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Scientific Articles   |    
The Efficacy of Combined Popliteal and Ankle Blocks in Forefoot Surgery
Rohit Samuel, BSc(Hons), MBChB, MSc, FRCS(Orth)1; Andrew Sloan, MBChB2; Kuntal Patel, MS(Orth), MRCS(Ed), DipSEM(GB&I)3; Magdy Aglan, MBBch, MSc, FFARCSI, FRCA4; Aamir Zubairy, MBBS, FRCSI, FRCS(Orth)4
1 67 Heaton Road, Stockport SK4 4JJ, United Kingdom. E-mail address: rohitsamuel@hotmail.com
2 18 Yewlands Avenue, Fulwood, Preston PR2 9QR, United Kingdom
3 10 The Pennines, Fulwood, Preston PR2 9GB, United Kingdom
4 Departments of Anaesthetics (M.A.) and Orthopaedic Surgery (A.Z.), Burnley General Hospital, Casterton Avenue, Burnley BB10 2PQ, United Kingdom
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Burnley General Hospital, Burnley, United Kingdom

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jul 01;90(7):1443-1446. doi: 10.2106/JBJS.G.01133
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Abstract

Background: Postoperative pain following forefoot surgery can be difficult to control with oral analgesia. The aim of this study was to compare the efficacy of a combined popliteal and ankle block with that of an ankle block alone in providing postoperative analgesia following forefoot surgery.

Methods: We performed a prospective, randomized, controlled single-blind study involving sixty-three patients, twenty-six of whom had a combined ankle and popliteal block and thirty-seven of whom had an ankle block alone. All patients underwent an elective osseous surgical procedure on the forefoot. Postoperative pain was evaluated with use of a visual analogue scale and a verbal response form. Patient satisfaction was also recorded.

Results: The patients who had had a combined popliteal and ankle block had significantly less pain at six hours postoperatively (p = 0.011), twenty-four hours postoperatively (p < 0.001), and at discharge (p = 0.014). This group of patients also had higher satisfaction with pain relief.

Conclusions: A popliteal block in conjunction with an ankle block provides significantly better pain relief than does an ankle block alone in patients undergoing forefoot surgery.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Rohit Samuel
    Posted on September 27, 2008
    Drs. Samuel and Zubairy respond to Mr. Jameson and Mr. Kumar
    NULL

    We thank Mr Jameson and Mr Kumar for their interest in our article. We agree that it is intuitive that two regional blocks would provide better pain relief than one after forefoot surgery but until the study was performed this could not be proven. Due to the deliberately chosen variety of cases used in the study we had a mixture of day-case patients and in-patients. One patient who had a popliteal block and was due for discharge the same day required overnight admission due to prolonged numbness in the leg. No other patient had a delayed discharge due to the type of block used.

    Statistical analysis of the analgesia requirements was performed and is stated in the article. Although no statistically significant difference was seen between the two groups, codeine phosphate consumption was less in the combined block group (18mg vs 78mg). We agree that the sample size may have been insufficient to detect significance. Although combined popliteal and ankle blocks may appear to be unnecessary in lesser forefoot surgery we feel it is worth considering in larger procedures where postoperative analgesia may be predicted to be a problem.

    Simon S. Jameson
    Posted on July 07, 2008
    Combined popliteal and ankle block - is it really necessary?
    Glasgow Royal Infirmary

    To the Editor:

    The article by Samuel, et al.(1)compares post-operative pain and patient satisfaction following forefoot surgery in patients randomised to either combined ankle and popliteal nerve block or solely ankle block. Patients reported significantly better pain relief in the combined block group, and there were more highly satisfied patients.

    The benefits of regional blockage in peripheral surgery are well known (2,3). However, extensive, prolonged blockade could potentially delay discharge. The difference in pain scores between the two groups, although statistically significant, was marginal (1.5 versus 2.4 out of 10) at discharge, and all patients described only mild pain. In addition, no statistical analysis was performed on the satisfaction scores or the post-operative analgesic requirement. The authors also fail to describe the number of operations performed as a day case, and how many required an overnight stay. This would have been useful data, given the financial implications. Moreover, it is also entirely predictable that a more proximal block, together with a higher volume of local anaesthetic, would provide better pain relief.

    In a study of our forefoot practice with ankle block, 93% reported a pain score of 0 or one out of ten, with only 7% requiring additional analgesia, and all patients were discharged the same day (4). McLeod et al found that both ankle block and popliteal sciatic block provided effective pain relief and high satisfaction when patients undergoing forefoot osteotomies were randomised to one or other, but found ankle block to be more reliable (5).

    Samuel et al may have found a useful synergistic benefit when the combined blockade was used. However, as complications, length of hospital stay and financial implications were not discussed, it is difficult to advocate a change in practice for our patients based on this work.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References

    1. Samuel R, Sloan A, Patel K, Aglan M, Zubairy A. The efficacy of combined popliteal and ankle blocks in forefoot surgery. J Bone Joint Surg Am 2008;90:1443-1446

    2. Needoff M, Radford P, Costigan P. Local anesthesia for postoperative pain relief after foot surgery: a prospective clinical trial. Foot Ankle Int. 1995;16(1):11-3

    3. Rongstad K, Mann RA, Prieskorn D, Nichelson S, Horton G. Popliteal sciatic nerve block for postoperative analgesia. Foot Ankle Int. 1996;17(7):378-82

    4. Dhukaram V, Kumar CS. Nerve blocks in foot and ankle surgery. Foot Ankle Surg 2004;10:1-3

    5. McLeod DH, Wong DH, Vaghadia H, Claridge RJ, Merrick PM. Lateral popliteal sciatic nerve block compared with ankle block for analgesia following foot surgery. Can J Anaesth 1995;42(11):1065

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