SLR - December 2022 - Kristen M. Brett, DPM
Title: Regional Anesthesia Decreases Inpatient But Not Outpatient Opioid Demand in Ankle and Distal Tibia Fracture SurgeryReference: Cunningham DJ. Paniagua A. DeLaura I. Zhang G. Kim B. Kim J. Lee T. LaRose M. Adams S. Gage MJ. Regional Anesthesia Decreases Inpatient But Not Outpatient Opioid Demand in Ankle and Distal Tibia Fracture Surgery. Foot & Ankle Specialist. 2022 Apr 19.
Level of Evidence: Level III
Reviewed By: Kristen M. Brett, DPM
Residency Program: Regions Hospital/HealthPartners Institute, Saint Paul, MN
Podiatric Relevance: Regional anesthesia is commonly used in foot and ankle surgery across the world in patients undergoing elective surgery as well as trauma reconstruction. Foot and ankle physicians commonly prescribe opioids along with other non-narcotic pain medications in attempt to achieve a multimodal approach to limiting postoperative pain. In attempts to decrease postoperative pain and limit narcotic use foot and ankle surgeons use peripheral nerve blocks in conjunction with anesthesia. Little research regarding regional anesthesia and postoperative opioid demand in patients suffering from high energy fractures exists in literature. The purpose of this paper was to evaluate the impact of regional anesthesia on inpatient opioid consumption and outpatient opioid demand in patients that are undergoing surgery for fractures of the ankle and distal tibia.
Methods: This was a retrospective study evaluating patients 18 years or older at a single institution between 2013 and 2018 who underwent surgery for an ankle or distal tibial fracture. Inpatient opioid consumption was defined as use of an opioid 0-72 hours postoperatively and outpatient opioid consumption was between 1 month and 90 days postoperatively. Oxycodone was the narcotic given at the dose of 5 mg. Statistical analysis was used to compare baseline and outcome differences between patients with and without regional anesthesia. Additionally, the authors looked at additional factors including age, sex, race, BMI, smoking, preoperative opioid use, ASA score, injury mechanism and regional anesthesia characteristics.
Results: There was a significant decreased use of opioids reported for inpatients who had regional anesthesia from the 0-24-hour time frame postoperatively however there was no significant difference noted outpatient. Patients who suffered higher energy injuries, multiple injuries, open fractures, and injuries that required multiple surgeries has lower use of regional anesthesia. There was a significantly higher rate of opioid filling at the 2-6-week timeframe in patients with regional anesthesia. In the outpatient prescribing there was a significant increase in prescribing in patients smoking, preoperative opioid use, high energy mechanism and regional anesthesia. Decrease prescribing was seen in patients who had increased age and additional surgeries.
Conclusions: Use of regional anesthesia in patients undergoing surgery for ankle and distal tibial fractures was seen to decrease opioid demand in patients who were inpatient with in the first 24 hours following surgery however there was a significantly increase demand for opioids in the outpatient setting. The authors theorize that increase opioid demand within the 2 to 6-week postoperative mark could be secondary to the discontinuation of the block and possible rebound pain. Additionally, the authors noted that due to their study being retrospective in nature, they are only able to report on outpatient prescribing and not consumption. The authors of this study suggest that the use of regional anesthesia can decrease initial opioid use but may increase opioid use in the outpatient setting.