Long-Acting Narcotic Multimodal Anesthesia Versus Standard of Care Anesthesia for Hallux Valgus Patients Undergoing a Percutaneous Distal Metatarsal Osteotomy: A Multi-Center Randomized Controlled Trial.

Abstract

Hallux valgus surgery often results in significant post-operative pain, requiring narcotics. Optimizing pain management while minimizing opioid consumption remains an important clinical challenge. This study investigates whether multimodal analgesia (acetaminophen, naproxen, and pregabalin) with the use of long-acting tramadol reduces the need for short-acting narcotics following minimally invasive hallux valgus surgery under regional ankle block anesthesia. A total of 114 patients aged 18-70 with BMI ≤ 40 undergoing hallux valgus surgery were randomized into Experimental (Exp) and Standard (S) groups. The Exp group (n=56) received acetaminophen, naproxen, pregabalin, and Ralivia (tramadol extended release) pre-operatively, along with a post-operative regimen including rescue hydromorphone. The S group (n=58) followed standard protocols with hydromorphone as the primary analgesic. Pain (VAS scores) and short-acting narcotic use were recorded post-operatively, alongside steps and sleep using smartwatches. Two-sided t-tests compared VAS scores and narcotic consumption. Exp patients used significantly fewer short-acting narcotics in the first week, averaging 5.24 hydromorphone pills (20.96 MME) vs. 13.53 hydromorphone pills (54.12 MME) in the S group (p < 0.0005), however the Exp group consumed a higher overall MME. Notably, of all patients in the study, 27.2% did not consume any short-acting narcotics post-operatively (43.1% in Exp group and 10.7% in S group). Pain scores at 24 and 48 hours were significantly less in the Exp group (p=0.001, p=0.012), but the difference was minimal and not clinically significant. Steps and sleep were comparable between groups. Multimodal analgesia with long-acting narcotics in minimally invasive surgery was associated with reduced short-acting narcotic use, but higher overall MME compared to the standard protocol.