Disclaimer: This article is intended solely for informational and educational purposes only. It does not constitute medical advice.
Regional anesthesia has become a cornerstone of perioperative care for ankle surgery, offering an alternative to general anesthesia, reducing opioid consumption, and improving patient satisfaction and comfort. Peripheral nerve blocks (PNBs) are now used as a sole anesthetic in some cases and as an adjunct in others. Additionally, though its use is less common, neuraxial anesthesia may also be appropriate in some cases.
Anatomically, sensation to the ankle and foot is supplied by terminal branches of the sciatic and femoral nerves. The sciatic nerve divides into the tibial and common peroneal nerves, the latter splitting further into superficial and deep peroneal branches, while the femoral nerve terminates as the saphenous nerve supplying the medial ankle and foot (Fraser and Doty, 2017). A popliteal sciatic block, performed via lateral or posterior approaches, anesthetizes nearly the entire foot but must be paired with a separate saphenous nerve block to cover the medial aspect, since the saphenous nerve is not addressed by a popliteal injection (Pearce and Hamilton, 2010; Fraser and Doty, 2017). More distally, a standard ankle block infiltrating the posterior tibial, saphenous, sural, and superficial and deep peroneal nerves is well suited to forefoot and midfoot procedures (Myerson et al., 1992; Pearce and Hamilton, 2010).
Ultrasound guidance has largely supplanted nerve stimulation for block placement, with meta-analyses showing reduced procedural pain, less local anesthetic use, and fewer inadvertent vascular punctures, though overall block success and complication rates are comparable between the two approaches (Fraser and Doty, 2017). Continuous catheter techniques extend analgesia beyond the typical 13-to-18-hour duration of a single-injection block and have been shown in multiple randomized trials to improve pain scores, reduce opioid use, and increase patient satisfaction relative to single-shot injections, albeit with a small associated risk of catheter-related infection (Pearce and Hamilton, 2010; Fraser and Doty, 2017).
Research has also compared two regional anesthesia techniques for ankle surgery: peripheral nerve block and spinal anesthesia. A 2023 systematic review and meta-analysis of nine randomized trials found that spinal anesthesia offers faster block performance and onset, while peripheral nerve blocks provide substantially longer sensory and motor blockade and lower postoperative analgesic requirements, alongside less hypotension and reduced vasoactive drug use (Lee et al., 2023). The AnAnkle trial similarly demonstrated that popliteal sciatic and saphenous blocks yielded superior pain and opioid-consumption profiles compared with spinal anesthesia in acute ankle fracture surgery, despite a notable rebound pain phenomenon as the block resolved—an effect clinicians must anticipate and manage proactively (Sort et al., 2021).
For simpler ankle and foot injuries, wide-awake local anesthesia with no tourniquet (WALANT), using lidocaine with epinephrine for hemostasis, has also demonstrated low pain and anxiety scores, short hospital stays, and no complications in a retrospective series of 31 patients, suggesting a role in fast-track and office-based treatment pathways (Bilgetekin et al., 2020).
Overall complication rates for regional anesthesia techniques remain low. When nerve injury occurs, it is typically transient and attributable to intraneural rather than perineural injection, and systemic toxicity is rare but requires vigilance regarding dosing and inadvertent intravascular injection (Pearce and Hamilton, 2010; Fraser and Doty, 2017). Selection of technique should be individualized and take into consideration procedure complexity, patient comorbidities, desired duration of analgesia, and institutional resources.
References
- Bilgetekin, Y.G., Kuzucu, Y., Öztürk, A., Yüksel, S., Atilla, H.A., and Ersan, Ö. (2020). The use of the wide-awake local anesthesia no tourniquet technique in foot and ankle injuries. Foot and Ankle Surgery. https://doi.org/10.1016/j.fas.2020.07.002
- Fraser, T.W., and Doty, J.F. (2017). Peripheral nerve blocks in foot and ankle surgery. Orthopedic Clinics of North America. https://doi.org/10.1016/j.ocl.2017.06.008
- Lee, M., Lee, C., Lim, J., Kim, H., Choi, Y.-S., and Kang, H. (2023). Comparison of a peripheral nerve block versus spinal anesthesia in foot or ankle surgery: a systematic review and meta-analysis with a trial sequential analysis. Journal of Personalized Medicine, 13, 1096. https://doi.org/10.3390/jpm13071096
- Myerson, M.S., Ruland, C.M., and Allon, S.M. (1992). Regional anesthesia for foot and ankle surgery. Foot & Ankle International, 13(5), 282–288. https://doi.org/10.1177/107110079201300510
- Pearce, C.J., and Hamilton, P.D. (2010). Current concepts review: regional anesthesia for foot and ankle surgery. Foot & Ankle International, 31(8), 732–739. https://doi.org/10.3113/FAI.2010.0732
- Sort, R., Brorson, S., Gögenur, I., Hald, L.L., Nielsen, J.K., Salling, N., Hougaard, S., Foss, N.B., Tengberg, P.T., Klausen, T.W., and Møller, A.M. (2021). Peripheral nerve block anaesthesia and postoperative pain in acute ankle fracture surgery: the AnAnkle randomised trial. British Journal of Anaesthesia, 126(4), 881–888. https://doi.org/10.1016/j.bja.2020.12.037