The Journal of Foot & Ankle Surgery xxx (2014) 1–11

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The Journal of Foot & Ankle Surgery

journal homepage: www.jfas.org

Original Research

Pain Management for Elective Foot and Ankle Surgery:

A Systematic Review of Randomized Controlled Trials
Jia Wang, MD 1, George T. Liu, DPM, FACFAS 2, Helen G. Mayo, MLS 3,
Girish P. Joshi, MBBS, MD, FFARSCI 4
1
Resident, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX
2
Assistant Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
3
Research and Liaison Librarian, University of Texas Southwestern Health Sciences Digital Library and Learning Center, University of Texas Southwestern
Medical Center, Dallas, TX
4
Professor, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX

a r t i c l e i n f o a b s t r a c t

Level of Clinical Evidence: 2 Pain after foot and ankle surgery can significantly affect the postoperative outcomes. We performed a systematic
review of randomized controlled trials assessing postoperative pain after foot and ankle surgery, because the
Keywords:
ambulatory surgery surgery will lead to moderate-to-severe postoperative pain, but the optimal pain therapy has been controversial.
multimodal A systematic review of randomized controlled trials in English reporting on pain after foot and ankle surgery in
podiatry adults published from January 1946 to February 2013 was performed. The primary outcome measure was the
postoperative pain postoperative pain scores. The secondary outcome measures included supplemental analgesic requirements and
regional analgesia other recovery outcomes. With 953 studies identified, 45 met the inclusion criteria. The approaches improving
pain relief (reduced pain scores or opioid requirements) included peripheral nerve blocks, wound infiltration,
intravenous dexamethasone, acetaminophen, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 selective
inhibitors, and opioids. Wound instillation, intra-articular injection, and intravenous regional analgesia had
variable analgesia. The lack of homogeneous study design precluded quantitative analyses. Optimal pain
management strategies included locoregional analgesic techniques plus acetaminophen and nonsteroidal anti-
inflammatory drugs or cyclooxygenase-2 selective inhibitors, with opioids used for “rescue,” and 1 intra-
operative dose of parenteral dexamethasone. Popliteal sciatic nerve blocks would be appropriate when
expecting severe postoperative pain (extensive surgical procedure), and ankle blocks and surgical incision
infiltration would be appropriate when expecting moderate postoperative pain (less extensive and minimally
invasive surgical procedures). Additional studies are needed to assess multimodal analgesia techniques.
Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.

Pain after foot and ankle surgery can significantly affect the post-
operative outcomes (1). Inadequately controlled postoperative pain
has been associated with prolonged recuperation in the post-
anesthesia recovery room, delayed discharge to home, unanticipated
hospital admission from an outpatient surgical facility, a prolonged
hospital stay, and a delayed return to normal daily activities (2,3).
Although multiple randomized controlled trials (RCTs) have evaluated
the techniques for pain management after foot and ankle surgery, we
are unaware of any systematic reviews assessing the effectiveness of
the analgesic interventions for pain management after elective foot
Financial Disclosure: None reported.
Conflict of Interest: Dr. Joshi has received honoraria from Pfizer, Pacira, and
Cadence Pharmaceuticals; none reported for the other authors.
Address correspondence to: Girish P. Joshi, MBBS, MD, FFARSCI, Professor,
Department of Anesthesiology and Pain Management, University of Texas South-
western Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9068.
E-mail address: girish.joshi@utsouthwestern.edu (G.P. Joshi).
and ankle surgery. Consequently, the optimal pain management for
these patients has remained controversial.
The aim of the present study was to perform a systematic review of
published RCTs assessing the management of pain after elective foot
and ankle surgery. The primary outcome measure was the post-
operative pain scores, and the secondary outcome measures included
supplemental analgesic requirements, recovery outcomes, and
adverse effects related to the analgesics. The systematic review would
be used to determine the strength of the currently available evidence
and the knowledge gaps, which could guide future research. In
addition, our review can serve as a starting point for developing
recommendations for clinical decision-making in the management of
pain in adults undergoing elective foot and ankle surgery.
Materials and Methods
A systematic review of the published data concerning pain management after foot
and ankle surgery was conducted according to the “Preferred Reporting Items for

1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2014.05.003
2 J. Wang et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–11
Fig. Flow chart of literature search, which was performed according to the “Preferred Reporting Items for Systematic reviews and Meta-Analyses” guidelines. aRandomized controlled
trials.
Systematic Reviews and Meta-Analyses” guidelines (4). The data search was performed
using Ovid MEDLINE, the Cochrane Database of Systematic Reviews, the Database of
Abstracts of Reviews of Effects, and the Cochrane Central Register of Controlled Trials
databases from January 1946 to February 2013 according to the protocol recommended
by the Cochrane Collaboration (5). The primary aim was to evaluate the postoperative
pain scores, and the secondary aims were to evaluate other outcome measures,
including supplemental analgesic requirements, recovery outcomes, and adverse
effects related to analgesics.
The range of search terms was broad and included surgical, analgesic, and pain terms.
In addition, the search terms were applied in various combinations to maximize the
search and prevent missing any publications. Furthermore, the reference lists of the
included studies and review articles on similar topics were searched manually. The
search was limited to meta-analysis, systematic reviews, reviews, randomized controlled
studies or trials, English language, adults, and humans. The search terms included exp
Anesthesia, Conduction OR exp Anesthetics, Local OR exp Analgesics OR Pain, Post-
operative OR Pain Measurement OR pain OR pains OR painful* OR painkil* OR pain
management OR postoperative pain OR post-operative pain OR analgesi* OR anaesthe*
OR anesthe* OR McGill scale or McGill rating or McGill pain or vas or visual analog* or vrs
or verbal rating scale* OR nrs OR numerical rating scale* OR epidural OR neuraxial OR
intrathecal OR paravertebral OR spinal OR infiltration OR nerve block* OR neural block*
OR parasacral block* OR transgluteal block* OR popliteal fossa block* OR ankle block* OR
field block* OR NSAID* OR nonsteroidal anti-inflammator* OR non-steroidal anti-
inflammator* OR COX-2 OR paracetamol OR acetaminophen OR clonidine OR opioid* OR
ketamine OR corticosteroid* OR gabapentin OR pregabalin. These pain terms were
“AND”-ed with the following search terms for foot and ankle surgery: exp foot/su OR exp
foot bones/su OR exp foot joints/su OR toe joint/su OR ankle injuries/su OR foot injuries/
su OR exp foot deformities/su OR exp foot diseases/su OR diabetic foot/su OR Tarsal
Tunnel Syndrome/su OR exp Hallux Varus/su OR exp Hallux Valgus/su OR exp Hallux
Rigidus/su OR exp Hallux Limitus/su OR Lateral Ligament, Ankle/su OR Arthroplasty,
Replacement, Ankle OR [(foot OR feet OR ankle* OR toe OR toes OR digit* OR heel OR
hallux OR forefoot OR midfoot OR hindfoot OR rearfoot OR fore-foot OR mid-foot OR
hind-foot OR rear-foot) AND (surg* OR operation* OR operativ* OR podiatr*)].
Study Inclusion and Exclusion Criteria
The search results were screened in a stepwise manner to identify eligible studies.
In the first step, 2 independent reviewers (G.T.L. and G.P.J.) screened the titles and
excluded irrelevant reports. Of the remaining studies, the abstracts and/or full text were
reviewed for inclusion. RCTs in English that had assessed analgesic interventions after
foot and ankle surgery in adults and had reported pain scores (i.e., linear analog, verbal,
or numerical rating scale) and/or provided postoperative analgesic consumption were
included. The exclusion criteria consisted of unpublished studies, studies of
Table 1
Studies assessing conventional analgesics for management of pain after elective foot and ankle surgery (n ¼ 16 randomized controlled trials)

Study Study Design Jadad Pain Scores Supplemental Analgesia Interval to First Outcome
Score Supplemental Analgesia
Acetaminophen (paracetamol)
Jarde, 1997 (7) Postoperative propacetamol IV (n ¼ 2 ;30 min to 4 hr in IV group versus oral NA NA NS adverse events
108) versus paracetamol PO (n ¼ 106) group (p < .05) :Satisfaction with treatment groups
versus placebo (n ¼ 109) ;30 min to 6 hr in both paracetamol versus placebo (p < .05)
groups versus placebo group (p < .01)
Nonsteroidal anti-inflammatory drugs
Jarde, 1992 (8) Postoperative niflumic acid 1 g (n ¼ 33) 3 ;Days 1 to 7 in niflumic acid group ;Days 1 to 7 in niflumic acid NA ;Edema (p ¼ .0005)
versus placebo (n ¼ 36) for 7 days (p < .05) group (p < .05) :Satisfaction (p < .001) in niflumic acid
group
Soulier, 1997 (9) Postoperative flurbiprofen 50 mg 5 ;0 to 24 hr in flurbiprofen group NA NA NS adverse events
(n ¼ 29) versus acetaminophen (p < .01)
300 mg þ codeine 30 mg (n ¼ 24) NS 25 to 96 hr
every 4 to 6 hr for 96 hr
Riff, 2009 (10) Postoperative diclofenac liquid-filled 4 ;PODs 1 to 5 in diclofenac group ;Diclofenac group (p < .001) NA ;Nausea, headache, vomiting,
soft gelatin capsule 25 mg (n ¼ 101) (p < .001) constipation
versus placebo (n ¼ 97) (p < .05)

Daniels, 2010 Postoperative diclofenac liquid-filled
(11) soft gelatin capsule 25 mg (n ¼ 96)
versus placebo (n ¼ 95)
Wang, 2010 Naproxen 550 mg 1 hr
(12) preoperatively þ 550 mg every 12 hr
postoperatively (n ¼ 27) versus
pregabalin 300 mg 1 hr
preoperatively þ 150 mg every 8 hr
postoperatively (n ¼ 32) versus
placebo (n ¼ 27)
Cyclooxygenase-2 selective inhibitors
Desjardins, Part 1: POD 1, single dose of rofecoxib
2004 (13) 50 mg PO (n ¼ 82) versus diclofenac
100 mg enteric-coated (n ¼ 81)
versus placebo (n ¼ 75)
Part 2: PODs 2 to 5, rofecoxib 50 mg PO
(n ¼ 82) versus placebo (n ¼ 157)
Pollak, 2006 Valdecoxib 40 mg þ valdecoxib 20 mg
(14) (n ¼ 118) versus valdecoxib 40 mg
(n ¼ 113) versus placebo (n ¼ 113)
PODs 2 to 5, valdecoxib 20 mg twice
daily (n ¼ 159) versus valdecoxib
20 mg once daily (n ¼ 155) versus
placebo (n ¼ 154)
Brattwall, 2010 Postoperative etoricoxib 120 mg PO
(15) daily for days 1 to 4, then 90 mg daily
for days 5 to 7 (n ¼ 49) versus
tramadol sustained-release 100 mg
PO twice daily for days 1 to 7 (n ¼ 49)
Desjardins, Preoperative parecoxib 20 mg IV
2004 (16) (n ¼ 17) versus parecoxib 40 mg IV
(n ¼ 16) versus placebo (n ¼ 17)
4 ;PODs 1 to 5 in diclofenac group
(p  .01)
5 ;2 to 48 hr in naproxen group versus
pregabalin (p < .05) and placebo
(p < .001) groups
;2 to 24 hr in pregabalin group versus
placebo group (p ¼ .009)
5 ;Rofecoxib group versus diclofenac
and placebo groups (p < .001)
NS diclofenac group versus placebo
group
4 ;PODs 1 to 5 in both valdecoxib
treatment groups versus placebo
group (p  .05)
NS between valdecoxib groups
5 ;Days 1 to 7 in etoricoxib group
(p < .05)
4 ;Both parecoxib groups versus placebo
group (p < .05)
NS between parecoxib groups
;Diclofenac group (p  .0003)
;Naproxen (p < .001) and
pregabalin (p ¼ .005) groups
versus placebo group
NS naproxen group versus
pregabalin groups
;Rofecoxib group versus
diclofenac and placebo
groups (p < .001)
;Diclofenac group versus
placebo groups (p ¼ .007)
;Both valdecoxib groups
versus placebo group
(p  .05)
NS between valdecoxib
groups
NS
;Parecoxib groups (p < .05)
J. Wang et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–11
:Satisfaction in diclofenac group
(p < .001)
NA NS adverse events
:Satisfaction in diclofenac group
(p < .0001)
:Naproxen group :Sedation scores in pregabalin group
versus pregabalin versus naproxen (p ¼ .014) and
group (p ¼ .039) placebo (p ¼ .020) groups
:Pregabalin (p ¼ .004) :Satisfaction in naproxen and
and naproxen groups pregabalin groups versus placebo
(p < .001) versus group
placebo group NS satisfaction in pregabalin group
versus naproxen group
:Rofecoxib group NS adverse events
versus diclofenac :Satisfaction in rofecoxib group versus
and placebo groups diclofenac and placebo groups
(p < .001) (p < .001)
:Both valdecoxib :Satisfaction in both valdecoxib groups
groups versus placebo versus placebo group (p < .001)
group (p < .05) ;Opioid-related adverse effects in both
valdecoxib groups versus placebo
group
NA ;Opioid-related adverse events in
etoricoxib group (p < .01)
;Compliance with study regimen in
tramadol group (p ¼ .035)
:Satisfaction in etoricoxib group
(p ¼ .031)
NA NS adverse events and satisfaction
(continued on next page)

3
Table 1 (continued)
Study Study Design
Apfelbaum, 2008 Single day study:
(17) POD 0, parecoxib 40 mg IV þ parecoxib
20 mg IV (n ¼ 124) versus parecoxib
40 mg IV (n ¼ 111) versus placebo
(n ¼ 103)
Multiday study: PODs 1 to 2, parecoxib
20 mg IV twice daily (n ¼ 148) versus
parecoxib 20 mg IV once daily
(n ¼ 149) versus placebo (n ¼ 146)
Opioids
Thipphawong, Postoperatively, 1 dose inhaled
2003 (18) morphine 2.2 mg (n ¼ 24) versus 3
doses inhaled morphine 6.6 mg
(n ¼ 23) versus morphine 4 mg IV
(n ¼ 19) versus placebo (n ¼ 23)
Stoker, 2007 (19) Phase 1: postoperative 0 to 8 hr
morphine 3.75 mg intranasally
(n ¼ 24) versus morphine 7.5 mg
intranasal (n ¼ 22) versus morphine
15 mg intranasal (n ¼ 23) versus
morphine 30 mg intranasal (n ¼ 21)
versus morphine 7.5 mg IV (n ¼ 45)
versus placebo (n ¼ 46)
Phase 2: postoperative 8 to 24 hr
morphine 7.5 mg intranasally
(n ¼ 47) versus morphine 15 mg
intranasally (n ¼ 60)
Stegmann, 2008 Postoperative tapentadol 50 mg (n ¼ 66)
(20) versus tapentadol 100 mg (n ¼ 63)
versus oxycodone 10 mg (n ¼ 67)
versus placebo (n ¼ 67)
Richards, 2011 Postoperative dual-opioid combination
(21) (MoxDuo) of morphine and
oxycodone 12 mg/8 mg (n ¼ 20)
versus MoxDuo 6 mg/4 mg (n ¼ 31)
versus morphine 12 mg (n ¼ 27)
versus oxycodone 8 mg (n ¼ 30)
versus morphine 6 mg (n ¼ 30)
versus oxycodone 4 mg (n ¼ 27) q6h
for 48 hr
Dexamethasone
Mattila, 2010 Dexamethasone 9 mg PO once
(22) preoperatively and then at 24 hr
postoperatively (n ¼ 25) versus
placebo (n ¼ 25)
Abbreviations: ;, decrease; :, increase; IV, intravenously; LOS ¼ length of stay; NA, not applicable; NS, not significant; PO, orally; POD, postoperative day.
Conventional analgesics included acetaminophen (paracetamol), nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 selective inhibitors, opioids, and dexamethasone.
Jadad Pain Scores
Score
3 NS POD 0 between parecoxib groups
;POD 2 in parecoxib twice daily group
versus parecoxib once daily group
(p  .05)
5 ;3 Doses of inhaled morphine and IV
groups versus 1 dose inhaled
morphine and placebo groups
NS 1 dose of inhaled morphine versus
placebo
5 ;0 to 4 hr Active treatment groups
versus placebo group (p < .0001)
;0 to 24 hr 15 mg Intranasal group
versus 7.5 mg intranasal group
(p < .0001)
3 ;Days 2 to 3 tapentadol 50 mg
(p  .0001), Days 2 to 4 tapentadol
100 mg (p  .0284), days 2 to 3
oxycodone (p  .0365) groups versus
placebo group
;Days 2 to 3 tapentadol 100 mg group
versus oxycodone group (p  .0455)
NS, days 2 to 4 tapentadol 50 mg group
versus oxycodone group
5 ;0 to 24 hr in MoxDuo 12 mg/8 mg
group versus morphine 12 mg
(p ¼ .009), oxycodone 8 mg
(p ¼ .037), and MoxDuo 6 mg/4 mg
groups (p ¼ .011)
;0 to 48 hr in MoxDuo 12 mg/8 mg
group versus MoxDuo 6 mg/4 mg
group (p ¼ .037)
NS 0 to 48 hr in MoxDuo 6 mg/4 mg
group versus morphine 12 mg and
oxycodone 8 mg groups
5 ;PODs 0 to 1 at rest and with
movement in dexamethasone group
(p < .05)
NS PODs 2 to 3
Supplemental Analgesia
;Both parecoxib groups versus
placebo group (p  .05)
NS POD 0 between parecoxib
groups
;POD 2
parecoxib twice daily group
versus parecoxib once daily
group (p  .05)
;3 Doses of inhaled morphine
and IV groups versus 1 dose
and placebo groups (p ¼ .01)
NS 3-inhaled doses group versus
IV groups
NS
;Days 1 to 4 in all treatment
groups versus placebo
NS between treatment groups
NA
;PODs 0 to 3 in dexamethasone
group (p ¼ .049)
4
Interval to First Outcome
Supplemental Analgesia
:Both parecoxib groups ;POD 0, pruritus in parecoxib
versus 40 þ 20 mg group versus placebo
placebo group (p < .05) group (p  .01)
NS between parecoxib ;PODs 2 to 3, opioid-related adverse
groups events in both parecoxib groups
versus placebo group (p  .05)
:Satisfaction in both parecoxib groups
versus placebo (p < .001)
NS NS adverse events and satisfaction
:30 mg Intranasal group :Dysgeusia, nasal congestion,
versus all other groups throat irritation, sneezing in intranasal
J. Wang et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–11
(p < .0001) groups
:Oxygen desaturation in phase 1, 30
mg intranasal and IV groups and both
phase 2 groups
:Satisfaction during phase 2 in 7.5 mg
intranasal group versus 15 mg
intranasal group (p ¼ .0001)
:All treatment groups ;Nausea, dizziness, vomiting,
versus placebo constipation
(p < .0001) :GI tolerability for tapentadol 50 mg
versus oxycodone
:Dizziness and somnolence in
tapentadol 100 mg versus oxycodone
NS somnolence for tapentadol 50 mg
versus oxycodone
:Satisfaction in tapentadol 50 mg and
100 mg groups versus placebo
(p  .05)
NA ;Adverse events, severe nausea and
vomiting with MoxDuo 6 mg/4 mg
group versus morphine 12 mg and
oxycodone 8 mg groups (p < .05)
NA ;POD 1, nausea in dexamethasone
group (p < .05)
NS LOS, satisfaction
 J. Wang et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–11 5

Table 2
Studies assessing peripheral local analgesics for management of pain after elective foot and ankle surgery (n ¼ 6 randomized controlled trials)

Study Study Design
Intra-articular administration
Westman, 1997 Preoperative intra-articular
(23) pethidine 0.5% with
adrenaline 0.4% (n ¼ 10)
versus prilocaine 0.5% with
adrenaline 0.4% (n ¼ 10)
Rasmussen, 2000 Postoperative intra-articular
(24) bupivacaine 0.5%
3 mL þ morphine 0.5%
1 mL þ methylprednisolone
4% 1 mL (n ¼ 18) versus
placebo (n ¼ 18)
Middleton, 2006 Postoperative intra-articular
(25) bupivacaine 0.5% 20 mL
(n ¼ 17) versus placebo
(n ¼ 18)
Wound infiltration
Curda, 1983 (26) Postoperative dexamethasone
0.4% (n ¼ 51) versus
placebo (n ¼ 51)
Golf, 2011 (27) Preoperative DepoFoamÒ
bupivacaine 1.5% 8 mL
(n ¼ 93) versus placebo
(n ¼ 92)
Kim, 2011 (28) Ropivacaine 0.75%
4 mL þ morphine 1%
0.1 mL þ ketorolac 3%
0.1 mL þ epinephrine 0.1%
0.06 mL þ NS 5 mL (n ¼ 30)
versus placebo (n ¼ 30)
Jadad Pain Scores
Score
3 ;PODs 0 to 3 at rest in
pethidine group (p < .05)
NS PODs 0 to 3 with
movement
5 ;At rest (p ¼ .005), walking ;Treatment group
(p ¼ .009), heel walking
(p ¼ .009) and toe
walking (p ¼ .009) in
treatment group
4 ;POD 0 in bupivacaine
group (p < .05)
NS POD 1
4 ;24 hr and PODs 4 to 7 in
dexamethasone group
(p  .0004)
5 ;24 hr (p ¼ .0005) and
36 hr (p < .0229) in
bupivacaine group
NS at 48 hr
2 ;Treatment group
(p < .0001)
Supplemental Analgesia
NS
(p ¼ .04)
;POD 0 in bupivacaine
group (p ¼ .009)
NA
;0 to 24 hr in bupivacaine :Bupivacaine group ;Moderate adverse events
group (p ¼ .0077)
;Treatment group
Interval to First Outcome
Supplemental
Analgesia
NA NS nausea, tiredness,
mobilization, LOS,
satisfaction
NA ;Days until pain free
(p ¼ .0004), stopped use of
crutches (p ¼ .0001),
returned to work (p ¼ .002),
resumed sports (p ¼ .04) in
treatment group
;Joint effusions at 4 and 8 wk
in treatment group (p ¼ .01)
NA NS adverse events
NA NS infections or wound
healing
(p < .0001) with bupivacaine
NS in wound healing
NA NS adverse events
:Satisfaction in treatment
group (p < .0001)

Abbreviations: ;, decrease; :, increase; LOS, length of stay; NA, not applicable; NS, not significant; POD, postoperative day.
Peripheral local analgesics included intra-articular administration and wound infiltration.

nonpharmacologic interventions, studies that reported foot and ankle surgery data
pooled with other surgical procedures, studies comparing anesthetic and/or surgical
techniques, and studies comparing 1 local anesthetic with another local anesthetic.
Quality of Included Studies, Analysis of Outcome, and Statistical Analysis
The quality of the eligible studies was assessed using a 3-item instrument on a 0 to 5
quality scale to indicate whether a study had reported appropriate randomization,
double-blinding, and statements of withdrawn participants, as described by Jadad et al
(6). The Jadad scores were calculated by addressing the following questions: was the study
described as randomized (this included the use of terms such as randomly, random, and
randomization); was the study described as double blind; and was a description provided
of withdrawals and dropouts. The studies were given 1 point if they were randomized; an
additional point was given if the method of randomization had been described and was
appropriate (e.g., computer generated). One point was given if the study had been
described as double-blind; an additional point was given if the method of blinding had
been described and was appropriate (e.g., identical placebo). One point was given if
withdrawals or dropouts had been described. One point was deducted if the randomi-
zation described was inappropriate (e.g., patients had been allocated alternately or ac-
cording to the date of birth or hospital number), and another point was deducted if the
study had been described as double-blind, but the method of blinding was inappropriate
(e.g., a comparison of tablet versus injection with no double dummy). Other factors
assessed included description interventions (i.e., precise details of the interventions
intended for each group and how and when they were actually administered), sample size
calculations, and the statistical methods used to compare groups.
Summary information for each included study was extracted and recorded in data
tables. This information included pain scores, supplementary analgesic use, interval to
first supplemental analgesic request, functional outcome, and adverse effects. It was
assumed that the postoperative pain scores were assessed at rest, unless otherwise
specified in the report. The studies were stratified according to the class of analgesic
and the mode of delivery. The effectiveness of each intervention for each outcome was
evaluated qualitatively by assessing the number of studies showing a significant dif-
ference between treatment arms (p  .05, as reported in the study publication).
Quantitative analyses (i.e., meta-analyses) were not performed, owing to the limited
number of included studies with a homogeneous study design.
Results
A total of 953 studies of analgesic interventions after foot and ankle
surgery were identified, of which 45 studies were included in the
systematic review. A flow chart of the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses diagram is shown in the Fig.
Tables 1 to 3 provide details of the included studies (7–51). Overall,
the approaches that showed improved pain relief (reduced pain scores
and/or opioid requirements) included acetaminophen (paracetamol),
nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 selective
inhibitors, opioids, and intravenous dexamethasone as well as regional
analgesia techniques (e.g., peripheral nerve blocks, ankle block, and
wound infiltration with local anesthetics). The techniques that pro-
vided variable results include wound instillation with local anes-
thetics, intra-articular injection of local anesthetic with or without an
opioid, and intravenous regional analgesia.
Although studies assessing peripheral nerve blocks reported
improved pain relief, no clear analgesic superiority was found for
proximal (at the hip) compared with distal (at the knee) peripheral
nerve blocks. Compared with distal blocks at the ankle, popliteal
sciatic nerve blocks appeared to provide a longer duration of anal-
gesia. However, direct comparisons of these approaches were limited.
Continuous perineural local anesthetic infusion also prolonged the
duration of analgesia. Although significant variations were found in
the concentrations of the local anesthetics used, no clear benefit was
noted of 1 long-acting local anesthetic versus another (i.e., bupiva-
caine, ropivacaine, and levobupivacaine). No differences in pain were
found when additives were included with the local anesthetics. The
analgesic benefits of the additives (e.g., clonidine and fentanyl) with
Table 3

6
Studies assessing peripheral nerve blocks for management of pain after elective foot and ankle surgery (n ¼ 23 randomized controlled trials)

Study Study Design
Peripheral nerve blocks at the hip
Fanelli, 1998 (29) Preoperative combined
posterior gluteal sciatic–
femoral nerve block with
ropivacaine 0.75% 25 mL
(n ¼ 15) versus
bupivacaine 0.5% 25 mL
(n ¼ 15) versus
mepivacaine 2% 25 mL
(n ¼ 15)
Casati, 1999 (30) Preoperative combined
posterior gluteal sciatic–
femoral nerve block with
ropivacaine 0.5% (n ¼ 81)
versus ropivacaine 0.75%
Jadad Pain Scores
Score
3 ;Ropivacaine and
bupivacaine groups versus
mepivacaine group
(p ¼ .0001)
5 ;All ropivacaine groups
versus mepivacaine group
(p < .001)
;Ropivacaine 0.75% and 1%
groups versus ropivacaine
Supplemental Analgesia Interval to First Supplemental Outcome Motor or Sensory Onset or
Analgesia Recovery
;Ropivacaine and NA NS ;Onset of sensory (p ¼ .002)
bupivacaine groups and motor (p ¼ .001)
versus mepivacaine blockade in ropivacaine
group (p < .05) group and mepivacaine
versus bupivacaine groups
:Interval to motor recovery
of knee (p ¼ .005) and foot
(p ¼ .0001) in ropivacaine
and bupivacaine groups
versus mepivacaine group
;All ropivacaine groups :All ropivacaine groups NS :Onset of both sensory and
versus mepivacaine versus mepivacaine group motor blockade in
group (p < .001) (p < .001) ropivacaine 0.5% versus
:Ropivacaine 0.75% and 1% other groups (p < .001)
versus ropivacaine 0.5% ;Interval to knee and foot

J. Wang et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–11
(n ¼ 87) versus ropivacaine 0.5% group (p < .05) (p < .05) motor recovery in
1% (n ¼ 86) versus mepivacaine group versus
mepivacaine 2% (n ¼ 82) ropivacaine groups
(p < .001)
Casati, 2000 (31) Preoperative combined 5 NS NS :Ropivacaine + clonidine NS NS adverse events
sciatic–femoral nerve block block group (p ¼ .038) :Interval to motor recovery
with ropivacaine 0.75% 30 with ropivacaine and
mL + clonidine 1 mg/kg clonidine groups
(n ¼ 14) versus ropivacaine (p ¼ .0016)
alone (n ¼ 15)
Magistris, 2000 (32) Preoperative combined 4 NS NS NS NS NA
posterior gluteal sciatic–
femoral nerve block with
ropivacaine 0.75% 30 mL +
fentanyl 1 mg/kg (n ¼ 15)
versus ropivacaine alone
(n ¼ 15)
Casati, 2002 (33) Preoperative posterior gluteal 4 NS NS NS NS NS
sciatic nerve block with
bupivacaine 0.5% 20 mL
(n ¼ 15) versus
levobupivacaine 0.5%
20 mL (n ¼ 15)
di Benedetto, 2002 (34) Postoperative subgluteal 3 NS ;PCA group NA NS NA
sciatic nerve block with (p ¼ .0005)
continuous infusion of
ropivacaine 0.2%, 10 mL/hr
(n ¼ 24) versus ropivacaine
0.2% PCA (n ¼ 24)
di Benedetto, 2002 (35) Preoperative subgluteal 2 NS NS NA NS NA
sciatic nerve block with
ropivacaine 0.75% 20 mL
(n ¼ 30) versus posterior
popliteal approach (n ¼ 30)
 Casati, 2005 (36) Preoperative posterior gluteal
sciatic nerve block with
levobupivacaine 0.5%
(n ¼ 15) versus
levobupivacaine 0.75%
(n ¼ 15) versus ropivacaine
0.75% (n ¼ 15)
Bugamelli, 2007 (37) Preoperative posterior gluteal
sciatic nerve block with
ropivacaine 0.5%
25 mg + mepivacaine 1.5%
225 mg (n ¼ 10) versus
ropivacaine 0.5% 40 mg +
mepivacaine 1.5% 225 mg
(n ¼ 10) versus
mepivacaine 1.5% 300 mg
(n ¼ 10)
Fournier, 2010 (38) Preoperative posterior gluteal
sciatic nerve block with
levobupivacaine 0.5%
20 mL (n ¼ 40) versus
ropivacaine 0.5% 20 mL
(n ¼ 40)
Blumenthal, 2011 (39) Preoperative combined
femoral–popliteal nerve
block with (femoral)
ropivacaine 0.5% 10 mL and
postoperative continuous
infusion of ropivacaine
0.2%, 5 mL/hr + (popliteal)
ropivacaine 0.5% 30 mL and
postoperative ropivacaine
0.3%, 14 mL/hr, then at
24 hr ropivacaine 0.2%,
14 mL/hr (n ¼ 25) versus
postoperative popliteal
catheter continuous
infusion only (n ¼ 25)
Peripheral nerve blocks at the knee
McLeod, 1994 (40) Preoperative lateral popliteal
sciatic nerve block with
bupivacaine 0.5% 20 mL
(n ¼ 21) versus wound
infiltration with
bupivacaine 0.5% 10 mL
before incision + 10 mL
after surgery (n ¼ 19)
4 ;8 hr in levobupivacaine
0.75% group versus
levobupivacaine 0.5%
group (p < .05)
NS 16 hr and 24 hr among all 3
groups
5 :Duration in ropivacaine
40 mg group versus
mepivacaine group
(p < .01)
NS duration in ropivacaine
25 mg group versus
mepivacaine group
4 :Duration in
levobupivacaine group
(p < .031)
5 ;24 to 48 hr with movement ;0 to 48 hr in
in combined block group
(p ¼ .01)
NS 0 to 48 hr at rest
;6 mo with movement in
combined block group
(p ¼ .03)
2 ;0 hr Moderate to severe
pain in wound infiltration
group
(p < .05)
; POD 0, moderate to severe
pain in popliteal sciatic
nerve block group (p < .05)
:Duration in popliteal sciatic
nerve block group (p < .05)
;Levobupivacaine :Levobupivacaine groups NS ;Onset of sensory and motor
0.75% group versus versus ropivacaine group block levobupivacaine
levobupivacaine 0.5% (p ¼ .002) 0.75% group versus
and ropivacaine levobupivacaine 0.5%
groups (p ¼ .05) group (p ¼ .02)
:Interval to sensory block
recovery for
levobupivacaine 0.75%
group versus ropivacaine
group (p < .05)
:Interval to motor block
recovery for
levobupivacaine 0.75%
group versus
levobupivacaine 0.5% and
ropivacaine groups
(p < .05)
NA NA :Interval to ankle NS onset of sensory blockade
joint movement among all 3 groups
between ropivacaine
J. Wang et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–11
40 mg group versus
mepivacaine group
(p ¼ .008)
:Interval to sensory
function in
ropivacaine 40 mg
group versus
mepivacaine group
(p ¼ .002)
;0 to 24 hr in :Levobupivacaine group NS NS onset of sensory and motor
levobupivacaine (p < .0001) blockade
group (p < .034) :Interval to motor recovery
in levobupivacaine group
(p < .044)
NA NS NA
combined block
group (p ¼ .01)
;6 mo in combined
block group
NS NA NS nausea, adverse NA
events
:Satisfaction in
popliteal sciatic
nerve block group
(p < .05)
(continued on next page)
7
Table 3 (continued)

8
Study Study Design Jadad Pain Scores Supplemental Analgesia Interval to First Supplemental Outcome Motor or Sensory Onset or
Score Analgesia Recovery
McLeod, 1995 (41) Preoperative lateral popliteal 2 NS POD 0 ;POD 0 in ankle block NA NS NA
sciatic nerve block with :Duration in popliteal sciatic group (p < .05)
bupivacaine 0.5% nerve block group (p < .05)
15 mL + below-the-knee
subcutaneous field block
with bupivacaine
0.25% 8 mL (n ¼ 21) versus
ankle block with
bupivacaine 0.5% 20 mL
(n ¼ 19)
Fernandez-Guisasola, Preoperative posterior 4 :Duration in ropivacaine ;0 to 24 hr in NA NS satisfaction :Interval to sensory recovery
2001 (42) popliteal sciatic nerve group (p < .001) ropivacaine group in ropivacaine group
block with ropivacaine 0.5% (p < .001)
40 mL (n ¼ 25) versus ;Interval to complete motor
mepivacaine 1% 40 mL block in ropivacaine group
(n ¼ 26) (p < .05)
White, 2003 (43) Preoperative popliteal sciatic 5 ;0 to 48 hr in bupivacaine ;Bupivacaine group NA ;LOS in bupivacaine NA

J. Wang et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–11
nerve block with group (p < .05) (p < .05) group (p ¼ .05)
bupivacaine 0.25% 30 mL NS PODs 2 to 7 :Tingling sensation
with postoperative in foot in bupivacaine
continuous bupivacaine group (p < .05)
0.25%, 5 mL/hr (n ¼ 10) :Satisfaction in
versus placebo (n ¼ 10) bupivacaine group
(p < .02)
NS leg weakness,
numbness
Zaric, 2004 (44) Postoperative popliteal sciatic 5 ;POD 1 to 2 in ropivacaine NS NA NS NA
perineural catheter with group (p ¼ .001)
continuous infusion of NS duration
ropivacaine 0.2% 275 mL at
5 mL/hr (n ¼ 30) versus
placebo (n ¼ 30)
Samuel, 2008 (45) Combined ankle + popliteal 2 ;6 hr (p ¼ .011), 24 hr NS NS :Satisfaction in NA
block preoperatively with (p < .001), at discharge combined block
levobupivacaine 0.5% (p ¼ .014) in combined group (96% versus
(ankle) and block group 76%)
levobupivacaine 0.25%
20 mL (popliteal) (n ¼ 26)
versus ankle block alone
(n ¼ 37)
Taboada, 2008 (46) Preoperative popliteal block 5 ;6 to 12 hr in automated ;Automated bolus group NA NS NS
with mepivacaine 1.5% bolus group (p < .05) (p ¼ .055)
30 mL and 0.125% NS 24 hr
levobupivacaine,
automated 5 mL bolus
every 1 hr for 24 hr (n ¼ 22)
versus continuous infusion
levobupivacaine 0.125%,
5 mL/hr (n ¼ 22)
Zaric, 2010 (47) Postoperative perisciatic 5 NS ;POD 1 in ropivacaine NA NS NS
infusion of ropivacaine 5 mL/hr group
0.2% 8 mL/hr (n ¼ 20) (p ¼ .03)
versus ropivacaine 0.2%
5 mL/hr (n ¼ 20)
Peripheral nerve blocks at the ankle
Needoff, 1995 (48) Preoperative ankle block with
bupivacaine 0.5% 12 mL
(n ¼ 20) versus placebo
(n ¼ 20)
Reinhart, 1996 (49) Preoperative ankle or
metatarsal block with
lidocaine 1.73% + clonidine
10 mg/mL (n ¼ 27) versus
lidocaine + clonidine 20 mg/
mL (n ¼ 25) versus
lidocaine alone (n ¼ 30)
Reinhart, 2000 (50) Preoperative ankle block with
lidocaine 1.73% + ketorolac
0.4% (n ¼ 22) versus
lidocaine 1.73%
alone + ketorolac 20 mg IV
(n ¼ 20) versus lidocaine
1.73% + ethanol 1.3%
(n ¼ 19) versus lidocaine
1.73% alone (n ¼ 18)
Clough, 2003 (51) Preoperative ankle block with
bupivacaine 0.5% 20 mL
(n ¼ 18) versus placebo
(n ¼ 21)
Abbreviations: ;, decrease; :, increase; IV, intravenous; LOS, length of stay; NA, not applicable; NS, not significant; PCA, patient-controlled analgesia; POD, postoperative day.
Peripheral nerve blocks included at the hip, knee, and ankle.
4 ;6 hr in ankle block group
(p < .05)
NS 24 hr and 48 hr
5 NS
:Duration in clonidine 10 mg/
mL group versus lidocaine
alone group (p < .01)
5 ;Lidocaine + ketorolac group
versus lidocaine alone (3 to
9 hr; p < .05) versus
lidocaine + ketorolac IV (4
to 9 hr; p < .05) versus
lidocaine + ethanol (3 to 9
hr; p < .01)
;Lidocaine + ketorolac IV
group versus lidocaine (3 to
4 hr; p < .05) and lidocaine
+ ethanol groups (3 to 9 hr;
p < .05)
:Duration in
lidocaine + ketorolac group
versus lidocaine (p < .01)
and lidocaine + ethanol
groups (p < .05)
5 NS
NS
;0 to 9 hr in clonidine
10 mg/mL group
versus lidocaine
alone group (p < .05)
NS 0 to 9 hr in clonidine
20 mg/mL group versus
lidocaine alone group
;0 to 9 hr in
lidocaine + ketorolac
group versus lidocaine
(p < .05) and lidocaine +
ethanol groups (p < .01)
;0 to 9 hr in lidocaine
+ ketorolac IV group
versus lidocaine
+ ethanol (p < .05)
NS
NA NS NA
:Clonidine 10 mg/mL group :Postoperative NS interval to sensory
versus lidocaine alone hypotension in 1 recovery
group (p < .01) patient in clonidine
20 mg/mL group
:Lidocaine + ketorolac, NS NS interval to sensory
lidocaine + ketorolac IV, recovery
lidocaine + ethanol group
versus lidocaine alone
group (p < .05)
:Lidocaine + ketorolac group
versus lidocaine + ethanol
group (p < .05)
J. Wang et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–11
NA NS NA
9
10 J. Wang et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–11

Table 4
Overall recommendations for pain management in elective foot and ankle surgery

Intervention
Preoperative
Oral acetaminophen plus NSAID or COX-2 selective inhibitors approximately 1 to 2 hr preoperatively, if no contraindications (GoR A)
Popliteal sciatic nerve block with long-acting local anesthetic, if no contraindications, for surgical procedures associated with severe postoperative pain (GoR B)
Intraoperative
Dexamethasone 4 to 8 mg, IV after induction of general anesthesia (GoR A)
Acetaminophen IV, if not administered PO preoperatively (GoR A)
Parenteral NSAID or COX-2 selective inhibitor, if not administered PO preoperatively (GoR A)
Ankle block and/or wound infiltration with long-acting local anesthetic at end of surgery, if popliteal sciatic nerve block not performed preoperatively (GoR B)
Postoperative
Oral acetaminophen plus NSAID or COX-2 selective inhibitor, supplemented with weak opioids (e.g., tramadol) for low-to-moderate intensity pain and stronger opioids
(e.g., hydrocodone, oxycodone, and hydromorphone) for moderate-to-high intensity pain, administered as needed (GoR A)

Abbreviations: COX-2, cyclooxygenase-2; GoR, grade of recommendation (A, good evidence [level I studies with consistent findings] for or against recommending intervention;
B, fair evidence [level II or III studies with consistent findings] for or against recommending intervention; C, poor quality evidence [level IV or V studies with consistent findings] for
or against recommending intervention; I, insufficient or conflicting evidence not allowing recommendation for or against intervention); IV, intravenously; NSAID, nonsteroidal
anti-inflammatory drug; PO, orally.

the local anesthetic solutions, presumably to improve efficacy and
prolong the duration of analgesia, remain contradictory.
Discussion
The present systematic review has provided salient observations
regarding pain management after foot and ankle surgery. The evidence
from the included studies, data from surgical procedures with a similar
pathophysiology of pain (e.g., other orthopedic surgical procedures)
(2,3), and the current understanding of a multimodal analgesia
approach have allowed the development of optimal pain management
strategies for patients undergoing foot and ankle surgery (Table 4).
The use of multimodal therapies (i.e., combinations of drugs and/
or techniques) has been shown to provide superior pain relief and a
reduction in opioid requirements and opioid-related adverse events
(2). Most of the studies assessing pain management after foot and
ankle surgery evaluated dual modality analgesic therapies (i.e., 1 drug
or technique versus placebo or another drug or technique, with
opioids used as “rescue”). Several studies used a combination of
opioid and acetaminophen as the rescue medication and, thus,
essentially provided multimodal analgesia with the study drug or
technique, acetaminophen, and an opioid.
Locoregional analgesic techniques can provide excellent dynamic
pain relief (i.e., pain relief during movement) (52,53) and, thus, should
be used as the first-line analgesic therapy. Because of the lack of
superiority of peripheral nerve blocks at the hip (i.e., a sciatic nerve
block at the gluteus and a femoral nerve block), and the concerns of
delayed ambulation and increased risks of falls (54), distal nerve
blocks (i.e., popliteal sciatic and ankle block) should be preferred. A
popliteal sciatic nerve block (single injection or continuous perineural
infusion) might be appropriate for an extensive surgical procedure
with the anticipation of severe postoperative pain, and an ankle block
(which can also be categorized as a field block) and surgical incision
infiltration with a long-acting local anesthetic might be appropriate
for less extensive and minimally invasive surgical procedures.
Locoregional analgesic techniques should be supplemented with
acetaminophen because of its favorable efficacy–side effect profile
(55,56). Because of differences in the mechanisms of action and
reports of improved analgesic efficacy (57,58), the combination of
acetaminophen and conventional nonsteroidal anti-inflammatory
drugs or cyclooxygenase-2 selective inhibitors should be used
whenever possible. These drugs should be administered at the
appropriate time (i.e., preoperatively or intraoperatively) to provide
sufficient analgesia in the early recovery period and in the post-
operative period (2,3,59). In addition, intraoperative administration of
dexamethasone 4 to 8 mg intravenously can be considered, if the
patient has no contraindications (60). Although concern exists for
increased gastrointestinal side effects, increased wound infection, and
delayed wound healing, it has been shown that a single dose of
dexamethasone is safe. Finally, opioids should be used as “rescue”
analgesics on an as needed basis, because they have often been
associated with undesirable adverse effects that could hinder
recovery (61). Weak opioids (e.g., tramadol) can be used for low-to-
moderate intensity postoperative pain and stronger opioids (e.g.,
hydrocodone, oxycodone, and hydromorphone) for moderate-to-high
intensity postoperative pain.
Our systematic review had several limitations. It is possible that
some well-designed non–English language publications could have
been missed owing to their exclusion from our systematic review.
Nevertheless, it is unlikely that such inclusion would have influenced
the overall conclusions of the present study. Our systematic review has
revealed several areas in which the evidence is insufficient or conflict-
ing. The evidence to identify optimal analgesic combinations and the
optimal route of analgesic administration that would allow improved
pain relief and avoid adverse side effects is limited. The role of
a2d ligands (e.g., gabapentin and pregabalin) should be evaluated (62),
particularly in patients at high risk of persistent postoperative pain.
Finally, properly designed studies evaluating the analgesic benefits of
the recommendations outlined in the present review are needed. The
effect of effective analgesia on long-term outcomes, including the pain
scores after discharge, range of movement at 3 months, and the
incidence of chronic pain, should be evaluated further.
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