Opioid Crisis and Acute Pain Management After Foot and Ankle Surgery

Strategies for Reducing Perioperative Opioid Use in Foot and Ankle Surgery: Education, Risk Identification, and Multimodal Analgesia

There remains a high prevalence and substantial risks of opioid utilization amongst orthopedic patients. The goal of this review is to discuss strategies for responsible opioid use in the perioperative setting following foot and ankle orthopedic surgeries. We will highlight 1) education interventions, 2) risk identification, and 3) non-opioid alternatives for postoperative pain management.

The Impact of Time and State Opioid Legislation on Opioid Prescription Filling in Total Ankle Arthroplasty

Total ankle arthroplasty (TAA) is an increasingly utilized treatment for ankle arthritis, and opioids are commonly used as part of perioperative pain control. However, many states have enacted opioid-limiting legislation to reduce perioperative opioid prescribing. The aim of this study was to evaluate the impact of time and state legislation on perioperative opioid prescribing in TAA. This study is a retrospective, observational review of 90-day perioperative opioid prescribing in 1,829 patients undergoing TAA throughout the United States using a large insurance database. Initial and cumulative volumes and rates of opioid prescription filling were recorded along with baseline patient and operative characteristics. Dates of state legislation enactment were also recorded. Student t-tests, analysis of variance, and multivariable linear and logistic regression were utilized to analyze the impact of time and state legislation on opioid prescription filling. In the 90-day perioperative time period, initial and cumulative opioid prescription filling in oxycodone 5-mg equivalents has decreased significantly from 2010 (63.8 initial and 163.3 cumulative) to 2019 (41.1 initial and 67.2 cumulative). States with opioid-limiting legislation saw larger and more significant reductions in initial and cumulative opioid prescription filling preact to postact (63.3-50.6 with legislation vs 61.4-51.9 without legislation initial and 146.4-93.3 with legislation vs 125.1-108.6 without legislation cumulative). This study demonstrates that foot and ankle surgeons in states with opioid-limiting legislation have responded by significantly reducing 90-day perioperative opioid prescribing in TAA. These results encourage states without legislation to enact opioid-specific laws to reduce opioid prescribing.

Acute postoperative pain management protocols in podiatric surgery within Australia: a Delphi study

Background

There is limited evidence in the literature to describe an analgesic protocol that takes into consideration the extent of foot and ankle surgery. The aim of this study was to develop a guide for acute postoperative pain management for podiatric surgery in Australia, and to identify opportunities to improve the current list of scheduled medicines available to podiatric surgeons.

Methods

A Delphi method involving 3 survey rounds was employed for this study. Twelve expert panellists in the field of podiatric surgery and anaesthesiology were invited to participate, and 10 panellists remained by the end of the study. Round 1 involved 15 open-ended questions. These answers formed the basis of the 55 statements that were developed for the following 2 survey rounds, where panellists rated the appropriateness of each statement on a 9-point Likert scale. The third survey round was an opportunity for panellists to revise their answers to each statement in light of the majority response.

Results

For mild acute postoperative pain, non-opioid oral analgesics were recommended as an appropriate management option. For moderate and severe acute postoperative pain, both non-opioid and opioid products were found to be appropriate by the majority. It was agreed that oral opioids be reserved for breakthrough pain at all severity levels. All other statements in the Delphi study pertaining to drug hypersensitivities or allergies, stratification of pain management, opioid prescription concerns, and access to pain medications were accepted as appropriate by the majority of panellists.

Conclusion

The agreed approach to acute postoperative pain management for podiatric surgeons in Australia was with a stepwise approach, utilising multimodal therapy, and reserving oral opioids for breakthrough pain. Additionally, there was consensus for podiatric surgeons in Australia to have wider access to alternative analgesics and anti-emetics that have similar or improved efficacies with better safety profiles.

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.