This audit summarizes the results of using ultrasound-guided ankle blocks for foot and ankle surgeries performed as day procedures. 76 patients received ultrasound-guided ankle blocks in addition to general anesthesia. The blocks provided satisfactory postoperative pain relief, with 88% of patients reporting pain scores of 1 or less in recovery. Rescue analgesics were required for 10.5% of patients and antiemetics for 5.2%. Patients spent on average 38 minutes in recovery and were discharged from the day surgery unit about 2.2 hours after surgery. No immediate complications from the ultrasound-guided ankle blocks were observed. The audit concludes that ultrasound-guided ankle blocks provide effective postoperative pain relief for foot and ankle day surgeries with low rates

1. Audit on Ultrasound guided Ankle
block for foot and Ankle surgery
Dr H Ningegowda
Dr R Makker
Dr M Kumar
West Hertfordshire NHS trust

2. Background
Foot surgeries are often painful post operatively
and is mostly performed as day surgery procedure.
Suitable regional anaesthetic techniques include a
spinal anaesthetic, popliteal sciatic block, Ankle
block, metatarsal block or a combination of these
techniques.
Ankle block may be performed using a landmark
based or ultrasound-guided(USG) technique. The
USG technique may improve block success
compared with the conventional technique.

3. Why this Audit?
In SACH around 350-400 foot and ankle day
surgery procedures are done every year.
We started performing Ankle blocks using
Ultrasound and we wanted to evaluate the
efficacy of the Ankle block.
This audit was done during 2013-14 at SACH.

4. Aims of audit
• Evaluate postoperative pain relief after USG
Ankle block.
• Incidence of Post operative nausea and
vomiting [PONV].
• Time to discharge from Recovery and Day-
Surgery Unit.
• Complications of USG Ankle block.

5. Methods & Materials
After registering with the Trust audit
department 76 patients posted for day surgery
foot and ankle procedures were evaluated.
All patients were seen by Anaesthetist on the
day of surgery, explained plan of GA and USG
Ankle block.
Verbal consent for Ankle block obtained.

6. GA
Fentanyl
Propofol
Ondensetron
Dexamethasone
Paracetamol
Parecoxib
Maintainence with O2 + Air + Desflurane [MAC 1 – 1.2]
Volume controlled ventilation
Standard monitoring with ECG,HR, SpO2, NIBP, ETCO2
Airway was maintained using Igel/LMA

7. USG Ankle block
All the USG Ankle block was performed after
induction in anaesthetic room using standard Local
anaesthetic mixture of 10mls 0.25% Chirocaine and
10mls of 2% Lidocaine [Total volume 20mls].
Blocks were performed by the 3 authors and by
trainees under supervision.
STOP before Block observed.
High frequency probe, 22G Sonoplex 50mm needle.
In plane technique was used for all the cases.

8. Nerve supply of Foot

9. Posterior Tibial
Nerve [PTN]
Inject 5-7mls

10. Superficial
Peroneal
Nerve[SPN]
Inject 3-5mls

11. Deep Peroneal
Nerve [DPN]
Inject 3-5mls

12. Saphenous
Nerve [SaN]
Inject 3-4mls

13. Sural Nerve
[SuN]
Inject 3-4mls

14. After application of torniquet, patient was taken to
operating theatre.
After the operation patient was transferred to recovery.
Rescue analgesic of Morphine upto 10mgs in recovery
was prescribed.
All patients were prescribed regular Paracetamol and
NSAIDs postoperatively.
Codeine and Tramadol PRN was prescribed.
All patients were seen before discharge and feedback
taken.

15. Commonly performed Foot and Ankle
procedures
• Hallux IPJ fusion
• Excision of Mortons Neuroma
• Foot SCARF + AKIN Osteotomy
• Metatarsal DMMO ,Extensor Tenotomy
• Minimal Invasive chielectomy
• 1st MTPJ fusion

16. Data collected
• Duration of surgical procedure
• Torniquet time
• Pain score in recovery
• Rescue analgesics given in recovery
• PONV in recovery and antiemetics given
• Duration spent in recovery.
• Duration spent in Day surgery before ready to
discharge home.
• Analgesics /antiemetics required in Day Surgery
unit.

17. Pain assessment in recovery

18. Results
Total patients
n = 76
Female : Male
72:4
Average age
54 yrs [24-78 yrs]
Duration of procedure
44 mins [21- 66 mins]
Torniquet time
38 mins [28 – 62 mins]
2 of these 76 patients had surgery under USG
Ankle block and sedation.

19. Pain score in recovery
Pain score Number
0 32
1 38
2 2
3 2
4 2 n = 76

20. Patients requiring rescue analgesics
8 of 76 [10.5% ]
Patients requiring antiemetics
4 of 76 [5.2%]
Average time to discharge from Recovery
38 mins [24-56 mins]

21. Average time to discharge from Day Surgery unit
2.2 hrs [ 1.4- 3.6 hrs]
No Analgesics/Antiemetics were required in Day
Surgery Unit.
No immediate complications after USG Ankle
block noted.

22. Conclusion & Recommendation
Ultrasound guided Ankle block provides satisfactory post
operative pain relief for day surgery foot and ankle
procedures.
Low incidence of PONV
Foot and Ankle day surgeries can be performed with sedation
and USG Ankle block provided there is atleast 20-30 minutes
gap in between the block and operation.
Availability of USG machine in theatres/ Hockey stick High
Frequency Probe.
Design of leaflet on USG Ankle block to be given to patients
when they come for preoperative assessment.
Reaudit the efficacy including the patient satisfaction
feedback.

23. References
• Chan WS . Ultrasound guided versus Anatomic
landmark guided ankle blocks . Reg Anaesth
pain med 2011
• Ultrasound guided ankle block – CEACCP –
Oxford journal 2013
• Ultrasound guided ankle block- NYSORA

24. THANK YOU