioperative period. The aim of our study was to assess the role of preemptive local anesthetic infiltration and postoperative pain after hallux valgus surgery.

METHODS

We evaluated 118 patients who underwent modified chevron and mini-invasive Mitchell-Kramer bunionectomy of the first distal metatarsal. After spinal anesthesia each patient randomly received an infiltration of local anesthetic or the same amount of normal saline 10 minutes before the skin incision. We measured the intensity of pain 4, 8, 12, 16, 24, and 72 hours after the release of the tourniquet using a visual analogue scale (VAS). Rescue analgesia and all other side effects were noted.

RESULTS

Preemptive analgesia resulted in less pain during the first 24 hours after surgery. The decrease of VAS score was significantly lower in the study group during all the short postoperative periods measured. The rescue analgesia was administered in 11.9% of patients in the injected group and 42.4% in the placebo group (P < .05). In the injected group we did not observe significant difference in VAS score between patients post-chevron and miniinvasive Mitchell-Kramer osteotomy of the first distal metatarsal. No systemic adverse effects were noted. One persistent injury of dorsomedial cutaneous nerve was observed.

CONCLUSION

Preemptive local anesthetic infiltration was an efficient and safe method to reduce postoperative pain after hallux valgus surgery. The analgesic effect was satisfactory in both traditional and minimally invasive techniques.

Continuous Infragluteal Sciatic Nerve Block for Postoperative Pain Control After Total Ankle Arthroplasty

Continuous peripheral nerve blocks (CPNB) for postoperative pain control are being used more frequently for total ankle arthroplasty. The purpose of this study was to compare the amount of opioid analgesia used in patients with an infragluteal CPNB to that of patients with no CPNB for postoperative pain management after total ankle replacement. A retrospective cohort study was performed on 78 consecutive patients who had a total ankle arthroplasty from October 2006 to June 2013. The primary outcome measure was opioid analgesia use in the first 48 hours postoperatively. The mean postoperative narcotic use in oral morphine equivalents was 64.6 mg in the CPNB group compared to 129.6 mg in the no CPNB group (P < .001). Using an infragluteal CPNB as a means of postoperative pain control in patients undergoing a total ankle replacement is associated with significantly decreased opioid use compared to patients receiving no CPNB.

LEVELS OF EVIDENCE

Therapeutic, Level IV, case series.

Femoral and sciatic nerve block for hindfoot and ankle surgery

BACKGROUND

The use of regional anesthesia, such as ankle block or sciatic nerve block, has gained in popularity due to considerations of patient comfort and safety in foot and ankle surgery. However, if the operation extends above the midfoot or if a thigh tourniquet is required, general or spinal anesthesia is needed. The authors aimed to determine by prospective study whether a 'double block', involving femoral and sciatic nerve blocks, is advantageous under such conditions.

MATERIALS AND METHODS

The effectiveness of a preoperative double block was prospectively evaluated in 26 consecutive patients undergoing a variety of foot and ankle procedures, compared with 32 patients with sciatic nerve block alone. Time of analgesia onset, length of block coverage, and complications were noted. Degree of pain was measured using VAS (Visual Analog Scale) scores at the operation, just after surgery, and at 2 h, 1 day, and 2 days after surgery.

RESULTS

The surgical procedures performed under double block were ankle arthroscopy and medial ankle ligament reconstruction, and Achilles tendon repair, and the following conditions were treated; surgery for medial ankle fracture, ankle fusion, subtalar fusion, and surgery for hindfoot diseases, such as, talocalcaneal coalition. The average time required to analgesia onset was 63 min for a double block and 61 min for sciatic nerve block alone. Analgesia time lasted 12.0 h for a double block and 12.4 h for sciatic nerve block alone. Average VAS scores at the operation and immediately after the operation were 0.03 (range 0-1) and 0.16 (range 0-2) for sciatic nerve block, and 0.35 (range, 0-4), 0.31 (range 0-2) for double block. Average VAS scores at 2 h, 1 day, and 2 days postoperatively were 0.28 (range, 0-2), 2.16 (range 0-6), and 1.63 (range 0-5) for sciatic nerve block, and 0.42 (range 0-5), 2.27 (range 0-7), and 1.72 (range 0-8), respectively, for double block.

CONCLUSION

The results of this prospective study suggest that double block provides good surgical anesthesia and good postoperative pain control for hindfoot and ankle surgery.

Techniques of popliteal nerve regional anesthesia

Regional anesthesia for blockade of the sciatic nerve in the popliteal fossa is a useful adjunct to pain management in the perioperative setting for foot and ankle surgeons. The present tip aimed to provide a review of the relevant anatomy and technique for popliteal nerve block from the posterior and lateral approaches and to provide discussion and images of the use of peripheral nerve stimulation and ultrasound guidance as adjuvant methods to improve efficacy and reproducibility.

Popliteal blocks for foot and ankle surgery: success rate and contributing factors

The purpose of the present study was to evaluate the factors contributing to the success of popliteal nerve blocks performed by podiatric surgical residents in various stages of training. A retrospective review was conducted of 143 consecutively performed blocks during a 2-year period. A total of 29 blocks using a lateral approach and 114 blocks using a modified posterior approach were performed. The intrinsic and extrinsic variables contributing to block outcome were analyzed. A total of 109 successful blocks were performed, for an overall success rate of 76.2%. Significant differences (p < .002) were found between the success and failure groups with respect to the patients body mass index and age. No differences were observed between the success and failure groups with respect to the block approach or months of resident training. In conclusion, podiatric surgical residents in all stages of training can safely and effectively perform popliteal nerve blocks for peri- and postoperative analgesia. Surgeons should be aware of the potential influence of patients body mass index and age on the overall block success rates.

The role of continuous peripheral nerve blocks

A continuous peripheral nerve block (cPNB) is provided in the hospital and ambulatory setting. The most common use of CPNBs is in the peri- and postoperative period but different indications have been described like the treatment of chronic pain such as cancer-induced pain, complex regional pain syndrome or phantom limb pain. The documented benefits strongly depend on the analgesia quality and include decreasing baseline/dynamic pain, reducing additional analgesic requirements, decrease of postoperative joint inflammation and inflammatory markers, sleep disturbances and opioid-related side effects, increase of patient satisfaction and ambulation/functioning improvement, an accelerated resumption of passive joint range-of-motion, reducing time until discharge readiness, decrease in blood loss/blood transfusions, potential reduction of the incidence of postsurgical chronic pain and reduction of costs. Evidence deriving from randomized controlled trials suggests that in some situations there are also prolonged benefits of regional anesthesia after catheter removal in addition to the immediate postoperative effects. Unfortunately, there are only few data demonstrating benefits after catheter removal and the evidence of medium- or long-term improvements in health-related quality of life measures is still lacking. This review will give an overview of the advantages and adverse effects of cPNBs.

Comparison of multi-drug injection versus placebo after hallux valgus surgery

BACKGROUND

Hallux valgus surgery is followed by a significant amount of postoperative pain. Local multi-drug injection can be an option for pain control, but few clinical studies exist.

METHODS

Between May 2008 and July 2009, 30 consecutive patients (60 feet) received simultaneous bilateral proximal osteotomies for the correction of hallux valgus deformities. Each patient received local infiltration of the test solution made with ropivacaine, morphine, ketorolac, and epinephrine on one foot and same amount of normal saline on the other foot. The test side and the control side were randomly selected and both the patient and the surgeon remained blinded until the end of the data collection.

RESULTS

The multi-drug injection resulted in significantly less pain at 4 hours after the operation through the night of the first postoperative day. The difference in visual analogue scale (VAS) between the two sides was most significant at 8 hours after the operation, and then gradually decreased through the first and second postoperative day. Mean satisfaction VAS was significantly higher on the injection side (8.2+/-0.9) compared to the control side (6.2+/-1.9, p<0.0001).

CONCLUSION

Local multi-drug injection was easy to perform and safe and effective in reducing pain and enhancing patient satisfaction after hallux valgus surgery.

Popliteal block with transfibular approach in ankle arthrodesis: a case series

Introduction

Ankle arthrodesis is primarily undertaken to control severe pain in the ankle joint. Immediate postoperative pain is usually treated using oral analgesics, intravenous opiates and regional anaesthesia. The outcomes of ankle fusion, including patient satisfaction studies, are well documented in the literature. However, the advantage of popliteal block in the management of early postoperative pain after ankle fusion for osteoarthritis has not been widely reported. This study aims to determine the role of popliteal block using ankle fusion in the management of ankle osteoarthritis.

Case presentation

Ankle arthrodeses were performed in 27 patients over a five-year period. Eighteen patients were males (one had bilateral arthrodesis) and eight were females. Their mean age was 56 years and they were all Caucasians. The notes and radiographs of the patients were reviewed in retrospect for the duration of their hospital admission, time to union and complications.

Conclusion

Popliteal block is a safe and effective technique for postoperative analgesia in ankle arthrodesis. By using this technique, we achieved a significant reduction in the duration of hospital stay for our patients after ankle arthrodesis. The resultant cost saving was GBP717 for each patient.

Current world literature

This bibliography is compiled by clinicians from the journals listed at the end of this publication. It is based on literature entered into our database between 1 February 2008 and 31 January 2009 (articles are generally added to the database about two and a half months after publication). In addition, the bibliography contains every paper annotated by reviewers; these references were obtained from a variety of bibliographic databases and published between the beginning of the review period and the time of going to press. The bibliography has been grouped into topics that relate to the reviews in this issue.