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Regional Anesthesia for Foot and Ankle Surgery Mark S. Myerson, Charles M. Ruland and Steven M. Allon Foot Ankle Int 1992 13: 282 DOI: 10.1177/107110079201300510 The online version of this article can be found at: http://fai.sagepub.com/content/13/5/282
Published by: http://www.sagepublications.com
On behalf of:
American Orthopaedic Foot & Ankle Society
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Copyright © 1992 by the American Orthopaedic Foot Society, Inc.
Regional Anesthesia for Foot and Ankle Surgery Mark S. Myerson, M.D., Charles M. Ruland, M.D., and Steven M. Allon, M.D. Baltimore, Maryland
ABSTRACT We present our experience with the use of regional anesthesia in 1295 of 1862 (69.5%) surgical procedures of the foot and ankle between 1986 and 1989. Regional anesthesia was used for surgical procedures of the forefoot, midfoot, hindfoot, and ankle in the setting of elective surgery and trauma. From the viewpoint of the surgeon, regional anesthesia was completely successful in 95% of the procedures performed. Sample patient surveys confirmed that 87% of patients were satisfied with the use of regional anesthesia for their operative procedure. There were four (0.3%) minor complications, one being lidocaine toxicity. With increasing experience, the expanded indications and uses of regional anesthesia for foot and ankle surgery are proving to be simple, safe, reliable, and well tolerated by the patient.
MATERIALS AND METHODS
Between 1986 and 1989, we used regional anesthesia in 1295 of 1862 (69.5%) surgical procedures of the foot and ankle in the setting of trauma and elective surgery. The average age of the patients undergoing elective surgery was 44 years (range 14-84 years), and 31 years (range 16-76 years) for those in the setting of trauma. The regional block was administered by the senior author in all patients undergoing elective surgery and on occasion by other members of the foot and ankle team for patients with trauma. Between 1986 and 1988, intravenous sedation was utilized as an adjunct to regional anesthesia in 16% of patients undergoing elective surgery. This required the presence of an anesthesiologist, and the patient was not allowed food nor drink for the appropriate duration prior to surgery. Currently, all outpatient foot and ankle surgery is performed under regional anesthesia without intravenous sedation. An anesthesiologist is not present during the procedure, and routine cardiovascular monitoring is performed by the circulating nurse. Each block is administered by the senior author 1 hr prior to commencing the surgery. Regulations at our institution preclude the administration of intravenous sedation by the operating surgeon. Since the patient is allowed to eat or drink, we routinely use a short-acting oral benzodiazepine (lorazepam)-1 mg the night before surgery, 1 mg in the morning, and, if the procedure is performed in the afternoon, an additional 1 mg 2 hr before surgery. This does preclude the use of other types of anesthesia should the block fail completely. However, we feel that there are advantages to this technique that overshadow the rare complication of a failed block. The more extensive hindfoot and ankle procedures which are performed under regional anesthesia are normally supplemented with intravenous sedation administered by an anesthesiologist, who monitors the patient.
INTRODUCTION
A variety of anesthetic techniques, including general, spinal, epidural, intravenous, regional, and local anesthesia, are readily available to the surgeon performing procedures of the foot and ankle. As the scope and volume of orthopaedic foot and ankle surgery increase, especially in the outpatient setting, the role of regional anesthesia continues to expand. With increasing experience, regional anesthesia is proving to be simple, safe, reliable, and well tolerated by the patient.2,4,9,13,18,19,22 Different techniques of regional anesthesia for the foot have been well described, and most of them have been used strictly for forefoot and midfoot surgery.1,2.8,9,13,18-20,22 In this study, we present our experience with regional anesthesia in the setting of elective and trauma surgery for procedures of the forefoot, midfoot, hindfoot, and ankle. The expanded indications and uses for regional anesthesia are discussed. From Union Memorial Hospital, 201 E. University Pkwy, Baltimore, Maryland 21218. Address reprint requests to Dr. Myerson. 282
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Foot & Ankle/Vol. 13, No. 5/June 1992 Techniques of Regional Anesthesia
No tourniquet is used, and bleeding is controlled with hemostat clamps and minimal use of electrocautery. In the event of uncontrollable bleeding during hindfoot surgery, an Esmarch bandage? is used temporarily. The anesthetic agent used for the standard ankle and digital blocks is 0.5% bupivacaine hydrochloride (Marcaine) without admixed epinephrine. This is administered 1 hr before surgery commences. If there is insufficient time available to allow a more gradual onset of the block before surgery, then an equal volume of 0.5% bupivacaine hydrochloride and 1% lidocaine hydrochloride (Xylocaine) is used. Once the block is administered, patients remain in a lounge until surgery commences. The level of anesthesia is checked with the pinch of a forceps prior to the patient entering the operating room; if incomplete, it is supplemented with a mixture of 0.5% bupivacaine and 0.5% lidocaine. This same mixture is also used intraoperatively to supplement an incomplete or inadequate block. The total dose of lidocaine and marcaine injected is calculated for each patient. In a normal, healthy adult, the maximum safe dose of lidocaine without epinephrine should not exceed 4.5 mg/ kg of body weight, and in general, it is recommended that the maximum total dose does not exceed 300 mg. For a 70 kg adult, this comprises approximately 30 ml of 1% (10 mg/ml) lidocaine. The maximum safe dose of Marcaine without epinephrine should not exceed 2.5 mg/kg of body weight, comprising a maximum dose of approximately 175 mg, or 35 ml of a 0.5% Marcaine solution for a 70 kg adult. The effects of these two anesthetic agents are additive, and an equal combination of lidocaine and bupivacaine without epinephrine should be limited to half the maximum safe dose of each of these agents. When used together, the maximum safe dose should be limited to 15 ml of 1% lidocaine with 17.5 ml of 0.5% Marcaine. A dilute concentration of epinephrine (1 :200,000) may be used with lidocaine and Marcaine, thereby reducing the rate of absorption and peak plasma concentrations. With epinephrine, the required dose is decreased, the duration of the anesthetic effect is prolonged, and larger total doses may be used. When used with epinephrine, the maximum safe dose of lidocaine should not exceed 7 mg/kg of body weight, with a maximum total dose not to exceed 500 mg. In the average 70-kg man, this comprises 50 ml of a 1% lidocaine with epinephrine (1 :200,000) solution. When Marcaine with epinephrine is used, the recommended maximum safe dose should not exceed 3.2 mg/kg of body weight with a maximum total dose of 225 mg for a 70 kg man.
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The elimination half-life of lidocaine following an intravenous bolus injection is 1.5 hr, and for Marcaine it is 2.7 hr. The recommended repeat dose for Marcaine with or without epinephrine is once every 3 hr. To our knowledge, there are no recommendations as to when this dose may be repeated for lidocaine. With a shorter half-life, when compared with Marcaine, we would expect that a repeat dose of lidocaine may be administered in 1 to 2 hr. The technique of administering the regional anesthetic differs according to the procedure performed. A standard ankle block is used for midfoot and forefoot procedures, digital blocks for procedures limited to two or fewer lesser toes distal to the metatarsophalangeal joint, and modified regional blocks for the hindfoot and ankle. These are described below. Standard Ankle Block
The various sensations that the block may cause, including stinging, pressure, fullness, and particularly sudden paresthesias, are carefully explained to the patient. The block is administered with the patient lying supine in a preoperative waiting lounge. The tibial nerve is blocked approximately two finger breadths proximal to the medial malleolus, 1 to 1112 ern anterior to the Achilles tendon (Fig. 1). The tibial artery is palpated, and a 25-gauge 1112-in needle is inserted just posterior to it. It is occasionally easier to palpate the tibial nerve subcutaneously by rolling it gently at the level of the medial malleolus than to locate the posterior tibial pulse.
Fig. 1. Standard ankle block.
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In the presence of swelling or if the pulse is not palpable, the medial malleolus is used as the surface landmark. The needle is advanced slowly, the flexor retinaculum pierced, and the syringe aspirated to avoid inadvertent intravenous or arterial injection. Approximately 10 ml of anesthetic solution is slowly injected. A palpable fullness along the neurovascular sheath beneath the flexor retinaculum confirms correct placement of the solution. Paresthesias are extremely uncomfortable to the patient and should not be elicited to verify correct placement of the needle. If this occurs, the needle is withdrawn approximately 2 mm and redirected. Very slow introduction of the needle and the anesthetic agent is well tolerated and, generally, the patient will report only a sense of pressure or fullness in this location. The intermediate and mediodorsal cutaneous branches of the superficial peroneal nerve are blocked with subcutaneous infiltration across the dorsum of the midfoot with 5 ml of solution (Fig. 2). If surgery is performed on the lateral aspect of the foot, the sural nerve is blocked by infiltrating subcutaneously lateral and inferior to the peroneal tendons at the level of the lateral malleolus. The deep peroneal nerve is blocked at the level of the ankle joint by penetrating the extensor
\
\~ _/
Fig. 2. The intermediate and mediodorsal cutaneous branches of the superficial peroneal nerve are blocked.
retinaculum between the extensor digitorum and extensor hallucis longus tendons and injecting 2 to 3 ml of anesthetic solution (Fig. 3). Digital Blocks
One to 2 ml of anesthetic solution are infiltrated medially, dorsally, and laterally around the base of each toe. If a limited soft tissue procedure is performed at the metatarsophalangeal joint, then the dorsal block is infiltrated slightly more proximally, at the level of the metatarsal neck. For more extensive surgery about the metatarsophalangeal joint or if more than two toes are operated upon, then a standard ankle block is used. Hindfoot and Ankle Surgery
As can be seen in Table 1, regional anesthesia was used in 284 procedures about the hindfoot and ankle. The technique is modified for these more extensive procedures and more dilute, larger volumes of anesthetic are used. A similar block is used for ankle arthroplasty, ankle fractures, osteotomies, and arthrodesis procedures of the hindfoot. Approximately 40 ml of 0.25% bupivacaine are used admixed with epinephrine in a concentration of 1:200,000. The epinephrine provides a slight vasoconstrictive effect, decreases bleeding, and prolongs the efficacy of the block. The sural, superficial and deep peroneal, and saphenous nerves are all infiltrated 3 to 4 cm proximal to the ankle joint. The posterior tibial nerve is infiltrated 6 to 8 cm proximal to the level of the medial malleolus, slightly deeper, and more posterior. The retrocalcaneal space is infiltrated with 5 ml, and the ankle joint and sinus tarsi are infiltrated with an additional 5 ml each. If the posterior tibial or peroneal tendons are being operated upon, then their respective sheaths are infiltrated with 5 ml, omitting the superficial block on the opposite side of the ankle. The block for Achilles tendon procedures is administered circumferentially about the tendon, both superficially and then infiltrating deeply into the retrocalcaneal space and more proximally at the musculotendinous junction. To evaluate the success of these varied regional anesthesia techniques, 180 patients undergoing elective surgery under regional anesthesia in 1988 answered a questionnaire on the day of surgery in the immediate postoperative period. A total of 75% of these patients completed a similar survey at their first postoperative visit to ascertain any change in their perspectives regarding the use of regional anesthesia. A total of 206 patients who underwent surgical procedures under regional anesthesia between 1987 and 1988 were sent the same questionnaire by mail, and the answers of the 173 respondents were evaluated.
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TABLE 1 Procedures Performed Forefoot Bunionectomy, cheilectomy, bunionnette Lesser toe procedures MP and IP fusion of the hallux Rheumatoid forefoot procedures Metatarsal osteotomies Neuroma resection Amputation Hardware removals Debridements Incision and drainage Sesamoidectomies Midfoot Soft tissue tumor resections Hardware removal Amputations Tarsometatarsal arthrodesis Osteotomies Incision and drainage Wound debridements Hindfoot Tendon procedures Nerve procedures (tibial, sural, peroneal) Wound debridements Retrocalcaneal procedures Arthrodesis Osteotomies, ostectomies Hardware removal Incision and drainage Amputations Ankle Ligament reconstruction Cheilectomy, ankle arthroplasty, synovectomy Trauma Forefoot fractures Midfoot fractures Ankle fractures Soft tissue coverage/local flaps/skin grafts
Fig. 3. The deep peroneal nerve is blocked at the level of the ankle joint.
RESULTS
The regional anesthesia was completely successful from the standpoint of the surgeon in 1231 of the 1295 patients (95%). To be completely successful, no supplementary regional anesthetic was used intraoperatively, and no general anesthesia or unplanned intravenous sedation was resorted to. The block failed completely in three patients (0.2%) in whom no amount of regional anesthesia had any effect whatsoever on controlling the sensation of pain. A 34-year-old, healthy male patient undergoing a fifth metatarsal osteotomy had 10 ml of 1% lidocaine and 10 ml of 0.5% bupivacaine infiltrated initially. An additional 10 ml of 0.5% lidocaine and 5 ml of 0.5% bupivacaine were infiltrated 1 to 2 hr later. No anesthetic effect was obtained and
278 193 71 102
50 47
29 25 15 7
12
23 20 19 8 5 5 4
57 24 28 27 34 37 7
4 13 20
27 7 12 6
58
since the patient had not been adequately prepared, general anesthesia was resorted to later in the day. In a second patient, an ankle debridement was abandoned due to failure to obtain any anesthesia. However, three subsequent attempts at spinal anesthesia also failed, despite apparent correct positioning of the needle and visualization of the spinal fluid tap. A third patient complained of pain during an elective forefoot procedure, and this sensation persisted even immediately adjacent to the area of skin infiltrated with the local anesthetic. These failures were distinctly different from those in 14 patients (1.1%), where adequate anesthesia was thought to have been obtained by the surgeon, but the patient was extremely anxious and tolerated neither the pressure sensations nor any manipulation of the foot, interpreting this as painful. In five of these patients, intravenous sedation, which had not been planned preoperatively, was used to complete the procedure. In the remaining nine, a nurse was able to calm
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the patient well enough so that the procedure was completed uneventfully. In 47 patients (3.6%), the regional block had worked partially; additional local anesthetic was administered intraoperatively, and the procedure was completed uneventfully and successfully in each patient. There was no correlation between success of the block and the type of procedure performed. A total of 353 patient surveys were evaluated. There was a good correlation between the responses obtained on the day of surgery (180 patients) and those of patients whose surgery was performed up to 1 year earlier (173 patients). There was minimal change in the patient's perspective of the anesthesia from the day of surgery to the answers obtained 1 week later. Their responses confirmed a high success rate of the regional anesthesia, and 92% of patients were satisfied with the level of intraoperative comfort obtained. The average duration of anesthesia was 9 hr (range 6-28 hr). Nine percent of patients found the noises of the operating room unpleasant, and 98% were pleased to be able to discuss the progress of surgery with the nurses and physicians. Forty-two percent experienced pressure, pulling, or vibration; however, only 6% of patients were bothered by these sensations. Of the 353 respondents, 79% stated that they would prefer local over other forms of anesthesia if they had to undergo foot or ankle surgery in the future. Of the remaining 21%, 42% chose intravenous sedation in addition to local anesthesia, 47% general, and 11% spinal or epidural anesthesia. These responses, however, were at a time when no preoperative oral sedation was used. There were four complications from the regional anesthesia. One patient, a 60-kg man, was blocked successfully for debridement of an open foot injury. During the procedure, the patient became hypotensive and a supraventricular tachycardia developed. This was treated with intravenous fluids, and the surgery concluded uneventfully with halothane mask anesthesia. No residual adverse cardiorespiratory sequelae were detected in this patient. This complication was thought to be due to lidocaine toxicity. This patient had received 12 ml of 1% lidocaine (120 mg) and 12 ml of 0.5% bupivacaine (60 mg) in the emergency department, and an additional 10 ml of 0.5% lidocaine (50 mg) and 10 ml of 0.5% Marcaine (50 mg) intraoperatively. This amounts to 170 mg of lidocaine and 110 mg of Marcaine, reaching the toxic range for this 60-kg man. There were three minor complications in patients who developed a severe vasovagal reaction induced by the sight of the syringe or immediately following insertion of the needle. No other complications, such as postoperative neuritis, hematoma formation, or infection at the injection site, occurred.
DISCUSSION
We have expanded the uses and indications for regional anesthesia of the foot and ankle and found the success rate and patient acceptance to be high. Since we do not routinely use a tourniquet, we are able to perform more extensive procedures of the hindfoot and ankle under regional anesthesia, including trauma. We attempt to block most patients with open or closed forefoot and midfoot trauma immediately after a thorough neurovascular examination. This significantly enhances patient comfort while in the emergency department, and expedites definitive treatment of the injury, since many of these patients are not adequately prepared for general anesthesia. We rarely use general anesthesia in the patient with diabetes. This has been invaluable because many of these patients have multiple medical problems that increase the risk of general anesthesia significantly. Fatality occurs in approximately one in 10,000 routine procedures in which general or spinal anesthesia is performed." The incidence of these and other significant complications, such as myocardial infarction, pulmonary compromise, and hypotensive shock, increase 15fold in higher risk patients with diabetes or other major systemic cardiopulmonary disorder." The concern for toxic anesthetic levels using peripheral extremity nerve blocks, while present, is not nearly as pressing as it is in cases in which intravenous local anesthesia is used.5 ,10- 12 ,15- 17,2 1 Intravenous regional anesthesia introduced by Bier in 1908 has been associated with complications of cardiac arrhythmias 14 and death .11 Adverse reactions following the administration of lidocaine are similar to those observed with other amide local anesthetics; in general, these are dose related and result from high plasma levels caused by excessive dosage, rapid absorption, or intravascular injection. Most of the data on toxicity of regional anesthesia are derived from its use in the upper extremities. We believe that the absorption from the lower extremities may be similar, but we have no data to support this. Lidocaine may cause stimulation of the central nervous system (CNS), producing restlessness, nervousness, dizziness, confusion, tremors, and convulsions. These excitatory manifestations may occur transiently or not at all, in which case the first manifestations of toxicity are depressant and characterized by drowsiness, unconsciousness, and respiratory arrest. Cardiovascular manifestations are usually depressant and include bradycardia, hypotension heart block, and ventricular arrhythmias (including ventricular tachycardia and ventricular fibrillation), which may lead to cardiac arrest. These cardiovascular effects are usually seen only after high systemic concentrations are attained and CNS
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effects produced. Marcaine toxicity has similar CNS and cardiac manifestations. Cases of suspected lidocaine or Marcaine toxicity should be managed immediately by monitoring of cardiorespiratory status and of the patient's level of consciousness. Oxygen should be administered immediately. CNS excitability and muscular spasm can be managed with a short-acting intravenous barbiturate or neuromuscular blockade with succinylcholine. Convulsions, as well as respiratory depression or failure, are treated by maintenance of a patent airway, appropriate ventilatory support, and intravenous benzodiazepines. Rarely, individuals are hypersensitive to local anesthetics and develop allergic dermatitis, urticaria, angioneurotic edema, bronchospasm, or even fatal anaphylaxis. The reaction may occur as a result of sensitivity either to the local anesthetic agent or to the methylparaben used as an antimicrobial preservative in multiple dose vials. Management of allergic reactions is by conventional means. Over the years, we have found that the success rate of regional anesthesia both from the perspective of patient and physician improves if the block is administered well in advance of the surgery. The patients are far less anxious when they realize that the foot is indeed completely anesthetic before surgery commences. Based on the patient responses to the questionnaires, we started using preoperative oral sedation and found that both the block and the patient's perspective of the operation improved. Patients were instructed to bring in headphones with them to listen to music of their choice and no longer found the operating room noises unpleasant. A frustrating problem occurs when a satisfactory block has been given, but the patient has not been adequately prepared and is extremely anxious during surgery. Although the level of anesthesia may be sufficient for most patients, this discomfort may become intolerable, and it is difficult to "catch up" by administering additional anesthesia. For these reasons, we prefer to give the block at least 1 hr before surgery, so that any additional local is administered before the patient enters the operating room. There is clearly a variability in the amount of anesthetic agent that patients require. There are patients for whom the standard volume and concentration of block seems inadequate and for whom the anesthetic effect recedes quickly. These are often patients who report that they "need extra Novocain" at the dentist's office. There are several possible explanations of this variable effect of equivalent doses in different individuals. Increased nerve fiber size, decreased pH, and increased serum calcium concentration are inversely proportional to the rate of onset and potency of anesthetic effect. Long-acting agents such as bupivacaine are lipophilic and more protein bound than shorter
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acting, hydrophilic, and less protein-bound agents, such as lidocaine. Greater body size and fat stores might delay onset of action, but allow for longer anesthesia. Increased urine acidity can cause ionization of the agent to a more water-soluble and less resorbable form, thus increasing excretion and decreasing serum concentration. Both lidocaine and bupivacaine are amides and, therefore, are almost entirely metabolized by the hepatic endoplasmic reticulum. A deficiency or defect in such enzymes or other liver disease, could result in increased circulatory levels and effects of the drugs. Regional anesthesia may be used in the presence of local sepsis of the foot; however, due to the decreased pH of the surrounding tissues, the block may not work adequately if given adjacent to this focal sepsis. As can be seen from Table 1, we used regional anesthesia in a total of 21 patients who had some focal form of sepsis. The block, however, was not administered locally around the abscess or infection, but a standard ankle block was given to minimize the effect of the decreased pH on the amide. Although economic issues should not be a significant consideration in determining the type of anesthesia one chooses for a patient, regional anesthesia is clearly more efficient and less costly. There is no charge for anesthesia services, no utilization of the recovery room after the operation, less usage of inpatient resources, and decreased turnover time between surgical procedures in the operating room. Current regulatory trends to curtail hospital costs have encouraged and, in many instances, mandated short stay and outpatient surgical procedures. While the use of regional anesthesia certainly meets these requirements, the quality of patient care should never be compromised and must remain our primary objective. We have been satisfied with the results of regional anesthesia for many procedures of the foot and ankle. During the time of this study, 69.5% of the procedures were performed under regional foot and ankle anesthesia. With increasing experience, including hindfoot and ankle procedures, almost 80% of our procedures are now performed under regional anesthesia, a trend to be recommended.
REFERENCES
1. Adriani, J.: Labat's Regional Anesthesia. Techniques and Clinical Applications, 4th Ed. Philadelphia, W.B. Saunders, 1985. 2. Beskin, J.L., and Baxter, D.E.: Regional anesthesia for ambulatory foot and ankle surgery. Orthopaedics, 10:109-11, 1987. 3. Bier, A.: Ueber einen neunen weg Local anasthesia en den Gleidmassen zu erzeugen. Arch. kin. Chir., 86:1007-1016,1908. 4. Bridenbaugh, L.D.: Regional anesthesia for surgery of the extremities. Clin. Anesth., 2:198,1969.
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5. Davies, J.A.: Intravenous regional analgesia with prilocaine for foot surgery. The effect of slow injections and high tourniquet inflation pressures. Anaesthesia, 44:902-906, 1989. 6. Dripps, R., Eckenhoff, J., and Vandam, L.: Introduction to Anesthesia, 7th Ed. Philadelphia, W.B, Saunders, 1988, p. 415. 7. Rang, M.: Anthology of Orthopaedics. London, Edinburgh, E & S Livingstone, 1966, pp. 167-174. 8. Flood, B.M., and Shah, M.V.: Intravenous regional anesthesia for lower limb orthopaedic surgery (letter). Ann. R. Coli. Surg. Engl., 70:257-259,1988. 9. Giachino, A.A.: Surgeon administered local anesthesia for forefoot surgery. Can. J. Surg., 31:383-384, 1988. 10. Hanton, R.J., and Punchihewa, V.G.: Intravenous regional ananalgesia using bupivacaine. Anaesthesia, 37:350-351, 1982. 11. Heath, M.L.: Deaths after intravenous regional anesthesia. Br. Med. J., 285:913-914.1982. 12. Kennedy, B.R., Duthie, A.M., Parbrook, G.D., and Carr, T.L.: Intravenous regional anesthesia: an appraisal. Sr. Med. J., 1:954-957,1965. 13. Kofoed, H.: Peripheral nerve blocks at the knee and ankle in operations for common foot disorders. Clin. Orthop., 168:97101,1982. 14. Kotelko, D.M., Shnider, S.M., Daily, P.A., Brizgys, R.V., Levinson, G., Shapiro, W.A., Koike, M., and Rosen, M.A.:
15.
16.
17.
18.
19.
20. 21. 22.
Supivacaine-induced cardiac arrhythmias in sheep. Anesthesiology, 60:10-18, 1984. Mazze, R.I., and Dunbar, R.W.: Intravenous regional anesthesia-report of 497 cases with toxicity study. Acta Anaestheslol, Scand. (Suppl.), 36:27-34,1969. Rosenberg, P.H., and Kalso, E.A.; Acute bupivacaine toxicity as a result of venous leakage under the tourniquet cuff during a Bier block. Anesthesiology, 58:95-98,1983. Sage, D., Feldman, H., Arthur, G.R., and Covino, B.G.: Cardiovascular effects of lidocaine and bupivacainein the awake dog. Anesthesiology, 59:A210, 1983. Sarratian, S.K., Ibrahim, I.N., and Breihan, J.H.: Ankle foot peripheral nerve block for mid and forefoot surgery. Foot Ankle, 4:86-90, 1983. Sarratian, S.K.: Regional Anesthesia of the Midfoot and Forefoot. In Disorders of the Foot. Jahss, M.H. (ed.). Philadelphia, W.B. Saunders. 1982. Schurman, D.J.: Ankle-block anesthesia for foot surgery. Anesthesiology, 44(4):348-352, 1976. Scott, D.B.: Toxicity and clinical use of prilocaine. Proc. R. Soc. Med., 58:420-422,1965. Sharrock, N.E., Waller, J.F., and Fierro, L.E.: Midtarsal block for surgery of the forefoot. Br. J. Anaesth., 58:37-40,1986.
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Regional Anesthesia for Foot and Ankle Surgery Mark S. Myerson, Charles M. Ruland and Steven M. Allon Foot Ankle Int 1992 13: 282 DOI: 10.1177/107110079201300510 The online version of this article can be found at: http://fai.sagepub.com/content/13/5/282
Published by: http://www.sagepublications.com
On behalf of:
American Orthopaedic Foot & Ankle Society
Additional services and information for Foot & Ankle International can be found at: Email Alerts: http://fai.sagepub.com/cgi/alerts Subscriptions: http://fai.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
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0198-0211/92/1305-0282$03.00/0 FOOT
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Copyright © 1992 by the American Orthopaedic Foot Society, Inc.
Regional Anesthesia for Foot and Ankle Surgery Mark S. Myerson, M.D., Charles M. Ruland, M.D., and Steven M. Allon, M.D. Baltimore, Maryland
ABSTRACT We present our experience with the use of regional anesthesia in 1295 of 1862 (69.5%) surgical procedures of the foot and ankle between 1986 and 1989. Regional anesthesia was used for surgical procedures of the forefoot, midfoot, hindfoot, and ankle in the setting of elective surgery and trauma. From the viewpoint of the surgeon, regional anesthesia was completely successful in 95% of the procedures performed. Sample patient surveys confirmed that 87% of patients were satisfied with the use of regional anesthesia for their operative procedure. There were four (0.3%) minor complications, one being lidocaine toxicity. With increasing experience, the expanded indications and uses of regional anesthesia for foot and ankle surgery are proving to be simple, safe, reliable, and well tolerated by the patient.
MATERIALS AND METHODS
Between 1986 and 1989, we used regional anesthesia in 1295 of 1862 (69.5%) surgical procedures of the foot and ankle in the setting of trauma and elective surgery. The average age of the patients undergoing elective surgery was 44 years (range 14-84 years), and 31 years (range 16-76 years) for those in the setting of trauma. The regional block was administered by the senior author in all patients undergoing elective surgery and on occasion by other members of the foot and ankle team for patients with trauma. Between 1986 and 1988, intravenous sedation was utilized as an adjunct to regional anesthesia in 16% of patients undergoing elective surgery. This required the presence of an anesthesiologist, and the patient was not allowed food nor drink for the appropriate duration prior to surgery. Currently, all outpatient foot and ankle surgery is performed under regional anesthesia without intravenous sedation. An anesthesiologist is not present during the procedure, and routine cardiovascular monitoring is performed by the circulating nurse. Each block is administered by the senior author 1 hr prior to commencing the surgery. Regulations at our institution preclude the administration of intravenous sedation by the operating surgeon. Since the patient is allowed to eat or drink, we routinely use a short-acting oral benzodiazepine (lorazepam)-1 mg the night before surgery, 1 mg in the morning, and, if the procedure is performed in the afternoon, an additional 1 mg 2 hr before surgery. This does preclude the use of other types of anesthesia should the block fail completely. However, we feel that there are advantages to this technique that overshadow the rare complication of a failed block. The more extensive hindfoot and ankle procedures which are performed under regional anesthesia are normally supplemented with intravenous sedation administered by an anesthesiologist, who monitors the patient.
INTRODUCTION
A variety of anesthetic techniques, including general, spinal, epidural, intravenous, regional, and local anesthesia, are readily available to the surgeon performing procedures of the foot and ankle. As the scope and volume of orthopaedic foot and ankle surgery increase, especially in the outpatient setting, the role of regional anesthesia continues to expand. With increasing experience, regional anesthesia is proving to be simple, safe, reliable, and well tolerated by the patient.2,4,9,13,18,19,22 Different techniques of regional anesthesia for the foot have been well described, and most of them have been used strictly for forefoot and midfoot surgery.1,2.8,9,13,18-20,22 In this study, we present our experience with regional anesthesia in the setting of elective and trauma surgery for procedures of the forefoot, midfoot, hindfoot, and ankle. The expanded indications and uses for regional anesthesia are discussed. From Union Memorial Hospital, 201 E. University Pkwy, Baltimore, Maryland 21218. Address reprint requests to Dr. Myerson. 282
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Foot & Ankle/Vol. 13, No. 5/June 1992 Techniques of Regional Anesthesia
No tourniquet is used, and bleeding is controlled with hemostat clamps and minimal use of electrocautery. In the event of uncontrollable bleeding during hindfoot surgery, an Esmarch bandage? is used temporarily. The anesthetic agent used for the standard ankle and digital blocks is 0.5% bupivacaine hydrochloride (Marcaine) without admixed epinephrine. This is administered 1 hr before surgery commences. If there is insufficient time available to allow a more gradual onset of the block before surgery, then an equal volume of 0.5% bupivacaine hydrochloride and 1% lidocaine hydrochloride (Xylocaine) is used. Once the block is administered, patients remain in a lounge until surgery commences. The level of anesthesia is checked with the pinch of a forceps prior to the patient entering the operating room; if incomplete, it is supplemented with a mixture of 0.5% bupivacaine and 0.5% lidocaine. This same mixture is also used intraoperatively to supplement an incomplete or inadequate block. The total dose of lidocaine and marcaine injected is calculated for each patient. In a normal, healthy adult, the maximum safe dose of lidocaine without epinephrine should not exceed 4.5 mg/ kg of body weight, and in general, it is recommended that the maximum total dose does not exceed 300 mg. For a 70 kg adult, this comprises approximately 30 ml of 1% (10 mg/ml) lidocaine. The maximum safe dose of Marcaine without epinephrine should not exceed 2.5 mg/kg of body weight, comprising a maximum dose of approximately 175 mg, or 35 ml of a 0.5% Marcaine solution for a 70 kg adult. The effects of these two anesthetic agents are additive, and an equal combination of lidocaine and bupivacaine without epinephrine should be limited to half the maximum safe dose of each of these agents. When used together, the maximum safe dose should be limited to 15 ml of 1% lidocaine with 17.5 ml of 0.5% Marcaine. A dilute concentration of epinephrine (1 :200,000) may be used with lidocaine and Marcaine, thereby reducing the rate of absorption and peak plasma concentrations. With epinephrine, the required dose is decreased, the duration of the anesthetic effect is prolonged, and larger total doses may be used. When used with epinephrine, the maximum safe dose of lidocaine should not exceed 7 mg/kg of body weight, with a maximum total dose not to exceed 500 mg. In the average 70-kg man, this comprises 50 ml of a 1% lidocaine with epinephrine (1 :200,000) solution. When Marcaine with epinephrine is used, the recommended maximum safe dose should not exceed 3.2 mg/kg of body weight with a maximum total dose of 225 mg for a 70 kg man.
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The elimination half-life of lidocaine following an intravenous bolus injection is 1.5 hr, and for Marcaine it is 2.7 hr. The recommended repeat dose for Marcaine with or without epinephrine is once every 3 hr. To our knowledge, there are no recommendations as to when this dose may be repeated for lidocaine. With a shorter half-life, when compared with Marcaine, we would expect that a repeat dose of lidocaine may be administered in 1 to 2 hr. The technique of administering the regional anesthetic differs according to the procedure performed. A standard ankle block is used for midfoot and forefoot procedures, digital blocks for procedures limited to two or fewer lesser toes distal to the metatarsophalangeal joint, and modified regional blocks for the hindfoot and ankle. These are described below. Standard Ankle Block
The various sensations that the block may cause, including stinging, pressure, fullness, and particularly sudden paresthesias, are carefully explained to the patient. The block is administered with the patient lying supine in a preoperative waiting lounge. The tibial nerve is blocked approximately two finger breadths proximal to the medial malleolus, 1 to 1112 ern anterior to the Achilles tendon (Fig. 1). The tibial artery is palpated, and a 25-gauge 1112-in needle is inserted just posterior to it. It is occasionally easier to palpate the tibial nerve subcutaneously by rolling it gently at the level of the medial malleolus than to locate the posterior tibial pulse.
Fig. 1. Standard ankle block.
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In the presence of swelling or if the pulse is not palpable, the medial malleolus is used as the surface landmark. The needle is advanced slowly, the flexor retinaculum pierced, and the syringe aspirated to avoid inadvertent intravenous or arterial injection. Approximately 10 ml of anesthetic solution is slowly injected. A palpable fullness along the neurovascular sheath beneath the flexor retinaculum confirms correct placement of the solution. Paresthesias are extremely uncomfortable to the patient and should not be elicited to verify correct placement of the needle. If this occurs, the needle is withdrawn approximately 2 mm and redirected. Very slow introduction of the needle and the anesthetic agent is well tolerated and, generally, the patient will report only a sense of pressure or fullness in this location. The intermediate and mediodorsal cutaneous branches of the superficial peroneal nerve are blocked with subcutaneous infiltration across the dorsum of the midfoot with 5 ml of solution (Fig. 2). If surgery is performed on the lateral aspect of the foot, the sural nerve is blocked by infiltrating subcutaneously lateral and inferior to the peroneal tendons at the level of the lateral malleolus. The deep peroneal nerve is blocked at the level of the ankle joint by penetrating the extensor
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Fig. 2. The intermediate and mediodorsal cutaneous branches of the superficial peroneal nerve are blocked.
retinaculum between the extensor digitorum and extensor hallucis longus tendons and injecting 2 to 3 ml of anesthetic solution (Fig. 3). Digital Blocks
One to 2 ml of anesthetic solution are infiltrated medially, dorsally, and laterally around the base of each toe. If a limited soft tissue procedure is performed at the metatarsophalangeal joint, then the dorsal block is infiltrated slightly more proximally, at the level of the metatarsal neck. For more extensive surgery about the metatarsophalangeal joint or if more than two toes are operated upon, then a standard ankle block is used. Hindfoot and Ankle Surgery
As can be seen in Table 1, regional anesthesia was used in 284 procedures about the hindfoot and ankle. The technique is modified for these more extensive procedures and more dilute, larger volumes of anesthetic are used. A similar block is used for ankle arthroplasty, ankle fractures, osteotomies, and arthrodesis procedures of the hindfoot. Approximately 40 ml of 0.25% bupivacaine are used admixed with epinephrine in a concentration of 1:200,000. The epinephrine provides a slight vasoconstrictive effect, decreases bleeding, and prolongs the efficacy of the block. The sural, superficial and deep peroneal, and saphenous nerves are all infiltrated 3 to 4 cm proximal to the ankle joint. The posterior tibial nerve is infiltrated 6 to 8 cm proximal to the level of the medial malleolus, slightly deeper, and more posterior. The retrocalcaneal space is infiltrated with 5 ml, and the ankle joint and sinus tarsi are infiltrated with an additional 5 ml each. If the posterior tibial or peroneal tendons are being operated upon, then their respective sheaths are infiltrated with 5 ml, omitting the superficial block on the opposite side of the ankle. The block for Achilles tendon procedures is administered circumferentially about the tendon, both superficially and then infiltrating deeply into the retrocalcaneal space and more proximally at the musculotendinous junction. To evaluate the success of these varied regional anesthesia techniques, 180 patients undergoing elective surgery under regional anesthesia in 1988 answered a questionnaire on the day of surgery in the immediate postoperative period. A total of 75% of these patients completed a similar survey at their first postoperative visit to ascertain any change in their perspectives regarding the use of regional anesthesia. A total of 206 patients who underwent surgical procedures under regional anesthesia between 1987 and 1988 were sent the same questionnaire by mail, and the answers of the 173 respondents were evaluated.
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TABLE 1 Procedures Performed Forefoot Bunionectomy, cheilectomy, bunionnette Lesser toe procedures MP and IP fusion of the hallux Rheumatoid forefoot procedures Metatarsal osteotomies Neuroma resection Amputation Hardware removals Debridements Incision and drainage Sesamoidectomies Midfoot Soft tissue tumor resections Hardware removal Amputations Tarsometatarsal arthrodesis Osteotomies Incision and drainage Wound debridements Hindfoot Tendon procedures Nerve procedures (tibial, sural, peroneal) Wound debridements Retrocalcaneal procedures Arthrodesis Osteotomies, ostectomies Hardware removal Incision and drainage Amputations Ankle Ligament reconstruction Cheilectomy, ankle arthroplasty, synovectomy Trauma Forefoot fractures Midfoot fractures Ankle fractures Soft tissue coverage/local flaps/skin grafts
Fig. 3. The deep peroneal nerve is blocked at the level of the ankle joint.
RESULTS
The regional anesthesia was completely successful from the standpoint of the surgeon in 1231 of the 1295 patients (95%). To be completely successful, no supplementary regional anesthetic was used intraoperatively, and no general anesthesia or unplanned intravenous sedation was resorted to. The block failed completely in three patients (0.2%) in whom no amount of regional anesthesia had any effect whatsoever on controlling the sensation of pain. A 34-year-old, healthy male patient undergoing a fifth metatarsal osteotomy had 10 ml of 1% lidocaine and 10 ml of 0.5% bupivacaine infiltrated initially. An additional 10 ml of 0.5% lidocaine and 5 ml of 0.5% bupivacaine were infiltrated 1 to 2 hr later. No anesthetic effect was obtained and
278 193 71 102
50 47
29 25 15 7
12
23 20 19 8 5 5 4
57 24 28 27 34 37 7
4 13 20
27 7 12 6
58
since the patient had not been adequately prepared, general anesthesia was resorted to later in the day. In a second patient, an ankle debridement was abandoned due to failure to obtain any anesthesia. However, three subsequent attempts at spinal anesthesia also failed, despite apparent correct positioning of the needle and visualization of the spinal fluid tap. A third patient complained of pain during an elective forefoot procedure, and this sensation persisted even immediately adjacent to the area of skin infiltrated with the local anesthetic. These failures were distinctly different from those in 14 patients (1.1%), where adequate anesthesia was thought to have been obtained by the surgeon, but the patient was extremely anxious and tolerated neither the pressure sensations nor any manipulation of the foot, interpreting this as painful. In five of these patients, intravenous sedation, which had not been planned preoperatively, was used to complete the procedure. In the remaining nine, a nurse was able to calm
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the patient well enough so that the procedure was completed uneventfully. In 47 patients (3.6%), the regional block had worked partially; additional local anesthetic was administered intraoperatively, and the procedure was completed uneventfully and successfully in each patient. There was no correlation between success of the block and the type of procedure performed. A total of 353 patient surveys were evaluated. There was a good correlation between the responses obtained on the day of surgery (180 patients) and those of patients whose surgery was performed up to 1 year earlier (173 patients). There was minimal change in the patient's perspective of the anesthesia from the day of surgery to the answers obtained 1 week later. Their responses confirmed a high success rate of the regional anesthesia, and 92% of patients were satisfied with the level of intraoperative comfort obtained. The average duration of anesthesia was 9 hr (range 6-28 hr). Nine percent of patients found the noises of the operating room unpleasant, and 98% were pleased to be able to discuss the progress of surgery with the nurses and physicians. Forty-two percent experienced pressure, pulling, or vibration; however, only 6% of patients were bothered by these sensations. Of the 353 respondents, 79% stated that they would prefer local over other forms of anesthesia if they had to undergo foot or ankle surgery in the future. Of the remaining 21%, 42% chose intravenous sedation in addition to local anesthesia, 47% general, and 11% spinal or epidural anesthesia. These responses, however, were at a time when no preoperative oral sedation was used. There were four complications from the regional anesthesia. One patient, a 60-kg man, was blocked successfully for debridement of an open foot injury. During the procedure, the patient became hypotensive and a supraventricular tachycardia developed. This was treated with intravenous fluids, and the surgery concluded uneventfully with halothane mask anesthesia. No residual adverse cardiorespiratory sequelae were detected in this patient. This complication was thought to be due to lidocaine toxicity. This patient had received 12 ml of 1% lidocaine (120 mg) and 12 ml of 0.5% bupivacaine (60 mg) in the emergency department, and an additional 10 ml of 0.5% lidocaine (50 mg) and 10 ml of 0.5% Marcaine (50 mg) intraoperatively. This amounts to 170 mg of lidocaine and 110 mg of Marcaine, reaching the toxic range for this 60-kg man. There were three minor complications in patients who developed a severe vasovagal reaction induced by the sight of the syringe or immediately following insertion of the needle. No other complications, such as postoperative neuritis, hematoma formation, or infection at the injection site, occurred.
DISCUSSION
We have expanded the uses and indications for regional anesthesia of the foot and ankle and found the success rate and patient acceptance to be high. Since we do not routinely use a tourniquet, we are able to perform more extensive procedures of the hindfoot and ankle under regional anesthesia, including trauma. We attempt to block most patients with open or closed forefoot and midfoot trauma immediately after a thorough neurovascular examination. This significantly enhances patient comfort while in the emergency department, and expedites definitive treatment of the injury, since many of these patients are not adequately prepared for general anesthesia. We rarely use general anesthesia in the patient with diabetes. This has been invaluable because many of these patients have multiple medical problems that increase the risk of general anesthesia significantly. Fatality occurs in approximately one in 10,000 routine procedures in which general or spinal anesthesia is performed." The incidence of these and other significant complications, such as myocardial infarction, pulmonary compromise, and hypotensive shock, increase 15fold in higher risk patients with diabetes or other major systemic cardiopulmonary disorder." The concern for toxic anesthetic levels using peripheral extremity nerve blocks, while present, is not nearly as pressing as it is in cases in which intravenous local anesthesia is used.5 ,10- 12 ,15- 17,2 1 Intravenous regional anesthesia introduced by Bier in 1908 has been associated with complications of cardiac arrhythmias 14 and death .11 Adverse reactions following the administration of lidocaine are similar to those observed with other amide local anesthetics; in general, these are dose related and result from high plasma levels caused by excessive dosage, rapid absorption, or intravascular injection. Most of the data on toxicity of regional anesthesia are derived from its use in the upper extremities. We believe that the absorption from the lower extremities may be similar, but we have no data to support this. Lidocaine may cause stimulation of the central nervous system (CNS), producing restlessness, nervousness, dizziness, confusion, tremors, and convulsions. These excitatory manifestations may occur transiently or not at all, in which case the first manifestations of toxicity are depressant and characterized by drowsiness, unconsciousness, and respiratory arrest. Cardiovascular manifestations are usually depressant and include bradycardia, hypotension heart block, and ventricular arrhythmias (including ventricular tachycardia and ventricular fibrillation), which may lead to cardiac arrest. These cardiovascular effects are usually seen only after high systemic concentrations are attained and CNS
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effects produced. Marcaine toxicity has similar CNS and cardiac manifestations. Cases of suspected lidocaine or Marcaine toxicity should be managed immediately by monitoring of cardiorespiratory status and of the patient's level of consciousness. Oxygen should be administered immediately. CNS excitability and muscular spasm can be managed with a short-acting intravenous barbiturate or neuromuscular blockade with succinylcholine. Convulsions, as well as respiratory depression or failure, are treated by maintenance of a patent airway, appropriate ventilatory support, and intravenous benzodiazepines. Rarely, individuals are hypersensitive to local anesthetics and develop allergic dermatitis, urticaria, angioneurotic edema, bronchospasm, or even fatal anaphylaxis. The reaction may occur as a result of sensitivity either to the local anesthetic agent or to the methylparaben used as an antimicrobial preservative in multiple dose vials. Management of allergic reactions is by conventional means. Over the years, we have found that the success rate of regional anesthesia both from the perspective of patient and physician improves if the block is administered well in advance of the surgery. The patients are far less anxious when they realize that the foot is indeed completely anesthetic before surgery commences. Based on the patient responses to the questionnaires, we started using preoperative oral sedation and found that both the block and the patient's perspective of the operation improved. Patients were instructed to bring in headphones with them to listen to music of their choice and no longer found the operating room noises unpleasant. A frustrating problem occurs when a satisfactory block has been given, but the patient has not been adequately prepared and is extremely anxious during surgery. Although the level of anesthesia may be sufficient for most patients, this discomfort may become intolerable, and it is difficult to "catch up" by administering additional anesthesia. For these reasons, we prefer to give the block at least 1 hr before surgery, so that any additional local is administered before the patient enters the operating room. There is clearly a variability in the amount of anesthetic agent that patients require. There are patients for whom the standard volume and concentration of block seems inadequate and for whom the anesthetic effect recedes quickly. These are often patients who report that they "need extra Novocain" at the dentist's office. There are several possible explanations of this variable effect of equivalent doses in different individuals. Increased nerve fiber size, decreased pH, and increased serum calcium concentration are inversely proportional to the rate of onset and potency of anesthetic effect. Long-acting agents such as bupivacaine are lipophilic and more protein bound than shorter
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acting, hydrophilic, and less protein-bound agents, such as lidocaine. Greater body size and fat stores might delay onset of action, but allow for longer anesthesia. Increased urine acidity can cause ionization of the agent to a more water-soluble and less resorbable form, thus increasing excretion and decreasing serum concentration. Both lidocaine and bupivacaine are amides and, therefore, are almost entirely metabolized by the hepatic endoplasmic reticulum. A deficiency or defect in such enzymes or other liver disease, could result in increased circulatory levels and effects of the drugs. Regional anesthesia may be used in the presence of local sepsis of the foot; however, due to the decreased pH of the surrounding tissues, the block may not work adequately if given adjacent to this focal sepsis. As can be seen from Table 1, we used regional anesthesia in a total of 21 patients who had some focal form of sepsis. The block, however, was not administered locally around the abscess or infection, but a standard ankle block was given to minimize the effect of the decreased pH on the amide. Although economic issues should not be a significant consideration in determining the type of anesthesia one chooses for a patient, regional anesthesia is clearly more efficient and less costly. There is no charge for anesthesia services, no utilization of the recovery room after the operation, less usage of inpatient resources, and decreased turnover time between surgical procedures in the operating room. Current regulatory trends to curtail hospital costs have encouraged and, in many instances, mandated short stay and outpatient surgical procedures. While the use of regional anesthesia certainly meets these requirements, the quality of patient care should never be compromised and must remain our primary objective. We have been satisfied with the results of regional anesthesia for many procedures of the foot and ankle. During the time of this study, 69.5% of the procedures were performed under regional foot and ankle anesthesia. With increasing experience, including hindfoot and ankle procedures, almost 80% of our procedures are now performed under regional anesthesia, a trend to be recommended.
REFERENCES
1. Adriani, J.: Labat's Regional Anesthesia. Techniques and Clinical Applications, 4th Ed. Philadelphia, W.B. Saunders, 1985. 2. Beskin, J.L., and Baxter, D.E.: Regional anesthesia for ambulatory foot and ankle surgery. Orthopaedics, 10:109-11, 1987. 3. Bier, A.: Ueber einen neunen weg Local anasthesia en den Gleidmassen zu erzeugen. Arch. kin. Chir., 86:1007-1016,1908. 4. Bridenbaugh, L.D.: Regional anesthesia for surgery of the extremities. Clin. Anesth., 2:198,1969.
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5. Davies, J.A.: Intravenous regional analgesia with prilocaine for foot surgery. The effect of slow injections and high tourniquet inflation pressures. Anaesthesia, 44:902-906, 1989. 6. Dripps, R., Eckenhoff, J., and Vandam, L.: Introduction to Anesthesia, 7th Ed. Philadelphia, W.B, Saunders, 1988, p. 415. 7. Rang, M.: Anthology of Orthopaedics. London, Edinburgh, E & S Livingstone, 1966, pp. 167-174. 8. Flood, B.M., and Shah, M.V.: Intravenous regional anesthesia for lower limb orthopaedic surgery (letter). Ann. R. Coli. Surg. Engl., 70:257-259,1988. 9. Giachino, A.A.: Surgeon administered local anesthesia for forefoot surgery. Can. J. Surg., 31:383-384, 1988. 10. Hanton, R.J., and Punchihewa, V.G.: Intravenous regional ananalgesia using bupivacaine. Anaesthesia, 37:350-351, 1982. 11. Heath, M.L.: Deaths after intravenous regional anesthesia. Br. Med. J., 285:913-914.1982. 12. Kennedy, B.R., Duthie, A.M., Parbrook, G.D., and Carr, T.L.: Intravenous regional anesthesia: an appraisal. Sr. Med. J., 1:954-957,1965. 13. Kofoed, H.: Peripheral nerve blocks at the knee and ankle in operations for common foot disorders. Clin. Orthop., 168:97101,1982. 14. Kotelko, D.M., Shnider, S.M., Daily, P.A., Brizgys, R.V., Levinson, G., Shapiro, W.A., Koike, M., and Rosen, M.A.:
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