Postoperative pain following foot and ankle surgery: a prospective study

The effectiveness of ambulatory continuous popliteal sciatic nerve blockade on patient-reported overall benefit of analgesia in patients undergoing foot or ankle surgery (CAREFREE trial); a randomized, open label, non-inferiority trial

STUDY OBJECTIVE

Management of pain after foot and ankle surgery remains a concern for patients and healthcare professionals. This study determined the effectiveness of ambulatory continuous popliteal sciatic nerve blockade, compared to standard of care, on overall benefit of analgesia score (OBAS) in patients undergoing foot or ankle surgery. We hypothesized that usage of ambulatory continuous popliteal sciatic nerve blockade is non-inferior to standard of care.

DESIGN

Single center, randomized, non-inferiority trial.

SETTING

Tertiary hospital in the Netherlands.

PATIENTS

Patients were enrolled if ≥18 years and scheduled for elective inpatient foot or ankle surgery.

INTERVENTION

Patients were randomized to ambulatory continuous popliteal sciatic nerve blockade or standard of care.

MEASUREMENTS

The primary outcome was the difference in OBAS, which includes pain, side effects of analgesics, and patient satisfaction, measured daily from the first to the third day after surgery. A non-inferiority margin of 2 was set as the upper limit for the 90% confidence interval of the difference in OBAS score. Mixed-effects modeling was employed to analyze differences in OBAS scores over time. Secondary outcome was the difference in opioid consumption.

MAIN RESULTS

Patients were randomized to standard of care (n = 22), or ambulatory continuous popliteal sciatic nerve blockade (n = 22). Analyzing the first three postoperative days, the OBAS was significantly lower over time in the ambulatory continuous popliteal sciatic nerve blockade group compared to standard of care, demonstrating non-inferiority (-1.9 points, 90% CI -3.1 to -0.7). During the first five postoperative days, patients with ambulatory continuous popliteal sciatic nerve blockade consumed significantly fewer opioids over time compared to standard of care (-8.7 oral morphine milligram equivalents; 95% CI -16.1 to -1.4).

CONCLUSIONS

Ambulatory continuous popliteal sciatic nerve blockade is non-inferior to standard of care with single shot popliteal sciatic nerve blockade on patient-reported overall benefit of analgesia.

A phase 3 active-controlled trial of liposomal bupivacaine via sciatic nerve block in the popliteal fossa after bunionectomy

STUDY OBJECTIVE

To investigate the efficacy, safety, pharmacodynamics, and pharmacokinetics of liposomal bupivacaine (LB) administered via ultrasound-guided sciatic nerve block in the popliteal fossa in participants undergoing bunionectomy.

DESIGN

Two-part, randomized, double-blind, active-controlled trial (NCT05157841).

SETTING

Operating room, postanesthesia care unit, and health care facility (6 sites).

PATIENTS

Adults with American Society of Anesthesiologists physical status classification ≤3 and body mass index ≥18 to <40 kg/m2 undergoing elective distal metaphyseal osteotomy.

INTERVENTIONS

Part A participants were randomized 1:1:1 to LB 266 mg, LB 133 mg, or bupivacaine hydrochloride 50 mg (BUPI). Part B participants were randomized 1:1 to LB (at the dose established by part A) or BUPI.

MEASUREMENTS

The primary endpoint was area under the curve (AUC) of numerical rating scale (NRS) pain intensity scores 0-96 h after surgery. Secondary endpoints included total postsurgical opioid consumption, opioid-free status 0-96 h after surgery, and pharmacokinetic endpoints.

MAIN RESULTS

Part A enrolled 22 participants per group. In part B, additional participants were randomized to LB 133 mg (n = 59) and BUPI (n = 60) (185 total). LB 133 mg had significant reductions versus BUPI in the AUC of NRS pain intensity score (least squares mean [LSM], 207.4 vs 371.4; P < 0.00001) and total opioid consumption 0-96 h after surgery (LSM, 17.7 [95% confidence interval (CI), 13.7, 22.8] morphine milligram equivalents [MMEs] vs 45.3 [95% CI, 35.1, 58.5] MMEs; P < 0.00001) and an increased proportion of opioid-free participants (24.4% vs 6%; odds ratio, 5.04 [95% CI, 2.01, 12.62]; P = 0.0003) in parts A + B. Adverse events were similar across groups.

CONCLUSIONS

LB 133 mg administered via sciatic nerve block in the popliteal fossa after bunionectomy demonstrated superior and long-lasting postsurgical pain control versus BUPI. The clinical relevance of these findings is supported by concurrent reductions in pain and opioid consumption over 4 days after surgery and a significantly greater percentage of participants remaining opioid-free.

Factors Influencing PROMIS Scores and Patient Reported Outcomes Following Surgical Intervention of Isolated Lisfranc Injury: Minimum 2 Year Follow-up

Lisfranc injuries are rare but significant foot injuries, as they often result from polytrauma patients, and are often misdiagnosed, which further complicate their evaluation and contribute to their propensity towards disability. It is recommended that, on diagnosis, Lisfranc injuries be treated as soon as possible to decrease the risk of future chronic pain, disability, or osteoarthritis. Our study evaluated patients who completed the patient reported outcome measurement information systems (PROMIS) along with the foot function index (FFI) following operative fixation for Lisfranc injury. Fifty-one patients between 2010 and 2020 met inclusion criteria and were selected for this study, with completion. Utilizing the electronic medical record (EMR), patient charts were reviewed to obtain basic patient demographic information and comorbidities. Operative reports were reviewed to determine which procedure was performed for definitive fixation. Primary arthrodesis was associated with a significant decrease in complication rates (p = .025) when compared to ORIF. Females, arthrodesis, and procedures using a home run (HR) screw were independent risk factors for significantly higher reports of PROMIS pain interference. Arthrodesis also was associated with lower PROMIS pain interference scores. Arthrodesis and males exhibited higher scores in all FFI categories. Our results provide evidence that patient reported outcomes following Lisfranc surgery reported via PROMIS, FFI and VAS scores are independently influenced by patient demographics, comorbidities, and surgical variables. Analysis of potential associations between these patient characteristics and PROMIS and FFI scores provides evidence for physicians to manage patient expectations prior to operative treatment of a nonpolytraumatic Lisfranc injury.

Design and implementation of a training programme on ultrasound-guided lower limb peripheral nerve blockade: An Advanced Clinical Practitioner's personal journey

Increased demand in services, workforce pressures and continued financial constraints has resulted in a significant expansion in advanced clinical practice roles in the United Kingdom. This article will describe the personal experience of a perioperative Advanced Clinical Practitioner in the design and implementation of a training programme to achieve competence in ultrasound-guided lower limb peripheral nerve blockade. Three specific lower limb peripheral nerve blockade were included in the training programme, namely sciatic nerve block at the popliteal fossa, saphenous nerve block, and femoral nerve block. Key service drivers underpinning development, rationale for Advanced Clinical Practitioner involvement in lower limb peripheral nerve blockade and governance will also be discussed.

Distal subsartorial compartment block of the saphenous nerve - A dissection study and a patient case series

STUDY OBJECTIVE

A saphenous nerve block is an important tool for analgesia after foot and ankle surgery. The conventional midthigh approach to saphenous nerve block in the femoral triangle may impede ambulation by impairing quadriceps motor function.

PRIMARY OBJECTIVE

Developing a selective saphenous nerve block targeting the nerve distal to its emergence from the adductor canal in the subsartorial compartment.

DESIGN

This study consists of A) a dissection study and B) Data from a clinical case series.

SETTING

A) Medical University of Innsbruck, Austria (dissection of 15 cadaver sides) and. B) Aarhus University Hospital, Denmark (5 patients).

INTERVENTIONS

A) Five mL of methylene blue was injected into the subsartorial compartment distal to the intersection of the saphenous nerve and the tendon of the adductor magnus guided by ultrasound. B) Five patients undergoing major hindfoot and ankle surgery had a subsartorial compartment block with 10 mL of local anesthetic in addition to a popliteal sciatic nerve block.

MEASUREMENT

A) The frequencies of staining the saphenous and medial vastus nerves. B) Assessment of postoperative pain by NRS score (0-10) and success rate of saphenous nerve block by presence of cutaneous anesthesia in the anteromedial lower leg, and motor impairment by ability to ambulate.

MAIN RESULTS

A) The saphenous nerve was stained in 15/15 cadaver sides. A terminal branch of the medial vastus nerve was stained in 2/15 cadaver sides. B) All patients were fully able to ambulate without support. No patients had any post-surgical pain from the anteromedial aspect of the ankle and foot (NRS score 0). The success rate of saphenous nerve block was 100%.

CONCLUSION

The saphenous nerve can be targeted in the subsartorial compartment distal to the intersection of the nerve and the tendon of the adductor magnus. The subsartorial compartment block provided efficient analgesia without quadriceps motor impairment.

Pain relief after major ankle and hindfoot surgery with repetitive peripheral nerve blocks: A feasibility study

BACKGROUND

Major ankle and hindfoot surgery (e.g., ankle, triple and subtalar arthrodesis) typically causes severe postoperative pain, especially the first two postoperative days. Current modalities of postoperative analgesic treatment often include continuous peripheral nerve blocks of the saphenous and sciatic nerves via catheters in order to extend the duration of pain- and opioid-free nerve blockade to 48 h. Unfortunately, the 48 h-efficacy of continuous infusion via a catheter is reduced by a high displacement rate. We hypothesised that one-time repetition of the single injection peripheral nerve blocks would provide effective analgesia with a low opioid consumption the first 48 postoperative hours.

METHODS

Eleven subjects preoperatively received a popliteal sciatic and a saphenous single injection nerve block with a protracted local anaesthetic mixture. Surgery was performed under general anaesthesia. The one-time repetition of the single injection nerve block was carried out approximately 24 h after the primary nerve block. The main outcomes were pain and cumulative opioid consumption during the first 48 postoperative hours.

RESULTS

Nine of the 11 (82%) patients had effective analgesia without opioids during the first 48 postoperative hours. Two patients each required a single dose of 7.5 mg of oral morphine equivalents after 43 h.

CONCLUSION

One-time repetition of single injection saphenous and sciatic nerve blocks consistently provided effective analgesia practically without opioids for 48 h after major elective ankle and hindfoot surgery.

Wide-Awake Local Anesthetic No Tourniquet Surgery of the Foot and Ankle

Wide awake local anesthetic no tourniquet (WALANT) surgery of the foot and ankle has the potential to offer safe and effective surgeon-based anesthesia for a significant number of surgeries about the foot and ankle. This has been documented with significant and growing body of literature. WALANT could offer significant advantages with respect to patient experience, per case cost of procedures as well as for improving access for patients to operative resources in a setting of scarcity or restricted access.

Time and State Legislation Have Decreased Opioid Prescribing in Elective Foot and Ankle Surgery in the United States

BACKGROUND

Legislation in the United States has been enacted to reduce opioid overuse and abuse in the setting of the opioid epidemic, and a notable target has been opioid overprescription. However, the impact of this legislation on elective foot and ankle surgery is largely unknown. The purpose of this study was to evaluate the impact of opioid-limiting legislation on opioid prescribing in elective foot and ankle surgery.

METHODS

The 90-day perioperative opioid prescription filling in oxycodone 5-mg equivalents was identified in all patients 18 years of age and older undergoing nontrauma, nonarthroplasty foot and ankle surgery from 2010 to 2019 using a commercial database. States with and without legislation were identified, and opioid prescription filling before and after the legislation were tabulated. Unadjusted and adjusted analyses were performed to evaluate the impact of time and state legislation on perioperative opioid prescribing in this patient population.

RESULTS

Initial and cumulative opioid prescribing decreased significantly from 2010 to 2019 (39 vs 35.7 initial and 98.1 vs 55.7 cumulative). States with legislation had larger and more significant reductions in initial and cumulative opioid prescribing compared with states without legislation over similar time frames (41.6 to 35.1 with legislation vs 40.6 to 39.1 without legislation initial prescription filling volume and 87.7 to 62.8 vs 88.6 to 74.1 cumulative prescription filling volume).

CONCLUSION

State legislation and time have been associated with large, clinically relevant reductions in 90-day perioperative cumulative opioid prescription filling, although reductions in initial opioid prescription filing have remained low. These results encourage states without legislation to enact restraints to reduce the opioid epidemic.

LEVELS OF EVIDENCE

Level III: Retrospective, prognostic cohort study.

Modifiable factors associated with a consistently high acute pain trajectory after surgical treatment of traumatic fractures in Ethiopia: a multi-center prospective cohort study

BACKGROUND

In Ethiopia, little is known about postoperative pain trajectories and possible predictive factors associated with them in patients undergoing surgery following traumatic fractures.

METHODS

This multi-center prospective observational cohort study included surgical candidates for traumatic fractures (n = 218). Worst pain intensity was measured with an 11-point numeric rating scale on the first 4 postoperative days and day of hospital discharge. Growth mixture modeling was used to identify subgroups of patients based on their pain trajectories, and logistic regression models to quantify associations between pain trajectories and demographic, clinical, psychological, and life style factors.

RESULTS

Two postoperative pain trajectory subgroups were identified: rapid pain relief (48% of included individuals) and consistently high pain (52% of included individuals). Sub-analysis stratified by cause of injury demonstrated that higher preoperative pain was an independent risk factor for consistently high postoperative pain regardless of the patient's injury type: traffic accident (OR = 1.48, 95% CI 1.23-1.79), machine/tool injury or conflict (OR = 1.58, 95% CI 1.11-2.26), or fall (OR = 1.47, 95% CI 1.08-1.99). Moreover, longer surgical time was a risk factor for consistently high postoperative pain among patients who had a fall-related injury (OR = 1.02, 95% CI 1.00-1.03). In contrast, among patients with a traffic-related injury, receiving a nerve block was a protective factor (OR = 0.19, 95% CI 0.04-0.87) compared with general anesthesia.

CONCLUSION

Higher preoperative pain and longer surgical time were associated with a consistently high acute postoperative pain trajectory. Clinicians may use these potentially modifiable factors to identify patients at risk for consistently high pain during the early postoperative period.

Impact of Clinical Pharmacist Consultations on Postoperative Pain in Ambulatory Surgery

Post-operative pain is a common symptom of ambulatory surgery. The objective of this study was to evaluate a pain management protocol integrating a pharmacist consultation. We conducted a quasi-experimental, single center, before-after study. The control group was recruited between 1 March and 31 May 2018 and the intervention group between 1 March and 31 May 2019. Outpatients in the intervention group received a pharmacist consultation, in addition to the usual anesthesiologist and nurse consultations. Pharmacist consultations were conducted in two steps: the first step consisted of general open-ended questions and the second step of a specific and individualized pharmaceutical interview. A total of 125 outpatients were included in each group. There were 17% (95% CI 5 to 27%, p = 0.022) fewer patients with moderate to severe pain in the pharmaceutical intervention group compared with the control group, which corresponded to a decrease in the mean pain level of 0.9/10 (95% CI -1.5/10; -0.3/10; p = 0.002). The multivariate analysis did not reveal any confounding factors, showing that only the pharmaceutical intervention could explain this result. This study demonstrates a positive impact of pharmacist consultations on postoperative pain in ambulatory surgery.

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.

The effect of osteotomy technique (flat-cut vs wedge-cut Weil) on pain relief and complication incidence following surgical treatment for metatarsalgia in a private metropolitan clinic: protocol for a randomised controlled trial

Background

Weil osteotomies are performed to surgically treat metatarsalgia, by shortening the metatarsal via either a single distal oblique cut with translation of the metatarsal head (flat-cut) or through the removal of a slice of bone (wedge-cut). The wedge-cut technique purportedly has functional and mechanical advantages over the flat-cut procedure; however, in vivo data and quality of evidence are currently lacking. This study aims to investigate whether wedge-cut Weil osteotomy compared to traditional flat-cut Weil is associated with increased pain relief and fewer complications up to 12 months postoperatively.

Methods

Patient, surgical and clinical data will be collected for 80 consecutive consenting patients electing to undergo surgical treatment of propulsive metatarsalgia in a randomised control trial, embedded within a clinical registry. The primary outcome is patient-reported pain as assessed by the Foot and Ankle Outcome Score (FAOS) - Pain subscale, and the secondary outcome is the incidence of procedure-specific complications at up to 12 months postoperatively. The groups will be randomised using a central computer-based simple randomisation system, with a 1:1 allocation without blocking and allocation concealment. A mixed-effects analysis of covariance will be used to assess the primary outcome, with confounders factored into the model. A binary logistic regression will be used to assess the secondary outcome in a multivariable model containing the same confounders.

Discussion

To the best of the authors’ knowledge, the trial will be the first to examine the clinical efficacy of the wedge-cut Weil osteotomy compared to the flat-cut technique with a prospective, randomised control design.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12620001251910. Registered on 23 November 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06591-4.

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.

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

Pain after lower limb orthopedic surgery can be severe. Poorly controlled pain is associated with adverse outcomes. Peripheral nerve blocks (PNB) have become popular in foot and ankle surgery for their effective pain control and low complication rates. It has always been assumed that hindfoot procedures are more painful than midfoot/forefoot procedures often requiring inpatient stay for pain relief. There are no published studies evaluating this assumption. To investigate whether hindfoot procedures are more painful than forefoot/midfoot procedures by measuring pain scores, assessing effectiveness of PNBs and patient satisfaction. One hundred forty patients undergoing elective foot and ankle surgery were prospectively studied. Inclusion criteria: Adults undergoing elective foot and ankle surgery. Exclusion criteria: Patients 16 years or under, those with alternate sources of pain, peripheral neuropathy, known substance abuse, psychiatric illness and incomplete pain scores. Pain was measured via the Visual Analog Scale at 3 time intervals: immediately, 6 hours and at 24 hours postoperatively. Analysis was via t-test. A p value of <.05 demonstrated a statistical significance. Forefoot/midfoot versus hindfoot surgery pain scores showed that there was no significant difference at any postoperative interval. PNB versus no PNB pain scores showed there was no significant difference, except at 24 hours postoperatively (p value .024). Patients who had a PNB experienced rebound pain at 24 hours. Hindfoot surgery is not more painful than forefoot/midfoot surgery. Patients who had a PNB experienced rebound pain at 24 hours postoperatively, a finding that requires further research.

Prevalence of chronic pain syndrome in patients who have undergone hallux valgus percutaneous surgery: a comparison of sciatic-femoral and ankle regional ultrasound-guided nerve blocks

Background

Chronic pain syndrome (CPS) is a common complication after operative procedures, and only a few studies have focused on the evaluation of CPS in foot-forefoot surgery and specifically on HV percutaneous correction. The objective of this study was to compare postoperative pain levels and incidence of CPS in two groups of patients having undergone femoral-sciatic nerve block or ankle block regional anaesthesia before hallux valgus (HV) percutaneous surgery and the association between postoperative pain levels and risk factors between these patient groups.

Methods

A consecutive patient series was enrolled and evaluated prospectively at 7 days, 1, 3 and 6 months after surgery. The participants were divided into two groups according to the regional anaesthesia received, femoral-sciatic nerve block or ankle block, and their outcomes were compared. The parameters assessed were postoperative pain at rest and during movement by the numerical rating scale (NRS), patient satisfaction using the Visual Analogue Scale (VAS), quality of life and return to daily activities. Statistical analysis was performed.

Results

One hundred fifty-five patients were assessed, 127 females and 28 males. Pain at rest (p < 0.0001) and during movement (p < 0.0001) significantly decreased during the follow-ups; at 6 months, 13 patients suffered from CPS. Over time, satisfaction remained stable (p > 0.05), quality of life significantly increased and patients returned to daily activities and work (p < 0.0001). No significant impact of type of anaesthesia could be detected. ASA 3 (p = 0.043) was associated to higher pain during movement; BMI (p = 0.005) and lumbago (p = 0.004) to lower satisfaction. No operative-anaesthetic complications were recorded. Postoperative pain at rest and during movement improved over time independently of the regional block used, with low incidence of CPS at last follow-up. Among risk factors, only a higher ASA was associated to higher pain during movement, while higher BMI and lumbago to lower satisfaction.

Conclusions

Both ultrasound-guided sciatic-femoral and ankle blocks were safe and effective in reducing postoperative pain with low incidence of CPS at last follow-up.

Trial registration

Clinical Trial NCT02886221. Registered 1 September 2016.

Ultrasound-guided single popliteal sciatic nerve block is an effective postoperative analgesia strategy for calcaneal fracture: a randomized clinical trial

Objectives

The aim of this study was to evaluate the postoperative analgesia effect of ultrasound-guided single popliteal sciatic nerve block for calcaneal fracture.

Methods

A total of 120 patients scheduled for unilateral open reduction and internal fixation of calcaneal fracture were enrolled in this prospective randomized study. Patients in group B received ultrasound-guided single popliteal sciatic nerve block after operation, but Patients in group A did not. All patients received patient-controlled intravenous analgesia (PCIA) after operation. The time to initiation of PCIA, the time of first pressing the analgesia pump, duration of analgesia pump use and the total number of times the patient pressed the analgesia pump were recorded. The time of rescue analgesia and the adverse reactions were recorded. Pain magnitude of the patients immediately after discharge from operating room (T1), and at 4th (T2), 8th (T3), 12th (T4), 16th (T5), 24th (T6) and 48th (T7) h after the operation were assessed with visual analog scale (VAS). In addition, patient, surgeon and nurse satisfaction were recorded.

Results

The VAS scores at T2 ~ T5, the time of rescue analgesia and the adverse reactions, the total number of times the patient pressed the analgesia pump were significantly declined in group B (p < 0.001). The time to initiation of PCIA, the time of first pressing the analgesia pump, duration of analgesia pump use were prolonged and patient surgeon and nurse satisfaction were improved in group B (p < 0.05).

Conclusion

Ultrasound-guided single popliteal sciatic nerve block is an effective postoperative analgesia strategy for calcaneal fracture.

Trial registration

ChiCTR, ChiCTR2100042340. Registered 19 January 2021, URL of trial registry record: http://www.chictr.org.cn/showproj.aspx?proj=66526.

Complications Associated with Peripheral Nerve Blocks

Outpatient orthopedic surgery is gradually becoming the standard across the country, as it has been found to significantly lower costs without compromising patient care. Peripheral nerve blocks (PNBs) are largely what have made this transition possible by providing patients excellent pain control in the immediate postoperative period. However, with the increasing use of PNBs, it is important to recognize that they are not without complications. Although rare, these complications can cause patients a significant amount of morbidity. It is important for surgeons to know the risks of peripheral nerve blocks and to inform their patients.

Percutaneous Reduction and Hollow Screw Fixation Versus Open Reduction and Internal Fixation for Treating Displaced Intra-Articular Calcaneal Fractures

BACKGROUND We investigated the outcomes of displaced intra-articular calcaneal fractures (DIACFs) treated by percutaneous reduction and hollow screw fixation (PRHCF) versus open reduction and internal fixation (ORIF). MATERIAL AND METHODS Seventy-one patients were randomly allocated to group A (by PRHCF) and group B (by ORIF). Operative time, visual analogue scale (VAS) score, time from injury to operation, postoperative hospital stay, preoperative and postoperative radiographic measurements, and complications were recorded. Functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scores. RESULTS Finally, 59 patients were followed up for at least 12 months (range, 12-24 months). Group A showed significantly more advantages than group B in term of operative time, intraoperative blood loss, time to operation, postoperative hospital stay, and postoperative pain relief during the first 3 days (P<0.001). However, more intraoperative fluoroscopy was required in group A than in group B (P<0.001). The calcaneal width, height, length, Böhler angle, and Gissane angle in each group were significantly improved postoperatively (all P<0.001), although not significantly different in the postoperative comparisons between both groups. The AOFAS scores were slightly superior in group A than in group B (88.3 vs. 86.4, P=0.08). The rate of incidence of postoperative complications was lower in group A than in group B (3.2% vs. 10.8%, respectively; OR, 0.28, 95% CI, 0.03 to 2.84), although there was no significant difference (P=0.337). CONCLUSIONS PRHCF showed comparable clinical and radiological outcomes as ORIF, demonstrating it is a safe and effective alternative in treating DIACFs.

Effectiveness of hallux valgus surgery on patient quality of life: a systematic review and meta-analysis

Background and purpose - The quality of life (QoL) of patients with hallux valgus (HV) usually improves postoperatively. Evidence regarding the effect of HV surgery on different domains of patient QoL remains inconclusive. This systematic review and meta-analysis estimates the effect of HV surgery on patient QoL through distinguishing effects on physical domains (comprising physical function and body pain domains) using the EuroQol-5D, short form (SF) health survey-12, and SF-36 QoL scales and a visual analogue scale (VAS) score and mental and social domains using QoL scales.Patients and methods - MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were systematically searched from inception to March 2019 for studies on the effect of HV surgery on patient QoL. A standardized mean difference score was calculated for each specific QoL domain (mental, social, pain, physical, and VAS) using Cohen's d index. The pooled effect size (ES) was estimated using a random-effects model based on the DerSimonian and Laird method.Results - From 12 published studies selected, the estimated pooled ES for QoL was 1.01 (95% confidence interval [CI] 0.52-1.51; I² = 87%) for body pain and 0.43 (CI 0.31-0.55, I² = 35%) for physical function. Regarding the composite mental and social domains of QoL, the pooled ES estimates were 0.24 (CI 0.00-0.47, I² = 80%) and 0.42 (CI 0.21-0.63, I² = 6.4%), respectively. The pooled difference in means for the VAS score was -4.1 (CI -4.5 to -3.6, I² = 90%).Interpretation - Our data showed that HV surgery decreased patients' perceptions regarding pain. Furthermore, the data confirmed that HV surgery increased patients' QoL, particularly concerning physical and social domains.

Opioid Consumption and Time to Return to Work After Percutaneous Osteotomy in Foot Surgery

Surgeries involving the foot and ankle are painful procedures, with many patients unwilling to discontinue prescribed narcotics at 3 months postoperatively. Percutaneous techniques allow for smaller incisions and minimal soft tissue disruption. Fifty consecutive patients underwent outpatient percutaneous foot surgery. Data were collected on pain medication taken and time to return to work. A mean of 3.3 tablets of oxycodone were consumed during the first 2 weeks. No patient was taking narcotics after 2 weeks. Mean time to return to work was 18.9 days. Percutaneous foot and ankle surgery led to a significant reduction in narcotic consumption. [Orthopedics. 2020;43(4):e334-e337.].

Effect of Intraoperative Sedation with Dexmedetomidine Versus Propofol on Acute Postoperative Pain Following Major Foot Surgery under Popliteal Sciatic Nerve Block: A Randomized Controlled Trial

Intravenous (IV) dexmedetomidine is reported to prolong analgesia following peripheral nerve blocks. Popliteal sciatic nerve block provides effective postoperative analgesia, but some patients still experience severe pain during the early postoperative period. We aimed to evaluate the postoperative analgesic effects of IV dexmedetomidine versus propofol in patients undergoing foot surgeries under popliteal sciatic nerve block. Forty patients were enrolled and randomly assigned to receive either IV propofol (n = 20) or IV dexmedetomidine (n = 20) for intraoperative sedation. All the patients received continuous popliteal sciatic nerve block. The corresponding drug infusion rate was adjusted to achieve a modified observer’s assessment of alertness/sedation score of 3 or 4. The primary outcome was postoperative cumulative opioid consumption during the first 24 h after surgery. Thirty-nine patients were analyzed. The median (interquartile ranges) postoperative cumulative opioid consumption during the first 24 h after surgery was significantly lower in the dexmedetomidine group (15 (7.5–16.9) mg) than in the propofol group (17.5 (15–25) mg) (p = 0.019). The time to first rescue analgesic request was significantly greater in the dexmedetomidine group than in the propofol group (11.8 ± 2.2 h vs. 10.0 ± 2.7 h, p = 0.030) without the prolonged motor blockade (p = 0.321). Intraoperative sedation with dexmedetomidine reduced postoperative opioid consumption and prolonged analgesic duration after a popliteal sciatic nerve block.

The efficacy and safety of continuous versus single-injection popliteal sciatic nerve block in outpatient foot and ankle surgery: a systematic review and meta-analysis

Background

Continuous popliteal sciatic nerve block (CPSNB) has been performed in outpatient foot and ankle surgery as a regional anesthesia method to relieve postoperative pain. Its efficacy as well as safety is yet to be established. There are two purposes of this study: (1) to validate the efficacy of CPSNB with regards to better pain relief and reduced analgesics consumption; (2) to assess the safety of CPSNB.

Methods

We performed a comprehensive literature review on Web of Science, the Cochrane Library, PubMed and Embase and only included randomized controlled trials (RCTs). Five RCTs that compared the efficacy and safety of CPSNB with the single-injection popliteal sciatic nerve block group were included. The primary outcome parameters were visual analog scale (VAS) scores at postoperative 24, 48 and 72 h. The secondary outcome parameters were amount of oral analgesics consumed, overall patient satisfaction and need of admission after surgery. A sensitivity analysis was performed to explore the consistency of the results.

Results

In comparison with the single-injection group, CPSNB was associated with a lower VAS score at postoperative 24 and 48 h (p < 0.05). There were no neuropathic symptoms or infection events after the nerve block. However, there were several minor complications associated with the pump and catheter system, with drug leakage being the most common complication (N = 26 of 187, 13.9%).

Conclusion

CPSNB is an effective method in pain management for outpatient foot and ankle surgery. Both methods appear to be safe as none of the patients experienced neuropathic symptoms or infection. Further studies with larger sample size are needed to compare the risk of major complications between the two methods.

Level of evidence

I; meta-analysis.

Opioid Crisis and Acute Pain Management After Foot and Ankle Surgery

Opioid abuse has plagued the United States, with a resurgence since the early 2000s. Governmental agencies, pharmaceutical companies, patients, and physicians have all contributed to this crisis. Severe pain has been reported following foot and ankle surgery. There are current national guidelines for chronic opioid prescribing, but guidelines for acute pain have not been established. Prescribing fewer opioids, education on opioid risks, proper disposal of unused medication, and participating in prescription monitoring programs help reduce opioid abuse. Multimodal analgesia is paramount in managing pain while reducing opioid consumption after postoperative foot and ankle surgery.

Intermittent bolus versus continuous infusion popliteal sciatic nerve block following major foot and ankle surgery: a prospective randomized comparison

BACKGROUND AND OBJECTIVES

Foot and ankle surgery is associated with severe pain that can be reduced with continuous popliteal sciatic nerve block. We tested the hypothesis that programmed intermittent bolus (PIB) delivery of local anesthetic provides superior analgesia to a continuous infusion (CI) regimen.

METHODS

60 patients undergoing major foot and ankle surgery were randomized to receive PIB (10 mL of ropivacaine 0.2% every 2 hours) or CI (5 mL/hour) continuous popliteal sciatic nerve block with patient-controlled regional analgesia (5 mL every 30 min as needed) provided for all. Primary outcome was the average of static and dynamic numerical rating scale (NRS) pain scores through 48 hours. Secondary outcomes included rest and movement NRS pain scores at different timepoints, opioid consumption, local anesthetic consumption, intensity of sensory and motor block, patient satisfaction and the incidence of opioid-related side effects.

RESULTS

There was no significant difference in the primary outcome of average NRS pain score through 48 hours, opioid consumption or the volume of local anesthetic administered. Patients in group PIB had significantly decreased strength of toe dorsiflexion at 6 hours (p=0.007) and 12 hours (p=0.001) and toe plantarflexion at 12 hours (p=0.004). Patient satisfaction and the incidence of side effects was similar between groups.

CONCLUSIONS

Both CI and PIB regimens provided excellent analgesia, low opioid consumption and high patient satisfaction. While there was no difference in analgesic outcomes, PIB dosing resulted in a more profound motor block.

TRIAL REGISTRATION NUMBER

NCT02707874.

Peripheral nerve catheters: A critical review of the efficacy

Continuous peripheral nerve blocks are commonly used for postoperative analgesia after surgery. However, catheter failure may occur due to either primary (incorrect insertion) or secondary reasons (displacement, obstruction, disconnection). Catheter failure results in unanticipated pain, need for opioid use, and risk of readmission or delay in hospital discharge. This review aimed to assess definition and frequency of catheter failure, and discuss the alternatives to prolong duration of single-shot nerve blocks. A literature search was performed on peripheral catheters reporting failure as the main outcome measure. Thirty-three studies met the selection criteria, comprising 2711 catheters. Literature review suggests that peripheral nerve catheters have clinically significant failure rate when the assessment is performed using an objective (imaging) method. Subjective methods of assessment (without imaging) may underestimate the incidence of catheter failure.

Can Patients Forecast Their Postoperative Disability and Pain?

BACKGROUND

Forecasting is a construct in which experiences and beliefs inform a projection of future outcomes. Current efforts to predict postoperative patient-reported outcome measures such as risk-stratifying models, focus on studying patient, surgeon, or facility variables without considering the mindset of the patient. There is no evidence assessing the association of a patient's forecasted postoperative disability with realized postoperative disability. Patient-forecasted disability could potentially be used as a tool to predict postoperative disability.

QUESTIONS/PURPOSES

(1) Do patient-forecasted disability and pain correlate with patient-realized disability and pain after hand surgery? (2) What other factors are associated with patient ability to forecast disability and pain?

METHODS

We completed a prospective, longitudinal study to assess the association between forecasted and realized postoperative pain and disability as a predictive tool. One hundred eighteen patients of one hand/upper extremity surgeon were recruited from November 2016 to February 2018. Inclusion criteria for the study were patients undergoing hand or upper extremity surgery, older than 18 years of age, and English fluency and literacy. We enrolled 118 patients; 32 patients (27%) dropped out as a result of incomplete postoperative questionnaires. The total number of patients eligible was not tracked. Eighty-six patients completed the preoperative and postoperative questionnaires. Exclusion criteria included patients unable to give informed consent, children, patients with dementia, and nonEnglish speakers. Before surgery, patients completed a questionnaire that asked them to forecast their upper extremity disability (DASH [the shortened Disabilities of the Arm, Shoulder and Hand] [QuickDASH]) and pain VAS (pain from 0 to 10) for 2 weeks after their procedure. The questionnaire also queried the following psychologic factors as explanatory variables, in addition to other demographic and socioeconomic variables: the General Self Efficacy Scale, the Pain Catastrophizing Scale, and the Patient Health Questionnaire Depression Scale. At the 2-week followup appointment, patients completed the QuickDASH and pain VAS to assess their realized disability and pain scores. Bivariate analysis was used to test the association of forecasted and realized disability and pain reporting Pearson correlation coefficients. Unpaired t-tests were performed to test the association of demographic variables (for example, men vs women) and the association of forecasted and realized disability and pain levels. One-way analysis of variance was used for variables with multiple groups (for example, annual salary and ethnicity). All p values < 0.05 were considered statistically significant.

RESULTS

Forecasted postoperative disability was moderately correlated with realized postoperative disability (r = 0.59; p < 0.001). Forecasted pain was weakly correlated with realized postoperative pain (r = 0.28; p = 0.011). A total of 47% of patients (n = 40) were able to predict their disability score within the MCID of their realized disability score. Symptoms of depression also correlated with increased realized postoperative disability (r = 0.37; p < 0.001) and increased realized postoperative pain (r = 0.42; p < 0.001). Catastrophic thinking was correlated with increased realized postoperative pain (r = 0.31; p = 0.004). Patients with symptoms of depression realized greater pain postoperatively than what they forecasted preoperatively (r = -0.24; p = 0.028), but there was no association between symptoms of depression and patients' ability to forecast disability (r = 0.2; p = 0.058). Patient age was associated with a patient's ability to forecast disability (r = .27; p = 0.011). Catastrophic thinking, self-efficacy, and number of prior surgical procedures were not associated with a patient's ability to forecast their postoperative disability or pain.

CONCLUSIONS

Patients undergoing hand surgery can moderately forecast their postoperative disability. Surgeons can use forecasted disability to identify patients who may experience greater disability compared with benchmarks, for example, forecast and experience high QuickDASH scores after surgery, and inform preoperative discussions and interventions focused on expectation management, resilience, and mindset.

LEVEL OF EVIDENCE

Level III, prognostic study.

The Importance of the Saphenous Nerve Block for Analgesia Following Major Ankle Surgery: A Randomized, Controlled, Double-Blind Study

BACKGROUND AND OBJECTIVES

Major ankle surgery causes intense postoperative pain, and whereas the importance of a sciatic nerve block is well established, the clinical significance of a supplemental saphenous nerve block has never been determined in a prospective, randomized, double-blind, placebo-controlled trial. We hypothesized that a saphenous nerve block reduces the proportion of patients experiencing significant clinical pain after major ankle surgery.

METHODS

Eighteen patients were enrolled and received a popliteal sciatic nerve block. Patients were randomized to single-injection saphenous nerve block with 10 mL 0.5% bupivacaine with 1:200,000 epinephrine or 10 mL saline (Fig. 1). Primary outcome was the proportion of patients reporting significant clinical pain, defined as a score greater than 3 on the numerical rating scale. Secondary outcomes were maximal pain and analgesia of the cutaneous territory of the infrapatellar branch of the saphenous nerve.

RESULTS

Eight of 9 patients in the placebo group reported significant clinical pain versus 1 of 9 patients in the bupivacaine-epinephrine group (P = 0.003). Maximal pain was significantly lower in the active compared with the placebo group (median, 0 [0-0] vs 5 [4-6]; P = 0.001). Breakthrough pain from the saphenous territory began within 30 minutes after surgery in all cases. Sensory testing of the cutaneous territory of the infrapatellar branch of the saphenous nerve showed correlation between pain reported in the anteromedial ankle region and the intensity of cutaneous sensory block in the anteromedial knee region.

CONCLUSIONS

The saphenous nerve is an important contributor to postoperative pain after major ankle surgery, with significant clinical pain appearing within 30 minutes after surgery.

CLINICAL TRIALS REGISTRATION

This study has been registered at ClinicalTrials.gov, identifier NCT02697955.

Postoperative Pain After Surgical Treatment of Ankle Fractures: A Prospective Study

Background:

Postoperative pain after fixation of ankle fractures has a substantial effect on surgical outcome and patient satisfaction. Patients requiring large amounts of narcotics are at higher risk of long-term use of pain medications. Few prospective studies investigate patient pain experience in the management of ankle fractures.

Methods:

We prospectively evaluated the pain experience in 63 patients undergoing open reduction and internal fixation of ankle. The Short-Form McGill Pain Questionnaire was administered preoperatively and postoperatively (PP) at 3 days (3dPP) and 6 weeks (6wPP). Anticipated postoperative pain (APP) was recorded.

Results:

No significant differences were found between PP, APP, and 3dPP; however, 6wPP was markedly lower. Significant correlations were found between PP and APP and between preoperative and postoperative Short-Form McGill Pain Questionnaire scores. PP and APP were independent predictors of 3dPP; however, only APP was predictive of 6wPP. Sex, age, and inpatient versus outpatient status were not notable factors. No statistically significant differences were found in pain scores between fracture types.

Conclusions:

Both preoperative pain severity and anticipated postoperative pain are predictive of postoperative pain levels. Orthopaedic surgeons should place a greater focus on the postoperative management of patient pain and expectations after surgical procedures.

Optimizing Outpatient Total Ankle Replacement from Clinic to Pain Management

Outpatient total ankle arthroplasty is a potential significant source of cost savings. The ability to institute an effective outpatient total ankle program depends on appropriate patient selection, surgeon experience with total ankle replacement, addressing preoperative patient expectations, the involvement of an experienced multidisciplinary care team including experienced anesthesiologists, nurse navigators, recovery room nursing staff and physical therapists, and most importantly, such a program requires complete institutional logistical support.

Effect of Perineural Dexamethasone on the Duration of Single Injection Saphenous Nerve Block for Analgesia After Major Ankle Surgery: A Randomized, Controlled Study

BACKGROUND AND OBJECTIVES

Patients undergoing major elective ankle surgery often experience pain from the saphenous nerve territory persisting beyond the duration of a single-injection saphenous nerve block. We hypothesized that perineural dexamethasone as an adjuvant for the saphenous nerve block prolongs the duration of analgesia and postpones as well as reduces opioid-requiring pain.

METHODS

Forty patients were included in this prospective, randomized, controlled study. All patients received a continuous sciatic catheter and were randomized to receive a single-injection saphenous nerve block with 10 mL of 0.5% bupivacaine with 1:200,000 epinephrine with addition of 1 mL of saline or 1 mL of 0.4% (ie, 4 mg) dexamethasone. The primary outcome was duration of saphenous nerve block estimated as the time until the first opioid request. Secondary outcomes were opioid consumption and pain.

RESULTS

The mean (SD) duration of the saphenous nerve block until first opioid request was 29.4 (8.4) hours in the dexamethasone group and 23.2 (10.3) hours in the control group (P = 0.048). The median opioid consumption [interquartile range] during the first 24 hours was 0 mg [0-0] versus 1.5 mg [0-14.2] in the dexamethasone and control groups, respectively. Nonparametric comparison of opioid consumption from 0 to 24 hours was statistically significant. The opioid consumption was similar in the two groups in the time interval 24 to 48 postoperative hours.

CONCLUSION

Perineural dexamethasone as an adjuvant for the single-injection subsartorial saphenous nerve block can prolong analgesia and reduce opioid-requiring pain after major ankle surgery.

SPECT/CT in Postoperative Foot and Ankle Pain

Postoperative pain is a clinically relevant issue in orthopedic patients, affecting more than 40% 1 year after foot and ankle surgery. Because of the very complex anatomy with many different joints and several motion axes, clinical examination and conventional imaging are sometimes not sufficient to identify a local pain generator. Local uptake of bone-seeking radiopharmaceuticals is known to correlate accurately with sites of pain generating foci and, thus, bone scintigraphy has been an established method to evaluate these respective patients for many years. However, the specificity is rather low if only planar images are acquired. The development of SPECT and especially of hybrid SPECT and CT imaging has significantly enhanced the specificity of this technique. The combination of both functional and morphological imaging, ideally performed with a dedicated SPECT/CT system to minimize misregistration owing to motion artifacts and to enhance image quality by attenuation correction, allows an early and reliable detection of pathologic bone processes, even in patients where radiological imaging with MRI or CT is hampered by metal implants. In diabetic patients with a neuropathic Charcot osteoarthropathy, infection can be differentiated from inflammatory bone alterations (causing bone marrow edema) almost certainly using SPECT/CT with radiolabeled white blood cells and antigranulocyte antibodies, allowing an individual and precise treatment planning either in the initial course of the disease or even after surgery. This article reviews the most frequent clinical challenges in patients after foot and ankle surgery, including a description of the various surgical procedures, the different imaging options with their advantages and disadvantages, and aims to integrate bone SPECT/CT into the clinical diagnostic workup.

The effect of perineural dexamethasone on duration of sciatic nerve blockade: a randomized, double-blind study

BACKGROUND

Major hindfoot and ankle surgery is associated with severe postoperative pain, which is effectively alleviated by combined sciatic and saphenous nerve blockade. Local anaesthetics with added dexamethasone consistently prolongs the duration of pain relief compared to local anaesthetics alone. However, whether the extended duration of pain relief is due to an effect on duration of sensorimotor block per se vs. systemic absorption of the dexamethasone is still not fully elucidated. We aimed to investigate the postoperative duration of sensorimotor blockade with either dexamethasone or saline added to bupivacaine-epinephrine.

METHODS

Fifty six patients scheduled for surgery were randomly assigned to a popliteal sciatic nerve block of 18 ml 0.5% bupivacaine-epinephrine with either 2 ml of 0.4% dexamethasone or 2 ml 0.9% normal saline added. Sensory and motor functions were tested every 30 min until normalized nerve functions. Primary outcome was time until complete return of sensorimotor functions.

RESULTS

Mean (SD) time until return of normal sensory and motor functions was 26 (6) vs. 16 (4) hours, P < 0.001, postponing block remission by 10 (95% CI: 8-13) hours. Mean (SD) time until first opioid request was 34 (11) vs. 15 (7) hours, P < 0.001, extending first opioid request by 19 (95% CI: 13-25) hours. Total oral morphine equivalents administered 0-48 h differed significantly between the two groups by 39 (95% CI: 23-55) mg.

CONCLUSIONS

Addition of 8 mg dexamethasone to 0.5% bupivacaine-epinephrine significantly prolongs the duration of sensorimotor popliteal sciatic nerve blockade, and reduces pain and opioid consumption in patients after major hind foot and ankle surgery.

Evaluation of a novel biodegradable thermosensitive keto-hydrogel for improving postoperative pain in a rat model

This study evaluates the sustained analgesic effect of ketorolac-eluting thermosensitive biodegradable hydrogel in the plantar incisional pain model of the rat hind-paw. A ketorolac-embedded 2, 2'-Bis (2-oxazolin) (BOX) linking methoxy-poly(ethylene glycol) and poly(lactide-co-glycolide) (mPEG-PLGA) diblock copolymer (BOX copolymer) was synthesized as keto-hydrogel based on optimal sol-gel phase transition and in vitro drug release profile. The effect of keto-hydrogel on postoperative pain (POP) was assessed using the established plantar incisional pain model in hind-paw of rats and compared to that of ketorolac solution. Pain and sensory threshold, as well as pain scoring, were evaluated with behavioral tests by means of anesthesiometer and incapacitance apparatus, respectively. Pro-inflammatory cytokine levels (TNF-α, IL-6, VEGF, and IL-1β) around incisional wounds were measured by ELISA. Tissue histology was assessed using hematoxylin and eosin and Masson’s trichrome staining. Ten mg/mL (25 wt%) keto-hydrogel showed a sol-gel transition at 26.4°C with a 10-day sustained drug release profile in vitro. Compared to ketorolac solution group, the concentration of ketorolac in tissue fluid was higher in the keto-hydrogel group during the first 18 h of application. Keto-hydrogel elevated pain and sensory threshold, increased weight-bearing capacity, and significantly reduced the levels of TNF-α, IL-6, and IL-1β while enhanced VEGF in tissue fluid. Histologic analysis reveals greater epithelialization and collagen deposition around wound treated with keto-hydrogel. In conclusion, our study suggests that keto-hydrogel is an ideal compound to treat POP with a secondary gain of improved incisional wound healing.

Pain Resolution After Hallux Valgus Surgery

BACKGROUND

Although more than 1500 publications on hallux valgus can be found in the current literature, none of them have reported on the course of pain resolution after hallux valgus surgery. Thus, this study aimed to investigate pain resolution after hallux valgus surgery and to identify predictive factors associated with residual pain at 6 months after surgery.

METHODS

We prospectively followed up 308 patients who underwent hallux valgus surgery at a tertiary hospital at 6 months and 2 years after surgery. Multivariate logistic regression analysis was performed to evaluate the risk factors associated with residual pain after surgery.

RESULTS

Ninety-four patients (31%) had some degree of residual pain at 6 months after surgery. After excluding 4 patients who developed osteoarthritis of the first metatarsophalangeal joint over the next 18 months, 73 of the remaining 90 (81%) experienced improvement in visual analog scale (VAS) by the 2-years follow-up. Their median VAS improved from 4 (interquartile range [IQR] 3, 5) at 6 months to 0 (IQR 0, 3) at 2 years (P < .001). A higher preoperative VAS increased the risk of having persistent pain at 6 months after sugery (odds ratio [OR] 1.388, 95% confidence interval [CI] 1.092, 1.764, P = .007), whereas a higher preoperative Mental Component Score of SF-36 (MCS) reduced this risk (OR 0.952, 95% CI 0.919, 0.987, P = .007).

CONCLUSIONS

As much as 31% of patients will have residual pain at 6 months after surgery. Preoperative VAS and MCS are predictors for residual pain. However, these patients will continue to improve over the next 18 months, with 71% of them being pain free at 2 years after surgery.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Role of regional anesthesia in foot and ankle surgery

Regional anesthesia has increasingly expanded its role in the perioperative care of patients undergoing foot and ankle surgery. In addition to avoiding side effects associated with both general anesthesia and neuraxial anesthetic techniques, especially those related to cardiovascular and pulmonary systems, regional nerve blocks have been shown to improve postoperative pain and reduce hospital stay and associated expenses. The techniques utilized to achieve analgesia of the foot and ankle are diverse, multifaceted, and often incorporate ultrasound guidance. Given the aging of patient populations, and especially the growing incidence of cardiovascular-, pulmonary-, and obesity-related morbidity, the use of regional blocks is likely to expand in these surgical procedures. This review highlights some of the most current developments in the expanding role of regional anesthesia in foot and ankle surgery.

LEVELS OF EVIDENCE

Therapeutic, Level II.

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.

The benefits of implant removal from the foot and ankle

BACKGROUND

Following successful orthopaedic surgical procedures, implant removal is generally not necessary or recommended. However, patients with pain related to implants may benefit from this elective procedure. The foot and ankle may be more symptomatic from retained implants because of weight-bearing activities, shoe wear, and limited soft-tissue cushioning. In such cases, implant removal may provide good and reliable relief of symptoms.

METHODS

A prospective study of sixty-nine patients who underwent elective removal of symptomatic implants from the foot and ankle was undertaken to evaluate the patients' pain experience. The short-form McGill pain questionnaire was administered preoperatively and six weeks postoperatively. Postoperatively, patients were also asked whether they would repeat the procedure and whether they were satisfied with the results.

RESULTS

Patients reported significantly less pain following the procedure, with the average rating of pain on the visual analog scale (VAS) decreasing from 3.06 to 0.88 and the average rating of present pain intensity decreasing from 2.03 to 0.58 (p < 0.05 for both). Sixty-five percent of the patients reported no pain on either measure at six weeks postoperatively. Preoperative pain was correlated with postoperative pain (r = 0.24 and p < 0.05 for VAS, and r = 0.16 and p > 0.05 for present pain intensity).With the small sample size, preoperative and postoperative pain did not show a significant difference on the basis of implant location or patient age or sex. Ninety-four percent of patients said they would repeat the procedure under the same circumstances, and 91% of patients were satisfied with the results.

CONCLUSIONS

Following successful orthopaedic surgical procedures, removal of implants causing symptoms can result in pain relief and a high rate of patient satisfaction.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Continuous popliteal block for postoperative analgesia in total ankle arthroplasty

BACKGROUND

Total ankle arthroplasty is associated with severe postoperative pain. Development of analgesic techniques such as a block with continuous infusion at the popliteal level has been shown to result in good pain control, a decrease in the use of rescue analgesia and a low rate of complications. We reviewed our experience with this method of analgesia in patients who underwent total ankle arthroplasty.

METHODS

A prospective study of 30 patients undergoing total ankle arthroplasty was carried out. Twenty-two of these received and maintained a block at the popliteal level with a continuous infusion of bupivacaine, while the remaining eight received no such block.

RESULTS

The visual analog scale evaluation (VAS) showed a significant improvement in pain control in the group with the popliteal block after 6, 12, 18, and 24 hours postsurgery, with pain levels peaking and being most different between 6 and 12 hours postsurgery for the two groups. The group with the popliteal block also exhibited a significantly lower consumption of morphine and a greater degree of patient satisfaction.

CONCLUSION

The block with continuous infusion at the popliteal fossa was a safe technique for total ankle arthroplasty postoperative analgesia, which provided good pain control, a lower requirement of opiates and a higher level of patient satisfaction.

[Evaluation of the impact of prescription analgesic during the anaesthesia consultation on the incidence of postoperative pain at home in ambulatory orthopaedic surgery]

INTRODUCTION

Postoperative pain at home in ambulatory surgery is a major problem. To improve its management, the French society of anaesthesia emphasizes the importance of writing prescriptions for analgesic during the preanaesthetic consultation. The objective of this study was to assess the impact of this prescription on the incidence of postoperative pain at home in ambulatory orthopaedic surgery.

PATIENT AND METHODS

We conducted a prospective evaluation in the ambulatory surgery unit of Rouen University Hospital. We were able to identify two periods of 1 year with implementation of a systematic prescription of analgesics during the postoperative period (P1) or during the preanaesthetic consultation (P2). The evaluation of this measurement was made by a telephone survey conducted the day after surgery. The main parameter was the incidence of postoperative pain at home defined by the occurrence of a pain greater to 3/10 on a numerical scale (FR). Secondary parameters were demographic and anaesthetic data, the incidence of moderate pain (FR ≤ 3), treatment adherence and patient satisfaction.

RESULTS

We included 638 patients and 531 were analysed: 28% of patients had an EN greater than 3 the day following surgery. There is no difference between the two periods (30% for P1 versus 27% for P2). The analysis of subgroups showed that in the general anaesthesia group, 30% of patients had an EN greater than 3 for P1 versus 18% for P2 (P<0.01). Furthermore, 55% of patients expressed moderate pain (FR ≤ 3) for P1 versus 22% for P2 (P<0.01). Moreover, 89% of patients reported having an adequate analgesic treatment. The overall observance was 64%, 53% for P1 versus 75% for P2 (P<0.01).

DISCUSSION

The systematic prescription of analgesics during the preanaesthetic consultation does not decrease the intensity of moderate to severe pain. On the other hand, this procedure seems to be positive for the people who underwent a general anaesthesia.

Acute postoperative pain at rest after hip and knee arthroplasty: severity, sensory qualities and impact on sleep

INTRODUCTION

The management of acute postoperative pain poses a significant challenge in surgical specialities. Despite the prevalence and impact of acute postoperative pain, there is a paucity of published data regarding its occurrence and sensory qualities after joint replacement.

HYPOTHESIS

That a proportion of patients would experience severe acute postoperative pain at rest after total hip replacement (THR) and total knee replacement (TKR).

MATERIALS AND METHODS

Pain was assessed preoperatively, and then five times daily for the first three postoperative days in 105 THR and TKR patients. Pain severity was assessed using a pain Visual Analogue Scale and the sensory qualities of pain were assessed using the pain descriptors from the Short-Form McGill Pain Questionnaire.

RESULTS

Median acute pain scores peaked on the first postoperative day, with 58% of TKR patients and 47% of THR patients reporting moderate-severe pain. Preoperative pain was most frequently described as aching, stabbing and sharp, whereas acute postoperative pain was described as aching, heavy and tender. Night pain disturbed between 44-57% of TKR patients and 21-52% of THR patients on postoperative nights 1-3.

DISCUSSION

These findings demonstrate that acute postoperative pain at rest after joint replacement, particularly TKR, is poorly managed, although it does not reach the severity of preoperative pain.

LEVEL OF EVIDENCE

Level IV (observational cohort study).

Practical aspects of postoperative analgesia

The article summarizes the experience of the use of narcotic, non-narcotic and adjuvant drugs for postoperative analgesia. Most basic algorithms of postoperative pain relief available in a hospital are considered in complex post-operative intensive care in surgical clinic. Application of the recommended scheme is likely to prevent nosocomial narcotism in patients with prolonged pain.