Post op HAV surgery pain management

NewsBot · Dec 20, 2007

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Multi-modal-analgesia for pain management after Hallux Valgus surgery: a prospective randomised study on the effect of ankle block
Ibrahim Turan , Hamid Assareh , Christer Rolf and Jan Jakobsson
Journal of Orthopaedic Surgery and Research 2007, 2:26doi:10.1186/1749-799X-2-26

Background
Pain and emesis are the two major complaints after day case surgery. Local anaesthesia has become an important part of optimizing intra and post-operative pain treatment, but is sometimes not entirely sufficient. The aim of the present study was to study the effect of adding an ankle block to a multi-modal analgesic approach on the first 24-hour-need for rescue analgesia in patients undergoing elective Hallux Valgus surgery. Type of study: Prospective, randomized patient-blind study comparing ankle block with levo-bupivacaine, lidocaine and Saline placebo control.

Methods
Ninety patients were studied comparing ankle block (15 cc) using levo-bupivacaine 2.5 mg/ml, lidocaine 10 mg/ml or placebo (saline) on day-case elective Hallux Valgus surgery, supported by general anaesthesia in all cases. Primary study endpoint was number of patientas requiring oral analgesics during the first 24 post-operative hours.

Results
Ankle block had no effect on need for rescue analgesia and pain ratings during the 1st 24 postoperative hours, there was no difference seen between placebo and any of the two active local anaesthesia studied. The only differences seen was that both lidocaine and levo-bupivacaine reduced the intra-operative need for anaesthetic (sevoflurane) and that levo-bupivacaine patients had a lower need as compared to the lidocaine patients for oral analgesics during the afternoon of surgery.

Conclusion
Adding a single shot ankle block to a multi-modal pain management strategy reduces the need for intra-operative anaesthesia but has no major impact of need of rescue analgesics or pain during the first 24- hour after surgery.
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drsarbes · Dec 25, 2007

hmmmmmmm.
Well, give a marcaine block and make sure the bandage isn't tight and there will be little to no pain for 20-24 hrs.
Perhaps someone can explain the results of this study to me.
Is it trying to say that a post op block has no effect on post operative pain management?????
Ridiculous.

Steve

NewsBot · Aug 27, 2010

Pain management after elective hallux valgus surgery: a prospective randomized double-blind study comparing etoricoxib and tramadol.
Brattwall M, Turan I, Jakobsson J.
Anesth Analg. 2010 Aug;111(2):544-9. Epub 2010 Jun 28.

BACKGROUND: Pain is a common complaint after day surgery, and there is still a controversy surrounding the use of selective cyclooxygenase-2 (COX-2) inhibitors. In the present prospective, randomized, double-blind study we compared pain management with a selective (COX-2) inhibitor (etoricoxib) with pain management using sustained-release tramadol after elective hallux valgus surgery.

METHODS: One hundred ASA 1 to 2 female patients were randomized into 2 groups of 50 patients each; oral etoricoxib 120 mg x 1 x IV + 90 mg x 1 x day V-VII and oral tramadol sustained-release 100 mg x 2 x VII. Pain, pain relief, satisfaction with pain management, and need for rescue medication were evaluated during the first 7 postoperative days. A computed tomography scan evaluating bone healing was performed 12 weeks after surgery. A clinical evaluation of outcome (healing, mobility, and patient-assessed satisfaction) was performed 16 weeks after surgery.

RESULTS: Two patients withdrew before discharge from the hospital. Ninety-eight patients, 81 ASA 1 and 17 ASA 2 (82 nonsmokers and 14 smokers), mean age 49 years (19-65), weight 64 (47-83) kg, and height 167 (154-183) cm were evaluated. Overall pain was well managed, but the mean visual analog scale (VAS) was significantly lower among etoricoxib patients evaluated during the entire 7-day period studied (12.5 + or - 8.3 vs. 17.3 + or - 11, P < 0.05). patient's grading of pain relief (92 + or - 12 vs. 85 + or - 15, P < 0.05) and satisfaction with pain medication (47/49 vs. 39/49, P < 0.05) was higher among etoricoxib patients. Patients receiving tramadol reported significantly more side effects. Six patients, all in the tramadol group, discontinued the study because of side effects (P < 0.05). At 14-day follow-up 1 patient in the etoricoxib group and 5 patients in the tramadol group exhibited minor irritation in the wound area. The 12-week computed tomography scan showed good healing in 82 patients, 43 in the etoricoxib group, and 39 in the tramadol group. The study found ongoing healing in 11 patients, 4 in the etoricoxib group and 7 in the tramadol group. The 16-week patient-assessed Health Profile Quality of life revealed high patient satisfaction overall; 47 patients in each study group rated the outcome as satisfactory and the mean change in the patient-assessed quality of life VAS score was 6.2 and 2.6 for the etoricoxib and tramadol groups, respectively. Clinical follow-up at 16 weeks showed high functionality and no signs or symptoms of improper healing in any patient.

CONCLUSION: Etoricoxib was found to be more effective and associated with fewer side effects in comparison with tramadol sustained release as a component of multimodel analgesia after elective hallux valgus surgery. There were no signs of impaired wound or bone healing associated with the use of etoricoxib.
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W J Liggins · Aug 28, 2010

The study does not specify whether a full ankle block was carried out, although the volume of L.A. used would suggest that it was; however, the abstract does not describe what a 'single shot ankle block' consists of. If, as suggested, the test applied was the need for oral analgesics within the 24 hours post op. then I can understand the lidocaine group requiring this after 1 hour and the levo-bupivacaine requiring oral analgesia from perhaps 6 hours post-operatively. I concur with Steve that personally, I have not found levo-bupivacaine 2.5% as effective as bupivacaine 0.5%, but that is anecdotal.

If it is the case that a full ankle block has been carried out and that the L.A. is no more effective than saline for, say, the first 6 hours post-op. then one must question the technique.

Bill Liggins

NewsBot · Aug 30, 2010

This clinical trial was just registered:
A Study Comparing Etoricoxib and Diclofenac Sodium in Post Hallux Valgus Surgery Pain

The investigators hypothesize that cyclooxygenas-II-selective inhibitors (Coxibs) provide a better patients assessed overall satisfaction when used for pain management after elective hallux valgus surgery as compared to traditional Non-steroidal anti-inflammatory drugs (NSAIDs).
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NewsBot · Nov 23, 2011

Comparison of multi-drug injection versus placebo after hallux valgus surgery.
Kim BS, Shim DS, Lee JW, Han SH, Ko YK, Park EH.
Foot Ankle Int. 2011 Sep;32(9):856-60.
Abstract

BACKGROUND:
Hallux valgus surgery is followed by a significant amount of postoperative pain. Local multi-drug injection can be an option for pain control, but few clinical studies exist.

METHODS:
Between May 2008 and July 2009, 30 consecutive patients (60 feet) received simultaneous bilateral proximal osteotomies for the correction of hallux valgus deformities. Each patient received local infiltration of the test solution made with ropivacaine, morphine, ketorolac, and epinephrine on one foot and same amount of normal saline on the other foot. The test side and the control side were randomly selected and both the patient and the surgeon remained blinded until the end of the data collection.

RESULTS:
The multi-drug injection resulted in significantly less pain at 4 hours after the operation through the night of the first postoperative day. The difference in visual analogue scale (VAS) between the two sides was most significant at 8 hours after the operation, and then gradually decreased through the first and second postoperative day. Mean satisfaction VAS was significantly higher on the injection side (8.2+/-0.9) compared to the control side (6.2+/-1.9, p<0.0001).

CONCLUSION:
Local multi-drug injection was easy to perform and safe and effective in reducing pain and enhancing patient satisfaction after hallux valgus surgery.
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NewsBot · Oct 9, 2012

Anesthesia and postoperative analgesia after percutaneous hallux valgus repair in ambulatory patients.
Adam F, Pelle-Lancien E, Bauer T, Solignac N, Sessler DI, Chauvin M.
Ann Fr Anesth Reanim. 2012 Oct 3.

BACKGROUND:
Postoperative pain is often severe after hallux valgus repair. Sciatic nerve blocks with long-acting local anesthetics have been recommended for surgical anesthesia and postoperative analgesia. However, a novel percutaneous approach may require less analgesia and make the procedure suitable for ambulatory care. We thus tested the hypothesis that mid-foot block and sciatic nerve blocks provide comparable surgical anesthesia and postoperative analgesia, but that patients ambulate independently sooner after mid-foot block.

STUDY DESIGN:
Prospective, randomized study.

METHODS:
Forty patients scheduled for ambulatory percutaneous hallux valgus repair were randomly assigned to two anesthesia and analgesia blocks: foot infiltration achieved by a mild foot block, or sciatic nerve block (30mL of 7.5% ropivacaine for each block). Surgery was performed without sedation or additional analgesia. Both groups were given oral paracetamol/codeine and ketoprofene systematically; tramadol was added if necessary. Walking ability and pain scores were assessed for 48 postoperative hours.

RESULTS:
Demographic and morphometric characteristics, and duration of surgery were similar in each group. Pain scores were comparable and low in each group at rest and while walking. The time to ambulation without assistance was significantly less for patients in the infiltration group (3.8±1.4hours) than patients in the sciatic group (19.2±9.5hours; P<0.0001).

CONCLUSION:
After percutaneous hallux valgus repair, mid-foot block and sciatic nerve block provided comparable postoperative analgesia. However, mid-foot block seems preferable since the time to ambulation without assistance is much reduced.
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NewsBot · Oct 13, 2012

Comparison of 3 combinations of 0.5% levobupivacaine and 1% mepivacaine in popliteal sciatic block in hallux valgus outpatient surgery
Faulí A, Anglada MT, Gomar C, Sala X, López A, Pons M, Gambús P, Fábregas N.
Rev Esp Anestesiol Reanim. 2012 Oct 3.

BACKGROUND:
To compare 3 combinations of 0.5% levobupivacaine (L) and 1% mepivacaine (M) for popliteal block for hallux valgus surgery.

METHODS:
Prospective, double blind study of 120 patients undergoing unilateral hallux valgus outpatient surgery with posterior popliteal block with ultrasound-guided single injection. Patients were randomly allocated into three groups: G1: 20mL L+10mL M; G2: 10mL L+20mL M; and G3: 15mL L+15mL M. Recorded variables were: time of block, onset and reversal times for tibial and peroneal nerves block; postoperative pain until the 7(th) day by means of visual analogue scale (VAS), simple descriptive scale and the quality of nocturnal rest, complications, and patient satisfaction. ANOVA and chi2 were applied in the statistical analysis, with a P<0.05 considered significant.

RESULTS:
Groups were homogeneous for demographic and surgical characteristics. None of the patients required intraoperative complementary analgesia or anaesthesia. Block onset was significantly longer in G1 than in G2 and G3 (39.4±14.7 versus 32.2±16.5 and 33.2±12minutes). Recovery time from sensory and motor block was significantly longer in G1 than in G2 and G3 (29.5±9.3 versus 22.2±8.2 and 24.8±7.9hours). Postoperative pain level was below VAS 30 (1-100) in the three groups; none of the patients experienced severe pain. Maximum pain level appeared at 24h postoperatively. Patient satisfaction was high and there were no complications.

CONCLUSIONS:
Block onset time and anaesthetic efficacy was adequate in the three groups. The combination of 20mL levobupivacaine 0.5% with 10mL mepivacaine 1% provide a good alternative for a lasting postoperative analgesia.
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NewsBot · Dec 1, 2013

Subcutaneous Injection of Diclofenac for the Treatment of Pain Following Minor Orthopedic Surgery (DIRECT study): A Randomized Trial
Eugenio Chiarello et a
Pain Practice; Early View

Objectives
Parenteral diclofenac is frequently used for analgesia following minor orthopedic interventions. Currently available diclofenac formulations are for intramuscular (IM) or intravenous injection. A new 1 mL volume formulation of diclofenac containing hydroxypropyl-β-cyclodextrin (HPβCD) allows both SC and IM administration. The objective of this open-label, randomized, parallel group, active-controlled study was to assess the safety and efficacy of 75 mg diclofenac HPβCD, administered SC or IM, compared with IM Voltaren® 75 mg in inpatients undergoing minor orthopedic surgeries with moderate-to-severe postoperative pain.

Methods
A total of 325 patients were randomized to treatment. Surgery-related pain was comparable between groups before treatment and rapidly declined in all patients following diclofenac injection. The primary endpoint was investigator-assessed local tolerability up to 18 hours postinjection (redness, swelling, and hardening at the injection site each scored on a 4-point scale where 0 = none, 1 = mild, 2 = moderate, and 3 = severe).

Results
Local tolerability was found to be optimal for all the injected formulations, with mean overall scores (0 to 9) of 0.57, 0.31, and 0.26, for diclofenac HPβCD SC, diclofenac HPβCD IM, and Voltaren® IM, respectively. Consistently, the overall tolerability as judged by the patients and investigators was reported as good or excellent in more than 90% of cases in all groups.

Conclusions
Overall, the study results indicate that safety and efficacy were similar irrespective of the diclofenac formulation used; thus, the new SC diclofenac HPβCD has an acceptable tolerability profile and may be considered a valid alternative to IM-delivered diclofenac formulations.
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NewsBot · Mar 27, 2015

Onset and Duration of Anesthesia for Local Anesthetic Combinations Commonly Used in Forefoot Surgery; Surprise results with Sequential Blocks
Marie Mantini Blazer et al
The Foot; Article in Press

Highlights
•Sequential local anesthetic blocks may not be warranted.
•Mixing local anesthetics decreases the expected duration.
•Bupivacaine is a useful local anesthetic agent in digital surgery.
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Local anesthetic nerve blocks are frequently used for post-operative analgesia and to our knowledge no studies have evaluated the effects of injecting bupivacaine into an area previously injected with lidocaine.Sensation was tested in three groups of subjects receiving local anesthetic digital blocks. Group A received bupivacaine 0.25% plain. Group B received a 1:1 mixture of lidocaine 1% plain and bupivacaine 0.25%. Group C received an initial block of lidocaine 1% plain sequentially followed by bupivacaine 0.25% one hour later. Bupivacaine exhibited a delayed onset and the longest duration when compared to the other two groups. The group receiving the 1:1 mixture showed a rapid onset that resembled that of lidocaine and a shortened duration that did not resemble bupivacaine. The group receiving the sequential injections showed that even after a 1 hour interval following the lidocaine infiltration, there was a deleterious effect on duration of action of the bupivacaine. Using bupivacaine as a post-surgical block in the presence of residual lidocaine from a preoperative block is not warranted as once again, the extended duration of bupivacaine is mitigated. Bupivacaine alone as an initial operative block affords clinically acceptable onset of anesthesia while also providing extended duration of action.
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NewsBot · Nov 12, 2015

From LER:
Bunion surgery: Evolution of postoperative protocols

simonf · Nov 13, 2015

NewsBot said: ↑

Onset and Duration of Anesthesia for Local Anesthetic Combinations Commonly Used in Forefoot Surgery; Surprise results with Sequential Blocks
Marie Mantini Blazer et al
The Foot; Article in Press
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Anyone got the full article?

NewsBot · Dec 8, 2015

Ambulatory surgery under intra-articular anesthesia in the management of hallux valgus deformity. A report on fifty-four patients
V?zquez BR, G?mez GEE, S?nchez CR
source

Objective. To perform corrective surgery for hallux valgus under intra-articular anesthesia at the metatarso-phalangeal joint of the first toe. Materials and methods. A series of 54 patients (36 women, 18 men) with 83 feet, were operated on for correcting either hallux valgus or hallux rigidus by different techniques (Mc Bride, Keller, proximal first metatarsal osteotomy). Propofol-mydazolam is given intravenously for superficial sedation which is started before local anesthesia; 4 to 6 ml of a mixture of 4 ml of 0.5% bupivacaine altogether with 6 ml of 1:500 adrenalin in saline are injected into the articular space. The remaining mixture is used 2 ml for the colateral nerves on each side of the first metatarsal, and aditional infiltration is applied for the skin and to the zone of the first metatarsal base when a proximal osteotomy is planned. Results. Were uniformly excellent or good. Only 5 patients had a mild pain at starting operation, in whom the span of an average 10 minutes for anesthesia instalation was not completely respected. Post-operative analgesia was in average as long as 16 hours. Post-operative bleeding occurred in 8 cases, vasculitis in 6 and superficial infection in 3. No patient was needed to intubate or to applicate general anesthesia. Conclusion. Intra-articular anestesia is proposed as an effective method for hallux valgus correcting surgical procedures such as those described in the present paper. Complications are not atributable to the anesthetic procedure by itself.
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NewsBot · Apr 6, 2016

Similar levels of pain are reported in forefoot surgery after management as a day case and admission for 48 hours: A continuous prospective study of 317 patients.
Chaudier P et al
Bone Joint J. 2015 Dec;97-B(12):1645-50

While many forefoot procedures may be performed as a day case, there are no specific guidelines as to which procedures are suitable. This study assessed the early post-operative pain after forefoot surgery performed a day case, compared with conventional inpatient management. A total of 317 consecutive operations performed by a single surgeon were included in the study. Those eligible according to the criteria of the French Society of Anaesthesia (SFAR) were managed as day cases (127; 40%), while the remainder were managed as inpatients. The groups were comparable in terms of gender, body mass index and smoking status, although the mean age of the inpatients was higher (p < 0.001) and they had higher mean American Society of Anaesthesiologists scores (p = 0.002). The most severe daily pain was on the first post-operative day, but the levels of pain were similar in the two groups; (4.2/10, SD 2.5 for day cases, 4.4/10, SD 2.4 for inpatients; p = 0.53). Overall, 28 (9%) of patients who had their surgery as a day case and 34 (11%) of inpatients reported extreme pain (≥ 8/10). There were more day case patients rather than inpatients that declared their pain disappeared seven days after the surgery (p = 0.02). One day-case patient with excessive bleeding was admitted post-operatively. Apart from the most complicated cases, forefoot surgery can safely be performed as a day case without an increased risk of pain, or complications compared with management as an inpatient.
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NewsBot · Jul 1, 2016

Postoperative analgesic efficacy of dexamethasone sodium phosphate versus triamcinolone acetonide in bunionectomy: A prospective, single-blinded pilot randomized controlled trial
Chris Olivia Ongzalima et al
The Foot and Ankle Online Journal 9 (2): 3

Background: Corticosteroids are often administered via injection preoperatively to reduce post-operative inflammation and pain. Despite their wide anecdotal application in clinical practice, there are no current guidelines pertaining to appropriate corticosteroid selection. This study aims to investigate and compare the efficacy of dexamethasone sodium phosphate (DSP) and triamcinolone acetonide (TA) in postoperative pain management following hallux valgus surgery.
Methods: A randomized, prospective, single-blind study comparing preoperative DSP versus TA injections was conducted on 20 participants who were undergoing elective hallux valgus surgery. Postoperative pain scores (pain intensity and pain interference with daily activities) were assessed with Brief Pain Inventory Short Form (BPI-sf) questionnaire at the time of first postoperative oral analgesic consumption or 14 days after surgery if no analgesics were required. Differences in clinically significant pain scores were also assessed with prospectively defined response criteria.
Results: The difference in mean for pain intensity and pain interference were found to be significantly lower for TA group as compared to DSP group (p = 0.006 and p = 0.001) respectively. Significant difference was also observed in the proportion of participants who reported absence of postoperative pain scores between DSP and TA groups (p = 0.025 and p= 0.006) respectively. However, there were no significant differences between time to postoperative analgesia consumption and proportion of participants requiring oral analgesia (p>0.05).
Conclusions: This study provides preliminary evidence suggesting that TA is associated with lower pain scores compared to DSP. Further research is required to establish the effects of TA and DSP in managing postoperative pain following hallux valgus surgery.
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NewsBot · Oct 18, 2016

A randomised controlled trial comparing two popliteal nerve catheter tip positions for postoperative analgesia after day-case hallux valgus repair
A. L. Ambrosoli et l
Anaesthesia; Volume 71, Issue 11 November 2016

We compared the effect of two different positions of a sciatic nerve catheter within the popliteal fossa on local anaesthetic consumption and postoperative analgesia in patients undergoing day-case hallux valgus repair. Eighty-four patients were randomly allocated to receive a sciatic nerve catheter either between the tibial and peroneal components (sciatic group) or medial to the tibial nerve (tibial group). The primary endpoint was postoperative local anaesthetic consumption, while secondary endpoints were pain scores, number of occasions where sleep was disturbed by pain and incidence of insensate limb and foot drop at 24 h and 48 h postoperatively. Postoperative median (IQR [range]) local anaesthetic consumption was 126 (106–146 [98–180]) ml in the sciatic group versus 125 (114–158 [98–200]) ml in the tibial group (p = 0.103). Insensate limb occurred in 14 patients in the sciatic group versus one patient in the tibial group (p < 0.001), while foot drop was reported by six patients in the sciatic group and none in the tibial group (p = 0.012). Sciatic nerve catheter placement medial to the tibial nerve may be a superior analgesic technique for day-case foot surgery.
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NewsBot · Oct 28, 2017

Continuous Wound Infiltration After Hallux Valgus Surgery.
Braito M et al
Foot Ankle Int. 2017 Oct 1:1071100717736292. doi: 10.1177/1071100717736292

BACKGROUND:
Hallux valgus surgery is associated with significant early postoperative pain. The aim of this study was to investigate the use of continuous wound infiltration (CWI) with ropivacaine for pain management after hallux valgus surgery.
METHODS:
In this prospective, randomized, double-blind, and placebo-controlled single-center trial, 50 patients undergoing distal metatarsal osteotomy for idiopathic hallux valgus were allocated to CWI with ropivacaine 2 mg/mL at a rate of 2 mL/h or placebo for 24 hours postoperatively. Average and peak pain levels on the verbal numeric rating scale (NRS; 1-10) during the first 48 hours after surgery were recorded as primary outcome parameters. Secondary outcome parameters included consumption of narcotics, clinical outcome, incidence of postoperative complications, and patient satisfaction.
RESULTS:
No significant difference in mean ( P = .596) and peak ( P = .353) postoperative pain level was found for CWI with either ropivacaine (mean NRS 1.9 ± 0.8; peak NRS 3.5 ± 2.0) or placebo (mean NRS 2.0 ± 0.7; peak NRS 3.9 ± 1.7) during the early postoperative course. Furthermore, no significant difference between both groups was detected regarding narcotic consumption ( P = .354) and all other secondary outcome parameters. Two severe complications (local dysesthesia with CWI, catheter accidentally fixed by a suture) and 5 catheter dislocations were observed.
CONCLUSION:
CWI with ropivacaine 2 mg/mL at a rate of 2 mL/h for 24 hours after hallux valgus surgery did not reduce postoperative pain level in an inpatient setting.
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NewsBot · Mar 8, 2018

Oliceridine yielded clinically meaningful pain relief vs placebo after bunionectomy

NewsBot · Jul 4, 2020

PROSPECT guideline for hallux valgus repair surgery:
a systematic review and procedure‐specific
postoperative pain management recommendations
Katarzyna Korwin-Kochanowska, et al
Reg Anesth Pain Med 2020;0:1–7.

Hallux valgus repair is associated with moderate-tosevere postoperative pain. The aim of this systematic
review was to assess the available literature and develop
recommendations for optimal pain management
after hallux valgus repair. A systematic review using
PROcedure SPECific Postoperative Pain ManagemenT
(PROSPECT) methodology was undertaken. Randomized
controlled trials (RCTs) published in the English language
from inception of database to December 2019 assessing
postoperative pain using analgesic, anesthetic, and
surgical interventions were identified from MEDLINE,
EMBASE, and Cochrane Database, among others. Of the
836 RCTs identified, 55 RCTs and 1 systematic review
met our inclusion criteria. Interventions that improved
postoperative pain relief included paracetamol and nonsteroidal anti-inflammatory drugs or cyclo-oxygenase-2
selective inhibitors, systemic steroids, ankle block,
and local anesthetic wound infiltration. Insufficient
evidence was found for the use of gabapentinoids or
wound infiltration with extended release bupivacaine
or dexamethasone. Conflicting evidence was found for
percutaneous chevron osteotomy. No evidence was
found for homeopathic preparation, continuous local
anesthetic wound infusion, clonidine and fentanyl as
sciatic perineural adjuncts, bioabsorbable magnesium
screws, and plaster slippers. No studies of sciatic
nerve block met the inclusion criteria for PROSPECT
methodology due to a wider scope of included
surgical procedures or the lack of a control (no block)
group. The analgesic regimen for hallux valgus repair
should include, in the absence of contraindication,
paracetamol and a non-steroidal anti-inflammatory drug
or cyclo-oxygenase-2 selective inhibitor administered
preoperatively or intraoperatively and continued
postoperatively, along with systemic steroids, and
postoperative opioids for rescue analgesia.
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NewsBot · Jan 21, 2021

Outpatient surgery of the first ray of the foot: post-operative pain monitoring at home
L Steinmuller et al
Foot (Edinb). 2021 Jan 8

Introduction: At present, health facilities are forced to switch to outpatient care. While it lends itself well to this organizational arrangement, first ray surgery is broadly considered as painful by patients, who are often reluctant to this treatment. The evolution of post-operative pain in patients who underwent operations for first ray surgery from D0 to D15 were studied. Secondly, the duration of the oral analgesic treatment, the patient's satisfaction level, and searched for complications were assessed.

Methods: This is an observational, single-center and single-operator study. Between July and December 2019, forty patients who underwent first ray surgery (hallux valgus or rigidus) and eligible for outpatient treatment were included. The surgical technique of the hallux valgus treatment consisted of open surgery via double metatarsal and phalangeal osteotomy. The hallux rigidus surgery consisted of arthrodesis using an open dorsal plate. Home monitoring was carried out by a healthcare provider (e-HORUS). The protocol provided for pain management by means of a diffuser of Nefopam IV for a maximum of 5 days, combined with alleviating oral analgesics 1 and 2 and NSAIDs. The pain was evaluated on D0, D1, D3, D5, D8 and D15, using a numerical scale (NS) from 0 to 10. The degree of patient satisfaction was recorded at 1 month.

Results: 35 patients were followed. 5 patients were excluded due to incomplete data. The series included 26 women and 9 men, with an average age of 59.9 years. There were 30 hallux valgus and 5 hallux rigidus. The pain analyzed by the NS was 5.37 on D0, 3.34 on D1, 1.83 on D3, 1.43 on D5, 1.06 on D8 and 2.2 on D15. The average duration of Nefopam infusions was 3.89 days, and the average duration of oral analgesics was 17.7 days. The tolerance of the treatment was satisfactory in 79% of the cases. 69% of patients were very satisfied with the management of their pain. There were no scar complications or infections. No re-hospitalization was necessary. 3 algoneurodystrophies were identified. The existence of fibromyalgia or Parkinsonian syndrome was correlated with higher pain.

Discussion-conclusion: Pain management after outpatient first ray surgery using the injectable Nefopam protocol was satisfactory in the majority of cases, with a high degree of patient satisfaction. This protocol is routinely offered to our patients who must undergo first ray surgery.
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NewsBot · Jul 4, 2021

Opioid Usage after Hallux Valgus Correction Surgery
Zachary Thier et al
Source

Introduction:More than 200,000 surgeries for hallux valgus correction occur annually in the United States. Due to the post-operative pain associated with the procedure, opioids are often prescribed to help manage pain. Given the lack of objective data on opioid use and the difficulty of addressing a patient’s post-operative pain, we soughtto quantify, through a prospective analysis, patient’s narcotic use after hallux valgus surgery. The purpose of our study was to determine the average quantity and type of post-operative opioids consumed after hallux valgus surgery and to assess potentialpredictive factors for increased opioid consumption.Methods:Adult patients undergoing primary hallux valgus surgery were recruited from two foot and ankle fellowship trained orthopedic surgeons at a single institution. At the pre-operative visit, patients were consented and completed a demographical questionnaire. Data was collected from the operative and PACU record, as well as the 2, 6, and 12-week post-operative visits. A statistical analysis was performed to determine the average quantity of opioid and non-opioid pain medication consumed post-operatively, as well as any statistically significant correlations.Results:For the 58 subjects who completed treatment and data collection in the PACU, 53 consumed opioids. Initial prescriptions for these patients included Hydrocodone, 39 (73.58%) Oxycodone, 13 (24.52%) and Meperidine, 1 (1.89%). The average number of opioid pills collectively consumed at the two-week and 12-week post-operative visit was 19.99 and 22.52, respectively. At the two-week postoperative visit, only patient BMI showed a statistically significant association with increased opioid use.Conclusion:On average, patients consumed 22-24 narcotic pain pills after hallux valgus reconstruction surgery. If a physician prescribed 24 narcotics pills after surgery to patients that are not currently utilizing narcotic pain medication, there is a 95% chance they will not need additional pain medication during the two-week postoperative period.
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NewsBot · Jan 26, 2022

Feasibility study on local infiltration anesthesia for postoperative analgesia in patients with hallux valgus
Kong DH et al
Zhongguo gu Shang = China Journal of Orthopaedics and Traumatology, 01 Dec 2021, 34(12):1182-1185Language:chi

Objective
To evaluate the clinical efficacy of local infiltration anesthesia of ropivacaine combined with compound betamethasone for postoperative analgesia in patients with hallux valgus.
Methods
From September 2019 to December 2020, 48 patients with hallux valgus were treated surgically. According to different postoperative analgesia methods, the patients were divided into combined local infiltration group and intravenous analgesia pump group. There were 24 cases, in the combined local infiltration group including 2 males and 22 females;the age ranged from 21 to 78 years old, with an average of (58.3±7.7) years old;soft tissue release and chevron osteotomy were performed in 15 cases and metatarsophalangeal joint fusion in 9 cases;immediately after operation, 20 ml of ropivacaine combined with compound betamethasone mixed diluent was used for local infiltration anesthesia once. There were 24 patients in intravenous analgesia pump group, including 3 males and 21 females;the age ranged from 23 to 81 years old, with an average of(56.8±8.3) years old;soft tissue release and Chevron osteotomy were performed in 17 cases and metatarsophalangeal joint fusion in 7 cases;immediately after operation, intravenous analgesia pump was used for analgesia. The basic flow was 2 ml / h;the self control dose was 0.5 ml;and the locking time was 15 min. Visual analogue scale (VAS) was recorded at 12, 24, 48 and 72 hours after operation;and the VAS was recorded at 24 hours after operation. The occurrence of adverse drug reactions at 0 to 12 hours, 12 to 24 hours and 24 to 48 hours after operation were recorded;and the healing of incision was recorded.
Results
All patients were followed up, and the duration ranged from 14 to 17 days, with a mean of (14.60±0.92) days. There was significantdifference in VAS at 12, 24 and 48 hours between the combined local infiltration group and the intravenous analgesia pump group(P<0.05). There was no significant difference in VAS between the two groups 72 hours after operation (P>0.05). There was no significant difference in the number of adverse drug reactions between the two groups at 0 to 12 hours after operation (P>0.05);there was significant difference in the number of adverse drug reactions 12 to 24 hours after operation (P<0.05). No adverse drug reactions occurred in both groups 24 to 48 hours after operation. There was no significant difference in the grade of knife edge healing between the two groups after suture removal (P>0.05).
Conclusion
Compared with intravenous analgesia pump group, ropivacaine combined with compound betamethasone can significantly reduce postoperative wound pain without increasing adverse drug reactions, and does not increase wound infection.
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NewsBot · Apr 13, 2022

Acute postoperative pain management protocols in podiatric surgery within Australia: a Delphi study
Ping Ping Joanne Ang, Burke Hugo & Renee Silvester
Journal of Foot and Ankle Research volume 15, Article number: 27 (2022)

Background
There is limited evidence in the literature to describe an analgesic protocol that takes into consideration the extent of foot and ankle surgery. The aim of this study was to develop a guide for acute postoperative pain management for podiatric surgery in Australia, and to identify opportunities to improve the current list of scheduled medicines available to podiatric surgeons.

Methods
A Delphi method involving 3 survey rounds was employed for this study. Twelve expert panellists in the field of podiatric surgery and anaesthesiology were invited to participate, and 10 panellists remained by the end of the study. Round 1 involved 15 open-ended questions. These answers formed the basis of the 55 statements that were developed for the following 2 survey rounds, where panellists rated the appropriateness of each statement on a 9-point Likert scale. The third survey round was an opportunity for panellists to revise their answers to each statement in light of the majority response.

Results
For mild acute postoperative pain, non-opioid oral analgesics were recommended as an appropriate management option. For moderate and severe acute postoperative pain, both non-opioid and opioid products were found to be appropriate by the majority. It was agreed that oral opioids be reserved for breakthrough pain at all severity levels. All other statements in the Delphi study pertaining to drug hypersensitivities or allergies, stratification of pain management, opioid prescription concerns, and access to pain medications were accepted as appropriate by the majority of panellists.

Conclusion
The agreed approach to acute postoperative pain management for podiatric surgeons in Australia was with a stepwise approach, utilising multimodal therapy, and reserving oral opioids for breakthrough pain. Additionally, there was consensus for podiatric surgeons in Australia to have wider access to alternative analgesics and anti-emetics that have similar or improved efficacies with better safety profiles.
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NewsBot · Sep 6, 2022

Pain Management of Hallux Valgus Surgery Is Achieved by Cocktail Therapy
Jiewei Xie et al
Volume 2022 |Article ID 1084815 | https://doi.org/10.1155/2022/1084815

Background. Hallux valgus is a relatively common forefoot disease in clinical practice. The aim of our study was to assess the role of local cocktail drugs and postoperative pain after hallux valgus surgery. Methods. A retrospective case-control study was conducted to analyze 75 moderate to severe hallux valgus patients from June 1, 2018 to December 1, 2019. All patients were divided into cocktail and control groups according to whether the cocktail therapy was used or not after the operation. The anesthesiologist did not provide analgesic treatment other than nerve block anesthesia and intravenous anesthesia, such as analgesic pumps. The operative region of the cocktail group received a mixture of 10 ml of 0.75% ropivacaine, 10 ml of flurbiprofen axetil injection, and 1 ml of compound betamethasone injection, whereas the control group received nothing in the surgical spot. We recorded patients’ VAS scores preoperatively and at 6, 24 hours postoperatively; the length of hospital stay and the number of hospitalization expenses; the scores of Kolcaba comfort level; and the scores of Pittsburgh sleep quality. Result. There was no significant difference in age or sex between the two groups. The VAS scores at 6 and 24 hours postoperatively were significantly lower in the cocktail group. The average length of hospital stay was 8.24 days in the control group and 3.73 days in the cocktail group. The average total hospitalization cost of the control group was ¥28285.16, and that of the cocktail group was ¥22366.31. In expenses of total hospitalization costs, the cocktail group was lower than the control group. Kolcaba’s comfort various scores and the total score of the cocktail group were higher than the control group. The total score of PSQI and all dimensions in the experimental group were lower than those in the control group. Conclusion. We found a significant difference in the results of postoperative pain management except for age, sex, and hospitalization expenses. After hallux valgus surgery, inject cocktail drugs around the first metatarsophalangeal joint did reduce postoperative pain level. Level
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NewsBot · Apr 7, 2023

Opioid Usage After Hallux Valgus Correction Surgery
J Benjamin Jackson 3rd et al
Foot Ankle Spec. 2023 Apr 5

Background: Given the lack of objective data on opioid use and the difficulty of addressing a patient's postoperative pain, we sought to quantify patient's narcotic use after hallux valgus surgery. The purpose of our study was to determine the average quantity and type of postoperative opioids consumed after hallux valgus surgery and to assess potential predictive factors for increased opioid consumption.

Methods: At the preoperative visit, patients were consented and completed a demographical questionnaire. Data were collected from the operative record, 2, 6, and 12-week postoperative visits. Type and number of pills prescribed were recorded as well as number of pills consumed at each postoperative visit. A logistic regression was performed to determine the average quantity consumed postoperatively and any statistically significant correlations.

Results: The average number of opioid pills collectively consumed at the 2-week and 12-week postoperative visit was 20 and 23, respectively. At the 2-week postoperative visit, only patient body mass index (BMI) showed a correlation with increased opioid use.

Conclusion: Patients consumed an average of 23 of 40 (57.5%) narcotic pain pills prescribed after hallux valgus reconstruction surgery through the 12-week postoperative period. Owing to the opioid epidemic and potential for narcotic diversion, surgeons should counsel their patients on proper nonopioid postoperative pain management.
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NewsBot · May 4, 2023

Management of Anxiety for Ambulatory Hallux Valgus Surgery With a Virtual Reality Hypnosis Mask: Randomized Controlled Trial
Grégoire Rougereau et al
Foot Ankle Int. 2023 Apr 28

Background: The purpose of this study was to evaluate the impact of using virtual reality masks for the management of preoperative anxiety and its impact on postoperative and predischarge anxiety as well as postoperative analgesia during outpatient hallux valgus surgery.

Methods: From June 2020 to September 2021, preoperative anxiety of patients scheduled for a percutaneous hallux valgus surgery were analyzed using the State Trait Anxiety Inventory (STAI) questionnaire completed during the consultation. All patients with major anxiety, defined as a STAI score above 40, were included in a randomized prospective comparative single-center study. Sixty patients were included in the study and randomized into 2 arms of 30 patients according to whether or not they underwent a preoperative hypnosis session with a virtual reality mask before surgery.

Results: There was an improvement in the postoperative (42.5 vs 45.2, P < .04) and predischarge (25.3 vs 30.2 P < .03) anxiety scores in the group that used the mask before the procedure. There was a notable decrease in immediate higher-level postoperative analgesics such as morphine or ketamine (3.3% vs 26.6%, P < .03) in the arm using the mask.

Conclusion: In this study cohort undergoing percutaneous hallux valgus surgery, we found that use of a virtual reality hypnosis mask before surgery modestly reduced postoperative and predischarge anxiety as well as early postoperative consumption of higher-level analgesics in adults with significant preoperative anxiety
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NewsBot · May 9, 2023

Hallux Valgus Bunion Splint: Surgical Dressing Technique
Lauren K Lewis et al
Foot Ankle Spec. 2023 May 8

Background: Hallux valgus is a common condition with a complex etiology resulting in numerous treatment options. Recurrence of the deformity can occur following correction. Surgical technique and possibly also postoperative care play a role in reducing recurrence rates. This article highlights a postoperative surgical dressing technique which allows for semirigid support during the immediate postoperative period.

Methods: A wooden tongue depressor placed along the medial border of the hallux comprises the primary support for the dressing. The rigidity of the tongue depressor allows for the hallux to be drawn toward the depressor, encouraging neutral alignment of the hallux. Dressings are removed 2 weeks postoperatively, with new dressings applied in similar fashion and maintained in place until 6 weeks postoperatively.

Results: Based upon our observations, our surgical dressing technique provides sufficient support following hallux valgus correction surgery while being straightforward to replicate without the need for frequent dressing changes. The dressing materials are of negligible cost and are typically readily available. No associated wound complications have been observed.

Conclusions: We present an easily replicable and affordable option for postoperative hallux valgus correction surgical dressings.
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NewsBot · May 10, 2023

CPL-01 in the Management of Postoperative Pain After Bunionectomy

Subjects receive study drug during bunionectomy and are followed for pain and opioid use, with the hypothesis that those who receive CPL-01 will have less pain and less opioid use than either control arm.
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NewsBot · Jun 13, 2023

Post-Operative Opioid Consumption Following Hallux Valgus and Rigidus Surgery: A Guide to Post-Operative Prescription Writing
Jake Eisenschink, DPM, AACFAS et al
June 12, 2023

Prescribing post-operative pain medications is essential to foot and ankle surgery, however, prescribing an amount that results in an excess of pills has shown to lead to opioid abuse. The opioid epidemic has forced surgeons to analyze how we manage post-operative pain with a goal to prescribe the optimal number of pills that will reduce a patient's pain while limiting the amount that is left over. The purpose of this study was to develop a guideline for prescribing post-operative pain medication for hallux valgus and rigidus procedures. One hundred eighty-five opioid naive patients were followed after undergoing surgery for hallux valgus or hallux rigidus. The number of opioids consumed was obtained and compared to a number of variables. There were 28 different prescriptions given during the study. As the number of pills given decreased, so did the number of pills consumed (p=0.08). Of the 185 patients, 14 (7.56%) received a refill. Ninety-five patients were available for opioid consumption data analysis. Those patients consumed a median of 36.7% and 39.1% of their prescription for hallux valgus and hallux rigidus procedures respectively. Smokers consumed 2.4 times the number of narcotics compared to nonsmokers (p=0.002). The median number of 5-325 mg hydrocodone-acetaminophen pills consumed was 8.5 for distal metatarsal osteotomies and 10 for 1st metatarsophalangeal joint procedures. Body mass index, gender, number of procedures performed did not have a statistical difference in the number of opioids taken. Foot and ankle surgeons can reduce the amount of excess opioids by decreasing the initial prescription and educating the patient on proper pain management modalities.
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NewsBot · Oct 16, 2023

Anesthesia and postoperative pain management in hallux valgus ambulatory surgery: retrospective observational study
Miguel Martín-Ortega, Mireia Rodríguez Prieto, Marisa Moreno Bueno, Laurie Carmona Serrano, Gerard Moreno Giménez, Andrea Rivera Vallejo, Cristina López León and Sergi Sabaté Tenas
Source

Background and Aims Hallux valgus (HV) surgery is associated with severe postoperative pain, requiring an anesthetic-analgesic strategy based on peripheral nerve blocks (PNB). Our goal was to assess the anesthetic strategy and postoperative pain control in HV ambulatory surgery.

Methods A descriptive observational retrospective study was designed and included 49 patients in 2021 at Hospital de la Santa Creu i Sant Pau, Spain. Anesthetic techniques, time to discharge and postoperative pain at 24 hours of surgery were collected. Ethical approval was taken from Institut d’Investigació Biomèdica Sant Pau (IIBSP-HAL-2023-62).

Results The most used anesthetic technique was PNB in 95.92%: Ankle block (AB), sciatic popliteal block (SPB) with posterior tibial nerve block (PTB) and SPB exclusively. Only 6.4% of patients required general anesthesia due to a failed blockade. No patient required opioids as rescue analgesia. The median hospital discharge time was 115 minutes (92.5 min for AB versus 120 min for other PNB), with no statistically significant differences. At discharge, all patients reported NPRS scores of 0. On the day after, 65,3% (n=32) of patients reported NPRS score. Both techniques were effective in achieving mild pain (NPRS 2).
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