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.

Preoperative ankle block for postoperative analgesia in foot surgery

BACKGROUND

The use of a tourniquet and patients' preference for general anesthesia (GA) limit performing ankle blocks (AB) as a sole anesthetic technique for orthopedic foot surgery. The aim of this prospective and randomized study was to test the hypothesis that administration of an AB before GA could be effective for postoperative pain relief in patients undergoing outpatient hallux valgus surgery. Primary outcome measure was mean pain score and secondary outcome measures were time to mobilization of patients, time to hospital discharge, and complications.

METHODS

A total of 110 adult patients were randomly assigned into two groups: group GA (n = 55) and group GA + AB (n = 55). Group GA + AB received an AB using 100 mg lidocaine 2% and 75 mg bupivacaine 0.5% before the induction of GA. Pain intensity was evaluated using a visual analogue scale (VAS).

RESULTS

Mean VAS scores were higher and times to first rescue analgesic were shorter in group GA compared to group GA + AB (p = 0.001). More patients required rescue analgesic in group GA and pethidine consumption was higher (p = 0.001). Time to mobilization was shorter in GA + AB group (p = 0.001) but hospital discharge time was similar between groups (p = 0.269). The incidence of nausea and vomiting was higher in group GA (p = 0.002).

CONCLUSION

Ankle block is an effective and simple technique for reducing postoperative pain and opioid consumption. It reduced the time to mobilization without a delay in hospital discharge. It is concluded that the routine administration of AB before GA may be an effective and simple method for pain relief after foot surgery.

Is regional ankle block needed in conjunction with general anaesthesia for first ray surgery? A randomised controlled trial of ultrasound guided ankle block versus "blind" local infiltration

BACKGROUND

Regional anaesthesia is commonly utilised for foot and ankle surgery. Debate remains at to the level of regional anaesthesia that is required. The objective of this study was to evaluate whether surgeon-delivered "blind" local anaesthetic infiltration around the first ray (metatarsal block without ultrasound guidance) was as effective as an ultrasound guided ankle block in providing post-operative analgesia after osseous first ray surgery performed under general anaesthetic.

METHODS

50 patients were recruited to a single surgeon and anaesthetist double-blinded randomised controlled trial at a single-centre. 20mls of 0.5% levobupivacaine was used to perform either an ankle or metatarsal nerve block.

RESULTS

Forty-eight patients completed the study: 25 in the ankle block treatment arm and 23 in the metatarsal block arm. The demographics were comparable between groups. There was no statistical difference in visual analogue pain scores at two (21.3 vs 15.2), six (23.6 vs 20.8) and 24 (42.2 vs 50.4) hours following the procedure between the two groups (metatarsal block vs ankle block). Metatarsal block groups had a faster return of normal sensation (2.3 vs 2.8h) but there was no difference in time to safe mobilisation (2.6 vs 2.8h).

CONCLUSION

This study demonstrates the efficacy and safety of surgeon delivered "blind" metatarsal block is comparable to an ultrasound guided ankle block for first ray surgery performed under general anaesthetic.

LEVEL OF EVIDENCE

1.

The Effect of Preemptive Ankle Block using Ropivacaine and Dexamethasone on Postoperative Analgesia in Foot Surgery

BACKGROUND

Peripheral nerve blocks have become an increasingly popular form of anesthesia. Preemptive analgesia reduces central sensitization, postoperative pain, and analgesic consumption. Different additive has been used to prolong regional blockade and improve postoperative analgesia.

AIM

This study was conducted to evaluate whether preemptive ankle block using combination of ropivacaine and dexamethasone would succeed in improving the postoperative analgesia after foot surgery in patients receiving general anesthesia.

STUDY DESIGN

Randomized double-blind clinical trial.

PATIENTS AND METHODS

The study was done on forty American Society of Anesthesiologists physical Status I and II, patients undergoing elective forefoot and midfoot surgery under general anesthesia after written informed consent and Ethical Committee approval, general anesthesia was induced as usual, the patients were breathing spontaneously, laryngeal mask airway was inserted, and anesthesia was maintained using inhalational anesthetic. Ankle block was performed before surgery using 20 ml containing 18 ml ropivacaine 0.75% and 2 ml containing 8 mg dexamethasone in Group I and 20 ml containing 18 ropivacaine 0.75% plus 2 ml normal saline in Group II. Evaluation of ankle block was performed by testing the motor response to electric nerve stimulation of both the posterior tibial nerve and the deep peroneal nerve. The absence of any motor responses indicated success of the block. Surgery was started in 30 min after the block. After recovery from anesthesia, the following was measured, visual analog score at 1, 4, 6, 12, and 24 h, the time to the first rescue analgesic, the analgesic requirements, and any side effects.

STATISTICAL ANALYSIS

Data were presented as means (standard deviation). Mann-Whitney U-test were used for continuous data. Student's t-test was used for normal distributed data.

RESULTS

Patients were similar as regard to demographic data, type, and duration of surgery. Pain intensity was significantly lower in dexamethasone group (P < 0.05). Time to first rescue analgesic was prolonged in dexamethasone group (110 ± 3.3 min vs. 66 ± 7.9 min; P = 0.001) The analgesic consumption was significantly lower in dexamethasone group. The complication was minor and self-controlled in both groups.

CONCLUSION

The addition of dexamethasone to ropivacaine improved preemptive ankle block analgesia by decreasing postoperative pain intensity and analgesic consumption with minimal postoperative complication.

Use of peripheral blocks and tourniquets in foot surgery: A survey of Australian orthopaedic foot and ankle surgeons

BACKGROUND

The most common reasons for unplanned admission to the hospital from outpatient surgery have the potential to be minimised or eliminated by peripheral nerve blocks (PNB). Tourniquets are commonly used in elective extremity surgery but it's use is mostly guided by personal preferences and does no correlate with the existing literature. Our aim was to explore the current practice of PNB and tourniquet use by foot and ankle surgeons in Australia.

METHODS

The Australian Orthopaedic Foot and Ankle Surgery Society (AOFAS) annual meeting was held in Adelaide in 2011. Members were asked to complete an electronic survey on their current use of peripheral nerve blocks and tourniquets. Two specific elective case scenarios were included for comment, one pertaining to forefoot pathology, the other hindfoot pathology.

RESULTS

Twenty-three AOFAS members replied to the survey, an overall response rate of 76.6%. Of these, only two surgeons did not use ankle blocks in elective surgery and none were prepared to operate without a tourniquet. Most Australian foot and ankle surgeons were reluctant to use local anaesthetic techniques without an accompanying GA.

CONCLUSIONS

While the literature suggests that GA may add to complications without any benefit for the procedure and that distally based tourniquets may add benefit, these are not the favoured techniques in Australian foot and ankle surgeons.

The effect of posterior tibial and sural nerve blocks on postoperative pain of patients following open reduction and internal fixation of calcaneal fractures

INTRODUCTION

Postoperative pain control and achieving opioid-free anesthesia are major issues for surgically treated patients with calcaneal fractures. We evaluated the potential role of posterior tibial and sural nerve blocks as a part of multimodal pain control techniques in patients underwent open reduction and internal fixation (ORIF) of calcaneal fractures via extensile lateral approach.

METHODS

Forty-eight patients randomly allocated to receive either posterior tibial and sural nerve blocks with bupivacaine (peripheral nerve block (PNB) group) or normal saline, after induction of general anesthesia. Patients were assessed for pain intensity, Interval from entrance to the recovery room to the first request for analgesic, recovery room and ward morphine consumption, global satisfaction and morphine side effects.

RESULTS

PNB group had less pain score compared to sham block (SB) group at each time point measurement during recovery room stay. There was also significant difference between the 2 groups regarding the pain scores after 2, 4 and 6 h of the operation in the ward. Time to the first request for analgesic was significantly prolonged in the PNB group (P < 0.001). The recovery room and ward morphine consumption was significantly lower in the PNB group (P < 0.001). Global satisfaction in PNB group was significantly more than that of SB group. No complication related to the nerve block was detected at the first postoperative visit in the outpatient clinic.

CONCLUSION

Peripheral nerve block could result in less postoperative pain especially in the early hours after ORIF of calcaneal fractures and reduce opioid administration within the first 24 h following the surgery.

A comparison of ankle block and spinal anesthesia for foot surgery

Regional anesthesia methods in the lower extremity include central blocks where spinal and epidural anesthesia are performed as well as peripheral nerve blocks, which are performed by injecting anesthetics locally to nerves. The study aimed to provide a retrospective comparison of unilateral spinal block and ankle block methods in foot operations. Some 60 ASA I-III patients who underwent operation under regional anesthesia were retrospectively examined. Two groups, known as the Unilateral Spinal Block Group (Group S) (n=30) and the Ankle Block Group (Group A) (n=30), were designed. Average blood pressure (ABP), heart rate (HR), block formation time (BFT), time for being ready for operation (TBRFO), total operation duration (TOD), visual analogue scale (VAS), first analgesic need time (FANT) and any complications were all recorded. The BFTs were longer in Group A than Group S, while the FANTs were longer in Group A postoperatively. When these decreases in Group A and Group S were compared with the basal values before the block, all decreases in Group S following the block were considered statistically significant (P<0.05), while the decreases in Group A in the 5(th) and 15(th) minutes were not considered statistically significant. The VASs measured postoperatively at the 6(th), 12(th) and 24(th) hours of Group A were lower than those of Group S (P≤0.05). Despite the longer block formation, the ankle block is safer when compared to the spinal anesthesia, which involves risky hemodynamic changes in patients with associated diseases.

Anesthesia for the Patient Undergoing Foot and Ankle Surgery

Modern anesthetic management for foot and ankle surgery includes a variety of anesthesia techniques including general anesthesia, neuraxial anesthesia, or MAC in combination with peripheral nerve blocks and/or multimodal analgesic agents. The choice of techniques should be tailored to the nature of the procedure, patient comorbidities, anesthesiologist skill level, intensity of anticipated postoperative pain, and surgeon preference.

"High ankle block" for surgery at the ankle joint

BACKGROUND

Surgery around the ankle is increasingly embedded in outpatient treatment concepts. Unfortunately, the classic "ankle block" as a concept of regional anesthesia is inappropriate for surgery around the ankle because the injection sites are too distal to block this specific region.

METHODS

The "high ankle block" avoids this disadvantage by dislocating the injection points 15 cm proximal to the malleoli. Three of five peripheral nerves necessary to perform the block can be reached by a circumferential subcutaneous wall. The Posterior Tibial Nerve and the Deep Peroneal Nerve are addressed by an ultrasound guided approach.

RESULTS

The efficacy of the technique is highlighted by a case series (3 cases) in which the new blockade was used as a stand-alone procedure, i.e. without additional general anesthesia.

CONCLUSIONS

The "high ankle block" may serve as an ultrasound guided expansion to the classic techniques, extending the operative spectrum to the ankle region.

Anesthesia for the Patient Undergoing Foot and Ankle Surgery

Modern anesthetic management for foot and ankle surgery includes a variety of anesthesia techniques including general anesthesia, neuraxial anesthesia, or MAC in combination with peripheral nerve blocks and/or multimodal analgesic agents. The choice of techniques should be tailored to the nature of the procedure, patient comorbidities, anesthesiologist skill level, intensity of anticipated postoperative pain, and surgeon preference.