By: Asher Cherian, DPM1 and Laura Sansosti, DPM, FACFAS2

1Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA

2Clinical Assistant Professor, Temple University School of Podiatric Medicine, Philadelphia, PA

Pain control is an essential aspect of providing comprehensive care to our patients. There may be profound implications when inadequately managed, especially in the postoperative setting (1). In the background of an opioid epidemic, clinicians and healthcare providers should consider alternative methods to control acute and chronic pain. A multimodal approach to pain management is essential to reducing opioid requirements, minimizing adverse events from opioids, and hopefully increasing patient satisfaction. 

Local Anesthetics

Short-acting and long-acting local anesthetics can be used in a variety of clinical applications to provide non-opioid-based pain management. Local anesthetics have a unique benefit with overall low risk compared to oral medications. Local anesthetics can be administered via subcutaneous injection or topical application. Injectable local anesthetics are often administered during in-office procedures and pre-and post-operatively in the operating room to decrease postoperative pain and oral medication requirements. A significant amount of utility is provided by a local anesthetic infiltrated into an area of pain. It can provide adequate analgesia for several hours to days depending on the type and amount of local used. Depending on the clinical application, the determination to use a short-acting versus long-acting local anesthetic should be made. A diagnostic nerve block can also be a versatile tool for addressing painful symptoms for patients with idiopathic pain to a particular foot or ankle region. A literature review by Griffioen et al in 2018 found that regional blocks provided superior pain relief compared to opioids following a lower extremity fracture (2). There is also evidence within the orthopedic literature pertaining to total hip arthroplasty (THA) and total knee arthroplasty (TKA) that demonstrate the effectiveness and benefits of postoperative regional anesthesia. A study by Marques et al in 2014 showed that infiltration of local anesthetic following THA and TKA shortened hospital stays, reduced opioid consumption, led to earlier mobilization, and reduced vomiting (3). The study also concluded that receiving local anesthetic infiltration lowered pain scores at rest compared to controls after 24 and 48 hours (3). Postoperative local anesthetic blocks have provided significant postoperative analgesia after foot and ankle surgery (4). Patients who receive a popliteal fossa block have better pain scores, a more prolonged analgesic effect, and decreased opioid requirements in the immediate postoperative period (5). The popliteal fossa block was also found to have better pain scores and reduced opioid requirements than the ankle block (5). 

NSAIDs

NSAIDs work by inhibiting cyclo-oxygenase (COX), diminishing post-injury hyperalgesia. Mild to moderate pain can typically be treated with an oral NSAID or acetaminophen. Studies performed by Pogatzki-Zahn et al (2014) and Nonaka et al (2016) demonstrate NSAIDs to be more effective in postoperative pain control compared to acetaminophen (6,7). While these may not be benign medications in terms of potential renal and GI side effects and platelet inhibition, the use of selective COX-2 inhibitors decreases that risk. They also note that the harmful side effects of acetaminophen are often underestimated in terms of possible liver damage (6,7). Some may also argue that NSAIDs are detrimental to the early phases of bone healing. However, more long-term data is needed. A study by Cozowicz et al in 2018 found that COX-2 inhibitors and NSAIDs were associated with the strongest individual effect in opioid dose reduction. NSAIDs have also been shown to reduce opioid requirements following ankle fracture surgery (8). Effective pain control is critical during the first two days following ankle fracture surgery because patients, on average, consume the most opioids during this time. A study by McDonald et al in 2018 found that the addition of the NSAID Ketorolac significantly reduced postoperative pain while concurrently reducing opioid requirements (9). They also found that patients experienced less pain during postoperative days one to two, and the addition of Ketorolac maintained 

minor discomfort for up to four days post-operatively. The patients in their study found greater patient satisfaction with their pain management, less hypersensitivity, and fewer paresthesias when treated with a multimodal pain regimen, including NSAIDs (9). 

           With increasingly strict regulations on narcotic prescriptions and high addiction potential, the multimodal approach to postoperative pain control is critical. Each patient is a unique case and requires thought to their co-morbidities, planned procedure, and anticipated postoperative pain to determine the optimal regimen to control their symptoms. It is imperative to discuss expectations with your patient, especially regarding postoperative pain. Opioid contracts are increasingly utilized and serve as a good starting point for this discussion. For patients who have chronic pain, referral to pain management pre- or post-operatively can also be considered. By not solely utilizing opioid-based medications, we can reduce opioid dependency and provide better outcomes for our patients.

References:

1. Carr DB, Goudas LC. Acute pain. The Lancet. 1999; 353(9169): 2051–2058. 

2. Griffioen MA, O'Brien G. Analgesics administered for pain during hospitalization following lower extremity fracture: A review of the literature. Journal of Trauma Nursing. 2018; 25(6): 360–365. 

3. Marques EMR, Jones HE, Elvers KT, Pyke M, Blom AW, Beswick AD. Local anesthetic infiltration for perioperative pain control in total hip and knee replacement: Systematic review and Meta-analyses of short- and long-term effectiveness. BMC Musculoskeletal Disorders. 2014; 15(1). https://doi.org/10.1186/1471-2474-15-220.

4. Elliot R, Pearce CJ, Seifert C, Calder JD. A prospective, randomized trial is a continuous infusion versus single bolus popliteal block following major ankle and hindfoot surgery. Foot Ankle Int. 2010; 31(12):1043-1047. 

5. Schipper ON, Hunt KJ, Anderson RB, Davis WH, Jones CP, Cohen BE. Ankle block vs. single-shot Popliteal Fossa Block as primary anesthesia for forefoot operative procedures: Prospective, randomized comparison. Foot Ankle Int. 2017; 38(11): 1188–1191. 

6. Pogatzki-Zahn E, Chandrasena C, Schug SA. Nonopioid analgesics for postoperative pain management. Current Opinion in Anaesthesiology. 2014; 27(5): 513–519. 

7. Nonaka T, Hara M, Miyamoto C, Sugita M, Yamamoto T. Comparison of the analgesic effect of intravenous acetaminophen with Flurbiprofen Axetil on post-breast surgery pain: A randomized controlled trial. Journal of Anesthesia. 2016; 30(3): 405–409. 

8. Cozowicz C, Poeran J, Zubizarreta N, Liu J, Weinstein SM, Pichler L, Mazumdar M, Memtsoudis SG. Non-opioid analgesic modes of pain management are associated with reduced postoperative complications and resource utilization: A retrospective study of obstructive sleep apnea patients undergoing elective joint arthroplasty. British Journal of Anaesthesia. 2019; 122(1), 131–140. 

9. McDonald E, Daniel J, Nicholson K, Shakked R, Raikin S, Pedowitz D, Winters B. A prospective randomized study is evaluating the effect of perioperative NSAIDs on opioid consumption and pain management after ankle fracture surgery. Foot & Ankle Orthopaedics. 2018; 3(3). https://doi.org/10.1177/2473011418s00085.