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Summary Recommendations

PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.

Hallux valgus repair is a common orthopaedic surgery, associated with moderate-to-severe postoperative pain that may have a negative impact on recovery (Korwin-Kochanowska 2020; Gerbershagen 2013). Many pharmacological treatments, anaesthetic strategies and surgical techniques have been investigated to provide the best possible postoperative analgesia.

This review (Wust 2025) aimed to assess the available literature and update previous PROSPECT recommendations for optimal pain management after hallux valgus repair surgery (Korwin-Kochanowska 2020), which were based on data from 56 studies.

The systematic review and formulation of the recommendations were performed using the unique PROSPECT methodology, available at https://esraeurope.org/prospect-methodology/. This methodology was first published in Joshi 2019 and updated in Joshi 2023. Literature databases (CENTRAL, CINAHL, EMBASE, MEDLINE and Web of Science) were searched from 1 January 2019 to 19 November 2024 to identify randomised controlled trials and systematic reviews, in English, which investigated analgesic, anaesthetic and surgical interventions and assessed postoperative pain scores (the primary outcome measure). PROSPECT recommendations were updated, based on interpretation of the evidence from included studies, considering the balance of benefits and adverse effects, the use of basic analgesia, and the procedure-specific clinical context.

17 RCTs and seven systematic reviews and meta-analyses met the inclusion criteria.

This review is registered on PROSPERO: CRD420251013056.

Summary of recommendations and key evidence for pain management in patients undergoing hallux valgus repair surgery

Systemic pharmacological treatments
Paracetamol combined with an NSAID or COX-2 selective inhibitor, administered pre-operatively or intra-operatively and continued postoperatively.

  • Consistent with the PROSPECT methodology (Joshi 2023), studies that focused exclusively on these basic analgesics were excluded from the review; in the absence of contraindications, basic analgesics should be administered peri-operatively to all patients undergoing surgery.
Dexamethasone (systemic steroids), intra-operatively

  • Recent publications have underlined the analgesic value of concomitant dexamethasone with regional analgesic techniques (Desai 2023; Desai 2021); at an IV dose of 0.1–0.2 mg/kg, dexamethasone prolongs analgesia in the postoperative period by a mean duration of 8 hours in the presence of a regional analgesic technique with long-acting local anaesthetic
Opioid for rescue, postoperatively

  • The use of opioids should be reserved for rescue medication, as in the previous PROSPECT recommendations (Korwin-Kochanowska 2020)

Regional anaesthetic and analgesic techniques
Ankle block with single administration of local anaesthetics as first choice
Local anaesthetic wound infiltration as an alternative to ankle block

  • The recommendation is based on evidence from the previous PROSPECT review (Korwin-Kochanowska 2020), and is consistent with the previous recommendation; no new evidence for wound infiltration was identified in the updated literature review

Surgical procedures
Minimally invasive surgery or percutaneous osteotomy

  • The recommendation is based on evidence from a meta-analysis (Ji 2022) and three positive RCTs (Dragosloveanu 2022; Torrent 2021; Yoon 2024) showing analgesic benefit from use of a minimally invasive approach or percutaneous osteotomy compared with an open osteotomy

COX, cyclo-oxygenase; IV, intravenous; NSAID, non-steroidal anti-inflammatory drug; RCT, randomised controlled trial.

Analgesic interventions that are not recommended for pain management in patients undergoing hallux valgus repair surgery.

 

Overall recommendations for procedure-specific pain management in patients undergoing hallux valgus repair surgery
Pharmacological treatments
  • Paracetamol combined with an NSAID or COX-2 selective inhibitor administered pre-operatively or intra-operatively and continued postoperatively
  • Dexamethasone (systemic steroids), intraoperatively
  • Opioid for rescue postoperatively
Anaesthetic and analgesic strategies
  • Ankle block with single administration of local anaesthetics as first choice
  • Local anaesthetic wound infiltration as an alternative
Surgical procedures
  • Minimally invasive surgery or percutaneous osteotomy

COX, cyclo-oxygenase; NSAID, non-steroidal anti-inflammatory drug.

PROSPECT recommendations for hallux valgus repair surgery – Infographic