Prolonged Popliteal Fossa Nerve Blockade (Prolonged Pop)

Following major foot and ankle surgery patients complain of severe pain. Currently, Hospital
for Special Surgery (HSS) usually uses nerve blocks (injections of local anesthetic near
nerves supplying the lower leg) to help manage pain after this type of surgery. Patients
also receive additional pain pills, including narcotics as needed. This study looks at
addition of medications to the local anesthetic for the nerve blockade. The investigators
hope that these medications (dexamethasone and buprenorphine) will prolong the pain relief
from the nerve block. There are 3 groups in the study. One group is a control, and receives
usual therapy: nerve block + pain pills. This is typically what the patient would receive as
standard care if they were not in the study. One group uses a nerve block with additives (+
pain pills). One group gets a nerve block (local anesthetic only) + pain pills + intravenous
buprenorphine - this is meant to see if the buprenorphine acts directly on the nerve that
was blocked, or indirectly acts on the brain.

Patients will be followed while in the hospital, and contacted by telephone and/or email
after discharge for 2-3 days. Patients will be asked about their pain levels and the
duration of their block. The investigators will enroll 90 patients.

Inclusion Criteria:

- Patients of Dr. Levine or Dr. Roberts at Hospital for Special Surgery

- Patients aged 18-75

- Patients scheduled for discharge from HSS after foot or ankle surgery

- A single-injection popliteal fossa nerve block is judged appropriate

- Surgery confined to foot and ankle (no iliac crest bone graft planned - iliac
aspirate is not an exclusion criterion)

Exclusion Criteria:

- < 18 and > 75

- Surgery that will cause pain at sites outside the distal lower extremity (e.g. iliac
crest bone graft)

- Bilateral surgery

- Chronic pain (defined as regular use of opioid analgesics for > 3 months)

- Chronic use of steroids (defined as regular use of steroids for > 3 months)

- Contraindication to performance of the popliteal fossa nerve block with 30 cc 0.25%
bupivacaine (e.g. alleged bupivacaine sensitivity, low body weight, etc.)

- Contraindications to dexamethasone or buprenorphine (e.g. allergy, insulin dependent
diabetes mellitus, etc.)

- Patients who have been diagnosed with altered pain perception or have lack of
sensation

- Inability of the patient to describe postoperative pain (e.g. psychiatric disorder,
dementia)

- Non-English speaking patients (the questionnaire is in English, and translations
would have to be separately validated)