Gestion de la douleur à domicile après chirurgie de l’avant pied en ambulatoire

Abstract

Introduction: Healthcare structures must adapt to the shift to ambulatory care. While first ray surgery lends itself well to this organization, it is known to be painful for patients who are often reluctant to undergo this procedure. We studied the evolution of post-operative pain in patients undergoing first ray surgery from D0 to D5. A home nursing protocol was used. Secondary objectives were to assess patient satisfaction and to identify complications.Methods: This is a retrospective, observational, single-center, single-operator study. One hundred and thirty-eight patients undergoing surgery on the first ray of the foot (hallux valgus or rigidus) and eligible for ambulatory care were included between April 2019 and December 2022. The operative technique for the cure of hallux valgus was open surgery by double metatarsal and phalangeal osteotomy; for hallux rigidus, open dorsal plate arthrodesis. Home follow-up was carried out by a healthcare provider. The protocol allowed pain to be managed with an IV nefopam diffuser for a maximum of 5 days, combined with oral analgesics of levels 1 to 3. Pain was recorded at D0, D1, D3 and D5 using a numerical scale from 0 to 10. Patient satisfaction was assessed retrospectively by telephone call.Results: Ten patients were excluded due to incomplete data. The series comprised 102 women and 36 men, with an average age of 59.8 years. There were 116 hallux valgus and 22 hallux rigidus. Thirty-three patients had procedures associated with their 1st ray surgery. Pain analyzed by VAS was 4.21 at D0, 2.96 at D1, 1.90 at D3, 1.33 at D5. The mean duration of nefopam infusions was 4.31 days. Treatment tolerance was satisfactory in 88.4% of cases. Eighty-four percent of patients were very satisfied with their pain management. There were 4 early scar complications that resolved with local care. One infection was noted at a distance from the operation, requiring repeat surgery and re-hospitalization. Four postoperative algoneurodystrophies were identified. Three recurrences of hallux valgus required repeat surgery. The existence of fibromyalgia, algodystrophy, chronic pain on long-term morphine therapy, chronic inflammatory disease, depression or parkinsonian syndrome correlated with higher pain.Conclusion: Pain management after outpatient first ray foot surgery using the injectable nefopam protocol is satisfactory in the majority of cases, with a very high degree of patient satisfaction. This protocol is now routinely offered to our patients undergoing first ray surgery.Level of evidence: IV; cohort study.