Elsevier

Foot and Ankle Surgery

Volume 28, Issue 7, October 2022, Pages 858-862
Foot and Ankle Surgery

The effect of posterior tibial and sural nerve blocks on postoperative pain of patients following open reduction and internal fixation of calcaneal fractures

https://doi.org/10.1016/j.fas.2021.11.009Get rights and content

Highlights

  • Posterior tibial and sural nerve blocks are useful peripheral nerve blocks for ORIF of calcaneal fractures.

  • Peripheral nerve block can result in less postoperative pain after ORIF of calcaneal fractures.

  • Peripheral nerve block can reduce opioid administration after ORIF of calcaneal fractures.

Abstract

Introduction

Postoperative pain control and achieving opioid-free anesthesia are major issues for surgically treated patients with calcaneal fractures. We evaluated the potential role of posterior tibial and sural nerve blocks as a part of multimodal pain control techniques in patients underwent open reduction and internal fixation (ORIF) of calcaneal fractures via extensile lateral approach.

Methods

Forty-eight patients randomly allocated to receive either posterior tibial and sural nerve blocks with bupivacaine (peripheral nerve block (PNB) group) or normal saline, after induction of general anesthesia. Patients were assessed for pain intensity, Interval from entrance to the recovery room to the first request for analgesic, recovery room and ward morphine consumption, global satisfaction and morphine side effects.

Results

PNB group had less pain score compared to sham block (SB) group at each time point measurement during recovery room stay. There was also significant difference between the 2 groups regarding the pain scores after 2, 4 and 6 h of the operation in the ward. Time to the first request for analgesic was significantly prolonged in the PNB group (P < 0.001). The recovery room and ward morphine consumption was significantly lower in the PNB group (P < 0.001). Global satisfaction in PNB group was significantly more than that of SB group. No complication related to the nerve block was detected at the first postoperative visit in the outpatient clinic.

Conclusion

Peripheral nerve block could result in less postoperative pain especially in the early hours after ORIF of calcaneal fractures and reduce opioid administration within the first 24 h following the surgery.

Introduction

Liberal use of narcotic compounds for postoperative pain control, either prescribed by the physician or requested by the patient, besides outburst of their side effects have raised the necessity for evidence-based investigations. Recent studies have emphasized on use of multimodal techniques to minimize the administration of opioid medications and tried to define the protocols which may lead to a sort of opioid-free anesthesia [1]. Although calcaneal fractures account for 1–2% of all fractures, about 71% of them are intraarticular types [2], so special attention should be paid for anatomical perfect reduction of them. Currently, although the management of calcaneal fractures is still a matter of controversy, the extensile lateral approach is one of the most being used operative procedure for open reduction and internal fixation (ORIF) of a displaced intraarticular calcaneal fracture [3]. Pain on the first day following ORIF of calcaneal fracture was ranked the highest among 179 surgical interventions. Gerbershagen et al. reported pain score of 6.8 according to numeric rating scale (NRS) for surgically treated calcaneal fractures [4]. The calcaneus is innervated mainly by the medial and lateral calcaneal branches, originated from the posterior tibial and sural nerves, respectively. Nowadays, lower extremity nerve blocks are mostly performed using ultrasound guidance and nerve stimulator. In many cases of ankle block, anesthesiologists and regionalists prefer to place the block according to the anatomical landmarks without the aid of more sophisticated instruments, because of the ease of performance and the lower cost.

The aim of the study was to evaluate the efficacy of posterior tibial and sural nerve blocks using the landmark technique for controlling postoperative pain in patients underwent ORIF for displaced calcaneal fractures through extensile lateral approach. Although it is a traditional technique, to the best of our knowledge, it has not been studied in this particular form for this type of procedure. We investigated opioid-sparing effect of these nerve blocks as a part of multimodal pain control techniques. Our main hypothesis was that applying this technique could alleviate postoperative surgical pain while lowering the dose of morphine administration.

Section snippets

Methods

This randomized double-blind clinical trial was conducted on the patients with displaced intraarticular calcaneal fractures scheduled for ORIF through extensile lateral approach [5] by a single orthopedic foot and ankle surgeon (ARV) at a university affiliated hospital, Chamran Hospital of Shiraz, from February 2018 till September 2019. It was approved by the Ethics Committee of the university (IR.SUMS.MED.REC.1379.152) and registered in IRCT (IRCT2018092204108N1).

The sample size was calculated

Results

Totally, 48 patients recruited from 73 patients and completed the study (Fig. 3). Table 1 shows the demographic data of both groups. There was no significant difference for variables, hence they were matched.

There were significant differences between the 2 groups regarding fentanyl administration during the operation, interval from entrance to the recovery room to the first request for analgesic and also recovery room and ward morphine administration. Global satisfaction in PNB group was

Discussion

Obviously, ORIF of a calcaneal fracture is associated with a significant postoperative pain. To achieve an adequate pain control with less opioid administration within the first 24 h in these patients, we evaluated the efficacy of sural nerve and posterior tibial nerve blocks, as a part of multimodal pain control techniques. Our findings revealed that patients who received the nerve blocks experienced less pain with decreased request for additional drug (fentanyl) during surgery. The narcotic

Level of evidence

Level II.

Declarations of interest

none.

Funding sources

The project was financed by Vice Chancellor for Research of Shiraz University of Medical Science (Grant No. 14053).

Conflict of interest

The authors received no financial support for the research, authorship, and/or publication of this article.

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There are more references available in the full text version of this article.
1

ORCID ID: 0000-0002-7711-2823

2

ORCID ID: 0000-0002-9531-8382

3

ORCID ID: 0000-0002-9531-9319

4

ORCID ID: 0000-0002-4864-7749

5

ORCID ID: 0000-0001-6091-8890

6

ORCID ID: 0000-0001-9909-207X

7

ORCID ID: 0000-0002-6118-8938

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