• Derek Dillane, Ailar Ramadi, Stephanie Nathanail, Bruce D Dick, Geoff Bostick, Kitty Chan, Chris Douglas, Gordon Goplen, James Green, Susan Halliday, Braiden Hellec, Saifee Rashiq, Angela Scharfenberger, Guy Woolsey, Lauren A Beaupre, and M Elizabeth Pedersen.
• Department of Anesthesia and Pain Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
• Can J Anaesth. 2022 Aug 1; 69 (8): 105310671053-1067.

PurposeComplex elective foot and ankle surgeries are often associated with severe pain pre- and postoperatively. When inadequately managed, chronic postsurgical pain and long-term opioid use can result. As no standards currently exist, we aimed to develop best practice pain management guidelines.MethodsA local steering committee (n = 16) surveyed 116 North American foot and ankle surgeons to understand the "current state" of practice. A multidisciplinary expert panel (n = 35) was then formed consisting of orthopedic surgeons, anesthesiologists, chronic pain physicians, primary care physicians, pharmacists, registered nurses, physiotherapists, and clinical psychologists. Each expert provided up to three pain management recommendations for each of the presurgery, intraoperative, inpatient postoperative, and postdischarge periods. These preliminary recommendations were reduced, refined, and sent to the expert panel and "current state" survey respondents to create a consensus document using a Delphi process conducted from September to December 2020.ResultsOne thousand four hundred and five preliminary statements were summarized into 51 statements. Strong consensus (≥ 80% respondent agreement) was achieved in 53% of statements including the following: postsurgical opioid use risk should be assessed preoperatively; opioid-naïve patients should not start opioids preoperatively unless non-opioid multimodal analgesia fails; and if opioids are prescribed at discharge, patients should receive education regarding importance of tapering opioid use. There was no consensus regarding opioid weaning preoperatively.ConclusionsUsing multidisciplinary experts and a Delphi process, strong consensus was achieved in many areas, showing considerable agreement despite limited evidence for standardized pain management in patients undergoing complex elective foot and ankle surgery. No consensus on important issues related to opioid prescribing and cessation highlights the need for research to determine best practice.© 2022. Canadian Anesthesiologists' Society.

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