Major Ankle Surgery Research Articles

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

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. 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. 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. The saphenous nerve is an important contributor to postoperative pain after major ankle surgery, with significant clinical pain appearing within 30 minutes after surgery. This study has been registered at ClinicalTrials.gov, identifier NCT02697955.

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

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. 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. 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. 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.

Combined saphenous and sciatic catheters for analgesia after major ankle surgery: a double-blinded randomized controlled trial.

Continuous sciatic nerve block is used for pain management following major ankle surgery. Pain from the saphenous nerve territory often persists. We conducted a double-blinded randomized placebo-controlled trial to evaluate the effect of a supplementary saphenous catheter in the proximal thigh combined with a popliteal sciatic catheter and single-shot saphenous nerve block after major ankle surgery. Fifty patients received both sciatic and saphenous continuous catheters inserted along the short axis of the nerves with ultrasound-guidance. All patients had an initial sciatic nerve block followed by a continuous sciatic catheter infusion and an initial saphenous nerve block with ropivacaine. Participants were then randomized to infusion of either ropivacaine or isotonic saline in the saphenous catheter for 48 hr postoperatively. The primary outcome was total intravenous morphine consumption during the first 48 hr postoperatively. Secondary outcomes were clinical analgesia, saphenous analgesia, territory of worst pain, and patient satisfaction. Forty-four patients were included in the analysis. The mean (SD) 48-hr morphine consumption was 24.7 (21.6) mg in the intervention group and 27.8 (20.1) mg in the placebo group (P=0.63). The mean difference in 48-hr morphine consumption was 3.0mg (95% confidence interval, -9.7 to 15.7). There were no differences regarding the secondary outcomes. A saphenous catheter with a low-dose continuous infusion of ropivacaine, as an adjunct to a sciatic catheter, had no effect on the postoperative analgesia after major ankle surgery when both catheters were inserted along the short axis of the nerves. This trial was registered at ClinicalTrials.gov (NCT01445210).

Additional femoral catheter in combination with popliteal catheter for analgesia after major ankle surgery

BackgroundThe contribution of the saphenous nerve in pain after major ankle surgery is unknown. The aim of this study was to evaluate its contribution in this context. MethodsFifty patients were included in this prospective, randomized, controlled study. In all patients [Group P (popliteal) and Group F (popliteal+femoral)], a popliteal catheter was placed before operation and ropivacaine 0.5% (30 ml) administered via this catheter; major ankle surgery was then performed under spinal anaesthesia. In Group PF patients, an additional femoral catheter was sited before operation and ropivacaine 0.5% (10 ml) administered. Six hours after spinal anaesthesia (defined as T0), a continuous infusion of ropivacaine 0.3% (14 ml h−1) was started through the popliteal catheter until T24. Then, the concentration was reduced to 0.2% until T48. Patients in Group PF received continuous ropivacaine 0.2% (5 ml h−1) through the femoral catheter from T0 to T48. I.V. morphine patient-controlled analgesia was used as a rescue analgesia. Pain at rest, pain with movement, adverse effects, and i.v. morphine consumption were assessed. Pain at rest and on movement was evaluated 6 months after operation. ResultsPain at rest was comparable in the two groups. In Group PF, patients had significantly reduced pain during movement in the postoperative period (P=0.01) and 6 months after operation (P=0.03). Morphine consumption was significantly reduced in Group PF at T0–T24 and T24–T48 (P=0.01). Adverse effects were comparable in both groups. ConclusionsThe addition of continuous femoral catheter infusion of ropivacaine to a continuous popliteal catheter infusion improved postoperative analgesia during movement after major ankle surgery. This effect was still present 6 months after surgery.

Combined continuous popliteal and femoral nerve block improve analgesia after major ankle surgery

Combined continuous popliteal and femoral nerve block improve analgesia after major ankle surgery

84: Combined continuous popliteal and femoral nerve block improve analgesia after major ankle surgery

84: Combined continuous popliteal and femoral nerve block improve analgesia after major ankle surgery