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).

Hallux valgus repair surgery-specific evidence

Data table: Gabapentinoids for pain management after hallux valgus repair surgery

Arguments for…

• 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).

PROSPECT Recommendations

• Pregabalin is not recommended due to limited procedure-specific evidence.

Hallux valgus repair surgery-specific evidence

Data table: Steroids for pain management after hallux valgus repair surgery

Arguments for…

• Two trials found analgesic benefits with administration of steroids compared with placebo (Aasboe 1998, LoE 2, n=78; Mattila 2010, LoE 1, n=60).
  • In one study, the intervention group received IM betamethasone 12mg 30 minutes before surgery (Aasboe 1998); in the other, oral dexamethasone 9mg was given 60 minutes before and 24h after surgery (Mattila 2010). Of note, paracetamol was administered in these studies.
  • Pain scores in the intervention groups were reduced on POD0 in both studies (Aasboe 1998; Mattila 2010). One study reported reduced pain scores on POD1 and cumulative opioid consumption during the first 3 postoperative days (Mattila 2010).

PROSPECT Recommendations

• 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).

Hallux valgus repair surgery-specific evidence

Data table: Ankle block for pain management after hallux valgus repair surgery

Arguments for…

• Two studies examined the analgesic efficacy of an ankle block in addition to GA; both found a benefit (Kir 2018, LoE 2, n=65; Su 2019, LoE 2, n=90). These studies included basic analgesics.
  • In one study, patients with an ankle block had reduced pain scores on POD1 and up to 12 postoperative months, when compared with a control group (Kir 2018).
  • In the other study, reported pain scores at 6 postoperative hours and opioid consumption at 6 and 12 postoperative hours were reduced in the ankle block group when compared with wound infiltration of local anaesthetics or a control group (Su 2019).

PROSPECT Recommendations

• 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.

Hallux valgus repair surgery-specific evidence

• No studies of sciatic block met inclusion criteria for PROSPECT methodology due to a wider scope of included surgical procedures, or the lack of a control (no block) group.

PROSPECT Recommendations

• Additional research is needed to properly compare a sciatic nerve block with an ankle block under ultrasound guidance in a contemporary practice.

Hallux valgus repair surgery-specific evidence

Data table: Perineural adjuncts to combined sciatic and femoral nerve block for pain management after hallux valgus repair surgery

Arguments against…

• In two studies, the combination of clonidine (Casati 2000, LoE 1, n=30) or fentanyl (Magistris 2000, LoE 1, n=30) with ropivacaine 0.75% for a combined sciatic and femoral nerve block did not reduce pain scores (Casati 2000; Magistris 2000) or opioid consumption (Casati 2000) in the postoperative period. The mean time to first analgesic request was, however, increased from 13.7 to 16.8 hours with clonidine (p=0.04) (Casati 2000). These studies included basic analgesics.

PROSPECT Recommendations

• Clonidine as perineural adjunct for a combined femoral and sciatic nerve block is not recommended due to lack of procedure-specific evidence.
• Fentanyl as perineural adjunct for a combined femoral and sciatic nerve block is not recommended due to lack of procedure-specific evidence.

Hallux valgus repair surgery-specific evidence

Data Table: Wound infiltration for pain management after hallux valgus repair surgery

Arguments for…

• Six studies compared a wound infiltration technique with a control group (Braito 2018, LoE 1; Curda 1983, LoE 2; Golf 2011, LoE 1; Haddon 2003, LoE 1; Kim 2011, LoE 1; Viscusi 2019, LoE 1), where all studies included basic analgesics, except one (Curda 1983). Five of the six studies found improved analgesia in the wound infiltration groups.
  • In five studies, authors compared wound infiltration with normal saline to bupivacaine (Haddon 2003, LoE 1, n=34; Viscusi 2019, LoE 1, n=251), to a mixture of ropivacaine with morphine, ketorolac, epinephrine (Kim 2011, LoE 1, n=60), to extended release (liposomal) bupivacaine (Golf 2011, LoE 1, n=193) or to dexamethasone alone (Curda 1983, LoE 2, n=51).
  • In all five studies the active medication group showed a reduction of pain scores in the first 24 postoperative hours (Curda 1983; Golf 2011; Haddon 2003; Kim 2011; Viscusi 2019), and up to POD2 (Haddon 2003), or even POD7 (Curda 1983).

Arguments against…

• One study did not show any significant difference when running a continuous infusion of ropivacaine 0.2% at a rate of 2ml/h for 24 hours through a wound catheter, without initial bolus (Braito 2018, LoE 1, n=42).

PROSPECT Recommendations

• 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).
• Continuous wound infusion with local anaesthetic is not recommended due to lack of procedure-specific evidence.
• Wound infiltration with extended release bupivacaine is not recommended due to limited procedure-specific evidence.
• Wound infiltration with dexamethasone is not recommended due to limited procedure-specific evidence.

Hallux valgus repair surgery-specific evidence

Data table: Surgical techniques for pain management after hallux valgus repair surgery

Arguments for…

• A systematic review of hallux valgus surgery including 25 studies concluded that surgery is more effective than conservative treatment or no treatment in reducing pain in the first year following surgery (Klugarova 2017).

Arguments against…

• Fourteen studies investigated different surgical techniques, such as scarf osteotomy, chevron osteotomy, Hohmann procedure or Lapidus procedure (Avcu 2018, LoE 1; Baumhauer 2016, LoE 2; Deenik 2007, LoE 2; Faber 2004, LoE 1; Faber 2013, LoE 1; Glazebrook 2014, LoE 1; Jeuken 2016, LoE 2; Kaufmann 2018, LoE 2; Lechler 2012, LoE 2; Lee 2017, LoE 1; Sahin 2018, LoE 2; Saro 2007, LoE 1; Saro 2007b, LoE 1; Wester 2016, LoE 2). None of the studies mentioned whether basic analgesics were prescribed.
  • None was associated with a reduction in pain scores, except one (Lee 2017, LoE 1, n=50) that showed a reduction on POD1 to postoperative week 6, without difference at 6 postoperative months, in favour of percutaneous chevron/akin osteotomy when compared with an open scarf/akin osteotomy.
  • In contrast, one study (Kaufmann 2018, LoE 2, n=47) investigated a percutaneous approach versus an open chevron osteotomy, but did not find any difference.
  • Of note, two out of these 14 trials (Deenik 2007, LoE 2, n=96 and Jeuken 2016, LoE 2, n=55) specifically compared a scarf versus a chevron osteotomy and did not find any difference in postoperative pain scores.
• A systematic review of hallux valgus surgery including 25 studies concluded that the clinical impact of different surgical procedures on the clinical outcomes, such as gait measurement, quality of life and patient satisfaction, was negligible (Klugarova 2017).

PROSPECT Recommendations

• Percutaneous chevron osteotomy is not recommended due to conflicting procedure-specific evidence.

Hallux valgus repair surgery-specific evidence

Data table: Surgical material

Arguments against…

• Two trials compared the type of material used for the screws (bioabsorbable magnesium versus standard titanium) and did not find any difference in pain scores (Plaass 2018, LoE 2, n=26; Windhagen 2013, LoE 2, n=26). Neither study mentioned whether basic analgesics were prescribed.

PROSPECT Recommendations

• Bioabsorbable magnesium screws are not recommended due to lack of procedure-specific evidence.