Efficacy of Outpatient Bilateral Simultaneous Hallux Valgus Surgery

Abstract

Bilateral simultaneous hallux valgus correction is traditionally performed as an inpatient procedure due to concerns regarding adequate postoperative analgesia and difficulty mobilizing. We prospectively evaluated 40 consecutive patients (80 feet) who underwent outpatient surgical correction of bilateral symptomatic hallux valgus. Patients underwent preoperative radiological and clinical assessment using pain and American Orthopaedic Foot & Ankle Society (AOFAS) hallux assessment scores. Patients underwent preoperative counseling and were assessed for medical suitability for outpatient surgery. They were instructed to have responsible adult caregivers available for 24 hours postoperatively, easy access to after-hours emergency medical care, and access to a telephone. Procedures were performed under general anesthesia with local anesthetic ankle block.

Postoperatively, patients were discharged after assessment by medical, nursing, and physiotherapy staff with an oral analgesia regimen. Cast immobilization was not used. Patients were reviewed at 6 weeks and 3 months postoperatively with repeated clinical and radiological assessment. All patients were discharged home and none required inpatient ward admission. Post-discharge, no patient presented to the emergency department or their general practitioner as a consequence of poor pain control. At final follow-up assessment, mean AOFAS hallux scores had improved from 58.1 (range, 29-80) to 89.0 (range, 47-100) (P<.001). The mean hallux valgus angle improved from 33.2° (range, 15°-53°) to 16.9° (range, 3°-39°) and the intermetatarsal angle had improved from 13.2° (range, 6°-23°) to 8.5° (range, 4°-15°) (P<.001). Eighty-five percent of patients reported that they would recommend outpatient surgery. Bilateral hallux valgus surgery can be performed safely as an outpatient procedure in selected patients with acceptable levels of patient satisfaction.

An increasing number of orthopedic surgeries are now performed as outpatient procedures.^1,2 The clinical and economic benefits of outpatient surgery extend to the patient and the health care provider. Hospital stays are shorter, patients are able to recover in their own home environment, surgery cancellations due to inpatient bed shortages are unlikely, and the risks of hospital-acquired infection are reduced.^1,2

Published results of unilateral hallux valgus correction as an outpatient procedure indicate that it can be undertaken safely with a high degree of patient satisfaction.^3,4 However, hallux valgus has been reported to affect both feet in as many as 84% of cases.^5,6 As such, surgical correction of bilateral, symptomatic hallux valgus normally involves an inpatient admission due to concerns regarding postoperative pain control, or alternatively, 2 separate outpatient procedures. Performing this surgery as an inpatient procedure means that the institution cannot make use of the potential benefits of the outpatient surgery unit. Similarly, performing staged unilateral surgical corrections has social and economic implications for patients, as they must effectively recover from 2 separate surgical procedures.

This article reports the outcomes of bilateral corrective surgery for hallux valgus in a selected patient population.

Materials and Methods

Forty consecutive patients (80 feet) who presented to the outpatient surgery unit at our institution for surgical correction of bilateral hallux valgus were prospectively evaluated. Suitable patients were selected from those attending a specialist foot and ankle service with bilateral symptomatic hallux valgus.

Patient suitability was determined by assessing their medical and social circumstances. Clinical assessment for medical suitability for outpatient surgery was undertaken by a specialist nurse/anesthesiologist. Individuals who were American Society of Anesthesiologists (ASA) grades 1 and 2 were deemed suitable, along with those who were grade 3, providing their disease was well controlled. A body mass index (BMI) of ≤35 was also required. Each patient was counseled about the social and medical implications of having the procedure performed as an outpatient and was provided with an information sheet. In addition to being considered medically suitable for outpatient surgery, patients were instructed that they must have a responsible adult caregiver available for a minimum of 24 hours postoperatively, easy access to after-hours emergency medical care, and immediate access to a private telephone (Table 1).

Patients underwent preoperative clinical scoring using the American Orthopaedic Foot & Ankle Society (AOFAS) hallux assessment scoring system in addition to radiological assessment by dorsoplantar, oblique, and lateral weight-bearing radiographs of the feet (Figure 1). Preoperative pain scores were also recorded.

Figure 1: Preoperative radiographs of a patient with bilateral hallux valgus and varus deformity of the fifth metatarsophalyngeal joints.

All patients were admitted to a dedicated outpatient surgery ward on the day of the intended procedure. All procedures were performed under general anesthesia with local anesthetic ankle block for postoperative analgesia using the maximal individual dose of levobupivicaine (2 mg/kg). Surgeries were performed using pneumatic tourniquets with exsanguination using an Eshmarch bandage. Both feet were draped simultaneously. A number of surgical procedures have been described to correct the deformity of the first ray in hallux valgus, and several authors have published treatment algorithms to simplify the surgical management of this condition.^5,7-15 As such, the surgical procedure depended on a number of factors, including the degree of radiological deformity (hallux valgus and intermetatarsal angles) and the presence or absence of tarsometatarsal joint instability, first metatarsophalyngeal arthritis, and hallux valgus interphalangeus. Patients who required treatment of fixed lesser toe deformities in addition to the bilateral first ray deformity were not considered suitable for bilateral outpatient correction.

Postoperatively, patients were discharged after assessment by medical, nursing, and physiotherapy staff. Each patient was discharged with a standardized oral analgesia regimen (altered if potential drug allergies or interactions were reported), which included diclofenac sodium 50 mg three times daily, acetaminophen 1000 mg 4 times a day, and dihydrocodeine 30 mg to be taken as necessary for 10 days. Each patient was given an information sheet and was advised to contact the orthopedic unit, the after-hours emergency medical service, or the hospital emergency department immediately if any postoperative complications occurred. Patients were reviewed 10 days postoperatively in a nurse-led foot clinic for wound inspection, suture removal, and reduction of dressings. Cast immobilization was not used, and all patients were instructed to bear weight with the heel only for the first 6 weeks postoperatively.

Patients were subsequently reviewed at routine outpatient clinics 6 weeks and 3 months postoperatively. At 3-month follow-up, radiographs were taken as previously described to document the radiological outcome of surgery (Figure 2). Clinical evaluation was repeated using AOFAS hallux scores and pain scores.

Figure 2: Postoperative radiographs after correction with bilateral chevron/akin osteotomies and osteotomies of both fifth metatarsals performed as outpatient procedures.

Statistical analysis was performed using SPSS 13.0 software (SPSS Inc, Chicago, Illinois). Comparison of postoperative outcome scores was performed using the Mann-Whitney test.

Results

All 40 patients (80 feet) successfully underwent bilateral corrective surgery. The mean age of the study population was 45 years (range, 17-69 years; SD ±15.9). Thirty-nine (97.5%) of the 40 patients in the study group were women. The surgical procedures performed and the indications are listed in Table 2.

All patients were discharged home successfully from the outpatient surgery unit, and no patient had to be transferred to the inpatient ward prior to discharge.

One patient (2.5%) presented to her general practitioner in the perioperative period with a superficial wound infection, which was successfully treated with a course of oral antibiotics.

Clinical and radiological outcomes were documented at a mean follow-up of 3.2 months (range, 1.4-4.6 months), and a statistically significant improvement was noted in both of these outcome measures (P<.001; Table 3).

Patients were also surveyed to determine whether they would undergo the procedure again or recommend it to a friend based on their recent experience. Eighty-five percent of patients (34 of 40) reported that they would do so, and 15% (6 of 40) reported that they would in retrospect have preferred the procedure to be undertaken as an inpatient with an overnight stay. Reasons cited for this included postoperative pain (2), difficulties with mobilizing at home (2), and a desire to recover in an inpatient ward-based environment despite adequate analgesia (2).

A number of postoperative complications were recorded, including 1 postoperative superficial infection; 1 case of persisting metatarsalgia; 1 case of persistent pain due to prominent metalwork, which required removal; and 1 deformity recurrence requiring revision surgery. One patient suffered a traumatic fracture of the first metatarsal after tripping while walking after the original osteotomy had successfully healed. No symptoms were reported preinjury, and the fracture healed with conservative management. No further surgery was indicated or performed. All osteotomies and fusions progressed to radiological union.

Discussion

Dedicated outpatient surgery units are more resource efficient and allow a surgical department to release inpatient beds for more major cases.^1,2 Advances in anesthetic techniques have resulted in an increasing number of procedures being offered as outpatient surgeries.¹ Several studies have reported favorable outcomes after unilateral hallux valgus correction as a outpatient procedure.^3,4,6 However, hallux valgus is frequently a bilateral condition, and performing staged unilateral surgical corrections has social and economic implications to patients, as they must recover from 2 separate surgical procedures. A single procedure is associated with increased operating time, increased postoperative pain, and difficulty mobilizing.¹⁶

When a surgical procedure is offered on an outpatient basis, it is essential to ensure that a number of caveats are met. The procedure must be suitable for such a setting, the risk of early postoperative complications (from surgery and anesthetic) should be minimized, and admission to an inpatient ward postoperatively should be unlikely. We have demonstrated that bilateral hallux valgus correction adequately satisfies these criteria. In addition, objective measures of clinical and radiological outcomes were highly satisfactory, and patient satisfaction was similar to that reported for unilateral outpatient hallux valgus surgery.^3,4

To avoid readmission, it is essential that the home circumstances of any patient considered for bilateral outpatient surgery are carefully considered. If a patient does not meet our criteria for domestic support, an inpatient admission is offered. In addition, it is essential that a patient is properly informed of the potential problems that may arise in the early postoperative period and that the patient should be suitably motivated to undergo such surgery.

The provision of adequate postoperative analgesia is also fundamental to the success of this procedure, and the effective use of nerve blocks to achieve this is a key factor in extending the indications of outpatient surgery to bilateral hallux valgus corrective surgery. The safety and efficacy of peripheral nerve blocks in foot and ankle surgery have been well established, and levobupivicaine is a safe, effective local anesthetic agent able to provide analgesia for up to 10 hours postoperatively.^17,18 As such, no patient in this study required increased analgesia above the oral agents prescribed on discharge from the outpatient surgery unit.

Performing bilateral hallux valgus surgery may in theory increase the risk of certain postoperative complications, such as loss of fixation and deep venous thrombosis; however, no such problems were identified in this patient cohort.

Conclusion

Bilateral hallux valgus surgery can be performed safely on an outpatient basis in selected patients with acceptable levels of patient satisfaction. To our knowledge, this has not been previously reported in the literature.

References

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Authors

Messrs Murray, Holt, Crombie, and Kumar and Mss McGrory and Kay are from the Department of Orthopedic and Trauma Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom.

Messrs Murray, Holt, Crombie, and Kumar and Mss McGrory and Kay have no relevant financial relationships to disclose.

Correspondence should be addressed to: Graeme Holt, FRCS(Tr&Orth), Department of Orthopedic and Trauma Surgery, Glasgow Royal Infirmary, 84 Castle St, Glasgow, G4 0SF, United Kingdom (graemeholt@btinternet.com).

doi: 10.3928/01477447-20100429-09