Are Hindfoot Procedures More Painful than Forefoot Procedures? A Prospective Observational Study in Elective Foot and Ankle Surgery

Effect of Supplemental Regional Anesthesia on the Complication and Readmission Rate of Patients After Elective Foot and Ankle Surgery

BACKGROUND

The purpose of this study is to define the effect of facility type (inpatient vs outpatient) for the use of supplemental regional anesthesia (SRA), and SRA's effect on complications, readmissions, operation time, and length of hospital stay after elective foot and ankle surgery.

METHODS

We performed a retrospective review to identify a large cohort of adult patients who underwent elective foot and ankle surgery between 2006 and 2020 from the American College of Surgeons National Surgical Quality Improvement Program database. We fit log-binomial generalized linear models to estimate risk ratios for general anesthesia (GA) with SRA versus GA alone, and linear regression models to estimate the effect of GA with SRA on the average total hospital length of stay (in days) and operation time (in minutes); we also performed inverse propensity scores.

RESULTS

We found that there is no statistical difference in the rate of readmissions (P = .081) between patients under GA alone versus GA with SRA. In the propensity score analysis, patients who underwent midfoot/forefoot surgery had 3.85 times the risk of complications under GA with SRA compared with GA alone (P = .045). Also, patients who received GA with SRA had a longer unadjusted operative duration (102.22 minutes) when compared with patients who received GA alone (93.84 minutes) (P < .001). However, patients who received GA alone had a longer unadjusted hospital length of stay (0.88 days) when compared with patients who received GA with SRA (0.70 days) (P = .006).

CONCLUSION

This study found that, when compared with GA alone, GA with SRA leads to a statistically significant increased operative time but a shorter hospital stay without significantly increasing readmissions and only increasing the risk of complications for midfoot/forefoot surgery within 30 days postoperatively for elective foot and ankle surgery.

LEVEL OF EVIDENCE

Level III.

Development and internal validation of a multivariable risk prediction model for severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block

BACKGROUND

Rebound pain occurs after up to 50% of ambulatory surgeries involving regional anaesthesia. To assist with risk stratification, we developed a model to predict severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block.

METHODS

After ethics approval, we performed a single-centre retrospective cohort study. Patients undergoing lower limb surgery with popliteal sciatic nerve block from January 2016 to November 2019 were included. Exclusion criteria were uncontrolled pain in the PACU, use of a perineural catheter, or loss to follow-up. We developed and internally validated a multivariable logistic regression model for severe rebound pain, defined as transition from well-controlled pain in the PACU (numerical rating scale [NRS] 3 or less) to severe pain (NRS ≥7) within 48 h. A priori predictors were age, sex, surgery type, planned admission, local anaesthetic type, dexamethasone use, and intraoperative anaesthesia type. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC), Nagelkerke's R², scaled Brier score, and calibration slope.

RESULTS

The cohort included 1365 patients (mean [standard deviation] age: 50 [16] yr). The primary outcome was abstracted in 1311 (96%) patients, with severe rebound pain in 652 (50%). Internal validation revealed poor model performance, with AUROC 0.632 (95% confidence interval [CI]: 0.602-0.661; bootstrap optimisation 0.021), Nagelkerke's R² 0.063, and scaled Brier score 0.047. Calibration slope was 0.832 (95% CI: 0.623-1.041).

CONCLUSIONS

We show that a multivariable risk prediction model developed using routinely collected clinical data had poor predictive performance for severe rebound pain after foot and ankle surgery. Prospective studies involving other patient-related predictors are needed.

CLINICAL TRIAL REGISTRATION

NCT05018104.