Modern percutaneous hallux valgus surgery, including the minimally invasive chevron and Akin (MICA) technique, is considered to cause less pain than traditional methods because of reduced soft tissue morbidity. Nevertheless, opioids are often prescribed postoperatively. This study investigates whether mild to moderate analgesics (World Health Organization [WHO] level 1 and 2) are sufficient for pain control following modern percutaneous hallux valgus correction.
Methods:
This prospective single-surgeon case series includes 125 consecutive feet that underwent MICA surgery between May 2018 and May 2023; 95 feet (76%) were included with ≥12-month follow-up. Data on pre- and postoperative analgesic consumption and radiologic parameters were recorded. Patient-reported analgesic consumption was collected at prespecified visits via electronic questionnaires; no pill counts were performed. The primary endpoint was the proportion of patients using any opioid by the end of postoperative week 2. Secondary outcomes included radiologic parameters and complication rates.
Results:
The mean follow-up period was 1.6 years (±0.5). Fourteen percent (95% CI 0.08-0.22) required any opioids within the first two postoperative weeks, with a mean of 23.3 morphine milligram equivalents (MME; 95% CI 9.7-37.0). Two percent (95% CI 0.01-0.07) required WHO level 3 opioids. Seventy-five percent of patients stopped taking analgesics within 3 weeks (95% CI 0.65-0.82). Significant improvements were observed in hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA).
Conclusion:
In this prospective case series within a standardized care pathway, most patients did not require opioids, and high-potency opioids were rarely used. Routine prescription of high-potency opioids after third/fourth-generation percutaneous hallux valgus correction may be unnecessary for most patients in similar settings. Hardware-related findings should be interpreted cautiously because the screw design and osteotomy technique changed during the study period, which may have confounded comparisons.
AiyerAMasselDHSiddiquiNAcevedoJI. Biomechanical comparison of 2 common techniques of minimally invasive hallux valgus correction. Foot Ankle Int. 2021;42(3):373-380. doi:10.1177/1071100720959029
2.
AsterASForsterMCRajanRAPatelKJAsirvathamRGilliesC. Radiographic pre-operative assessment in hallux valgus: is it reliable?Foot. 2004;14(3):129-132. doi:10.1016/j.foot.2004.02.002
3.
BalesarVVBruinLLvan LiebergenMDeenikARKeizerSB. MICA procedure vs open chevron osteotomy for hallux valgus correction: a prospective cohort study. Foot Ankle Orthop. 2024;9(1):24730114231224725. doi:10.1177/24730114231224725
4.
BizCCorradinMPetrettaIAldegheriR. Endolog technique for correction of hallux valgus: a prospective study of 30 patients with 4-year follow-up. J Orthop Surg Res. 2015;10(1):102. doi:10.1186/s13018-015-0245-1
5.
BöschPWankeSLegensteinR. Hallux valgus correction by the method of Bösch: a new technique with a seven-to-ten-year follow-up. Foot Ankle Clin. 2000;5(3):485-498, v-vi.
6.
BroganKLindisfarneEAkehurstHFarookUShrierWPalmerS. Minimally invasive and open distal chevron osteotomy for mild to moderate hallux valgus. Foot Ankle Int. 2016;37(11):1197-1204. doi:10.1177/1071100716656440
7.
BroganKVollerTGeeCBorbelyTPalmerS. Third-generation minimally invasive correction of hallux valgus: technique and early outcomes. Int Orthop. 2014;38(10):2115-2121. doi:10.1007/s00264-014-2500-1
8.
BurgAPalmanovichE. Correction of severe hallux valgus with metatarsal adductus applying the concepts of minimally invasive surgery. Foot Ankle Clin. 2020;25(2):337-343. doi:10.1016/j.fcl.2020.02.001
9.
ChanJJGuzmanJZNordioAChanJCCirinoCMVulcanoE. Opioid consumption and time to return to work after percutaneous osteotomy in foot surgery. Orthopedics. 2020;43(4):e334-e337. doi:10.3928/01477447-20200428-01
10.
ChenJYAngBFHJiangLYeoNEMKooKSingh RikhrajI. Pain resolution after hallux valgus surgery. Foot Ankle Int. 2016;37(10):1071-1075. doi:10.1177/1071100716653084
11.
ClavienPABarkunJDe OliveiraML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187-196. doi:10.1097/SLA.0b013e3181b13ca2
12.
CottrellJConnorJPO. Effect of non-steroidal anti-inflammatory drugs on bone healing. Pharmaceuticals. 2010;3(5):1668-1693. doi:10.3390/ph3051668
13.
CoughlinMJSaltzmanCLNunleyJA2nd. Angular measurements in the evaluation of hallux valgus deformities: a report of the ad hoc committee of the American Orthopædic Foot & Ankle Society on angular measurements. Foot Ankle Int. 2002;23(1):68-74. doi:10.1177/107110070202300114
14.
DawsonJCoffeyJDollH, et al. A patient-based questionnaire to assess outcomes of foot surgery: validation in the context of surgery for hallux valgus. Qual Life Res. 2006;15(7):1211-1222. doi:10.1007/s11136-006-0061-5
15.
de CarvalhoKAMBaptistaADde Cesar NettoCJohnsonAHDalmau-PastorM. Minimally invasive chevron-Akin for correction of moderate and severe hallux valgus deformities: clinical and radiologic outcomes with a minimum 2-year follow-up. Foot Ankle Int. 2022;43(10):1317-1330. doi:10.1177/10711007221114123
16.
EisenschinkJLeveilleDLeveilleRMollicaARhodenizerJ. Postoperative opioid consumption following hallux valgus and rigidus surgery: a guide to postoperative prescription writing. J Foot Ankle Surg. 2023;62(5):873-876. doi:10.1053/J.JFAS.2023.05.009
17.
FinneyFTGossettTDHuHM, et al. New persistent opioid use following common forefoot procedures for the treatment of hallux valgus. J Bone Joint Surg Am. 2019;101(8):722-729. doi:10.2106/JBJS.18.00793
18.
FriggAZauggSMaquieiraGPellegrinoA. Stiffness and range of motion after minimally invasive chevron-Akin and open scarf-Akin procedures. Foot Ankle Int. 2019;40(5):515-525. doi:10.1177/1071100718818577
19.
FuhrmannRARippelWTraubA. Konservative Therapie des Hallux-valgus-Syndroms: was kann man mit Schienen und Einlagen erreichen? Article in German. Orthopade. 2017;46(5):395-401. doi:10.1007/s00132-017-3410-x
20.
GądekALiszkaHWordliczekJ. Postoperative pain and preemptive local anesthetic infiltration in hallux valgus surgery. Foot Ankle Int. 2015;36(3):277-281. doi:10.1177/1071100714553790
21.
GianniniSFaldiniCNanniMDi MartinoALucianiDVanniniF. A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI). Int Orthop. 2013;37(9):1805-1813. doi:10.1007/s00264-013-1980-8
22.
GurGOzkalODilekBAksoySBekNYakutY. Effects of corrective taping on balance and gait in patients with hallux valgus. Foot Ankle Int. 2017;38(5):532-540. doi:10.1177/1071100716683347
23.
HejnaEEMehrabanNHolmesGB, et al. New persistent opioid use after orthopaedic foot and ankle surgery: a study of 348 patients. J Am Acad Orthop Surg. 2021;29(16):e820-e825. doi:10.5435/JAAOS-D-21-00187
IshamSA. The Reverdin-Isham procedure for the correction of hallux abducto valgus. A distal metatarsal osteotomy procedure. Clin Podiatr Med Surg. 1991;8(1):81-94.
26.
JacksonJBThierZTBarfieldMEAltobelloKCSGonzalezTA. Opioid usage after hallux valgus correction surgery. Foot Ankle Spec. 2024;17(4):375-381. doi:10.1177/19386400231162409
27.
JowettCRJBediHS. Preliminary results and learning curve of the minimally invasive chevron Akin operation for hallux valgus. J Foot Ankle Surg. 2017;56(3):445-452. doi:10.1053/j.jfas.2017.01.002
28.
LaiMCRikhrajISWooYLYeoWNgYCSKooK. Clinical and radiological outcomes comparing percutaneous chevron-Akin osteotomies vs open scarf-Akin osteotomies for hallux valgus. Foot Ankle Int. 2018;39(3):311-317. doi:10.1177/1071100717745282
29.
LamPFletcherLWattC, et al. First metatarsal pronation correction after fourth-generation percutaneous transverse osteotomy for hallux valgus. Foot Ankle Int. 2025;46(10):1071-1082. doi:10.1177/10711007251344273
30.
LeeMWalshJSmithMMLingJWinesALamP. Hallux valgus correction comparing percutaneous chevron/akin (PECA) and open scarf/akin osteotomies. Foot Ankle Int. 2017;38(8):838-846. doi:10.1177/1071100717704941
31.
LewisTLHonsMRayR, et al. Third-generation minimally invasive chevron and akin osteotomies (MICA) in hallux valgus surgery: two-year follow-up of 292 cases. J Bone Joint Surg Am. 2021;103(13):1203-1211.
32.
LewisTLLauBAlkhalfanY, et al. Fourth-generation minimally invasive hallux valgus surgery with metaphyseal extra-articular transverse and akin osteotomy (META): 12 month clinical and radiologic results. Foot Ankle Int. 2023;44(3):178-191. doi:10.1177/10711007231152491
33.
LewisTLRayRGordonDJ. Time to maximum clinical improvement following minimally invasive chevron and akin osteotomies (MICA) in hallux valgus surgery. Foot Ankle Surg. 2022;28(7):928-934. doi:10.1016/j.fas.2022.01.003
34.
LewisTLRayRMillerGGordonDJ. Third-generation minimally invasive chevron and akin osteotomies (MICA) in hallux valgus surgery: two-year follow-up of 292 cases. J Bone Joint Surg Am. 2021;103(13):1203-1211. doi:10.2106/JBJS.20.01178
35.
LewisTLRobinsonPWRayR, et al. Five-year follow-up of third-generation percutaneous chevron and akin osteotomies (PECA) for hallux valgus. Foot Ankle Int. 2023;44(2):104-117. doi:10.1177/10711007221146195
36.
MetcalfSASaundersECMooreSK, et al. Compassion, stigma, and professionalism among emergency personnel responding to the opioid crisis: an exploratory study in New Hampshire, USA. J Am Coll Emerg Physicians Open. 2022;3(1):e12641. doi:10.1002/emp2.12641
37.
MikhailCMMarkowitzJDi LenardaLGuzmanJVulcanoE. Clinical and radiographic outcomes of percutaneous chevron-Akin osteotomies for the correction of hallux valgus deformity. Foot Ankle Int. 2022;43(1):32-41. doi:10.1177/10711007211031218
38.
MitchellCLFlemingJLAllenRGlenneyCSanfordGA. Osteotomy-bunionectomy for hallux valgus. J Bone Joint Surg Am. 1958;40-A(1):41-58; discussion 59-60.
39.
MoulodiNKamyabMFarzadiM. A comparison of the hallux valgus angle, range of motion, and patient satisfaction after use of dynamic and static orthoses. Foot. 2019;41:6-11. doi:10.1016/j.foot.2019.06.002
PountosIPanteliMWaltersGGiannoudisPV. NSAIDs inhibit bone healing through the downregulation of TGF-β3 expression during endochondral ossification. Injury. 2021;52(6):1294-1299. doi:10.1016/j.injury.2021.01.007
42.
RayJJFriedmannAJHanselmanAE, et al. Hallux valgus. Foot Ankle Orthop. 2019;4(2):2473011419838500. doi:10.1177/2473011419838500
43.
RedfernDVernoisJ. Minimally invasive chevron akin (MICA) for correction of hallux valgus. Tech Foot Ankle Surg. 2016;15(1):3-11. doi:10.1097/BTF.0000000000000102
44.
RogeroRFuchsDNicholsonK, et al. Postoperative opioid consumption in opioid-naïve patients undergoing hallux valgus correction. Foot Ankle Int. 2019;40(11):1267-1272. doi:10.1177/1071100719862606
45.
SchneiderWKnahrK. Metatarsophalangeal and intermetatarsal angle: different values and interpretation of postoperative results dependent on the technique of measurement. Foot Ankle Int. 1998;19(8):532-536.
46.
SpencerMRMiniñoAMWarnerM. Drug overdose deaths in the United States, 2001-2021. NCHS Data Brief. 2022;457:1-8.
47.
ToepferA. Sequential testing of passive and active stability of the first tarso-metatarsal joint can assist in differentiating hypermobility in the preoperative assessment of hallux valgus deformity. Fuß Sprunggelenk. 2025;23(3):200-202.
48.
ToepferAHäniSPotocnikP. Economic differences in traditional-open versus minimally-invasive hallux valgus surgery. Paper presented at: 6th International Congress of Foot & Ankle Minimally Invasive Surgery, October 5-7, 2023; Rio de Janeiro, Brazil, 2023:39.
49.
ToepferAPotocnikP. The learning curve in hallux valgus surgery. Foot Ankle Clin. 2025;30(2):251-267. doi:10.1016/j.fcl.2024.06.006
50.
ToepferASträssleM. 3rd generation MICA with the “K-wires-first technique” - a step-by-step instruction and preliminary results. BMC Musculoskelet Disord. 2022;23(1):66. doi:10.1186/s12891-021-04972-5
51.
ToepferASträssleM. The percutaneous learning curve of 3rd generation minimally-invasive chevron and akin osteotomy (MICA). Foot Ankle Surg. 2022;28(8):1389-1398. doi:10.1016/j.fas.2022.07.006
52.
VernoisJRedfernDJ. Percutaneous surgery for severe hallux valgus. Foot Ankle Clin. 2016;21(3):479-493. doi:10.1016/j.fcl.2016.04.002
53.
WhiteAEHenryJKDziadoszD. The effect of nonsteroidal anti-inflammatory drugs and selective COX-2 inhibitors on bone healing. HSS J. 2021;7(2):231-234. doi:10.1177/1556331621998634
54.
WustMDesaiNJoshiGP, et al. Pain management after hallux valgus repair surgery: an updated systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Eur J Anaesthesiol. 2025;43(1):11-18. doi:10.1097/EJA.0000000000002302
55.
YousafASaleemJAl-HilfiLKunasingamK. Third-generation minimally invasive chevron Akin osteotomy for hallux valgus: three-year outcomes. Indian J Orthop. 2023;57(7):1105-1111. doi:10.1007/s43465-023-00917-3
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