WHO level 1 and 2 analgesics are effective for perioperative pain management after percutaneous 3rd and 4th generation hallux valgus surgery

Developed by the Task Force on Pain Management, Acute Pain Section: L. Brian Ready, M.D. (Chair), Seattle, Washington; Michael Ashburn, M.D., Salt Lake City, Utah; Robert A. Caplan, M.D., Seattle, Washington; Daniel B. Carr, M.D., Boston, Massachusetts; Richard T. Connis, Ph.D., Woodinville, Washington; Cheryl L. Dixon M.D., Jacksonville, Florida; Lex Hubbard, M.D., Shreveport, Louisiana; and Linda Jo Rice, M.D., Hartford, Connecticut.Submitted for publication December 27, 1994. Accepted for publication December 27, 1994. Supported by the American Society of Anesthesiologists, under the direction of James F. Arens, M.D. Chairman of the Ad-Hoc Committee on Practice Parameters. Approved by the House of Delegates, October 19, 1994. A list of the articles used to develop these guidelines is available by writing to the American Society of Anesthesiologists.Address reprint requests to the American Society of Anesthesiologists: 520 North Northwest Highway, Park Ridge, Illinois 60068-2573.Click on the links below to access all the ArticlePlus for this article.Please note that ArticlePlus files may launch a viewer application outside of your web browser.Key words: Pain: acute; perioperative. Practice guidelines: acute pain management.Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints.Practice guidelines are not intended as standards or absolute requirements. The use of practice guidelines cannot guarantee any specific outcome. Practice guidelines are subject to revision from time to time, as warranted by the evolution of medical knowledge, technology, and practice. The guidelines provide basic recommendations that are supported by analysis of the current literature and by a synthesis of expert opinion, open forum commentary, and clinical feasibility data (Appendix).Acute pain in the perioperative setting has not been specifically defined in the available literature. The Task Force has not given preference to literature based on any particular system of definition or classification. For these guidelines, acute pain in the perioperative setting is defined as pain that is present in a surgical patient because of preexisting disease, the surgical procedure (e.g., associated drains, chest or nasogastric tubes, complications), or a combination of disease-related and procedure-related sources.The purpose of these guidelines is to facilitate the efficacy and safety of acute pain management in the perioperative setting and to reduce the risk of adverse outcomes. A number of adverse outcomes can result from undertreatment of postoperative pain. These include (but are not limited to) thromboembolic and pulmonary complications, extension of time spent in an intensive care unit and/or in a hospital, and reduced patient satisfaction. The principal adverse outcomes associated with management of perioperative pain include (but are not limited to) respiratory depression, brain injury, other neurologic injury, sedation, circulatory depression, nausea and/or vomiting, impairment of bowel function, pruritus, and urinary retention.These guidelines focus on modalities of perioperative pain management that require a higher level of expertise and organizational structure than "as needed" intramuscular or intravenous injections of opioids and that generally provide more effective relief of pain. Examples include (but are not limited to) epidural (and intrathecal) analgesia (EA), intravenous patient-controlled analgesia (PCA), and a number of regional analgesic (RA) techniques. The guidelines are not intended as an exhaustive or detailed consideration of specific techniques or all possible approaches.The specialty of anesthesiology brings an exceptional level of interest and expertise to the area of perioperative pain management. As a consequence, the anesthesiologist is in a unique position to provide leadership in integrating pain management into other aspects of perioperative care and thus improve this area of practice. In this leadership role, the anesthesiologist can contribute further to quality of care by developing and directing institution-wide perioperative analgesia programs that include collaboration with and participation by others, when appropriate.The role of anesthesiologists in managing acute pain extends beyond the perioperative setting. Patients with severe or concurrent medical illness such as sickle cell crisis, pancreatitis, or acute pain related to cancer or cancer treatment also benefit from aggressive pain control. Labor pain is another condition of interest to anesthesiologists. However, the complex interactions of concurrent medical therapies and physiologic alterations make it impractical to address pain management for these populations within the context of this document.These guidelines focus on management of acute pain in the perioperative setting for adult (including geriatric) and pediatric patients. The guidelines apply to inpatient and outpatient surgery. These guidelines are intended for use by anesthesiologists or by individuals who deliver care under the supervision of anesthesiologists.Evidence to support each guideline was carefully sought. The search included a comprehensive review of the published literature, surveys of the opinions of a large panel of consultants with expertise in acute pain management, and the opinions of the members of the Task Force. An indication of the strength of the evidence supporting each guideline is provided.The Task Force defines proactive planning as a process of integrating pain management into the perioperative care of patients. The literature, the panel of consultants, and the Task Force members strongly support the use of proactive planning for postoperative pain management. This support is based on recognized associations between preoperative and intraoperative analgesic techniques for the reduction of pain in the postoperative period.Recommendations: An individualized proactive plan (e.g., a predetermined strategy for postoperative analgesia) should be considered for all surgical patients. Factors that may influence the formulation of a proactive plan include (but are not limited to) type of surgery and expected severity of postoperative pain, underlying medical conditions (e.g., presence of respiratory or cardiac disease, allergies), the risk-benefit ratio of the techniques available, and patients' preferences and/or previous experience with pain. Proactive planning of perioperative pain should be part of the preoperative evaluation by the anesthesiologist and, in collaboration with others (e.g., nurses, surgeons, pharmacists), should be part of an institution's general plan for patient care.Activities that are commonly encompassed by proactive planning include (but are not limited to) (1) obtaining a pain history based on patients' experiences, (2) preoperative pain therapy when appropriate and feasible, (3) intraoperative procedures (e.g., wound infiltration) when appropriate and feasible, and (4) intraoperative or postincisional preparation of patients for postoperative pain management (e.g., initiating EA administration before the completion of surgery). Any treatment plan requires regular assessment and refinement based on the changing responses of individual patients.The available literature suggests that training and experience of hospital personnel (e.g. nurses, house-officers, pharmacists, psychologists) may be helpful in reduction of risk. There is strong agreement among the panel of consultants and the Task Force members that such education, training, and experience also contribute to improved quality of care.Recommendations: Anesthesiologists offering perioperative analgesia services should provide, in collaboration with others as appropriate, ongoing education and training to ensure that hospital personnel are knowledgeable and skilled with regard to the effective and safe use of the available treatment options within the institution. The scope of education should include topics ranging from basic bedside skills for evaluation of acute pain to an understanding of sophisticated pharmacologic techniques (e.g., PCA, EA, and various RA techniques) and nonpharmacologic techniques (e.g., relaxation, imagery, hypnotic methods). The need for education and training is ongoing as new personnel enter an institution and as modifications in therapeutic approaches are made.The panel of consultants and the Task Force members regard the concept of education of patients and families in planning and participation in perioperative pain control as being important to their comfort and well-being.Recommendations: Anesthesiologists offering perioperative analgesia services should provide, in collaboration with others as appropriate, education to patients and families regarding their roles in achieving comfort, reporting pain, and using the recommended analgesic methods to optimal benefit. Common misconceptions about the risk of side effects and addiction should be dispelled. Educational methods that facilitate optimal care of patients using PCA and other sophisticated methods might include (but are not limited to) discussion of analgesic methods at the time of the pre-anesthetic evaluation, brochures and video tapes to educate patients about therapeutic options, and discussion at the bedside during postoperative visits.The panel of consultants and the Task Force members strongly support the concept of assessment and documentation of response to perioperative pain therapy as important to effective care. Unless the response to pain therapy is regularly evaluated, there is no basis for rational, individualized therapy.Recommendations: Anesthesiologists offering perioperative analgesia services should use, in collaboration with others as appropriate, pain assessment instruments to facilitate the regular evaluation and documentation of pain, the effects of pain therapy, and side effects caused by the therapy (Table 1and Table 6templates 1 and 6).The panel of consultants and the Task Force members support the concept of 24-hour availability of anesthesiologists providing perioperative pain management as being important for maximizing patient comfort and safety. The condition of patients after surgery is frequently dynamic, and analgesic needs may change at any time.Recommendations: Most analgesic techniques place patients at some risk for side effects of complications that require prompt medical evaluation. Anesthesiologists responsible for perioperative analgesia, in collaboration with others as appropriate, should be available at all times to consult with ward nurses, surgeons, or other involved physicians and assist in evaluating patients who are experiencing problems with any aspect of postoperative pain relief.The available literature suggests that institutional protocols and procedures for ordering, administering, discontinuing, and transferring responsibility for pain management are helpful in providing effective and continuous pain control. The Task Force regards the use of institutional policies and procedures as a logical part of interdisciplinary management of perioperative pain, and there is strong agreement from the panel of consultants that this approach is beneficial. The development of hospital-wide policies and procedures helps standardize clinical practice using techniques such as PCA, EA, and various RA techniques (Table 2and Table 3templates 2 and 3). Standardization promotes safety and creates a framework for customization of care. Routine use of bedside documentation encourages caregivers to continually reevaluate pain treatment and respond to inadequate therapy in a timely manner. Daily evaluation, planning, and written documentation by those who are medically responsible for pain relief help establish the importance of a formal and structured approach to pain management (Table 4, Table 5, Table 6, Table 7templates 4-7).Recommendations: Anesthesiologists offering perioperative analgesia services should participate in developing, in collaboration with others as appropriate (especially nurses), standardized institutional policies and procedures for ordering, administering, discontinuing, and transferring responsibility for postoperative pain management. Policies (the foundation or "ground rules" for practice) and procedures (outlining the "how to" aspects of applying policies to patient care) should be readily available on each patient care unit. The polices and procedures also serve as ongoing educational and informational references.The literature strongly supports the efficacy and safety of three techniques used by anesthesiologists for the control of pain in the perioperative setting: (1) PCA with systemic opioids, (2) EA with opioids or opioid/local anesthetic mixtures (or intrathecal opioids), and (3) RA techniques, including (but not limited to) intercostal blocks, plexus infusions, and local anesthetic infiltration of incisions. The literature indicates that these three techniques used by anesthesiologists have no higher incidence of side effects than less effective techniques for perioperative pain management. The panel of consultants and the Task Force members strongly support the use of PCA, EA, and RA by anesthesiologists when appropriate and feasible.Recommendations: To meet the diverse needs of individual patients, anesthesiologists who manage perioperative pain should make available as appropriate a variety of effective therapeutic options such as PCA, EA, and RA.During the administration of anesthetics for surgery, the needs of many patients may best be met by taking advantage of the combined effects of a number of agents. Similarly, there is growing conviction that a multimodality approach (i.e., two or more analgesic agents or techniques used in combination) to providing postoperative analgesia has advantages over the use of a single modality.The literature supports the efficacy of two or more analgesic techniques (including nonpharmacologic methods) used in combination for the control of perioperative pain, especially when different sites and/or mechanisms of action are involved and/or when synergy of effect is achieved. In addition, the literature indicates that multimodality approaches are associated with side effects no greater than those resulting from single analgesic techniques for perioperative pain management. The panel of consultants and the Task Force members support the use of multimodality techniques when appropriate and feasible.Recommendations: Anesthesiologists managing perioperative pain should make available as appropriate a variety of analgesic techniques and should consider their use in combination under appropriate circumstances.Although dedicated individuals can improve perioperative pain control for the individual patients they treat, comprehensive programs provide optimal analgesia throughout an institution. Such programs have been advocated by national and international pain specialty societies [1,2]and the Federal government.* The Task Force strongly believes that, based on training, knowledge, skills, interest, and historical innovation, anesthesiologists are uniquely qualified to provide leadership within their institutions in developing and managing perioperative pain management programs.The panel of consultants and the Task Force members regard organized interdisciplinary activities (e.g., anesthesiologists in collaboration with nurses, surgeons, and pharmacists) as important and optimal in providing effective, safe, and continuous perioperative pain control (Table 8template 8). An essential feature of such an approach should be an ongoing strong working relationship between anesthesiologists and nurses.Recommendations: Anesthesiologists who manage perioperative pain should develop (in collaboration with nurses, surgeons, pharmacists, and others) an organized, interdisciplinary approach to perioperative pain management within their institutions.Pediatric patients (infants and children) present unique problems regarding perioperative pain management for reasons that include differences in the perception of care-givers regarding the need for analgesia, differences in the pharmacology of analgesic medications when used in this group, and the strong emotional components of pain in children. In the past, safe methods for providing analgesia have been underused in pediatric patients because of fear of opioid-induced respiratory depression.The emotional component of pain is very strong in children. Absence of parents, security objects, and familiar surroundings may be perceived by the child to be as painful as the surgical incision. When clear evidence of physical pain is not seen, the tendency of health-care providers is to assume pain is not present and therefore defer treatment. In addition, young childrens' fear of injections makes intramuscular opioids or other methods, which themselves cause discomfort, less acceptable to this group than to adults. Many children will choose to suffer in silence knowing that an expression of pain will result in a dreaded injection.Pain assessment is more difficult in children because, as they grow and develop, cognitive and emotional responses are different from adults and are constantly changing. Special instruments are available to assist young children in self-reporting of pain, and behavioral and physiologic parameters can be employed to assess preverbal children or in those who cannot self-report.The literature strongly supports the effectiveness of a variety of techniques in providing analgesia in pediatric patients. Many of these are the same techniques used in adults, although some techniques (e.g., caudal analgesia) are more commonly used in children. There is strong agreement among the panel of consultants and the Task Force members that it is important to recognize that pediatric patients represent a unique population with special features when planning and providing perioperative analgesia.Recommendations: Anesthesiologists who treat perioperative pain in pediatric patients should be familiar with the special features of this group. Based on that knowledge, pharmacologic and nonpharmacologic strategies for perioperative analgesia appropriate for the age of the child should be offered in a manner that promotes efficacy and safety.Elderly patients are a unique population facing surgery. They may experience physical and mental limitation and may have different attitudes than younger patients with regard to expressing pain and appropriate therapy for it. Altered physiology with aging changes the way analgesic drugs and local anesthetics are distributed and metabolized, frequently necessitating alterations in dosing. There is strong agreement from the panel of consultants and the Task Force members on the importance of recognizing the unique features of geriatric patients in planning and providing perioperative analgesia.The literature indicates that single and multimodality techniques that have been shown to be effective in younger adult patients are also effective (often with reduced drug dose requirements) in geriatric patients without increasing side effects.Recommendations: Anesthesiologists who treat perioperative pain in geriatric patients should be familiar with the special features of this group. In particular, dose reduction for drugs that may cause central nervous system depression should be considered.The increasing trend toward ambulatory surgery poses special problems in perioperative pain management. One of the most common reasons for unanticipated hospital admission in this population is inadequate pain control. Analgesic techniques must provide safe, adequate pain relief for patients who quickly leave the supervised hospital environment. Techniques such as EA and intravenous PCA, which require special nursing and monitoring, are not suitable for such patients, but others such as local anesthetic wound infiltration and oral nonsteroidal antiinflammatory drugs may be very effective.The panel of consultants and the Task Force members strongly agree that the provision of effective analgesia to ambulatory surgery patients is important and beneficial. A limited search of this evolving literature suggests that planning of perioperative analgesia for ambulatory patients including the use of certain procedures (e.g., local anesthetic wound infiltration and certain RA techniques) may improve analgesia without increasing the risk of side effects.Recommendations: Anesthesiologists who care for ambulatory surgery patients should proactively plan therapeutic strategies appropriate for them, recognizing that they are expected to leave the surgical facility within a few hours after the completion of surgery.The Task Force thanks those who responded to surveys on acute pain in the perioperative setting, reviewed guideline drafts, contributed oral and written testimony to the Open Forum, and participated in tests of clinical feasibility.The development of these guidelines included methods recommended in the following publications: (1) Clinical Practice Guidelines--Directions for a New Program, Committee to Advise the Public Health Service on Clinical Practice Guidelines, Division of Health Care Services, Institute of Medicine. Edited by Field MJ, Lohr KN, Washington, D.C., National Academy Press, original document 1990, summary document 1992; and (2) Woolf SH: Manual for Clinical Practice Guideline Development, Washington, D.C., U.S. Department of Health and Human Services. Agency for Health Care Policy and Research, publication number 91-0007, March 1991.The scientific assessment was based on the following statements or evidence linkages. These linkages represent directional hypotheses about relationships between perioperative pain management and clinical outcomes.1. Proactive planning for perioperative pain management improves pain control and reduces adverse outcomes.2. Education and training of hospital personnel improve pain control and reduce adverse outcomes.3. Education and participation of patients and families improve pain control and reduce adverse outcomes.4. Monitoring and documentation activities improve pain control and reduce adverse outcomes.5. Availability of anesthesiologists providing perioperative pain management improves pain control and reduces adverse outcomes.6. Standardized institutional policies and procedures for perioperative pain management improve pain control and reduce adverse outcomes.7. Use of PCA, EA, or RA techniques improves pain control and reduces adverse outcomes.8. Use of multimodality techniques improves pain control and reduces adverse outcomes.9. Organizational characteristics related to perioperative pain management improve pain control and reduce adverse outcomes.10. Pediatric perioperative pain management techniques improve pain control and reduce adverse outcomes.11. Geriatric perioperative management techniques improve pain control and reduce adverse outcomes.12. Ambulatory surgery acute pain management techniques improve pain control and reduce adverse outcomes.Scientific evidence was derived from aggregated research findings, including metaanalyses, and from surveys, open forum presentations, and other consensus-oriented activities. For purposes of literature aggregation, potentially relevant clinical studies were identified via electronic and manual searches of the literature. The search covered a 27-yr period from 1966 through 1993. More than 4,000 articles were identified initially, yielding 465 nonoverlapping articles that addressed the 12 evidence linkages. Studies that could not be analyzed statistically were reviewed and eliminated, yielding 233 articles used in the formal metaanalyses.A directional result for each study was determined initially by classifying the outcome as (1) supporting a linkage, (2) a linkage, or (3) The were to a directional assessment of support for each The literature to linkages EA, and RA as and studies with defined and for formal tests were to continuous and an procedure was to study combined tests were employed as (1) the combined based on of the from the and (2) the combined providing of the studies by each of the by the A procedure based on the for study using 2 2 was used when outcome was An acceptable level was at and were agreement was through assessment of for of the were to ensure among the study To control for a was for each combined search for studies was and no tests for research were from the combined tests for pain reduction were as 1 EA and RA and effect from to effect for all outcomes were (i.e., not for of tests and of effect were in all that the various studies common of the population effect for the linkages. among the Task Force members and two was by using a for agreement were as (1) type of study (2) type of (3) evidence and (4) literature for agreement (1) (2) and (3) linkage, These represent to of of the literature were by of opinions from a panel of anesthesiologists with expertise in acute pain in the perioperative setting and from the opinions of the Task Force were of the linkages (i.e., that they in in pain reduced adverse side and were important for the guidelines to The of consultants supporting each based on these were 1 2 and 12 was to the guidelines after completion of the feasibility of these guidelines into clinical practice was using a of opinions from a panel of anesthesiologists with expertise in acute pain in the perioperative setting. of the responses that these guidelines can be in a large of institutions with of the anesthesiologists that of the guidelines not result in the need to new or of guideline for all was to the who that be the was new of PCA epidural and anesthesiologists were to of the evidence linkages change their clinical the guidelines were The of consultants no change associated with each were as proactive planning education and training education and participation of patients and families and documentation availability of anesthesiologist institutional policies and procedures use of PCA, EA, and RA techniques use of multimodality techniques organizational characteristics pediatric techniques geriatric techniques and ambulatory surgery techniques of the that the guidelines have no effect on the of time spent on a that the guidelines reduce the of time spent For all the in the of time spent on a was the of who an in time spent on a the was Practice Pain or and Agency for Health Care Policy and Washington, D.C., U.S. Department of Health and Human Services, by with special interest in the used in these guidelines can further by writing L. Brian Ready, M.D., Department of Acute Pain of of Seattle,

There is some confusion in the terminology used when referring to MIS (Minimal invasive surgery) or percutaneous surgery. The correct term to describe these procedures should be percutaneous (made through the skin) and MIS should be reserved for procedures whose extent is between percutaneous and open surgery (e.g. osteosynthesis). Minimal incision surgery may be distinguished in first, second and third generation minimal incision surgery techniques.First generation MIS hallux valgus surgery is mainly connected with the Isham procedure; an intraarticular oblique and incomplete osteotomy of the head of the first metatarsal without fixation.The Bösch osteotomy and the SERI are classified as second generation MIS hallux surgery. They are both transverse subcapital osteotomies fixed with a percutaneous medial K-wire inserted into the medullary canal. For all these procedures, intraoperative fluoroscopic control is necessary.Open hallux valgus surgery can be divided into proximal, diaphyseal and distal osteotomies of the first metatarsal. Reviewing the available literature suggests minimally invasive and percutaneous hallux valgus correction leads to similar clinical and radiological results to those for open chevron or SCARF osteotomies. First generation minimally invasive techniques are primarily recommended for minor deformities. In second generation minimally invasive hallux valgus surgery, up to 61% malunion of the metatarsal head is reported. Once surgeons are past the learning curve, third generation minimally invasive chevron osteotomies can present similar clinical and radiological outcomes to open surgeries. Specific cadaveric training is mandatory for any surgeon considering performing minimally invasive surgical techniques.Cite this article: EFORT Open Rev 2021;6:432-438. DOI: 10.1302/2058-5241.6.210029

This systematic review aims to illustrate the published results of "minimally invasive" procedures for correction of hallux valgus. Based on former systematic reviews on that topic, the literature search was organised by two independent investigators. MEDLINE was systematically searched for available studies. The keywords used were "hallux valgus", "bunion", "percutaneous surgery", "minimally invasive surgery", "arthroscopy", "Bosch" and "SERI". Studies were assessed using the level of evidence rating. A total of 21 papers were included in this review. These studies described a total of 1,750 patients with 2,195 instances of percutaneous, minimally invasive or arthroscopic hallux valgus surgery. Clinical reports of results after minimally invasive hallux valgus surgery at meetings are common. Published results in peer-reviewed journals are less common and the majority of papers are level IV studies according to the level of evidence ratings. We found one level II and three level III studies. Reported complications seem to be less than one may see in one's own clinical practice. This possible bias may be related to the fact that most studies are published by centres performing primarily minimally invasive hallux valgus surgery.

Simple SummaryDespite developments in animal welfare science regarding perioperative pain management in calves (Bos taurus), there are concerns that current knowledge has not been adopted in practice. Given that the perceptions of veterinarians have implications for how the welfare needs of calves are assessed and managed in practice, this study sought to quantify veterinary perceptions towards perioperative pain management in calves, including barriers to its use and whether demographic differences may influence those perceptions. A nationwide survey was electronically distributed to veterinarians registered with the Veterinary Council of New Zealand. Veterinarians largely associated multimodal pain management with the greatest reduction in perioperative pain. Most veterinarians also perceived that postprocedural pain persists beyond 24 h for disbudding and castration and did not support the use of differential treatment based on developmental age. Despite this, certain barriers were identified for their potential to inhibit the use of pain management on-farm. While demographic differences were found to influence veterinary perceptions towards perioperative pain management, the findings revealed considerable support among veterinarians for improving pain mitigation in calves. Given the opportunity, veterinarians in New Zealand would likely support strengthening the minimum provisions afforded to calves in practice and policy.While veterinarians are instrumental to the welfare of calves (Bos taurus), limited knowledge exists concerning veterinary perceptions towards perioperative pain management in calves. As a part of a larger, nationwide study investigating the perceptions of veterinarians towards calf welfare, the current work sought to quantify veterinary perceptions towards perioperative pain management, including barriers to its use, and investigate demographic influences affecting those perceptions. An electronic mixed-methods survey was completed by 104 veterinarians registered with the Veterinary Council of New Zealand. The current work revealed that most veterinarians considered a multimodal approach as the most effective method for ameliorating perioperative pain in calves, rejected the practice of differential treatment based on developmental age, and perceived that postprocedural pain persists beyond 24 h for the majority of procedures included in the survey. Despite this, veterinarians identified certain barriers that may inhibit the provision of pain mitigation on-farm, including costs, inadequate recognition of pain, and ingrained farming practices. Certain demographic effects were found to influence perceptions towards perioperative pain management, including gender, the number of years since graduation, and species emphasis. Nevertheless, the current work demonstrated considerable support among veterinarians to improve pain management protocols during routine husbandry procedures. The asymmetries that exist between the current minimum provisions of perioperative pain management and veterinary perspectives suggest that substantive improvements are necessary in order to reconcile New Zealand’s existing regulatory regime with developments in scientific knowledge.

Podiatric physicians have come to realize that opioid use disorder (OUD) is a public health crisis causing morbidity, mortality, lost productivity, and legal cost in the United States. Opioid analgesics are efficient first-line pain relievers for acute and chronic lower-extremity pain syndrome. Perioperative pain management strategies have been proposed using opioid stewardship, but there are few standardized protocols to guide podiatric medical providers treating patients with OUD. First, we describe the pharmacology of therapeutic agents used as medications for addiction treatment for OUD and substance use disorder (SUD). Second, we offer criteria for selecting acute pain and perioperative management in patients with OUD and SUD per current medical literature. Finally, we review the literature applying opioid stewardship in the context of prescribing opioid analgesics in the presence of OUD and SUD. Three hypothetical clinical scenarios grounded in clinical-based literature are described with congruent data and founded guidelines. The first and second scenarios describe acute pain and perioperative management in patients with OUD receiving methadone and buprenorphine-naloxone, respectively. The third scenario describes acute pain and perioperative management in a patient with SUD receiving intravenous naltrexone. We hope that the lower-extremity specialist will appreciate that thoughtful management of acute perioperative pain among patients who receive medications for addiction treatment for OUD is critically important given the risks of destabilization during the perioperative period. The literature reveals the lack of rigorous evidence on acute pain management in patients who receive medication for OUD; however, some clinical evidence supports the practice of continuing methadone or buprenorphine for most patients during acute pain episodes.

To map the practice of paediatric perioperative pain assessment and management among consultant anaesthetists working in teaching institutions in the two provinces of Pakistan. A cross-sectional survey. Place and Duration of the Study: Department of Anaesthesiology, Teaching institutions of Sindh and Khyber Pakhtunkhwa (KPK), Pakistan, from January to October 2022. A questionnaire was designed to determine the participants' practices about perioperative pain assessment and management. It consisted of 26 questions that included participants' demographic data and questions about their paediatric practice. A total of 152 responses were received (response rate 76%). Most participants (n = 84, 55.3%) had a two-year diploma in anaesthesiology, while 38.2% had a four-year diploma. Additionally, 66.4% worked at public sector hospitals and 28.3% at private hospitals. Only 66% of respondents used paediatric pain scales for pain assessment in the recovery rooms. Most participants, 72.2%, had no Paediatric Pain Management Guidelines available at their institution. Only 5% had access to 5 analgaesic medications, while 32% had access to only 2 medications for intraoperative pain management. The practice of anaesthesiologists in these two provinces of Pakistan is highly varied since there is a lack of national guidelines. Paediatric anaesthesia, Acute pain, Pain management, Pain measurement, Paediatric pain assessment, Anaesthesia and analgaesia, Survey and questionnaires.

Revision of Recurrent Hallux Valgus Deformity Using a Percutaneous Distal Transverse Osteotomy: Surgical Considerations and Early Results

Percutaneous foot surgery is a surgical method of treating various bone and soft-tissue disorders of the foot. In hallux valgus pathology, it is called minimal incision surgery, and is another method to treat this disorder. As in all surgical techniques, there are complications in minimal incision hallux valgus surgery. In general, in percutaneous surgery, there have been reports of recurrence on the hallux valgus deformity or development of the opposite deformity (hallux varus), malunion, nonunion, head metatarsal necrosis, clawed hallux, and transfer keratotic lesions that cause pain, thermal injuries, and other complications. We describe some of the most frequent complications in minimally invasive surgery of the hallux valgus, and how to correct it.Level of Evidence:Diagnostic Level 5. See Instructions for Authors for a complete description of levels of evidence.

Category: Bunion; Other Introduction/Purpose: Hallux valgus is the most common foot deformity, and recurrent deformity is the most common complication after primary hallux valgus correction. The principles of HV revision surgery do not differ from the initial goal of hallux valgus correction, which is to restore physiologic alignment and alleviate symptoms. Choosing the appropriate procedure to address the given deformity pattern and the technical competence to perform the corrective procedure are the keys to success. To date, no 3rd or 4th generation minimally-invasive technique for the correction of recurrent hallux valgus has been described in the literature. The aim of this multicenter analysis is to evaluate the use of modern percutaneous bunion surgery techniques in the revision of recurrent hallux valgus. Methods: A total of 100 cases operated between 2013 and 2023 and contributed by 7 surgeons from 6 countries, all performing percutaneous 3rd and 4th generation Minimally-Invasive Chevron Akin (MICA) / Percutaneous Chevron Akin (PECA) / Minimally Invasive Extra-articular Transverse and Akin (META), were retrospectively evaluated. Minimum follow-up was 12 months (range 12-104). Radiological correction (HVA, IMA, tibial sesamoid position), surgery associated complications using the modified Clavien-Dindo-Sink classification and functional outcome (MOXFQ) were evaluated. Results: The complication rate was 21%. Most complications could be managed non-surgically. The most common complication was screw prominence leading to revision surgery with hardware removal in 8.5% of all cases. Major complications such as deep infection requiring revision surgery were extremely rare. HVA was corrected from a mean of 33.5° to 10.3° at 6 weeks and 9.0° at 12 months, IMA from a mean of 13.9° to 4.8° and 5.1°, respectively. The mean Clapham-Hardy tibial sesamoid position was classified as type 6 preoperatively and improved to type 2 postoperatively. PROMs using the MOXFQ score improved from a preoperative index score of 46.0 to 8.9. Conclusion: Modern percutaneous hallux valgus techniques have proven to be a reliable tool in the primary correction of hallux valgus and metatarsus primus varus, aiming to minimize surgical morbidity and maximize surgical efficiency without compromising safety. To date, there have been no reports of these procedures for recurrent hallux valgus. With adequate training and experience, the use of 3rd and 4th generation MICA/PECA/META is a safe procedure for the revision of recurrent hallux valgus resulting in significant improvements in radiographic parameters, functional outcome and patient satisfaction. The rate of relevant complications is not increased compared to traditional open surgical techniques.

Introduction: Patients with chronic pain or opioid use disorders (OUD) are often managed with prescriptions or medication-assisted treatments (MAT) involving methadone and buprenorphine. The pharmacology and mu opioid receptor (μOR) binding affinity of methadone and buprenorphine presents a multitude of challenges perioperatively, increasing the risk of ineffective pain management, marginalization, opioid withdrawal, and relapse. Literature review: Thorough preoperative assessment and preparation of patients on methadone and buprenorphine is advised to establish a tailored perioperative plan and postoperative analgesic expectations. Several perioperative pain management guidelines and protocols have been suggested, but there remains a lack of high quality evidence-based research and consensus to guide anesthesia and pain management providers. Appropriate strategies for patients on methadone and buprenorphine requires a multidisciplinary approach that considers the patient’s history with pain management, substance abuse, opioid use or abuse, and history of effective analgesic therapies. Existing case studies, expert opinions, and clinical practice advisories recommend continuation of methadone and buprenorphine perioperatively to avoid regimen disruptions and drug level fluctuations. Most recommendations are also in agreement for providers to implement multimodal analgesia and incorporate regional/neuraxial anesthesia when appropriate. Description of the case: The patient was a 52-year-old female undergoing spinal cord stimulator removal. Patient’s chart indicated a history of chronic pain and methadone therapy. Preoperative assessment was performed methodically to evaluate patient’s compliance with methadone. Although patient reported to have discontinued methadone therapy approximately six months prior, optimal perioperative pain management was addressed with a short-acting opioid, multimodal analgesia, and local anesthesia infiltration. Patient did not experience postoperative complications or inadequate pain control and was discharged within the same day. Discussion and conclusions: Methadone is a full μOR agonist with significant analgesic properties and should be continued on the day of surgery. Abrupt discontinuation of methadone can result in opioid withdrawal or place the patient at risk for relapse. Optimal perioperative pain management for patients on methadone includes utilization of short-acting opioid agonists, multimodal analgesia, regional/neuraxial anesthesia, and other non-opioid interventions. Consider incorporating agents such as volatile anesthetics, ketamine, benzodiazepines, acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, alpha-2 adrenergic receptor agonists, local anesthetics, and regional/neuraxial anesthesia. Buprenorphine is a partial μOR agonist with high receptor binding affinity and slow dissociation properties. Perioperative buprenorphine management varies widely, but many guidelines and protocols recommend continuing buprenorphine preoperatively. Appropriate pain management may be achieved with administration of multimodal analgesia, regional/neuraxial anesthesia, and opioid agonists with similar μOR binding affinity to buprenorphine. Hydromorphone and sufentanil are examples of full μOR agonists with high Ki values that may be used to overcome the receptor.

Comparison of turnaround time and total cost of HIV testing before and after implementation of the 2014 CDC/APHL Laboratory Testing Algorithm for diagnosis of HIV infection

This systematic review aims to illustrate the published results of “minimally invasive” procedures for correction of hallux valgus. Based on former systematic reviews on that topic, the literature search was organised by two independent investigators. MEDLINE was systematically searched for available studies. The keywords used were “hallux valgus”, “bunion”, “percutaneous surgery”, “minimally invasive surgery”, “arthroscopy”, “Bosch” and “SERI”. Studies were assessed using the level of evidence rating. A total of 21 papers were included in this review. These studies described a total of 1,750 patients with 2,195 instances of percutaneous, minimally invasive or arthroscopic hallux valgus surgery. Clinical reports of results after minimally invasive hallux valgus surgery at meetings are common. Published results in peer-reviewed journals are less common and the majority of papers are level IV studies according to the level of evidence ratings. We found one level II and three level III studies. Reported complications seem to be less than one may see in one’s own clinical practice. This possible bias may be related to the fact that most studies are published by centres performing primarily minimally invasive hallux valgus surgery.

Background: Hemophilia type A and B is associated with spontaneous bleeding in muscle tissues and joints. Acute hemarthrosis, representing 70–80% of all bleedings in severe hemophilia patients, is extremely painful. When surgical procedures are needed in hemophiliac patients, perioperative management should be planned with a multidisciplinary team. Our narrative review, through a rigorous analysis of the current literature, focuses on pain management in hemophiliac patients. Methods: The report synthesizes a literature review on hemophilia, adapting PRISMA guidelines. It identifies a research question on surgical procedures and perioperative pain management. Various sources, including electronic databases, are utilized. Study inclusion criteria are defined based on the research question. Forty studies are included. A detailed study selection is illustrated. Results: Guidelines for managing acute postoperative pain in the general population advocate for a multimodal analgesic administration to enhance synergistic benefits, reduce opioid requirements, and minimize side effects. Recent recommendations from the World Federation of Hemophilia (WFH) for postoperative pain management in hemophilia patients suggest tailoring treatment based on pain levels, in coordination with anesthesiologists. Conclusions: Pain management in hemophiliac patients undergoing orthopedic interventions requires a multidisciplinary approach, with further research needed to define a reliable global standard of treatment.

The management of postoperative pain after carpal tunnel syndrome surgical treatment at a tertiary hospital was analyzed and compared with the guidelines for perioperative pain management. This retrospective study included 579 patients operated on for carpal tunnel syndrome at the Split University Hospital Center in Split, Croatia. The following key data were collected from patient medical records: age, gender, type and dosage of premedication, type and dosage of anesthesia, type and dosage of postoperative analgesia per each postoperative day. The procedures related to perioperative pain were analyzed and compared with the current guidelines for perioperative acute pain management. Study results showed that 99.6% of patients with carpal tunnel syndrome were operated under local anesthesia, of which 2.9% also received sedation. Analgesics were prescribed to 45% of patients after surgery, and according to patient charts, 39% of patients actually received postoperative analgesic(s). Generally, postoperative pain was treated on the fi rst postoperative day, mostly with nonsteroidal anti-inflammatory drugs. Only two patients received weak opioids for postoperative pain. Many recommendations from the guidelines for perioperative acute pain management were not followed. In conclusion, the guidelines should be followed and appropriate interventions used to improve postoperative pain management.

The COVID-19 pandemic has swept across the world over the past few months. Many articles have been published on the safety of anesthetic medications and procedures used in COVID-19 positive patients presenting for surgery. Several other articles covered the chronic pain management aspect during the pandemic. Our review aimed to focus on perioperative pain management for COVID-19 patients. We conducted a literature search for pertinent recent articles that cover considerations and recommendations concerning perioperative pain management in COVID-19 patients. We also searched the literature for the relevant adverse effects of the commonly used medications in the treatment of COVID-19, and their potential drug–drug interactions with the common medications used in perioperative pain management. Professional societies recommend prioritizing regional anesthesia techniques, which have many benefits over other perioperative pain management options. When neuraxial and continuous peripheral nerve block catheters are not an option, patient-controlled analgesia (PCA) should be considered if applicable. Many of the medications used for the treatment of COVID-19 and its symptoms can interfere with the metabolism of medications used in perioperative pain management. We formulated an up-to-date guide for anesthesia providers to help them manage perioperative pain in COVID-19 patients presenting for surgery.