title: Multimodal analgesia therapy reduces length of hospitalization in patients undergoing fusions of the ankle and hindfoot.
abstract: BACKGROUND
  Multimodal postoperative analgesia employs multiple medications given perioperatively to block the generation and perception of pain at different points in the nociceptive pathway. This retrospective study examines its effect on the length of stay for patients undergoing hindfoot and ankle fusions.
  
  
  METHODS
  All patients operated upon by the senior authors between 2007 and 2011, inclusive, underwent ankle fusion, subtalar fusion, pantalar arthrodesis, triple arthrodesis, or combined ankle/subtalar fusions. The perioperative pain management was either the "traditional" method (patient-controlled-analgesia-delivered parenteral narcotics beginning immediately postoperatively) or the multimodal pain protocol (pre- and postoperative oral administration of opioids, celecoxib, pregabalin, acetaminophen, and prednisone). The choice of pain protocol was up to the surgeons, without any exclusion criteria. Physical therapy protocols were not changed during the study. The study included 220 patients; 175 received the multimodal protocol and 45 received traditional management. Multimodal protocol patients were younger (53.9 vs 59.7 years; P < .003), but there were no other differences between the groups with respect to gender, obesity, body mass index, tobacco use, alcohol use, or comorbidities. Complex cases (revision surgeries, Charcot joint surgeries, multiple concurrent procedures, etc) were equally represented in both groups.
  
  
  RESULTS
  Multimodal protocol patients had lower lengths of stay (2.5 days; 95% confidence interval [CI], 1.4-3.7) than traditional pain management patients (4.2 days; 95% CI, 2.7-5.7; P < .001). This was also true for both complicated and uncomplicated surgeries when considered separately.
  
  
  CONCLUSIONS
  This study provides the first evidence that multimodal therapy reduces the length of stay for patients undergoing major hindfoot or ankle fusion surgery, regardless of surgical complexity.
  
  
  METHODS
  Level III, comparative series.
authors.affiliation: Department of Orthopaedics and Rehabilitation, University of Vermont College of Medicine, Burlington, VT, USA.
authors.forename: James D
authors.initials: JD
authors.lastname: Michelson
authors.forename: Raymond A
authors.initials: RA
authors.lastname: Addante
authors.forename: Mark D
authors.initials: MD
authors.lastname: Charlson
mesh_terms: D000082:Acetaminophen / Q000627:therapeutic use; D016058:Analgesia, Patient-Controlled; D000700:Analgesics / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000627:therapeutic use; D000768:Anesthesia, General; D000775:Anesthesia, Spinal; D000843:Ankle Joint / Q000601:surgery*; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D001174:Arthrodesis; D000068579:Celecoxib; D052246:Cyclooxygenase 2 Inhibitors / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D004091:Hydromorphone / Q000627:therapeutic use; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000627:therapeutic use; D010098:Oxycodone / Q000627:therapeutic use; D059408:Pain Management / Q000379:methods*; D010149:Postoperative Pain / Q000517:prevention & control*; D011182:Postoperative Care; D011241:Prednisone / Q000627:therapeutic use; D000069583:Pregabalin; D011300:Preoperative Care; D011720:Pyrazoles / Q000627:therapeutic use; D012189:Retrospective Studies; D013380:Subtalar Joint / Q000601:surgery; D013449:Sulfonamides / Q000627:therapeutic use; D005680:gamma-Aminobutyric Acid / Q000031:analogs & derivatives / Q000627:therapeutic use
chemical_list: D000700:Analgesics; D000701:Analgesics, Opioid; D000893:Anti-Inflammatory Agents; D052246:Cyclooxygenase 2 Inhibitors; D011720:Pyrazoles; D013449:Sulfonamides; D000082:Acetaminophen; D000069583:Pregabalin; D005680:gamma-Aminobutyric Acid; D009020:Morphine; D010098:Oxycodone; D000068579:Celecoxib; D004091:Hydromorphone; D011241:Prednisone
keywords: fusion; outcome study; pain management; surgery