Hallux Valgus Repair Surgery 2019

Recommended: Pre- and intra-operative interventions

• Unless otherwise stated, ‘pre-operative’ refers to interventions applied before surgical incision and ‘intra-operative’ refers to interventions applied after incision and before wound closure
• Analgesics should be administered at the appropriate time (pre- or intra-operatively) to provide sufficient analgesia in the early recovery period

• Paracetamol (Grade D) and NSAID (Grade A) or COX-2-specific inhibitor (Grade A) are recommended in the absence of contraindications, started pre- or intra-operatively and continued in the postoperative period.
• Although there is limited procedure-specific evidence for paracetamol, as only one trial investigated analgesic efficacy for hallux valgus specifically, more than 300 patients were included in this study (Jarde 1997). Also, the PROSPECT methodology considers paracetamol a basic analgesic, with a favourable risk-benefit profile (Joshi 2019).

• Systemic steroids are recommended (Grade A) in the absence of contraindications, administered pre-operatively or just before surgery.
• Although the studies used IM betamethasone and oral dexamethasone, the effects of these drugs are systemic. We recommend IV dexamethasone because it is recommended for PONV prophylaxis (Gan 2014). Moreover, IV dexamethasone enhances the impact of a regional analgesic technique such as ankle block, or anaesthetic infiltration (Baeriswyl 2017).

• Ankle block is recommended (Grade A).
• Ankle block is recommended as the first-choice regional analgesic technique and wound infiltration as an alternative (Grade D).
• Only two trials investigated the benefit of an ankle block for this surgery specifically, but they both showed an important effect size (Kir 2018; Su 2019). Additionally, two trials published over 15 years ago concluded that an anatomic-landmark ankle block combined with GA reduced pain scores (Needoff 1995) or increased the time to first pain after forefoot surgery (Clough 2003), when compared with GA alone.
• Despite only a single trial showing the superiority of the ankle block over wound infiltration of local anaesthetics (Su 2019), ankle block should be favoured as it may allow the surgery to be performed without additional GA or SA (López 2012). Moreover, it also reduces the anaesthesia-related time in the operating theatre, especially if the regional procedure is performed prior to operating room entry.
• Additional research is needed to properly compare a sciatic nerve block with an ankle block under ultrasound guidance in a contemporary practice.

• Wound infiltration with single administration of local anaesthetic is recommended (Grade A).
• Ankle block is recommended as the first-choice regional analgesic technique and wound infiltration as an alternative (Grade D).

Recommended: Post-operative interventions

• Unless otherwise stated, ‘postoperative’ refers to interventions applied at or after wound closure
• Analgesics should be administered at the appropriate time (pre- or intra-operatively) to provide sufficient analgesia in the early recovery period

• Paracetamol (Grade D) and NSAID (Grade A) or COX-2-specific inhibitor (Grade A) are recommended in the absence of contraindications, started pre- or intra-operatively and continued in the postoperative period.
• Although there is limited procedure-specific evidence for paracetamol, as only one trial investigated analgesic efficacy for hallux valgus specifically, more than 300 patients were included in this study (Jarde 1997). Also, the PROSPECT methodology considers paracetamol a basic analgesic, with a favourable risk-benefit profile (Joshi 2019).

• Opioids are recommended for rescue postoperative analgesia (Grade D), if other recommended approaches are not adequate.

• Paracetamol (Grade D)
• COX-2 selective inhibitor or NSAID (Grade A)
• Systemic steroids (Grade A)
• Ankle block (Grade A) or wound infiltration with single administration of local anaesthetics (Grade A). Ankle block recommended as a first choice and wound infiltration as an alternative (Grade D).

• Paracetamol (Grade A)
• COX-2 selective inhibitor or NSAID (Grade A)
• Opioid for rescue (Grade D)