Hallux Valgus Repair Surgery 2019

Hallux valgus repair surgery-specific evidence

Data table: Paracetamol and NSAIDs/COX-2-selective inhibitors for pain management after hallux valgus repair surgery

Arguments for…

• One large study administered IV propacetamol 2g or oral paracetamol 1g in the PACU and reported that both reduced pain scores within 6 postoperative hours versus placebo; propacetamol was superior to paracetamol within 4 postoperative hours (Jarde 1997; LoE 2; n=323). There was no mention of whether basic analgesics (NSAIDs) were prescribed or not.
• 11 of 12 studies examining the analgesic efficacy of NSAIDs or COX-2 selective inhibitors found a benefit (Altman 2013, LoE 1; Apfelbaum 2008, LoE 1; Argoff 2016, LoE 1; Daniels 2010, LoE 1; Daniels 2012, LoE 2; Desjardins 2004, LoE 1; Desjardins 2004b, LoE 2; Gibofsky 2013, LoE 1; Gottlieb 2018, LoE 2; Riff 2009, LoE 2; Wang 2010, LoE 1; Willens 2015, LoE 2).
  • Three trials administered celecoxib 400mg daily and showed a reduction in pain scores on POD0 (Altman 2013, LoE 1, n=187) or within the first 48 postoperative hours (Gibofsky 2013, LoE 1, n=212), a reduction in opioid consumption on POD1 and POD2 (Argoff 2016, LoE 1, n=212) or only on POD2 (Gibofsky 2013).
  • Four large trials administered diclofenac 100mg for 48 hours, finding that pain scores and opioid consumption were consistently reduced during the study period (Daniels 2010, LoE 1, n=200; Daniels 2012, LoE 2, n=389; Riff 2009, LoE 2, n=201; Willens 2015, LoE 2, n=376). Another study reported no difference for both outcomes (Desjardins 2004, LoE 1, n=187).
  • Two trials investigated IV parecoxib 20mg or 40mg daily with the first dose administered 45 minutes pre-operatively (Desjardins 2004b, LoE 2, n=50; no basic analgesics were prescribed) or 8 hours postoperatively (Apfelbaum 2008, LoE 1, n=376) and demonstrated a reduction in pain scores within 24 postoperative hours (Apfelbaum 2008; Desjardins 2004b) and a reduction in opioid consumption on POD1 and POD2 (Apfelbaum 2008) without an apparent dose-response effect.
  • One trial showed a reduction in pain scores with meloxicam 30mg or 60mg during the first 48 postoperative hours without having any impact on opioid consumption and without an apparent dose-response effect (Gottlieb 2018, LoE 2, n=59; no basic analgesics were prescribed).
  • One trial assessing pregabalin 300mg or naproxen 550mg versus placebo showed a reduction in pain scores on POD1 in the pregabalin group, on POD1 and POD2 in the naproxen group and a reduction in opioid consumption on POD1 and POD2 in both active groups (Wang 2010, LoE 1, n=89).
• One trial showed that the combination of ibuprofen and paracetamol reduced pain scores and opioid consumption during the first 48 postoperative hours when compared with placebo, ibuprofen or paracetamol (Daniels 2019, LoE 1, n=276).

PROSPECT Recommendations

• 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).