SLR - October 2012 - Noah G. Oliver
Reference: Goldstein RY, Montero N, Jain S, Egol KA, Tejwani NC. Journal of Orthopaedic Trauma. Publish Ahead of Print.
Scientific Literature Review
Reviewed by: Noah G Oliver, DPM
Residency Program: Inova Fairfax Hospital, Falls Church, VA
Podiatric Relevance:
Postoperative pain management after ankle fracture fixation is a significant concern for both the patient and the surgeon. Postoperative pain is often managed with narcotics that can cause untoward side effects and possibly lengthen hospitalization. The addition of regional anesthesia in the form of a popliteal block at the time of surgery should be considered for improved postoperative pain control, decrease narcotic use and shorter hospital stay.
Methods:
This study design consisted of a prospective, randomized study including all patients treated with open reduction internal fixation for ankle fractures who met inclusion criteria and consented to participation. All operations were performed in a delayed fashion. Consenting patients were randomized into one of the following anesthesia protocols: general anesthesia without regional anesthesia or general anesthesia with a popliteal block. The popliteal block was performed under ultrasound visualization using 30cc of 0.25 percent bupivacaine with a 1:200,000 solution of epinephrine. Patients and staff were not blinded. Patients were followed for at least three months. Postoperatively, patients were either admitted to the hospital or discharged to home with a prescription for narcotics. Pain was assessed at two, four, eight, 12, 24 and 48 hours postoperatively using visual analogue scale while in hospital. Discharged patients rated pain on scale of zero to 10 via telephone.
Results:
Fifty-one of 55 consecutive patients with operatively treated ankle fracture were enrolled the study. Twenty-five patients were randomized to receive popliteal block while 26 patients received general anesthesia only. At two, four and eight hours postoperatively, patients in the popliteal block group had significantly better pain scores compared to the general anesthesia only group. At twelve and 48 hours, there was no significant difference between the two groups. However, at 24 hours, patients who had not received a popliteal block had significantly better pain control. Patients who received a popliteal block had a shorter hospital stay after surgery. There were no anesthesia related complications.
Conclusion:
The use of popliteal blocks in foot and ankle surgery can provide effective pain control postoperatively. Patients who received popliteal blocks experience a significant increase in pain between 12 and 24 hours postoperatively. Patients should be counseled on the importance of bridging to oral narcotics before the block wears off to avoid this “rebound pain.”