How Can Foot And Ankle Surgeons Responsibly Manage Post-Op Pain With Opioids?

With the opioid epidemic raging in the United States, podiatric surgeons must be able to provide effective and responsible pain relief without risking opioid addiction. A poster presented at the American College of Foot and Ankle Surgeons (ACFAS) 2021 Annual Scientific Conference, winner of the second place in the scientific format, identified several risk factors—including rearfoot surgery—for opioid abuse following lower extremity surgery.

The retrospective review focused on 6,887 patients (62 percent women) who had surgery of the forefoot, midfoot, rearfoot or ankle. The authors found certain factors that predicted the likelihood of opioid refills after a six-month initial prescription, including rearfoot procedures, opioid use six months before surgery, tobacco use, chronic pain, bipolar disorder, benzodiazepine use, selective serotonin reuptake inhibitor use, infection/ischemia procedures and prescriptions for non-steroidal anti-inflammatory drug (NSAID) and nerve medication. The authors hope the study will decrease the postop use of opioids.

When working with patients to relieve postop pain, study coauthor Christy King, DPM, FACFAS, follows two main principles. First, less is more. As she notes, since recent research has shown patients usually take fewer opioids when given fewer initially, she will provide smaller initial doses of narcotics and encourage other methods to help with pain control. Second, Dr. King finds it helpful to approach pain with multimodal techniques and comprehensive patient education. Utilizing NSAIDs (when appropriate), peripheral nerve blocks and nerve medication can help address the different aspects that contribute to a patient’s perception of pain, according to Dr. King, attending staff and the Research Director of the Kaiser San Francisco Bay Area Foot and Ankle Residency Program in Oakland, Calif.

How can one balance the risks associated with opioids with the need to adequately manage postop pain?

“It can be a constant and difficult battle to ensure the patients feel their provider cares about their pain and wants to address it while at the same time providing the information and support to decrease opioid use and dependence,” says Dr. King. “I find that it helps to frequently communicate with and counsel the patient throughout the perioperative period to discuss expectations, recovery patterns, and encourage transition away from opioids as soon as reasonably possible.”

Dr. King would like to see more research identifying patient and surgical characteristics that can help with preoperative patient education on postop pain along with further investigations of multimodal techniques that can help reduce opioid use.

“It would add a lot of value to pain control to also provide more mental health education and techniques to decrease postoperative depression from inactivity, limitations, pain, etc.,” says Dr. King.

Total Ankle Implant Shows Low Rate Of Complications And Revisions

By Brian McCurdy, Contributing Editor

An innovative total ankle implant has a low rate of complications and revisions, according to a poster presented at the American College of Foot and Ankle Surgeons (ACFAS) 2021 Annual Scientific Conference.

The review of six studies included a total of 432 total ankle arthroplasties in 417 patients with the Infinity Total Ankle System (Wright Medical Group). The weighted mean follow-up was 24.5 months and weighted mean patient age was 52.7 years.

The authors note a 10 percent complication rate, including nine low-grade complications, 16 medium-grade complications and 18 high-grade complications. The rate of total revision procedures in the study was six percent. The overall rate of implant survivorship was 94 percent, rising to 96 percent if excluding the nine deep infections requiring revision.

Nilin M. Rao, DPM, PhD, AACFAS, notes the advantages of the implant include minimal bone resection and talar component options which can be chamfer or flat cut depending on talar pathology. He adds that the implant also has an option for patient-specific instrumentation.

Dr. Rao says surgeons can use the Infinity Total Ankle System in all patients with end-stage ankle arthritis due to the interchangeability of the implants. Standard contraindications to ankle replacement are the same for this implant, notes Dr. Rao, a Fellow of the Silicon Valley Reconstructive Foot and Ankle Fellowship at Palo Alto Medical Foundation in Mountain View, Calif.

Due to some published studies in the last few years, Dr. Rao says long-term reports are needed specifically evaluating periprosthetic lucency and aseptic loosening.

What Impact Does Resistance Training Have On Microcirculation In Those With Diabetes?

By Jennifer Spector, DPM, FACFAS, Managing Editor

Microvascular disease can be a significant concern for those dealing with diabetes, however, what do we know about the impact of resistance training on microcirculation?

A recent study in Metabolic Syndrome and Related Disorders took a closer look at microcirculation and muscle strength in 63 participants with diabetes and 42 physically-matched controls without diabetes. The authors measured microcirculation (with near-infrared spectroscopy and a red laser) in the rectus femoris and medial gastrocnemius muscles, as well as in the patellar and Achilles tendons at baseline as well as during maximal isometric exercise.

Data showed that the subjects with diabetes had lower oxygen saturation in the muscles both at baseline and during isometric contraction. Total hemoglobin was also higher in the patellar and Achilles tendons at baseline for those with diabetes. Researchers also identified a correlation in the microcirculatory change of the rectus femoris muscle with knee extension force. They also collected data on hemoglobin A1c, triglycerides, high-density cholesterol, monofilament testing and ankle-brachial index.

Overall, the authors of this study aimed to demonstrate the effects of diabetes on the microcirculation of skeletal muscles and tendons and in response to isometric exercise. They say the results suggest a need for formulation of pathways to prevent complications from resistance training for individuals with diabetes.

David G. Armstrong, DPM, MD, PhD says this study is another example that highlights the importance of a better understanding of the physiology and pathology of microcirculation, especially in those with diabetes.

“There is little doubt that macro- and microvascular disease both conspire in creating diabetic complications,” he says.

Given that physicians often advise activity and exercise for patients with diabetes and/or those in ulcer remission, Dr. Armstrong says that one suggestion might be to, at least initially, recommend supervised programs led by individuals educated in preventive diabetic foot and lower extremity care.

“The bottom line still holds; if you don’t use it, you lose it!” he says. “Fostering movement in people and helping them move through the world is worth a life’s work.”