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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