A Better Block: A Prospective Randomized Control Trial of Single-Shot Liposomal Bupivacaine Combined with Dexamethasone vs. Liposomal Bupivacaine Alone Prior to Foot and Ankle Procedures

Category: Ankle, Other Keywords: Pain, PRO, ORIF Introduction/Purpose: Preoperative nerve blocks are commonly used in foot and ankle surgery to reduce postoperative pain. However, there is a lack of consensus regarding the formulation to provide optimal pain relief. Liposomal bupivacaine is a long-lasting nonopioid analgesic approved for use in interscalene brachial plexus nerve blockade. It is theorized that the addition of dexamethasone to liposomal bupivacaine may prolong analgesic duration. Patients have reported an opioid-free recovery and complete pain relief for almost a week with preoperative blocks of steroid and liposomal bupivacaine at our institution. We examine postoperative narcotic use and analgesic effect time with the use of liposomal bupivacaine combined with dexamethasone vs. liposomal bupivacaine alone when administered in a popliteal and saphenous block prior to foot and ankle orthopedic procedures. Methods: A prospective, randomized controlled trial was performed at a single surgery center. Foot and ankle procedure patients willing to consent were randomized in a 1:1 ratio to undergo preoperative block into one of the following two arms, noted as Dex and Control respectively: 20 mL liposomal bupivacaine (266 mg) + 10 mL of 0.75% bupivacaine (75 mg) administered in popliteal and saphenous block (30 mL total) vs. 20 mL liposomal bupivacaine (266 mg) + 1 mL of 10 mg dexamethasone + 10 mL of 0.75% bupivacaine administered in popliteal and saphenous block (31 mL total). Postoperatively, patients were asked their pain scores, opioid consumption, and other pain medication every twelve hours from day of surgery to postoperative day seven in a standardized pain diary and/or via telephone. On postoperative days seven and fourteen, patients were also asked to gauge subjective block duration and overall satisfaction with the block. Results: The cohort included 120 patients with a mean age of 44.9 years and no differences in comorbidities between the Dex and No Dex groups (all p > 0.31). Daily pain scores were lower each day in the Dex group vs. the control group with a significant difference on postoperative days two and six (p<.001, p=.031). Dex group patients also noted a mean block length of 7.8 days vs. 5.6 days in No Dex (p<0.001). The percent of patients taking narcotic medication was never more than 8% in the Dex group, vs. about 19% in the control group. The most significant difference in narcotic use occurred on day three, with a higher mean narcotic use in the control group (p=.049). Conclusion: This study demonstrates the added benefit of dexamethasone to liposomal bupivacaine popliteal and saphenous nerve block as a postoperative pain strategy for foot and ankle procedures. Patients reported lower pain and a longer perceived block length with a dexamethasone liposomal bupivacaine nerve block as compared to liposomal bupivacaine alone. We would be remiss to exclude the high efficacy of nerve blockade in general, about one third of all postoperative patients who had elected for a block used absolutely no narcotics.