[Hallux valgus surgery in 2005. Conventional, mini-invasive or percutaneous surgery? Uni- or bilateral? Hospitalisation or one-day surgery?].
There remains a good deal of controversy concerning forefoot surgery. Certain concepts such as conventional procedures, minimally invasive surgery, or percutaneous surgery are promoted because of their specific advantages including rapid recovery and compatibility with a short hospital stay or even outpatient surgery. Nevertheless, in 2005 many questions remain unanswered and highly variable practices have been basically founded on personal experience rather than scientific evidence. In addition, financial and lobbying pressure appears to have an influence on our choices, affecting the freedom of our therapeutic decision-making. Developed over a long period, conventional surgery has proven reliability, reproducibility and adaptability. Procedures termed minimally invasive are defined by the limited incision. Percutaneous surgery is not less invasive than other procedures; the techniques are performed under indirect visual control and often assisted with more or less sophisticated radioscopic techniques depending on the surgeon's own experience. In our opinion, percutaneous surgery should be considered as a new concept based on rapid and functional results. Patients often raise the question of a bilateral procedure. For hallux valgus, there is no consensus on whether unilateral or bilateral procedures are better, the best solution depending on postoperative weight bearing and thus on the technique employed. From a cost expenditures point of view, bilateral procedures have an impact. For the advantages in terms of macroeconomy for professional incapacity, the question is less univocal for healthcare authorities. Advances in perioperative anesthesia and analgesia have enabled a broader approach to ambulatory surgery. Outpatient surgery appears to have benefits in terms of organization and economics. Variables studied were as follows: duration of hospital stay, postoperative edema, number of days of sick leave and preoperative and early and late postoperative pain. Patients who underwent minimally invasive procedures had a significantly shorter hospital stay compared with three other groups. For bilateral procedures, hospital stay on average was longer than in the two other groups. There was no correlation between postoperative edema and pain or between the degree of edema at 15 days and two months. Mean sick leave was 54.6 days. This was significantly shorter for percutaneous procedures compared with conventional surgery or minimally invasive techniques. Preoperative pain was noted four to five on the Visual Analogue Scale (VAS). There was no significant difference between the different groups as a function of the type of surgery performed. Statistically, there is very little difference in the short term between the different techniques. A much longer study would be necessary to obtain evidence to guide our practices. While there is certainly no reason to condemn one method or another, surgeons must be careful about the promises given to patients which are generally based on personal experience but not necessarily supported by rigorous scientific data.
Leemrijse
T
T
Cliniques universitaires Saint-Luc, UCL, 1200 Bruxelles, Belgique.
Valtin
B
B
Besse
J-L
JL
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000556:Ambulatory Surgical Procedures; D005500:Follow-Up Studies; D006215:Hallux Valgus / Q000191:economics / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D015337:Multicenter Studies as Topic; D010027:Osteotomy; D010045:Outpatients; D010147:Pain Measurement; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology; D017060:Patient Satisfaction; D011183:Postoperative Complications; D017410:Practice Guidelines as Topic; D018582:Sick Leave; D013997:Time Factors; D016896:Treatment Outcome