SLR - July 2018 - Brian Schenavar

The Incidence of Complications Is Low Following Foot and Ankle Surgery for Which Peripheral Nerve Blocks Are Used for Postoperative Pain Management

Reference: Khan R, Eilis S, Cheng J, Curren J, Fields K, Roberts M, YaDeau J. The Incidence of Complications Is Low Following Foot and Ankle Surgery for Which Peripheral Nerve Blocks Are Used for Postoperative Pain Management. Hospitals for Special Surgery Journal. 2017 December 07: Online Publication.

Scientific Literature Review

Reviewed By: Brian Schenavar, DPM
Residency Program: Ascension, Wheaton Franciscan, Milwaukee, WI

Podiatric Relevance: Local anesthesia supplementation is a mainstay in podiatric practice and foot and ankle surgery. There are multiple schools of thought in regard to where, when and how local anesthesia should be administered for intraoperative and postoperative pain control. This Level III prospective therapeutic study looks to determine the incidence of neurological and peripheral nerve block complications for foot and ankle surgery. The paper compares popliteal (POPs) blocks and ankle blocks (ABs) and observes complication rates.

Methods: 2,516 patients received either a AB or POP for postoperative pain management. AB technique followed Sharrock method for regional AB. Guided ultrasound was typically utilized; however, this varied depending on the anesthesiologist. Blocks were completed with 30 cc of 0.25 percent or 0.5 percent bupivacaine with or without dexamethasone. Serious complications were broken down into one to four criteria ranging from motor, neurological, intervention and duration of complication. Follow-up was at two, six and 12 weeks, and complications were documented. These complications were then scored by a surgeon and anesthesiologist to determine its relation to the block.
                
Results: Complications were noted to be broken down between serious and neurological block-related complications. Total neurological complications were noted to be 7.2 percent. Serious complications were noted to be 0.7 percent. Contrary to previous literature, POP blocks demonstrated a higher complication rate than ABs, 8.8 percent and 2.5 percent, respectively. Dexamethasone was noted to have a higher complication rate; however, it was also used in more complex surgical procedures. Together, the surgeon and the anesthesiologist only agreed that 2.6 percent of the total complications and 10 percent of the serious complications were likely due to the block itself.

Conclusion: While foot and ankle surgeons routinely use local anesthesia, the complications of postoperative blocks must not be completely ignored. This study demonstrated that complications are real and, in some instances, postoperative outcomes can be influenced by the type and location of the peripheral nerve block. However, many of these complications resolved over time. From a podiatric relevance standpoint, it is important to collaborate with the anesthesiologist, who may be performing all or a portion of the nerve block. As a physician, it is important to weigh the benefits of the block with the potential complications to determine the best outcome for each individual patient. By examining this study, the extent of complications can be better understood. More research will need to be completed in the future to better weigh the risks versus benefits of these blocks. 

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