SLR - February 2018 - Amanda M. Kohut

Multimodal Analgesia in Foot and Ankle Surgery

Reference: Koshering, Jessica M. and Nathan G. Orgain. "Multimodal Analgesia in Foot and Ankle Surgery." Orthopedic Clinics 48.4 (2017): 495–505.

Scientific Literature Review

Reviewed By: Amanda M. Kohut, DPM
Residency Program: University of Florida Health, Jacksonville, FL

Podiatric Relevance: Advances in multimodal analgesia (MA) have allowed foot and angle surgeries to be performed in the outpatient setting. MA is utilized to minimize adverse effects of opioids prescribed postoperatively. Many complications are associated with increased postoperative pain, including prolonged hospitalization, increased readmission rate, higher costs and slower recovery. This article recommends several nonopioid medication options that can easily be assimilated into the surgeon’s perioperative pain management arsenal in an effort to reduce postoperative complications.

Key Points:

•    Michelson and colleagues (FAI 2013) found favorable outcomes with patients undergoing pedal fusions. This MA protocol consisted of perioperative oral administration of oxycodone, celecoxib, pregabalin, acetaminophen and prednisone; as compared to their control group, this regimen resulted in significantly reduced hospital stay and postoperative complications.
•    Selective COX-2 inhibitors (celecoxib, etoricoxib) have been found to be very effective; reducing the gastrointestinal and platelet effects of nonselective NSAIDs. Brattwall and colleagues (Anesthesia 2010) compared tramadol vs. etoricoxib following bunion surgery, finding that the COX-2 inhibitor group had increased satisfaction and decreased side effects compared with tramadol group. COX-2 inhibitors and NSAIDs, however, are still contraindicated when osseous healing is desired.
•    Gabapentin and pregabalin are gamma-aminobutyric acid analogues that bind to voltage-gated calcium channels and alter the release of excitatory neurotransmitters. Pregabalin has a faster onset and fewer side effects than gabapentin. As an adjunct for pain control, a typical starting dose is 75 mg bid. A randomized, placebo-controlled double-blind study of 240 subjects undergoing total knee arthroplasty showed notably lower rates of neuropathic pain, decreased opioid use and improved functional rehabilitation with pregabalin than the control group.
•    Tramadol and tapentadol both have mechanism of action at the opioid receptor mu and via monoamine reuptake inhibition. There is evidence that these medications have less respiratory depression than conventional opioids. Tapentadol has lower GI side effects than tramadol. Care must be taken when prescribing these medications with common antidepressant drugs, like SSRIs.
•    Single-dose preoperative or 24-hour perioperative use of high-dose glucocorticoids has been shown to be safe without evidence of increased risk for postoperative wound complications. A randomized, controlled trial of 50 subjects undergoing first metatarsal osteotomy found patients who received oral dexamethasone had greatly lowered pain scores, less nausea and lower concomitant narcotic consumption.

Conclusions: The increase in abuse, accidental death and high healthcare costs associated with opioids has brought to light the need for alternative methods of perioperative pain control. MA offers effective alternative methods of pain management, focusing on improving postoperative pain while reducing effects of individual agents via lower doses. MA can be very efficacious, especially in conjunction with preoperative local anesthesia techniques (wound infiltration, intraarticular injection).

The authors provide a sample case detailing their suggested regimen: preoperative acetaminophen 650–975 mg po, celecoxib 200–400 mg po, pregabalin 75–150 mg po (or gabapentin 300 mg po), tapentadol 50–100 mg po and regional anesthesia block. Postoperatively, acetaminophen 650 mg po q6h, pregabalin 75 mg po q12h for seven to 10 days, celecoxib 200 mg po q12h for three to seven days (soft-tissue procedures), tapentadol 50 mg po a12h or oxycodone 5 to 15 mg p 12h.

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