Popliteal Sciatic Nerve Block

» Opioid-related dependence remains a major concern following surgery in the United States, driving increased interest in non-opioid, multimodal pain control strategies within orthopaedic surgery. » Liposomal bupivacaine is an extended-release anesthetic approved for specific nerve blocks and offers the potential to prolong analgesia without the need for post-operative catheters. » Liposomal bupivacaine is currently approved for use in interscalene brachial plexus blocks, sciatic nerve blocks in the popliteal fossa, and adductor canal blocks. » Despite mixed clinical trial results compared to unencapsulated bupivacaine, liposomal formulations may provide clinical and economic advantages in selected orthopaedic settings.

The purpose of this study was to perform a systematic review of the literature examining postoperative outcomes following single site and combined peripheral nerve blocks (PNBs), including (1) sciatic and femoral nerve, (2) popliteal and saphenous nerve, and (3) popliteal and ankle nerve, during elective foot and ankle surgery. We hypothesized that combination blocks would decrease postoperative narcotic consumption and afford more effective postoperative pain control as compared to general anesthesia, spinal anesthesia, or single site PNBs. A review of the literature was performed according to the PRISMA guidelines. Medline, EMBASE, and the Cochrane Library were searched from January 2009 to October 2019. We identified studies by using synonyms for "foot," "ankle" "pain management," "opioid," and "nerve block." Included articles explicitly focused on elective foot and ankle procedures performed under general anesthesia, spinal anesthesia, PNB, or with some combination of these techniques. PNB techniques included femoral, adductor canal, sciatic, popliteal, saphenous, and ankle blocks, as well as blocks that combined multiple anatomic sites. Outcomes measured included postoperative narcotic consumption as well as patient-reported efficacy of pain control. Twenty-eight studies encompassing 6703 patients were included. Of the included studies, 57% were randomized controlled trials, 18% were prospective comparison studies, and 25% were retrospective comparison studies. Postoperative opioid consumption and postoperative pain levels were reduced over the first 24 to 48 hours with the use of combined PNBs when compared with single site PNBs, both when used as primary anesthesia or when used in concert with general anesthesia either alone or combined with systemic/local anesthesia in the first 24 to 48 hours following surgery. Studies demonstrated higher reported patient satisfaction of postoperative pain control in patients who received combined PNB. Nine of 14 (64%) studies reported no neurologic related complications with an overall reported rate among all studies ranging from 0% to 41%. Our study identified substantial improvement in postoperative pain levels, postoperative opioid consumption, and patient satisfaction in patients receiving PNB when compared with patients who did not receive PNB. Published data also demonstrated that combination PNB are more effective than single-site PNB for all data points. Notably, the addition of a femoral nerve block to a popliteal nerve block during use of a thigh tourniquet, as well as addition of either saphenous or ankle blockade to popliteal nerve block during use of calf tourniquet, may increase overall block effectiveness. Serious complications including neurologic damage following PNB administration are rare but do exist.

Following surgical procedures, over 80% of patients experience acute pain, with half of them expressing dissatisfaction with pain relief. The modern approach to surgical treatment and pain management increasingly relies on implementing multimodal analgesia, which includes the use of adjuvants in addition to long-acting local anesthetics (such as ropivacaine). This double-blind randomized study evaluated the analgesic effect of magnesium sulfate added to ropivacaine in the sciatic nerve block at the popliteal level for bunion correction surgery. In this double-blind study, fifty patients were enrolled and randomized in a 1:1 ratio to receive ropivacaine and MgSO<inf>4</inf> 200 mg or ropivacaine and physiological solution. The primary endpoint was the duration of sensory block. A statistically significant difference was observed in the onset time for sensory block (9.2 minutes vs. 21.8 minutes, P<0.001) and its duration (18.2 hours vs. 13.9 hours, P<0.001) between the two groups. Between 12 and 24 hours postoperatively, the maximum NRS pain scores in the magnesium group were lower than those in the control group (IQR [range]) 2 (2-3.8 [0-6.5]) vs. 6.7 (5.6-7.9 [2.7-9.2], P<0.001). The need for additional opioids after 12-24 hours was significantly higher in patients in the physiological solution group compared to those in the magnesium group. Our results suggest that magnesium added to the local anesthetic extends sensory block duration, reduces postoperative pain, improves the quality of analgesia, decreases the need for additional opioids. Further studies are needed to confirm these preliminary findings.

Introduction: In the context of the current opioid crisis, non-pharmacologic approaches to pain management have been considered important alternatives to the use of opioids or analgesics. Advancements in nano and quantum technology have led to the development of several nanotransporters, including nanoparticles, micelles, quantum dots, liposomes, nanofibers, and nano-scaffolds. These modes of nanotransporters have led to the development of new drug formulations. In pain medicine, new liposome formulations led to the development of DepoFoam&#x2122; introduced by Pacira Pharmaceutical, Inc. (Parsippany, NJ, USA). This formulation is the base of DepoDur&#x2122;, which comprises a combination of liposomes and extended-release morphine, and Exparel&#x2122;, which comprises a combination of liposomes and extended-release bupivacaine. In 2021, Heron Therapeutics (San Diego, CA, USA) created Zynrelef&#x2122;, a mixture of bupivacaine and meloxicam. Advancements in nanotechnology have led to the development of devices/patches containing millions of nanocapacitors. Data suggest that these nanotechnology-based devices/patches reduce acute and chronic pain. Methods: Google and PubMed searches were conducted to identify studies, case reports, and reviews of medical nanotechnology applications with a special focus on acute and chronic pain. This search was based on the use of keywords like nanotechnology, nano and quantum technology, nanoparticles, micelles, quantum dots, liposomes, nanofibers, nano-scaffolds, acute and chronic pain, and analgesics. This review focuses on the role of nanotechnology in acute and chronic pain. Results: (1) Nanotechnology-based transporters. DepoDur&#x2122;, administered epidurally in 15, 20, or 25 mg single doses, has been demonstrated to produce significant analgesia lasting up to 48 h. Exparel&#x2122; is infiltrated at the surgical site at the recommended dose of 106 mg for bunionectomy, 266 mg for hemorrhoidectomy, 133 mg for shoulder surgery, and 266 mg for total knee arthroplasty (TKA). Exparel&#x2122; is also approved for peripheral nerve blocks, including interscalene, sciatic at the popliteal fossa, and adductor canal blocks. The injection of Exparel&#x2122; is usually preceded by an injection of plain bupivacaine to initiate analgesia before bupivacaine is released in enough quantity from the depofoarm to be pharmacodynamically effective. Finally, Zynrelef&#x2122; is applied at the surgical site during closure. It was initially approved for open inguinal hernia, abdominal surgery requiring a small-to-medium incision, foot surgery, and TKA. (2) Nanotechnology-based devices/patches. Two studies support the use of nanocapacitor-based devices/patches for the management of acute and chronic pain. A randomized study conducted on patients undergoing unilateral primary total knee (TKA) and total hip arthroplasty (THA) provided insight into the potential value of nanocapacitor-based technology for the control of postoperative acute pain. The results were based on 2 studies, one observational and one randomized. The observational study was conducted in 128 patients experiencing chronic pain for at least one year. This study suggested that compared to baseline, the application of a nanocapacitor-based Kailo&#x2122; pain relief patch on the pain site for 30 days led to a time-dependent decrease in pain and analgesic use and an increase in well-being. The randomized study compared the effects of standard of care treatment to those of the same standard of care approach plus the use of two nanocapacitor-based device/patches (NeuroCuple&#x2122; device) placed in the recovery room and kept in place for three days. The study demonstrated that the use of the two NeuroCuple&#x2122; devices was associated with a 41% reduction in pain at rest and a 52% decrease in the number of opioid refills requested by patients over the first 30 days after discharge from the hospital. Discussion: For the management of pain, the use of nano-based technology has led to the development of nano transporters, especially focus on the use of liposome and nanocapacitors. The use of liposome led to the development of DepoDur&#x2122;, bupivacaine Exparel&#x2122; and a mixture of bupivacaine and meloxicam (Zynrelef&#x2122;) and more recently lidocaine liposome formulation. In these cases, the technology is used to prolong the duration of action of drugs included in the preparation. Another indication of nanotechnology is the development of nanocapacitor device or patches. Although, data obtained with the use of nanocapacitors are still limited, evidence suggests that the use of nanocapacitors devices/patches may be interesting for the treatment of both acute and chronic pain, since the studies conducted with the NeuroCuple&#x2122; device and the based Kailo&#x2122; pain relief patch were not placebo-controlled, it is clear that additional placebo studies are required to confirm these preliminary results. Therefore, the development of a placebo devices/patches is necessary. Conclusions: Increasing evidence supports the concept that nanotechnology may represent a valuable tool as a drug transporter including liposomes and as a nanocapacitor-based device/patch to reduce or even eliminate the use of opioids in surgical patients. However, more studies are required to confirm this concept, especially with the use of nanotechnology incorporated in devices/patches.

Continuous popliteal sciatic nerve block (CPSNB) has been performed in outpatient foot and ankle surgery as a regional anesthesia method to relieve postoperative pain. Its efficacy as well as safety is yet to be established. There are two purposes of this study: (1) to validate the efficacy of CPSNB with regards to better pain relief and reduced analgesics consumption; (2) to assess the safety of CPSNB. We performed a comprehensive literature review on Web of Science, the Cochrane Library, PubMed and Embase and only included randomized controlled trials (RCTs). Five RCTs that compared the efficacy and safety of CPSNB with the single-injection popliteal sciatic nerve block group were included. The primary outcome parameters were visual analog scale (VAS) scores at postoperative 24, 48 and 72&#x2009;h. The secondary outcome parameters were amount of oral analgesics consumed, overall patient satisfaction and need of admission after surgery. A sensitivity analysis was performed to explore the consistency of the results. In comparison with the single-injection group, CPSNB was associated with a lower VAS score at postoperative 24 and 48&#x2009;h (p&#x2009;<&#x2009;0.05). There were no neuropathic symptoms or infection events after the nerve block. However, there were several minor complications associated with the pump and catheter system, with drug leakage being the most common complication (N&#x2009;=&#x2009;26 of 187, 13.9%). CPSNB is an effective method in pain management for outpatient foot and ankle surgery. Both methods appear to be safe as none of the patients experienced neuropathic symptoms or infection. Further studies with larger sample size are needed to compare the risk of major complications between the two methods. I; meta-analysis.

Forefoot surgery is associated with severe postoperative pain. Ankle and sciatic nerve blocks provide satisfactory postoperative analgesia after forefoot surgery, but little is known on their respective duration of analgesia. This randomised controlled, single-blinded trial tested the hypothesis that after forefoot surgery in the setting of multimodal analgesia, an ankle block provides analgesia superior to that of a sciatic nerve block at the popliteal crease. A randomised controlled study. A single centre study in a university hospital in Switzerland, from September 2018 to November 2022. From 91 patients scheduled for forefoot surgery, 60 met the inclusion criteria of which 56 completed the protocol and their data were available for analysis. Exclusion criteria were existing sciatic nerve deficit, pre-existing peripheral neuropathy, chronic pain diagnosis, pregnancy, or identified contraindications to peripheral nerve block. Patients undergoing forefoot surgery were randomly allocated to either a multi-injection ankle block (partly under ultrasound guidance) or a sciatic nerve block at the popliteal crease (under ultrasound guidance) combined with a saphenous nerve block at the ankle. Patients in each group received a total of 30&#x200a;ml of ropivacaine 0.5% and a multimodal analgesic regimen inclusive of dexamethasone, paracetamol, ketorolac then ibuprofen. The primary outcome was duration of analgesia, defined as time to first morphine request. Mean&#x200a;&#xb1;&#x200a;SD duration of analgesia was 15.4&#x200a;&#xb1;&#x200a;8.0&#x200a;h in the ankle block group and 20.0&#x200a;&#xb1;&#x200a;10.3&#x200a;h in the sciatic nerve block group ( P &#x200a;=&#x200a;0.32). Of note, 15 of 26 (58%) and 24 of 30 (80%) patients of the ankle and sciatic nerve block groups did not request any morphine ( P &#x200a;=&#x200a;0.09). Other secondary outcomes were similar between groups. Compared with the ankle block, the sciatic nerve block at the popliteal crease does not provide a longer duration of analgesia in patients undergoing forefoot surgery in the setting of multimodal analgesia. Clinicaltrials.com identifier: NCT03683342.

The adductor canal block is a well-known procedure for controlling postoperative pain after medial malleolus fracture surgery. Continuous nerve block is a viable option for blocking pain for a longer period although the literature on this subject is scarce. Therefore, this study aimed to compare continuous adductor canal block (cACB) group to single-injection adductor canal block (sACB) group in those with bimalleolar or trimalleolar ankle fractures. The procedure was performed in addition to a continuous sciatic nerve block for postoperative pain relief and patient satisfaction. The study included 57 patients who had bimalleolar or trimalleolar ankle fractures and underwent open reduction and internal fixation between August 2016 and June 2018. Each patient received a continuous sciatic nerve block and was divided into two groups: those who received cACB and those who received sACB. Each postoperative pain was scored at 4, 8, 12, 24, 48, and 72&#xa0;h after surgery. Additionally, the consumption of rescue medications and patient satisfaction were evaluated. The two groups displayed no disparity in medial side ankle pain at 4&#xa0;h and 8&#xa0;h after surgery, but significantly higher pain in the sACB group at 12, 24, 48, and 72&#xa0;h after surgery. However, there was no difference in the pain at the lateral side of ankle and consumption of rescue medication. In addition, the cACB group showed more satisfaction than the sACB group did. CACB is better than sACB in terms of postoperative pain control and patient satisfaction. cACB can be used for postoperative pain control in ankle fractures involving the medial malleolus. Prospective Randomized Controlled Trial, Level 2.