What is the recommended nerve block for a hallux valgus repair?

Recommended Nerve Block for Hallux Valgus Repair

Ankle block is the recommended nerve block for hallux valgus repair surgery, as it provides effective postoperative pain relief while allowing early mobilization. 1

Evidence-Based Recommendation

The PROSPECT (PROcedure SPECific Postoperative Pain ManagemenT) guidelines specifically for hallux valgus repair surgery support the use of ankle block as part of a multimodal analgesic approach:

• Ankle block has been shown to reduce intraoperative anesthetic requirements and provide effective postoperative analgesia 1, 2
• Pretreatment with ankle block (tibial and peroneal nerve blocks) demonstrates superior pain relief compared to peri-incisional local anesthetic infiltration in the immediate postoperative period 3
• Ankle block should be performed with ultrasound guidance when possible to increase accuracy and reduce the risk of local anesthetic systemic toxicity 4

Technique Details

When performing an ankle block for hallux valgus repair:

• Target the tibial and peroneal nerves using 8-10 mL of 0.25% bupivacaine or equivalent local anesthetic 3
• Consider using lower concentrations of local anesthetics without adjuncts to avoid dense blocks that might delay diagnosis of compartment syndrome 4
• Ultrasound guidance improves precision and may reduce the volume of local anesthetic needed 4

Alternative Options

If ankle block is not feasible or contraindicated, consider these alternatives:

• Popliteal sciatic nerve block: Can provide effective analgesia, though may have a longer duration and potentially delay mobilization 5
• Plantar compartment block: A newer technique showing promise for hallux valgus surgery with potentially longer analgesic duration (median 17.3 hours) 6
• Peri-incisional local anesthetic infiltration: Less effective than ankle block but still provides some analgesic benefit 3

Multimodal Approach

The nerve block should be part of a comprehensive multimodal analgesic regimen including:

• Paracetamol (acetaminophen) and NSAIDs or COX-2 inhibitors administered preoperatively or intraoperatively and continued postoperatively 1
• Systemic steroids to reduce inflammation and pain 1
• Rescue opioids as needed for breakthrough pain 1

Clinical Considerations and Cautions

• Avoid dense, long-duration blocks that might mask compartment syndrome symptoms 4
• Be cautious with continuous catheter techniques, as they may delay mobilization without providing significant additional benefit 2
• Calculate safe doses of local anesthetics to prevent systemic toxicity 4
• Consider patient comorbidities and anticoagulation status when selecting regional techniques 4

Monitoring and Follow-up

• Assess block success thoroughly before proceeding with surgery to minimize the need for conversion to general anesthesia 4
• Monitor for respiratory function, especially if the block is combined with sedation 4
• Ensure patients have adequate multimodal analgesia as the block wears off to prevent rebound pain 1