Efficacy of a comprehensive multimodal analgesia protocol for postoperative pain management following foot and ankle surgery: a prospective randomized controlled trial

Postoperative pain following foot and ankle surgery significantly impacts patient recovery and satisfaction. This study aimed to evaluate the efficacy of a comprehensive multimodal analgesia protocol compared to conventional pain management in patients undergoing foot and ankle surgery. In this prospective, single-center randomized controlled trial, 82 patients (41 per group) undergoing primary foot and ankle surgery were assigned to either a multimodal analgesia protocol (multimodal group) or conventional pain management (conventional group). Both groups received continuous sciatic nerve block (CSNB) postoperatively and had access to rescue analgesics as needed. The multimodal protocol included a comprehensive time-sequenced approach with preoperative gabapentin and intravenous acetaminophen/ibuprofen, intraoperative dexamethasone, and scheduled postoperative medications including cryotherapy. Pain was assessed using visual analog scale (VAS) scores at multiple timepoints postoperatively and after CSNB removal. Rescue medication use and patient satisfaction were also recorded. Linear mixed model analysis revealed significantly lower VAS pain scores in the multimodal group at 10 h (P = 0.014), 12 h (P < 0.001), 18 h (P = 0.002), 24 h (P = 0.005), and 48 h (P = 0.003) postoperatively. After CSNB catheter removal, no significant between-group differences in pain scores were observed (P = 0.968). First-line rescue medication (Ultracet) usage was significantly lower in the multimodal group at 12 h, 24 h, and 48 h (P = 0.001, P = 0.012, P = 0.031, respectively). Second-line rescue analgesia (intravenous ketorolac) was required by a significantly smaller proportion of patients in the multimodal group, with significant between-group differences observed at 10 h (0% vs. 22%, P = 0.002), 12 h (10% vs. 42%, P = 0.002), 48 h (25% vs. 60%, P = 0.003), and 72 h (5% vs. 30%, P = 0.008). Patient satisfaction was significantly higher in the multimodal group (mean VAS 9.4 ± 1.0 vs. 8.1 ± 1.7; P < 0.001). A comprehensive multimodal analgesia protocol significantly improves pain control during the initial 48 h after foot and ankle surgery and enhances patient satisfaction compared to conventional pain management. These findings support the implementation of structured multimodal approaches to optimize postoperative pain management in foot and ankle surgical patients. Level of Evidence: Therapeutic Level I.