NARCOTIC-SPARING MULTIMODAL ANAESTHESIA VERSUS STANDARD-OF-CARE ANAESTHESIA FOR HALLUX VALGUS PATIENTS UNDERGOING A PERCUTANEOUS DISTAL METATARSAL OSTEOTOMY: A RANDOMIZED CONTROLLED TRIAL

Hallux Valgus surgery can result in moderate to severe post-operative pain requiring the use of narcotic medication. The percutaneous distal metatarsal osteotomy is a minimally invasive approach offering advantages such as minimal scarring, immediate weight bearing and reduced post-operative pain. This study aims to determine if a combination of multimodal analgesia, ankle block anesthesia and minimally invasive surgery can help eliminate the need for short-acting narcotics. One hundred forteen ambulatory patients aged 18-70 with BMI ≤ 40 undergoing percutaneous hallux valgus surgery were randomized into Narcotic-sparing (NS) or Standard (S) groups. There were 56 in NS and 58 in the S group. The NS group received acetaminophen, naproxen, pregabalin 75mg and 100mg Ralivia (tramadol extended release) before surgery and acetaminophen, naproxen, pregabalin 150mg one dose and Ralivia 100mg BID for 5 days, as well as a rescue short-acting narcotic (hydromorphone 1mg pills) after surgery. The S group received acetaminophen and naproxen prior to surgery and acetaminophen, naproxen and hydromorphone (1mg) post-operatively, our current standard. Visual analog scales (VAS) were used to assess pain and short-acting narcotic consumption was recorded at various post-operative time points. Patients wore a smart watch to record the number of daily steps and sleep hours. Two-sided t-tests were used to compare the VAS scores and narcotic consumption. During the first post-operative week, the NS group consumed significantly fewer short-acting narcotics than the S group, with 5.24 pills (20.96 MEQ) vs 13.53 pills (54.12 MEQ) on average (p = 0.001). At 24, 48, 72 hours, and 7 days, patients in the NS group recorded a mean average of 0.66, 2.38, 3.75, and 5.241 pills respectively. The S group recorded a mean average of 2.84, 7.82, 10.54, and 13.536 pills. Of all the patients included in the study, 27.2% did not consume any short-acting narcotics post-operatively (43.1% in the NS group and six patients 10.7% in the S group) and the average total short-acting narcotic consumption was under nine tablets. For the VAS scores at 24, 48, 72 hours, and seven days the NS group's average scores were 2.31, 3.16, 2.81, 2.14 respectively and the S group's average scores were 3.57, 4.09, 2.98, 1.85. The pain experienced by patients was better in the NS group at 24 (p = 0.001) and 48 (p = 0.012) hours, but no difference was found at 72 hours and 7 days. There was no significant difference for the number of daily steps and hours of sleep per night between both groups (on average 1800 steps/day and 8 hours sleep/night). Hallux valgus remains a common orthopedic foot problem for which surgical treatment results in moderate to severe post-operative pain. This study demonstrates that a minimally invasive approach to hallux valgus surgery, using multimodal analgesia, regional blocks, and long-acting Tramadol, significantly reduces the need for short-acting narcotics and allows for early mobilization and excellent pain control. Given the current narcotic epidemic, changing prescribing habits is crucial and this study allows surgeons to modulate the number of short-acting narcotic prescriptions based on average consumption.