PROSPECT guideline for hallux valgus repair surgery: a systematic review and procedure‐specific postoperative pain management recommendations

Overview

Hallux valgus repair, commonly called bunion surgery, is one of the most frequent elective foot operations. Because it involves bone cuts and fixation in a sensitive area, it often causes significant pain in the first days after surgery. This PROSPECT guideline, from the European Society of Regional Anaesthesia and Pain Therapy, gives procedure-specific recommendations based on a systematic review of randomised trials. Each intervention is assessed for clinical relevance, safety and added benefit over a basic analgesic regimen, not only for statistical effect.

Key recommendations

The guideline recommends a multimodal baseline of regular non-opioid analgesics given before or during surgery and continued afterwards, with opioids kept for breakthrough pain. For local and regional analgesia, it supports either a peripheral block at the ankle level or surgical wound infiltration with local anaesthetic, so the team can choose according to local expertise and logistics. Selected systemic adjuncts may complement this approach. The working group also identifies techniques that should not be used routinely, because the evidence is insufficient or conflicting or because the practical burden is disproportionate to the benefit.

Clinical implications

Many bunion operations are performed as day-case surgery, so effective analgesia that lasts after discharge is essential. The guideline encourages teams to plan for pain beyond the operating day, to prepare patients for the period when local anaesthesia wears off, and to minimise opioid exposure at home. It gives anaesthetists and foot and ankle surgeons a shared, evidence-based protocol. It also highlights the need for further high-quality trials that compare regional techniques directly and report outcomes that matter to patients, such as function and quality of recovery.