Hallux Valgus – Criteria Led Commissioning Statement

Scope

This commissioning statement refers to:

  • A bunion which is a deformity of the joint connecting the big toe to the foot and is known as Hallux Valgus. It is characterized by medial deviation of the first metatarsal bone and lateral deviation of the Hallux (Big Toe)

This commissioning statement does not refer to:

Status

Eligibility Criteria

  • Have been seen, assessed and treated within podiatry services
  • All appropriate conservative measures have been tried over a 6-month period and failed to relieve symptoms, including: up to 12 weeks of evidence based non-surgical treatments, i.e. Analgesics/ painkillers. bunion pads, footwear modifications
  • The patient suffers from severe pain on walking (not relieved by chronic standard analgesia) that causes significant functional impairment interfering with Actively of Daily Living (ADLs) i.e. ability to: work, attend education, ability to manage simple domestic duties, ability to manage as a carer
    • OR:
  • Severe deformity (with or without lesser toe deformity) that causes significant functional impairment OR prevents them from finding adequate footwear
  • Recurrent or chronic ulceration or infection
  • Understands post-operative pathway including:
    • 6-week post-operative period with plaster cast and may involve absence from work for sedentary work of 2-6 weeks and a possible 2-3 months for physical work
    • 6-8 weeks' post-operative period without driving (2 weeks if left side and driving automatic car)
    • Full function will be limited for approximately 4 months
    • Treatment prognosis is highly variable
    • There is a higher risk of ulceration or other complications, for example, neuropathy, for patients with diabetes. Such patients should be referred for an early assessment. A patient should not be referred for surgery for prophylactic or cosmetic reasons for asymptomatic bunions

Lifestyle Factors - Best Practice

Obesity

  • Patients with a BMI >30 should be encouraged by their Clinician to lose weight prior to surgery and signposted to appropriate support to address lifestyle factors that would improve their fitness for surgery and recovery afterwards.
  • There is a clinical balance between risk of surgical complications with obesity and the risk to delaying any surgery.
  • See Weight Management Care Pathways

Smoking

  • In line with 'Healthy Lives, Healthy People; a tobacco control plan for England', local authorities and health professionals are committed to encourage more smokers to quit.
  • Smoking remains the leading cause of preventable morbidity and premature death in England.
  • There is sufficient evidence to suggest that people who smoke have a considerably increased risk of intra- and post-operative complications such as chest infections, lung disorders, wound complications and impaired healing.
  • See Smoking Cessation Care Pathways
Please Note: The life style factors above are not a restriction to the commissioning statements unless otherwise stated

Evidence/Rationale

NICE Clinical Knowledge Summaries (CKS) makes clear that referral for bunion surgery is indicated for pain and is not routinely performed for cosmetic purposes1. Conservative treatment may be more appropriate than surgery for some older people, or people with severe neuropathy or other comorbidities affecting their ability to undergo surgery.

Referral for orthopaedic or podiatric surgery consultation may be of benefit if the deformity is painful and worsening; the second toe is involved; the person has difficulty obtaining suitable shoes; or there is significant disruption to lifestyle or activities.

If the person is referred for consideration of surgery, advise that surgery is usually done as a day case. Bunion surgery may help relieve pain and improve the alignment of the toe in most people (85%–90%); but there is no guarantee that the foot will be perfectly straight or pain-free after surgery.

Complications after bunion surgery may include infection, joint stiffness, transfer pain (pain under the ball of the foot), hallux varus (overcorrection), bunion recurrence, damage to the nerves, and continued long-term pain.

There is very little good evidence with which to assess the effectiveness of either conservative or operative treatments or the potential benefit of one over the other.

Untreated HV in patients with diabetes (and other causes of peripheral neuropathy) may lead to ulceration, deep infection and even amputation.

References

  1. NICE Clinical Knowledge Summaries http://cks.nice.org.uk/bunions
  2. Royal College of Surgeons Painful deformed great toe (2013) – under revision
  3. Abhishek A; Roddy E; Zhang W; Doherty M. Are hallux valgus and big toe pain associated with impaired quality of life? A cross-sectional study. Osteoarthritis Cartilage 2010 Jul;18(7):923-6
  4. Nix S; Smith M; Vicenzino B. Prevalence of hallux valgus in the general population: a systematic review and meta-analysis. J Foot Ankle Res 2010;3:21
  5. NICE. Surgical correction of hallux valgus using minimal access techniques. 332. London:
  6. National Institute for Health and Clinical Excellence; 2010 6. Ferrari J; Higgins JP; Prior TD. Interventions for treating hallux valgus (abductovalgus) and bunions.Cochrane Database Syst Rev 2004;(1):CD000964 7. Saro C; Jensen I; Lindgren U; Fellander-Tsai L.
  7. Quality-of-life outcome after hallux Valgus surgery. Qual Life Res 2007 Jun;16(5):731-8NICE Clinical Knowledge Summaries http://cks.nice.org.uk/bunions

Assurance & Governance

  • This policy was developed on: 05.2017
  • This policy was approved by: Clinical Strategy Group (NK) and Clinical Cabinet (WK)
  • Date approved: 05.2017
  • Publication Date: 05.2017
  • Review Date: 04.2018
  • Ref No: PA9 - 05.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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