Influence of hallux valgus management on Quality of Life

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Influence of hallux valgus management on Quality of Life M. Leigheb 1, A. Baricich 2, F. Grassi 1 1S.C.

2S.C.

Ortopedia e Traumatologia, A.O.U. “Maggiore della Carità”, University of Eastern Piedmont “A.Avogdro”, Novara (Italy) Recupero e Riabilitazione Funzionale, A.O.U. “Maggiore della Carità”, University of Eastern Piedmont “A.Avogdro”, Novara (Italy)

Hallux valgus (Figure 1) is common with a standardised prevalence of 28.4% in adults older than 40 years. (1) It can be a debilitating disease which influences the quality of life (QoL). In particular hallux valgus severity is significantly associated with reduced physical function, bodily pain, general health, social function, and mental health. There is a progressive reduction in both general and foot-specific health-related quality of life (HRQOL) with increasing severity of hallux valgus deformity. (2) Concurrent hallux valgus and big toe pain but not isolated hallux valgus associates with impaired overall satisfaction with health and low score on the physical, psychological and social domains of World Health Organization Quality of Life-BREF (WHOQOLBREF). (1) Patients expectations for hallux valgus surgery consist of improved walking, followed by reduced pain over the bunion and wearing daily shoes; these expectations vary according to age and gender but not occupation. (3) Possibilities of treatment for hallux valgus are different, from splinting and physical therapies to open classic surgical interventions with many techniques. Surgery produces a significant improvement in the quality of life. The severity of the deformity does not influence the QoL, however; the free choice of shoeware and the degree of satisfaction with the surgery has a positive effect on the QoL outcome. (4) Usually post-operative pain is relevant. A more appropriate hallux valgus management should consider the following topics: minimization of surgical invasiveness, prevention of complications, optimization of functional recovery, QoL improvement, optimization of pharmacological treatment. Distal transverse first metatarsal osteotomy has revealed to be efficacious in hallux valgus correction (5) and a good compromise between effectiveness and low invasiveness can be reached through the percutaneous approach. (6) Binding the advantages of the sharp transverse cut of the Bosh technique (5) and the percutaneous approach of the Percutaneous Distal Osteotomy (PDO) technique (6) we found out our favorite surgical treatment for hallux valgus. Aim of this paper is to evaluate effectiveness and safety of our protocol for hallux valgus surgery.

Exclusion criteria consisted of: other major diseases or painful foci, other associated corrections of deformities of the foot, advanced 1st metatarso-phalangealal arthritis/arthrosis (KellegrenLawrence stade IV), Inter-Phalangeal Valgus of the big toe > 20°, previous surgical interventions on the same hallux, specific contraindications to the protocol. Our management protocol (Standard Operative Procedure) consisted in: Day Surgery treatment of a single hallux, local (digital troncular) anesthesia with mepivacaine 2% / 5 ml + ropivacaine 7,5% / 5 ml (Figure 2), percutaneous distal metaphysis first metatarsal transverse osteotomy fixed in hypercorrection with a percutaneous longitudinal 2,5 mm Kirschner wire under amplifluoroscopic control (Figures 3, 4, 5), postoperative pain management with oxicodon/naloxone 10/5 mg bid per os starting 6 hours after anesthesia for 3 days, infection prophylaxis with a single pre-op-

Materials an methods We consecutively enrolled 24 patients with 30 cases of symptomatic hallux valgus operated on by the same surgeon (M.L.) from 1-9-2011 to 30-6-2012. Inclusion criteria were: age ≥ 18 years, symptomatic (pain NRS ≥ 3/10) hallux valgus, Inter-Metatarsal Angle (IMA) ≥ 12° and ≤18°. 130

Figure 1.—Hallux Valgus: clinical aspect.

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Figure 2.—Local anesthesia.

Figure 4.—Intra-operatory fluoroscopic control.

Figure 3.—Percutaneous correction.

erative dose of Amoxicillin 2,2g i. v., thrombo-prophylaxis with a daily s. c. prophylactic dose of L.M.W.Heparin for 12 days from surgery, immediate post-operative rehabilitative management with full weight bearing walking with a talus shoe for the first 30 days, active assisted Kynesi-therapy of the big toe after K. wire removal at 30 days post-operative. The outcomes we considered with relative measurement tools were: valgus angle and inter-metatarsal angle on weight bearing Xray for efficacy in valgus correction, VAS Foot and Ankle Outcome Score (from 0 to 100 x 20 items = max 2000 points) for QoL(7), Numerical Rating Scale (NRS) for pain, clinical reports for adverse effects and/or complications. Results Valgism correction with disappearance of prominent symptomatic bounionne was obtained in all patients (Figures 6 and 7) with a mean valgism angle passing from 35° (SD=14°) to 8° (SD=3°). (Figures 8-11)

Pain control was generally good but in two cases in which pain was NRS > 5/10 and thus analgesics were given for a prolonged period. (Figure 12) Only two patients complained of nausea and were therefore switched to a different analgesic. We needed additional antibiotic in one case of persistent local swelling and redness. No other undesired effects were experienced. VAS Foot & Ankle Outcome Score passed from a mean value of 1240 +/- 180 preoperatively to 1850 +/- 210 at 3 months post-op. follow up. (Figure 13) All the patients were satisfied by the treatment and would have it performed in the same way. Discussion Despite the esthetic result is mostly based on the clinical aspect, to measure the efficacy in valgus correction we considered the valgus angle and the intermetatarsal angle taken on weight bearing Xrays before and after surgical treatment believing these parameters to be more objectives and reproducible. In the beginning of our experience we used a Kirschner wire of 2 mm as originally described by Bosh (5,6) but after a few cases of skin lesions for the cutting effect of the narrow wire we passed to a greater caliber of 2,5 mm.


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Figure 7.—3 months follow up: hill rising.

Figure 5.—Post-op. dressing in hypercorrection. Figure 8.—Valgus angle pre and post-op.

Figure 6.—3 months follow up: orthostasis.

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Pain is one of the most relevant aspects of the quality of life and mostly in the post-operative period when strong, effective and well tolerated drugs are needed. For this reason the association of oxycodon and naloxone can be considered instead of usual Non Steroid Anti-Inflammatory Drugs. To increase the analgesic effect from the beginning of treatment perhaps we should start the drugs assumptions sooner after surgery or even before the local anesthesia. For thrombo-prophylaxis no absolute guideline exists for foot surgery at the moment. We believe that the best prophylaxis consists in reduced invasiveness with a percutaneous approach in a short surgical time and in an early full weight bearing walking, but anyway we routinely used a single prophylactic dose of Low Molecular Weight Heparin (LMWH) for 12 postoperative days even for a legal reason. Of course it is very important to consider the stratification of the thromboembolic risk (8) giving higher and prolonged doses of LMWH in selected cases. For infection prevention we assured a single preoperative dose of wide range antibiotic and were particularly careful in medications. As known diabetic patients are to be considered at higher risk of infection. The need to have a quantitative comparison of the quality of life and specifically referred to the foot before and after the treatment


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Figure 9.—Hallux valgus X-ray.

Figure 11.—One year follow up X-ray.

Figure 12.—Pain (NRS/time).

Figure 10.—Post-op. X-ray.

Figure 13.—VAS Foot & Ankle Outcome Score pre and post-op.


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led us to use the foot and ankle VAS questionnaire recently published by Richter et al. (7). Conclusions On the bases of these sample cases we can say that the right choice of the protocol of treatment in hallux valgus is important for quality of life improvement. According to our on-going experience in hallux valgus surgery, this protocol can be cosidered effective and safe for the patients: the mini-invasive approach, effective pain treatment with appropriate and better tolerated drugs combination and early rehabilitation decreases side effects and complications and improves QoL. References 1. Abhishek A, Roddy E, Zhang W, Doherty M. Are hallux valgus and big toe pain associated with impaired quality of life? A cross-sectional study. Osteoarthritis Cartilage. 2010 Jul;18(7):923-6.

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2. Menz HB, Roddy E, Thomas E, Croft PR. Impact of hallux valgus severity on general and foot-specific health-related quality of life. Arthritis Care Res (Hoboken). 2011 Mar;63(3):396-404. 3. Tai CC, Ridgeway S, Ramachandran M, Ng VA, Devic N, Singh D. Patient expectations for hallux valgus surgery. J Orthop Surg (Hong Kong). 2008 Apr;16(1):91-5. 4. Saro C, Jensen I, Lindgren U, Felländer-Tsai L. Quality-of-life outcome after hallux valgus surgery. Qual Life Res. 2007 Jun;16(5):731-8. 5. Bosch P, Wenke S, Legestein R. Hallux valgus correction by the method of Bosch: a new technique with seven to ten years follow-up. Foot Ankle Clin 2000;5:485-98. 6. Magnan B, Fieschi S, Bragantini A, Baldrighi C, Bartolozzi P. Trattamento chirurgico dell’alluce valgo con osteotomia distale percutanea del 1° metatarsale. Giornale Italiano di Ortopedia e Traumatologia 1998;24:473-88. 7. Richter M., Zech S., Geerling J., Frink M., Knobloch K., Krettek C. A new foot and ankle outcome score: Questionnaire based, subjective, visual-analogue-scale, validated and computerized. Foot and Ankle Surgery. 2006, (12), 191-199. 8. Felcher AH, Mularski RA, Mosen DM, Kimes TM, DeLoughery TG, Laxson SE. Incidence and risk factors for venous thromboembolic disease in podiatric surgery. Chest. 2009 Apr;135(4):917-22.


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