SLR - May 2013 - Kerianne Spiess
Reference: Goldstein RY, Montero N, Jain SK, Egol KA and Tejwani NC. Journal of Orthopedic Trauma, November 2012 Volume 26 pgs 557-561
Scientific Literature Reviews
Reviewer: Kerianne Spiess, DPM
Residency Program: Temple University Hospital
Podiatric Relevance: This study attempts to clarify whether intraoperative popliteal nerve block for ankle ORIF provides adequate pain control when compared to general anesthesia alone.
Methods: Fifty-one patients undergoing open reduction internal fixation for ankle fracture repair at the NYU Medical Center or the Hospital for Joint Diseases were randomized into two groups: those with and those without popliteal block. The study was not blinded. Patients in Group 2 received a popliteal block from a prone position after sedation, utilizing 30cc of 0.25 percent bupivacaine with 1:200,000 solution of epinephrine. Saphenous nerve block was done at the discretion of the anesthesiologist in Group 2, only if a medial malleolar fracture was present. All patients received general anesthesia via laryngeal mask airway or endotracheal tube.
Perioperatively, patients were assessed for allergic reactions, procedure length, tourniquet time, incision placement and time to incision.
Postoperatively, pain measurements were assessed at two, four, eight, 12, 24 and 48 hrs. Patients were either admitted or discharged at the discretion of the surgical team/hospital protocol. Patients that were discharged received narcotic pain medication prescriptions to take as needed, and were contacted via telephone for pain scores on a scale of 0-10. Admitted patients received oral or intravenous narcotic pain control, and were assessed using a visual analog scale.
Results: Of 51 patients eligible for the study, 25 received popliteal block and 26 did not. There were no statistical differences in the makeup of the two groups, including the type of ankle fracture and number of days to surgery. Additionally, there was no statistical difference in the ASA classification of the two groups.
A statistical significance was found in the time to incision, with the popliteal block group averaging 52.4 +/- 12.5 minutes and the control group averaging 42.2 +/- 8.9 minutes (P=0.001). At two, four and eight hours postoperatively, the popliteal block group had significantly better pain scores compared to the control ( P= 0.012, 0.001, 0.009). At 12 hours, the groups showed no difference in pain scores. At 24 hours, patients without regional block had better pain control (P=0.028), but at 48 hours the groups again showed no significant difference. Popliteal block patients were more apt to having an increase in pain from hours eight to 24, but had a shorter hospital stay following surgery, with discharge at 16.9 +/- 13 hours. The control group was more likely to have a decrease in pain from hours eight to 24 and have a longer average hospital stay (27.8hours +/- 22.7 hours). All patients were followed-up for a minimum of three months or until radiographic fracture union. No infections or neurological deficits were noted in either of the groups.
Conclusions: This study prospectively compared immediate postoperative pain in ankle fracture open reduction internal fixation cases using popliteal nerve block. When compared to the control group (general anesthesia alone) the popliteal block group had increased postoperative pain control for up to eight hours, which is similar to previous data. However this study highlights that in hours eight to 24 post-op, the popliteal block group experienced a “rebounding” increase in their pain levels when compared to the general anesthesia group. The authors propose that this finding of rebound pain may be minimized with the use of oral narcotics, starting one to two hours prior to the expected end of regional block duration. The study is limited in the fact that there was no standardization in the postoperative adjuvant pain medications, which included Morphine, Dilaudid or fentanyl via Patient Control Anesthesia (PCA), oral narcotics including Vicodin 5/500mg, Norco 5/325 mg or Dilaudid.