August, 2007

THE POSTOPERATIVE COURSE after foot and ankle surgery often includes significant pain, especially in the first 48 hours. Many patients are reluctant to undergo elective foot surgery because they've experienced this pain from an earlier procedure or they have heard about it from others. Fortunately, in my practice, severe postop pain is no longer a problem. About six months ago, we began using continuous peripheral nerve blocks rather than isolated peri-operative single-shot peripheral nerve blocks, and it's made a world of difference in terms of patient comfort.

While single-shot peripheral field blocks help stop pain for six to eight hours after the procedure, continuous infusions of .5% bupivicaine into the popliteal fossa provide analgesia from the knee to the toes for more than 48 hours post-op. Our anesthesia professionals at the Center for Advanced Surgery place the catheter behind the knee just prior to the start of the case. The catheter does not interfere with the operative field, and the use of an ankle or thigh tourniquet is still possible. The patient removes the catheter at home approximately 48 hours post-op.

The superiority of this analgesic method was clear from the moment we sent our first few patients home with the Accufuser pain pump. Previously, traditional narcotics were often insufficient to relieve patients' post-op discomfort, often resulting in multiple calls to the office for breakthrough pain. I have not received a single call for breakthrough post-op pain since using the Accufuser, and my patients now take minimal or no narcotics. (Some do need narcotics once the pain pump is discontinued, but only for a few days.) Because they take less narcotics, these patients recover much more quickly, with far fewer complications. They are out of bed sooner with little to no discomfort. They also have fewer opiateassociated complications like PONV, constipation and confusion.

I have used continuous infusion on patients whom I would traditionally admit to the hospital postoperatively, including those undergoing triple arthrodesis and other major hindfoot fusions. Since these patients don't need PCA morphine or Dilaudid, I can send them home the same day. That frees me to operate in an ASC, and significantly cuts my hospital inpatient workload.

There are a few pitfalls. The pain control is so good that it makes patient selection crucial. Patients must comprehend that they mustn't put weight on the foot even though it does not hurt. It is also critical to use extra cast padding over bony prominences to avoid pressure ulcers. Splints and casts must be molded meticulously, and must not be applied too tight. Cryotherapy should be used only with strict supervision.

I've had one leaky catheter and one patient with irritation at the catheter site. Both cases resolved uneventfully. I have experienced no other complications.

Continuous infusion has brightened my patients' outlook. We now have a whole group of patients who tell friends and family about their positive experience instead of bemoaning their pain. Rather than saying, “Never again,” they're saying, “That wasn't so bad!” As all surgeons know, there is no better advertisement than a satisfied, happy patient!

Dr. Sullivan is in private practice in Sea Girt, N.J. He is on staff and performs reconstructive foot and ankle surgery at The Center for Advanced Surgery, Jersey Shore University Medical Center, Monmouth Medical Center, Ocean Medical Center, and University Hospital UMDNJ in Newark, N.J.