Wide-Awake Local Anesthetic No Tourniquet Surgery of the Foot and Ankle.

Wide awake local anesthetic no tourniquet (WALANT) surgery of the foot and ankle has the potential to offer safe and effective surgeon-based anesthesia for a significant number of surgeries about the foot and ankle. This has been documented with significant and growing body of literature. WALANT could offer significant advantages with respect to patient experience, per case cost of procedures as well as for improving access for patients to operative resources in a setting of scarcity or restricted access.

Addressing varus and valgus deformity of the ankle: Algorithmic approach to total ankle arthroplasty.

Total ankle replacements have become increasingly popular, providing a viable alternative to ankle arthrodesis in patients with end stage ankle arthritis. Continued advancements in implant design have substantially improved long term survival outcomes as well as patient pain relief, range of motion, and quality of life. Surgeons continue to advance the indications for implantation of total ankle replacements in patients with more severe varus and valgus coronal plane deformity. This report of twelve cases demonstrates our algorithmic approach to total ankle arthroplasty in patients with deformity of the foot and ankle. By proposing a clinical algorithm with case examples, we aim to aid clinicians in successfully approaching coronal plane deformities of the foot and ankle when using total ankle replacement to ultimately improve clinical outcomes.

Wrist-ankle acupuncture for the treatment of acute orthopedic pain after surgery: a meta-analysis.

BACKGROUND: Wrist-ankle acupuncture (WAA) has been reported in the treatment of acute pain in orthopedic surgery. However, the effects of WAA on acute pain were controversial in the current studies. Therefore, the purpose of this meta-analysis was to critically evaluate the effects of WAA on acute pain in orthopedic surgery. METHODS: Several digital databases were searched from the inception of databases to July 2021, including CNKI, VIP, Wanfang, CBM, Pubmed, Cochrane Central Register of Controlled Trials, Embase, Medline, and Web of Science Core Collection. The risk of bias was evaluated using the Cochrane collaboration criteria. The primary outcome indicators included pain score, pain killer dosage, analgesia satisfaction, and adverse reaction incidence. All analyses were performed with Review Manager 5.4.1. RESULT: A total of 10 studies with 725 patients with orthopedic surgery (intervention group: 361, control group: 364) were included in this meta-analysis. The results demonstrated that the pain score of the intervention group was lower than the control group, and the difference was statistically significant [MD = - 0.29, 95%CI (- 0.37, - 0.21), P < 0.0001]. Compared with the control group, the patient in the intervention group used smaller amounts of pain killer [MD = - 0.16, 95%CI (- 0.30, - 0.02), P = 0.02]. The satisfaction of patients on pain relief was also higher in the intervention group, and the difference was statistically [OR = 0.25, 95%CI (0.15,0.41), P < 0.0001]. CONCLUSION: WAA has a certain effect on acute pain in orthopedic surgery, and the effect of WAA combined with other therapies is better than that of not using WAA therapy.

[Clinical characteristics analysis of 22 062 patients of foot and ankle deformity from QIN Sihe Orthopaedic Surgery Database between May 25, 1978 and December 31, 2020].

Objective: Based on the clinical data of patients with foot and ankle deformities in the QIN Sihe Orthopaedic Surgery Database, to analyze the characteristics and treatment strategies of foot and ankle deformities, and provide a basis for clinical decision-making. Methods: A total of 22 062 patients with foot and ankle deformities who received orthopedic surgery between May 25, 1978 and December 31, 2020 were searched in the QIN Sihe Orthopedic Surgery Database. The gender, age at operation, regional distribution, etiology, type of deformity, operation method, postoperative fixation method, and other information were collected. Results: Among the 22 062 patients, there were 13 046 males (59.13%) and 9 016 females (40.87%); the age at operation ranged from 1 to 77 years, with a median of 17 years, and 20 026 cases (90.77%) were aged 5 to 40 years. The patients came from 32 provinces, municipalities, and autonomous regions across the China and 5 countries including India and the United States, et al. The etiology and diseases type covered 154 kinds (of which sequelae of poliomyelitis, cerebral palsy, spina bifida and tethered spinal cord, congenital equinovarus foot, post-traumatic foot and ankle deformity, and Charcot-Marie-Tooth disease accounted for the highest proportion). The types of deformities included varus foot, equinus foot, valgus foot, talipes calcaneus, equinocavus, high arched foot, claw toe, and flail foot. Surgical methods included tendon lengthening, soft tissue release, tendon transposition, osteotomy orthopedics, and ankle arthrodesis. The 36 620 operations were performed, including 11 561 cases of hip, knee, and lower leg operations to correct the foot and ankle deformities. Postoperative fixation methods included Ilizarov external fixator in 2 709 cases (12.28%), combined external fixator in 3 966 cases (17.98%), and plaster or brace fixation in 15 387 cases (69.74%). Conclusion: Male patients with foot and ankle deformities account for a large proportion, and the population distribution is mainly adolescents, with a wide distribution of regions, causes and diseases, and talipes equinovarus and varus foot are the main types of deformities. Foot and ankle deformities are often combined with deformities of other parts of the lower limb, which requires a holistic treatment concept. The application of foot soft tissue and bone surgery combined with Ilizarov external fixator and combined external fixators provides a guarantee for the correction of complex foot and ankle deformities.

General Considerations About Foot and Ankle Arthrodesis. Any Way to Improve Our Results?

Nonunion and adjacent joint osteoarthritis (OA) are known complications after a fusion procedure, and foot and ankle surgeons are commonly exposed to such disabling complications. Determining who is at risk of developing nonunion is essential to reducing nonunion rates and improving patient outcomes. Several evidenced-based modifiable risk factors related to adverse outcomes after foot and ankle arthrodesis have been identified. Patient-related risk factors that can be improved before surgery include smoking cessation, good diabetic control (HbAc1 <7%) and vitamin D supplementation. Intraoperatively, using less invasive techniques, avoiding joint preparation with power tools, using bone grafts or orthobiologics in more complex cases, high-risk patients, nonunion revision surgeries, and filling in bone voids at the arthrodesis site should be considered. Postoperatively, pain management with NSAIDs should be limited to a short period (<2 weeks) and avoided in high-risk patients. Furthermore, early postoperative weight-bearing has shown to be beneficial, and it does not seem to increase postoperative complications. The incidence of surrounding joint OA after foot and ankle fusion seems to increase progressively with time. Owing to its progression and high probability of being symptomatic, patients must be informed consequently, as they may require additional joint fusions, resulting in further loss of ankle/foot motion. In patients with symptomatic adjacent joint OA and unsatisfactory results after an ankle arthrodesis, conversion to total ankle arthroplasty (TAA) has become a potential option in managing these complex and challenging situations.

[Clinical anatomical study on the treatment of tarsal tunnel syndrome with four-point vertical acupotomy].

OBJECTIVE: To explore safety and accuracy of four-point acupotomy for the treatment of tarsal tunnel syndrome regarding release of ankle tunnel flexor retinaculum to provide an anatomical basis of clinical treatment. METHODS: Twenty-nine adult specimens (15 males and 14 females) fixed with 10% formalin, aged from 47 to 98 years old with an average age of (81.10±11.14) years old, 29 on the right side and 29 on the left side, which were selected for the study from September 2020 to October 2020. Simulate the operation of loosening flexor retinaculumt with a needle knife on the human specimen, and place the specimen on the frog position of lower limbs with medial malleolus upward to determine the center of medial malleolus. Choose 4 different positions near the flexor retinaculum to insert the needle so that the needle body was perpendicular to skin and cutting edge direction was perpendicular to the running direction of the flexor retinaculum. The needle knife penetrates the skin and explores slowly. When the flexor retinaculum was reached, the needle tip may touch the tough tissue. At this time, the cutting is loosened for 4 times. After acupotomy release operation was completed, make a lateral incision on the skin surface along acupotomy direction, open the area of the exposed flexor retinaculum, dissecting layer by layer, observe and record the needle knife and its surrounding anatomical structure. The length of acupotomy cutting marks of flexor retinaculum was measured by electronic vernier caliper. The safety and accuracy of acupotomy loosening of ankle canal flexor retinaculum were evaluated by observing the number and degree of ankle canal contents such as tendons and nerves injured by needle knife. The safety is to count the number of cases of acupotomy injury to the contents of the ankle canal, and to calculate the injury rate, that is, the number of injury cases/total cases × 100%. The effective release was defined as the release length L ≥ W/2(W is the width of the flexor retinaculum, defined as 20 mm). RESULTS: For safety, there were no acupotomy injuries to nerves or blood vessels in 58 cases, 26 cases injuried to posterior tibial tendon which 17 of these tendon injury cases, the tendon was penetrated and severely injured, and flexor digitorum longus tendon was injured in 12 cases. Among these cases, tendon was penetrated and severely injured in 4 cases, and total injury rate was 32.14%. No nerve and vessel injury on c3 and c4 point. For accuracy, 58 specimens were successfully released. The length Lc of releasing trace for acupotomy was (10.40±1.36) cm, and length range 6.38 to 12.88 cm. Among all cases, the length of releasing trace was ≥10 mm in 37 cases. The overall success rate of release was 100.00%. Layered structure of ankle tube flexor retinaculumt:fiber diaphragm from flexor retinaculum divides contents of ankle tube into different chambers inward, and fiber diaphragm meets here to synthesize a complete flexor retinaculum at the midpoint of the line between the medial malleolus tip and calcaneal tubercle(above the neurovascular course). CONCLUSION: Four-point needle-knife method of releasing flexor retinaculum for the treatment of tarsal tunnel syndrome is performed at the attachment of the two ends of flexor retinaculum;the tendon, but not the nerves and blood vessels, is easily damaged. It is safe to insert needle on the side of calcaneus. The extent of release is relatively complete, but due to the "layered" structure of the flexor retinaculum, classic surgical technique could only release one layer of flexor retinaculum when a needle is inserted at the edge of the bone and cannot achieve complete release of the full thickness of the flexor. Therefore, it remains to be determined whether the desired effect can be achieved clinically.

Wrist-Ankle Acupuncture as Additional Therapy for Postoperative Multimodal Analgesia in Orthopedic Surgery: Systematic Review and Meta-Analysis.

BACKGROUND: The present meta-analysis analyzed the efficacy and safety of wrist-ankle acupuncture (WAA) as an additional therapy for postoperative multimodal analgesia after orthopedic surgery. METHODS: Electronic databases, including Cochrane Library, PubMed, EMBASE, Web of Science, CNKI, SinoMed, Wanfang, and VIP, were searched to identify randomized controlled trials and cohort studies that reported details of WAA as an additional therapy for postoperative multiple analgesia in orthopedic surgery before October 1, 2021. Analyzed outcomes included time points of the visual analog scale, use of patient-controlled intravenous analgesia (PCIA), and postoperative adverse events. Subgroup analysis was performed according to time points and complication type. RESULTS: Eleven randomized controlled trials and one cohort study were included in the meta-analysis. Among a total of 845 patients, there were 422 patients in the WAA groups and 423 patients in the control groups. The WAA groups showed a better analgesic effect (standard mean difference [SMD] = -1.34; 95% confidence interval [CI]: -1.76 to -0.91; P < 0.00001; I2 = 0.94), lower use of PCIA (SMD = -1.48; 95% CI: -2.26 to -0.69; P = 0.0002; I2 = 0.94), and lower occurrence of postoperative adverse events (risk ratio = 0.38; 95% CI: 0.30 to 0.49; P < 0.00001; I2 = 0) than did the control groups. CONCLUSION: WAA as an additional therapy for postoperative multimodal analgesia in orthopedic surgery showed advantages over control treatment in terms of pain relief, use of PCIA, and occurrence of postoperative adverse events.

Revision Lateral Ankle Reconstruction 40 Years After Chrisman-Snook Procedure: A Case Report.

CASE: A 70-year-old active woman presented with lateral ankle instability 40 years after a lateral ankle reconstruction procedure. Examination demonstrated gross instability, and advanced imaging revealed attenuation of her previous graft. She underwent anatomic reconstruction through a modified Brostrom-Gould technique and was able to return to hiking without pain. CONCLUSION: Recurrent lateral ankle instability after reconstruction represents a unique challenge for orthopaedic surgeons. Utilization of a modified Brostrom-Gould procedure with suture tape augmentation is a promising alternative to allograft or autograft reconstruction for patients with active lifestyle goals in the context of recurrent instability.

Surgical Considerations for Vitamin D Deficiency in Foot and Ankle Surgery.

Vitamin D deficiency affects nearly one-sixth of the world's population and is common in patients undergoing foot and ankle surgery. Vitamin D is critical for calcium homeostasis and plays an important role in the maintenance of bone health. Patients undergoing foot and ankle procedures can be evaluated preoperatively with vitamin D level testing, and deficiencies can be addressed with either preoperative or postoperative supplementation. Current data suggest that patients with adequate vitamin D levels may have better outcomes, but the details are not yet clear. Vitamin D supplementation is well tolerated with rare side effects.

Orthopaedic In-Training Examination Resources and Residency Training for the Foot and Ankle Domain.

BACKGROUND: Residency programs use the annual Orthopaedic In-Training Examination (OITE) prepared by the American Academy of Orthopaedic Surgeons (AAOS) to monitor resident progress and prepare them for the part 1 of the American Board of Orthopaedic Surgeons (ABOS) Certifying Examination. The purpose of this study was to determine resources residents currently use to prepare for the OITE and also to learn about their perception of training they receive in the foot and ankle subspecialty in their program and their interest in foot and ankle fellowship after residency. METHODS: An anonymous survey was sent to both allopathic programs and osteopathic residents to learn what resources residents used to study for the OITE, preparatory question sets, on-call resources, their perception on training received in foot and ankle surgery, and their intent to pursue fellowship training. RESULTS: A total of 130 residents participated in the survey. The majority of residents in allopathic and osteopathic residencies used Orthobullets (OB) to prepare for the OITE and use this resource while on-call. Most residents also used OB question sets to study along with the AAOS self-assessment examinations. In total, 43.2% of osteopathic residents felt they did not get enough exposure to foot and ankle subspecialty while in training, in contrast to 31.2% of allopathic residents. A total of 35% of all orthopaedic surgery residents felt they lacked enough exposure to foot and ankle orthopaedic surgery. Only 7 residents (6%, 6 allopathic, 1 osteopathic) intended to pursue a foot and ankle fellowship following graduation. CONCLUSION: Online resources such as OB continue to be frequently used by residents for preparation for the OITE. Greater than one-third of orthopaedic residents feel they do not get enough exposure to foot and ankle orthopaedic surgery. Improvement in this area could be helped by continued endeavors from the American Orthopaedic Foot and Ankle Society such as the Visiting Professor Program and Resident Scholarship Program. LEVELS OF EVIDENCE: Level V: Single Cross-Sectional Study.

Effect of Nerve Stimulation Use on the Success Rate of Ultrasound-Guided Subsartorial Saphenous Nerve Block: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Ultrasound-guided subsartorial saphenous nerve block is commonly used to provide complete surgical anesthesia of the foot and ankle in combination with a popliteal sciatic nerve block. However, in part owing to its small caliber and absence of a prominent vascular landmark in the subsartorial plane distal to the adductor canal, the saphenous nerve is more difficult to reliably block than the sciatic nerve in the popliteal fossa. Although the saphenous nerve is a sensory nerve only, neurostimulation can be used to elicit a "tapping" sensation on the anteromedial aspect of the lower leg extending toward the medial malleolus. Our objective was to test the hypothesis that the addition of nerve stimulation use to an ultrasound (US)-guided technique will increase the success rate of subsartorial saphenous nerve block. METHODS: With institutional human ethics board approval and participants' written informed consent, we enrolled 80 patients undergoing foot and ankle surgery in a randomized, single-blinded, parallel-group clinical trial. Patients were randomly assigned to receive US-guided subsartorial saphenous nerve block either alone (US group) or with the use of additional nerve stimulation (NS group; time limit, 5 minutes). For saphenous nerve blockade, all patients received 10 mL of 0.5% ropivacaine. The primary end point was complete absence of sensation to pinprick at 30 minutes at two different anatomic areas in the distribution of the saphenous nerve (2 cm proximal to the medial malleolus and 10 cm distal to the medial tibial condyle). Secondary end points included decreased sensation at 30 minutes and block failure (normal sensation) at 30 minutes. This trial was registered at ClinicalTrials.gov: NCT02382744. RESULTS: All 80 patients completed the trial (40 patients in each group). Twenty-two patients (55%) in the NS group versus 18 (45%) in the US group had complete absence of sensation to pinprick at 30 minutes at both anatomic areas of assessment (Fisher exact test, P = 0.25 [one sided]; 95% confidence interval of difference in proportions, -11.9% to 31.9%). The percentages of patients with any evidence of block (decreased or complete absence of sensation) at both areas at 30 minutes were 92.5% (NS) and 97.5% (US), respectively (P = 0.62 [two sided]); corresponding failure rates (normal sensation) were 7.5% (NS) and 2.5% (US). In the NS group, no response in the saphenous nerve distribution was elicited within 5 minutes of stimulation time limit in 20% of patients (n = 8). All of the patients in the NS group with normal sensation at 30 minutes (n = 3) were among this subcohort. CONCLUSIONS: The addition of the use of nerve stimulation did not improve the success rate of US-guided subsartorial saphenous nerve block. However, in the NS group, an inability to elicit a "tapping" sensation in the saphenous nerve distribution was associated with block failure.

Surgical Management of Gout in the Foot and Ankle A Systematic Review.

BACKGROUND: The surgical management of tophaceous gout has been well documented in the literature, including its effect on foot pain and disability. To date, there have been no systematic reviews assessing the quality of the literature relating to the operative management of tophaceous gout and the outcomes in the foot and ankle. METHODS: The following electronic databases were searched (1980-2014): Allied and Complementary Medicine, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Scopus, and the Cochrane Library. The articles identified were published in English and included adult participants (age ≥18 years) with diagnosed gout and surgical intervention to the foot and ankle. The Downs and Black Quality Index was modified to assess the quality of the articles being reviewed. RESULTS: Six articles were reviewed and were of moderate quality (mean quality score of 71%). Surgical management was conducted on men (88%) with a mean age of 52 years. There was wide variation in the types of surgical procedures performed, with 28% of studies reporting surgery to the first metatarsophalangeal joint. Most studies were retrospective. A wide range of outcome measures were reported: foot pain, function, preoperative and postoperative activity levels, monitoring of uric acid levels, and patient satisfaction after surgery. CONCLUSIONS: The review demonstrated a limited number of good-quality studies. Several surgical procedures for the foot and ankle in people with chronic tophaceous gout were reported. Future studies should include prospective observational studies using validated and reliable patient-reported outcome measures.

Ultrasound-Guided Ankle Blocks: A Review of Current Practices.

Ankle blocks are routinely indicated for surgical anesthesia and postoperative analgesia of procedures involving the foot. Traditionally, ankle blocks have been performed by relying on landmark identification of nerves. The literature regarding the performance and efficacy of ankle blocks is inconsistent. This can be attributed to several variables, such as provider technique, differences in patient populations, and the type and volume of local anesthetics administered. As with other peripheral nerve blocks originally performed using landmark technique, ultrasound imaging is now being incorporated into these procedures. Ultrasound guidance provides the anesthetist with several advantages over landmark techniques. The ability to identify peripheral nerves, view needle movements in real-time, and observe the spread of local anesthetic has been shown to result in greater block efficacy, even with reduced volumes of local anesthetic. Additionally, ultrasound imaging gives the provider the option to perform regional anesthesia in specific patient populations not considered possible when using landmark technique. Despite the limited literature on ultrasound-guided ankle blocks, outcome metrics seem to be consistent with those of other peripheral nerve blocks performed using this technology.

Inmovilización frente a tratamiento funcional en esguinces de tobillo grado III / Inmobilisation vs functional treatment for grade III ankle sprain treatment

Objetivo: Comparar los resultados obtenidos en eltratamiento de los esguinces de tobillo grado III usandoalternativamente tratamiento inmovilizador con férulaposterior y vendaje elástico funcional con movilizaciónprecoz y carga progresiva.Material y métodos: Estudio prospectivo, cuasi-aleatorizado, con valoración prospectiva por observadores independientes ciegos al tratamiento utilizado, de 111 pacientes con esguince de tobillo grado III según la clasificación sistemática de West Point. Fueron tratados alternativamente según orden de llegada con inmovilización con férula posterior sin permitircarga o mediante tratamiento funcional con carga parcial.Fueron revisados al mes y a los 3 meses mediante un examenfísico protocolizado, cuestionario de "De Bie" y escala desatisfacción del paciente. Resultados: Cincuenta y ocho pacientes (52,2%) recibieron tratamiento funcional frente a 53 (47,7%) tratados con inmovilización. El resultado al mes de revisión fue 71,6 en la escala de "Bie" en el grupo tratado funcionalmente frente al 55,8 en los tratados con inmovilización (p=0,002). A los tresmeses el resultado fue 88,8 en el grupo funcional frente a70,1 en la inmovilización (p=0,00l). Se encontrarondiferencias estadísticamente significativas (p<0,05) al mes y a los tres meses. Los pacientes tratados funcionalmente estuvieron más satisfechos al mes y a los tres meses de evolución. Conclusiones: El tratamiento funcional parece ser una estrategia favorable para el tratamiento de esguinces de tobillo grado III comparándolo con la inmovilización. Los pacientes tratados funcionalmente se encuentran más satisfechos con su tratamiento

Objetive: To study the early outcomes of patients with grade III acute lateral ankle ligament injuries treated either with immobilisation orwith functional treatment. Material and Methods: Prospective oren trial with external blinded assessor of 111 consecutive patients treated at the A&E department of our Hospital with acute grade III (West Point c1assification) lateral ankle 1igament injuries. The patients weret reated alternatively with immobilisation in a posterior plaster cast for three weeks with no weight bearing permitted or with functional treatment with early mobilization and assisted weight bearing. Patients were reviewed one and three months after the injury. We use a standardised follow-up examination and the De Bie ankle assessment questionnaire for evaluation. A patient satisfaction questionnaire was also performed. Results: Fifty eight patients (52,2%) received functional treatment and 53 (47,8%) were treated with immobilisation. At one month follow-up we found an average De Bie score of 71.6 in the group treated functionally and 55.8 in the group treated by immobilisation (p=0.002). At three months follow-up we found an average De Bie score of 88.8 in the group treated functionally and 70.1 in fue group treated by immobilisation (p=0.001). Statistically significant differences (p<0.05) were found at one and three months follow-up. Patients treated functionally were more satisfied with their treatment. Conclusions: Functional treatment appears to be a favourable strategy for treating acute grade III ankle sprains when compared with immobilisation. Patients treated functionally were more satisfied with their treatment

The role of electrical stimulation in bone repair.

Electric and electromagnetic fields regulate extra-cellular matrix synthesis and stimulate repair of fractures and nonunions. Studies of electric and electromagnetic fields suggest they (1) regulate proteoglycan and collagen synthesis and increase bone formation in models of endochondral ossification, (2) accelerate bone formation and repair, (3) increase union rates in fractures previously refractory to healing, and (4) produce results equivalent to bone grafts. Electric and electromagnetic fields regulate the expression of genes in connective tissue cells for extra-cellular matrix proteins, which results in an increase in cartilage and bone. They also increase gene expression for and synthesis of growth factors, which may be an intermediary mechanism of activity and may amplify field effects through autocrine and paracrine signaling.

Posterior labat vs. lateral popliteal sciatic block: posterior sciatic block has quicker onset and shorter duration of anaesthesia.

BACKGROUND: During foot and ankle surgery, a combination of a sciatic and femoral nerve block is a well-recognized technique for providing anaesthesia and post-operative analgesia. Our hypothesis is that the posterior gluteal sciatic block (PSB) is more efficient than the lateral popliteal sciatic block (LPSB), and this study compared the anaesthetic characteristics between these two techniques performed for elective ankle and foot surgery. METHODS: This retrospective database analysis reviewed the onset, duration of action, success rate and complications among 287 patients who were operated upon using sciatic block. PSB was performed in 149 patients and LPSB in 138 patients, all with the use of 30 ml of 5 mg/ml ropivacaine (150 mg). RESULTS: In the PSB group, the time to perform the block was shorter than in the LPSB group (2.5 +/- 1 vs. 4.5 +/- 4 min, P < 0.001), as was the time to complete sensory block (13 +/- 13 vs. 23 +/- 26 min, respectively; P < 0.001). However, the duration of sensory block was longer in the LPSB group (1130 +/- 470 vs. 960 +/- 310 min, respectively; P < 0.006). CONCLUSION: PSB is easier to perform, and has a quicker onset of sensory blockade whereas LPSB has a longer duration of analgesia.

Combined popliteal and saphenous nerve blocks at the knee: an underused alternative to general or spinal anesthesia for foot and ankle surgery.

Peripheral nerve blocks at the ankle have long been used for foot surgery. However, when local foot and ankle blocks are inappropriate or contraindicated, general and spinal anesthesia are the common alternatives. Both have disadvantages and require added equipment and monitors. Combined popliteal and saphenous nerve blocks at the knee can offer a desirable alternative to general and spinal anesthesia for foot and ankle surgery. In addition, popliteal and saphenous nerve blocks provide anesthesia of the entire lower leg, thus permitting a greater variety of procedures to be performed. This article reviews the anatomical considerations, various block techniques, and surgical applications of this useful approach to lower-leg anesthesia.

Current trends in preoperative patient evaluation and management for podiatric surgeons.

In preparation for elective foot and ankle surgery, the podiatric surgeon often will refer the patient for a preoperative evaluation. Surgeons rely on the input of that consultant to provide a determination as to the operative risk for the patient. This article reviews the fundamental parts of the preoperative evaluation, perioperative patient management, and recent changes and trends within this arena.