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The purpose of this exploratory study is to characterize the postoperative pain profile of patients undergoing operation with internal fixation of an ankle fracture under nerve block anaesthesia. Special attention is payed towards the possible existence and clinical relevance of a rebound pain phenomenon upon cessation of the nerve block.
Results are used to guide the set up of a randomized controlled trial on the subject.
Peripheral nerve blocks (PNB) are widely used as anaesthesia and postoperative pain control for surgery. Several studies have suggested multiple benefits of PNB's but primarily shown in elective surgery. Acute conditions like ankle fractures have a different pain profile and risks and benefits of PNB's have not been sufficiently researched in these cases.
A recent study (Goldstein et al. 2012) suggested that a rebound pain effect occur upon cessation of PNB effect defined as a pain increase to a significantly higher level than observed in patients with no PNB at the same point after surgery.
With this prospective, exploratory study we aim to examine the postoperative pain profile after PNB anaesthesia for ankle fracture surgery with focus on plausibility of a rebound pain effect (as defined above) upon PNB cessation.
Secondarily to explore a variety of factors related to postoperative pain profile and feasibility of PNB anaesthesia for ankle surgery including efficacy, risk factors, time factors as well as postoperative recovery and overall patient satisfaction. Results will provide focus for a following randomized controlled trial.
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| Measure | Description | Time Frame |
|---|---|---|
| Clinically relevant pain increase based on analysis of Numeric Rating Scale pain score (NRS) area under the curve (AUC) for the time period 12-24 hours compared to 0-12 hours postoperatively. | Pain scores are assessed and marked by the patient on a 0-10 numeric rating pain scale (NRS). | 0, 2, 4, 6, 9, 12, 15, 18, 21 and 24 hours postoperatively |
| Measure | Description | Time Frame |
|---|---|---|
| Opioid use 12-24 hours compared to 0-12 hours postoperatively | Rescue morphine doses are administered intravenously via a patient controlled analgesia (PCA) pump when needed. Times of use are electronically registered. | 0-24 hours continuous measurement |
| Calculated Composite Score for the time intervals 0-24h, 0-12h and 12-24h postoperatively |
| Measure | Description | Time Frame |
|---|---|---|
| Clinically relevant pain increase based on analysis of Numeric Rating Scale pain score (NRS) area under the curve (AUC) after cessation of nerve block compared to before cessation of nerve block. | The average postoperative time to cessation of nerve block defining the time periods for this comparison will be defined after visual evaluation of the given pain profiles. | 0, 2, 4, 6, 9, 12, 15, 18, 21 and 24 hours postoperatively |
Inclusion Criteria:
Exclusion Criteria:
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Patients scheduled for internal fixation of an ankle fracture under PNB-anaesthesia at Herlev Hospital identified from the operation booking system via consecutive screening.
Eligible ankle fractures will be those of anatomically uni-, bi- or trimalleolar composition including syndesmotic injury with distal but not proximal fibular fracture. The "third malleolus" is the distal posterior edge of the tibia. Fractures needing external fixation or causing ankle dislocation in need of imminent surgery is not eligible.
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| Name | Affiliation | Role |
|---|---|---|
| Rune Sort, MD | Department of Anaesthesiology, Herlev Hospital | Principal Investigator |
| Ann M Møller, Prof., DMSc | Department of Anaesthesiology, Herlev Hospital | Study Director |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Herlev Hospital | Herlev | Denmark | DK-2730 | Denmark |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 30411313 | Derived | Sort R, Brorson S, Gogenur I, Nielsen JK, Moller AM. Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery: An exploratory pilot study. Acta Anaesthesiol Scand. 2019 Mar;63(3):396-402. doi: 10.1111/aas.13290. Epub 2018 Nov 8. |
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| ID | Term |
|---|---|
| D010149 | Pain, Postoperative |
| D064386 | Ankle Fractures |
| ID | Term |
|---|---|
| D011183 | Postoperative Complications |
| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D010146 | Pain |
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We will calculate the "Silverman" composite score of opioid use and pain score combined. This in order to illustrate any increase in pain and to use for sample size calculations for a future randomised study on the subject. |
| 0-24 hours postoperatively |
| Time to first opioid dose postoperatively | 0-24 hours postoperatively |
| Time to patient estimated cessation of block effect | 0-24 hours postoperatively |
| NRS day 1-7 as both "average" and "worst" of the day | NRS are filled out by the patient in a diary. | Days 1-7 postoperatively |
| Daily opioid consumption day 1-7 | Registered in a diary. | Days 1-7 postoperatively |
| Score of the Quality of Recovery-15 (QoR-15) questionnaire preoperatively and on postoperative day 1. | Validation of the Danish translation of QoR-15 in this population of patients undergoing acute orthopaedic surgery under PNB-anaesthesia. A Danish version of the QoR-15 questionnaire is currently being validated in a mixed surgical patient population receiving surgery under general anaesthesia. We will attempt to validate the questionnaire on patients receiving nerve block (PNB) anaesthesia. | Preoperatively and postoperative day 1 |
| QoR-15 questionnaire score on day 1, 2 and 7 postoperatively | Postoperative day 1, 2 and 7. |
| Length of postoperative stay in hospital | Up to 3 weeks |
| Time to first meal/appetite postoperatively | 0-24 hours postoperatively |
| Incidence of postoperative nerve symptoms (PONS) on day 7 | Telephone interview | Postoperative day 7 |
| Postoperative nausea and vomiting (PONV) 24 hours postoperatively | 0-24 hours postoperatively |
| Antiemetic medication 24h postoperatively | 0-24 hours postoperatively |
| Time used for PNB administration | Preoperatively |
| Time to PNB effect on sensory and motor function | Preoperatively |
| Length of stay in the Operation Room (OR) - total and pre- and post-operatively | Operation day |
| Duration of surgery | Operation day |
| Partial block rate and Failed block rate | Partial = need for supplemental block preoperatively (if PNB seems insufficient after 30 min). Failed = need for General Anaesthesia. | Operation day |
| Need for PACU admission postoperatively | Most patients are expected to be send directly to the Orthopaedic ward following surgery. If not, the reason is noted. | Operation day |
| D009461 | Neurologic Manifestations |
| D012816 | Signs and Symptoms |
| D050723 | Fractures, Bone |
| D014947 | Wounds and Injuries |
| D016512 | Ankle Injuries |
| D007869 | Leg Injuries |