Opioid-free Forefoot Surgery — A Boon for the Right Patients

A nice RCT finds that an opioid-free analgesic approach was effective after hallux surgery , but safety remains an issue

What’s the Claim?

In patients undergoing forefoot surgery in one private practice, a randomized trial found that a multimodal analgesic regimen without any opioids was non-inferior to a more typical analgesic routine using oral analgesics. In fact, the nonopioid group had lower pain scores at 24 hours and two weeks, and the difference was large enough to be clinically important (a difference of 4 points out of 10 at 24 hours, and 2 points out of 10 at two weeks). The nonopioid approach involved a typical-looking multimodal program with preoperative medications (meloxicam, gabapentin, tylenol, and scopolamine patch for patients <75 years of age), intraoperative approaches (an ankle block, 30 mg ketorolac IV, ondansetron, and 10 mg of dexamethasone), PACU interventions (cryotherapy and IV acetaminophen), and a roster of discharge medications (ketorolac for 5 days, meloxicam for a month following that, gabapentin for 2 weeks, and acetaminophen as needed) plus cryotherapy. The usual-care group included an ankle block, ondansetron IV during surgery, optional cryotherapy, and hydrocodone/acetaminophen 5/325 mg, 1 to 2 tablets every four hours as needed.

How’s It Stack Up?

We almost didn’t cover this one because multimodal analgesic regimens have been found to be so effective in numerous other areas of orthopaedic surgery (especially, but not only, in arthroplasty). It surprised us to learn — and for this, we thank CORRelations’ advisor in Foot and Ankle, Gregory Guyton MD — that this is the first randomized trial in patients undergoing forefoot surgery, such as procedures for hallux valgus and hallux rigidus.

What’s Our Take?