OrthoBuzz has previously reported on studies examining the narcotic-prescribing patterns of foot and ankle surgeons. New findings published by Finney et al. in the April 17, 2019 issue of The Journal of Bone & Joint Surgery strongly suggest that the single most powerful and modifiable risk factor for persistent opioid use after bunion surgery was the opioid dose perioperatively prescribed by the surgeon.
The authors analyzed a US private-insurance database to identify >36,500 opioid-naïve patients (mean age, 49 years; 88% female) who underwent one of three surgical bunion treatments. Among those patients, the rate of new persistent opioid use (defined as filling an opioid prescription between 91 and 180 days after the surgery) was 6.2%, or >2,200 individuals. The authors found that patients who underwent a first metatarsal-cuneiform arthrodesis were more likely to have new persistent opioid use, compared with those who received a distal metatarsal osteotomy, which was the most common procedure performed in this cohort. Additional findings included the following:
- Patients who filled an opioid prescription prior to surgery were more likely to continue to use opioids beyond 90 days after surgery.
- Patients who resided in regions outside the Northeastern US demonstrated significantly higher rates of new persistent opioid use.
- The presence of medical comorbidities, preexisting mental health diagnoses, and substance-use disorders were associated with significantly higher new persistent opioid use.
However, physician prescribing patterns had the biggest influence on new persistent opioid use. A total prescribed perioperative opioid dose of >337.5 mg (equivalent to approximately 45 tablets of 5-mg oxycodone) was the major modifiable risk factor for persistent opioid use in this cohort. The authors also pointed out that 45 tablets of 5-mg oxycodone “is a relatively low amount when compared with common orthopaedic prescribing patterns” (see related JBJS study).
As orthopaedic surgeons in all subspecialties rethink their narcotic-analgesic prescribing habits, they should remember that regional anesthesia and non-opiate oral pain-management protocols have had a positive impact on pain management while minimizing narcotic use. The smallest dose of opioids for the shortest period of time seems to be a good rule of thumb.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Shahriar Rahman, MS, in response to a recent study in Foot and Ankle Clinics of North America.
It makes sense that orthopaedic conditions with multiple etiologic factors have a corresponding variety of treatment options. So it is with hallux valgus (bunion deformity). In the June 2018 edition of Foot and Ankle Clinics of North America, Smyth and Aiyer1 focus on the pathoanatomy of hallux valgus and various approaches to selecting an operative option.
With more than 100 different operative procedures described to correct hallux valgus, it can be challenging to pick the “right” procedure for each patient. The etiology of hallux valgus includes intrinsic factors (e.g., a long first metatarsal, the shape of the metatarsal head, and soft-tissue imbalances across the hallux metatarsophalangeal [MP] joint) and extrinsic factors (e.g., high-heeled, narrow toe-box shoes). Other kinematic factors of the foot, such as hypermobility of the first ray, are associated with hallux valgus, as is pes planus (flatfoot). Whatever the etiology, hallux valgus almost always progresses in a relatively predictable manner.1
Careful preoperative analysis is required to successfully treat hallux valgus, with the goal of restoring static and dynamic balance around the first MP joint. For optimum outcomes, a soft-tissue procedure (e.g., modified McBride procedure) is now commonly combined with osseous corrective techniques. The chevron osteotomy, which has been modified in multiple ways, achieves acceptable outcomes with reportedly high patient satisfaction levels, as does a percutaneous distal metatarsal osteotomy.2
More severe deformities are usually treated with proximal first metatarsal osteotomies—such as a proximal chevron, Ludloff osteotomy, or Scarf osteotomy—to increase the possible angular correction of the metatarsal. While these procedures are more “powerful” correction options, some studies have shown recurrence rates up to 30% at 10 years of follow up.1,2 In cases of severe deformity accompanied by arthritis of the tarsometatarsal (TM) joint, a modified Lapidus procedure may be an option for stabilizing the first TM joint. Hallux MP arthrodesis is also considered in patients who have severe deformity, arthritis, and neuromuscular disorders, and for the revision of a previously failed hallux valgus surgery.
There is currently no consensus as to which procedure is the gold standard for treating hallux valgus. Despite multiple comparative studies assessing the outcomes of different techniques, the decision ultimately depends on surgeon and patient preferences.
Shahriar Rahman, MS is a consultant orthopaedic surgeon at the Ministry of Health & Family Welfare in Bangladesh and a member of the JBJS Social Media Advisory Board.
- Smyth NA & Aiyer AA 2018, ‘Introduction: Why Are There so Many Different Surgeries for Hallux Valgus?’, Foot and Ankle Clinics, 23, no.2, pp.171-182.
- Adams SB, 2017, JBJS Clinical Summary: Hallux Valgus (Bunion Deformity), viewed 27 may 2018, https://jbjs.org/summary.php?id=188
Related Articles from JBJS Essential Surgical Techniques
- Hallux Valgus Correction With Bunionectomy, Lateral Release, And Proximal Opening Wedge Osteotomy Using Wedge-plate Fixation
- Lateral Soft-tissue Release With Medial Transarticular Or Dorsal First Web-space Approach Combined With Distal Chevron Osteotomy For Moderate-to-severe Hallux Valgus
- Treatment Of Advanced Stages Of Hallux Rigidus With Cheilectomy And Proximal Phalangeal Osteotomy
- Arthrodesis Of The Hallux Metatarsophalangeal Joint
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects
S D Boden, D O Davis, T S Dina, N J Patronas, S W Wiesel: JBJS, 1990 March; 72 (3): 403
Many important subsequent studies were inspired by the findings of this landmark JBJS study. Most of them emphasize that for lumbar-spine diagnoses, an MRI is only one (albeit important) piece of data; that interpretation of MRI is variable; and that all imaging information must be correlated to the patient’s clinical condition.
A Conservative Operation for Bunions
E D McBride: JBJS, 1928 October; 10 (4): 735
Many other bunion procedures have been described since 1928, but the principle of restoring congruency of the first metatarsophalangeal joint remains very important in bunion operations. The most substantial modification of McBride’s procedure is that the lateral sesamoid is no longer typically excised.
Recurrence rates after surgical treatment for hallux valgus (bunion) range from 4% to 25%. Findings from a study by Park and Lee in the July 19, 2017 edition of The Journal of Bone & Joint Surgery suggest that non-weight-bearing radiographs taken immediately after surgery can provide a good estimate of the risk of recurrence.
The study analyzed proximal chevron osteotomies performed on 117 feet. At an average follow-up of two years, the hallux valgus recurrence rate was 17%. (Recurrence was defined as a hallux valgus angle [HVA] of ≥20°.)
Bunions were 28 times more likely to recur when the postoperative HVA was ≥8° than when the HVA was <8°. The HVA continued to widen over time in patients with recurrent bunions, but stabilized at six months in those without recurrence. An immediate postoperative sesamoid position of grade 4 or greater was also significantly associated with recurrence.
If future studies confirm their results, the authors believe that such data could be used “to suggest intraoperative guidelines for satisfactory correction of radiographic parameters,” and thus help surgeons minimize the risk of hallux valgus recurrence. Commentator Jakup Midjord, MD concurs, noting that non-weight-bearing radiographs can be “closely related to intraoperative radiographs, so we can modify correction as needed in the operating room.”