Hallux Valgus Osteotomy Periprocedural Care

The patient should be educated on selection of proper footwear. Size is an important criterion. Because feet swell at the end of the day, shoe shopping is best done in the evening. A useful aid in determining an appropriate size is to draw the outline of the foot on tracing paper and then to ensure that the insert of the shoe covers the tracing completely.

Traditionally, a tourniquet is applied at the level of the thigh. Over the years, however, it has been found that tourniquets applied more distally in the leg just above the ankle work just as well and decrease the area that is unnecessarily exsanguinated, thereby limiting the reperfusion injury or effects. In addition, a more distal tourniquet need not be inflated to the same high pressure; typically, 250 mm Hg or 100 mm Hg higher than the systolic blood pressure is sufficient.

Anesthesia

Hallux valgus corrective procedures can be undertaken with a local anesthetic block around the base of the first metatarsal and in the first web space or with an ankle block if other toes will also be undergoing surgical intervention. A calf- or ankle-level tourniquet can be uncomfortable, and if such a tourniquet is required, a popliteal level block is also a suitable alternative. The block can be supplemented by sedation; alternatively, the procedure can be undertaken with laryngeal mask or endotracheal anesthesia, depending on the preferences of the patient and the anesthesiologist.

Regardless of whether the patient receives a general anesthetic or not, the author highly recommends preemptive analgesia and anesthetic techniques that are multimodal and give excellent preoperative anesthesia and postoperative pain control, which is an important objective (especially for prevention of chronic pain).

On the day of surgery, if no contraindications exist, a cyclooxygenase (COX)-2 inhibitor is given in the morning. The author has a motto ("needle before knife") and believes in injecting a mixture of short-acting and long-acting local anesthetic before making the skin incision in an effort to preemptively block noxious stimuli during surgery. Postoperatively, oral analgesics are started before the local anesthetic effect wears off and continued at the prescribed intervals for 2-3 days. With this regimen, patients can potentially go through the entire experience with little or no pain.

Positioning

Patient is positioned supine with pressure points padded. The author uses a triangular support under the knee, which helps keep the foot flat on the table and makes orientation easier to follow. ^[11] The foot is elevated over a bump of double-brick height and shape to clear it from the other limb, allowing unobstructed ease of access for the use of instruments (eg, the saw or drill) and fluoroscopy. The knee support also stabilizes the limb and lessens the need or reliance on assistance for maintaining position of the limb or the foot.

The patient is instructed to keep the dressings clean and dry and the leg elevated to minimize postoperative edema or swelling in the foot. Active exercises of the knee and hip are encouraged.

The first clinic visit after surgery should take place between postoperative days 7 and 10, at which time the wound is checked and dressings changed. The dressings are reapplied in a manner similar to their original placement, and either an accommodative shoe or a cast is applied for protection for the next 4-5 weeks. The patient is allowed to bear weight on the heel.

At 6 weeks, all dressings are taken down. Kirschner wires (K-wires), if used, are removed, and a weightbearing radiograph is obtained. Exercises of the great toe can begin, and the patient is allowed return to activities and full weightbearing as tolerated.