Home News Speaker recommends opioid-free, multimodal protocol after elective foot, ankle surgery

Speaker recommends opioid-free, multimodal protocol after elective foot, ankle surgery


September 22, 2022

2 min read



Gonzales T, et al. Opiate-free multimodal pain pathway in elective foot and ankle surgery: A prospective study. Presented at: American Orthopaedic Foot & Ankle Society Annual Meeting; Sept. 14-17, 2022; Quebec City (hybrid meeting).

Gonzales reports being a paid consultant for Biopro, DJ Orthopaedics, IN2Bones and Stryker; and being a board or committee member for the American Orthopaedic Foot & Ankle Society.

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QUEBEC CITY — For properly selected patients undergoing outpatient foot and ankle surgery, an opioid-free, multimodal pain management pathway provided safe and effective pain control with minimal adverse events, according to presented results.

“We have a crisis of opiates and, as orthopedic surgeons, we are part of that problem,” Tyler Gonzales, MD, MBA, said in his presentation at the American Orthopaedic Foot & Ankle Society Annual Meeting. “The literature – especially in foot and ankle – has moved to showing that we maybe don’t need as many narcotics as we prescribe.”

Doctor and a patient having a conversation
Source: Adobe Stock

Gonzales and colleagues prospectively analyzed 33 patients who underwent elective outpatient foot and ankle surgery, including bunion correction surgery with or without a lesser toe procedure, from Dec. 1, 2020, to Feb. 9, 2022. Mean age of patients in the study was 55 years. The average follow-up was 11.5 weeks.

Tyler Gonzales

Tyler Gonzales

All patients completed a comprehensive opioid-free, multimodal pain management protocol, which included oral pregabalin, acetaminophen, ketorolac and cyclobenzaprine to be administered immediately after surgery. Gonzales noted patients were given meloxicam on postoperative day 4. Outcome measures included VAS pain scores, ED visits, urgent care visits, need for pain medication, complications and patient satisfaction.

Overall, 18% of patients required opioids during the first 2 weeks postoperatively; however, no patients required opioids after 2 weeks. On postoperative day 1, the average VAS pain score (out of 10) was 4; on postoperative day 3, the average VAS pain score was 2.5; on postoperative day 8, the average VAS pain score was 1.6; and at 2 weeks postoperatively, the average VAS pain score was 1.4.

At 2 weeks postoperatively, four patients experienced nausea or upset stomach. Other common adverse events included drowsiness, tiredness and constipation, and no patients required an ED or urgent care visit. Additionally, 91% of patients were satisfied with their pain control; 78% would follow the same protocol again; and 82% would recommend the protocol to others.

“We use this pathway now in a large percentage of our practice, including all our [minimally invasive] cases, [and] including fusions and soft tissue procedures. We still use narcotics for total ankle [arthroplasty], open fusions and fractures, but it’s not 100% of these cases,” Gonzales said. “What’s interesting is [in] our other specialties in our hospital – after we started presenting this data – our residents started doing this in other services, because they found that the patients were not experiencing this pain,” he added.

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