SLR - May 2019 - Blake Hale

The Effects of Timing of Ankle Blocks in Forefoot, Midfoot or Hindfoot Reconstruction with the Use of an Ankle Tourniquet

Reference: Gwosdz, J, Bilbrew, L, Jupiter, D, & Panchbhavi, V. The Effects of Timing of Ankle Blocks in Forefoot, Midfoot or Hindfoot Reconstruction with the Use of an Ankle Tourniquet. Foot & Ankle Specialist, 11(6), 527–533.

Scientific Literature Review

Reviewed By: Blake Hale, DPM
Residency Program: Truman Medical Center Lakewood, Kansas City, MO

Podiatric Relevance: Peripheral regional anesthesia is performed in ambulatory surgical settings on a daily basis as a means to improve pain control in the postoperative period. One of the most commonly performed regional blocks for forefoot, midfoot and hindfoot procedures is the ankle block. When these blocks are performed during the case, it is largely based on attending preference, and there is no gold standard for direct timing. This study examines the timing of ankle block administration in relation to ankle tourniquet inflation on patients’ perceived pain as well as the effect on postoperative narcotic usage. It also investigates whether local incisional block improves postoperative pain.

Methods: A level II prospective comparative trial was performed over a six-month period, including patients over 18 undergoing forefoot, midfoot or hindfoot elective outpatient surgery. Forty-one patients met the inclusion criteria and were randomly assigned to one of three groups. All three groups underwent an ankle block using 20 cc of .25 percent bupivacaine. In group A, ankle block was prior to tourniquet inflation with no incisional block. In group B, ankle block was after tourniquet inflation with no incisional block. In group C, ankle block was after ankle tourniquet inflation, and a local incisional block was performed with an additional 5–20 cc of .25 percent bupivacaine. The patient’s VAS pain score was recorded at time of discharge, 24 hours, 48 hours and two weeks after surgery. All patients received a muscle relaxer, a neuropathic pain modulator, such as gabapentin, tramadol and a hybrid analgesic, such as Tylenol III or Norco. Narcotic consumption was standardized using morphine equivalents. The amount of narcotic consumption was measured at 24 and 48 hours, postoperatively.

Results: At 24 hours postop, mean VAS score for group C was significantly lower than group B. While group C was had lower VAS scores at 24 hours than group A, it did not reach significance. At 48 hours and two weeks, there was no statistically significant difference between the groups’ mean VAS scores. There was no difference in narcotic consumption at 24 and 48 hours between the groups in terms of morphine equivalents. There were no reported complications secondary to the local anesthetic blocks performed.

Conclusions: Timing of ankle blockade in relation to ankle tourniquet inflation did not show significant influence on patients' VAS scores in the postoperative period. Larger cohort studies with stricter inclusion criteria for specific procedures that are inherently more painful may improve the weight of this study’s conclusion; however, it does appear that a local incisional block improves postoperative pain control. 

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