Useful Pre-operative Information

Questions & Answers. Consulting Foot Pain - David Tollafield, Birmingham

This information has been adapted for my website and some details covering NHS training have been removed. Although more podiatric surgeons are offering surgery in hospitals, majority still practice in day care units often in the community. This is not an NHS hospital although we see some NHS patients here. The unabridged document is available from The College of Podiatry, London but a number of areas are not applicable as treatment is performed in a regulated independent hospital with a fully integrated team of healthcare professionals with 24/7 support.

Please use this information to assist your understanding of the care offered before your planned foot operation. If you need to discuss your care please contact the hospital, my secretary or the pre-anaesthetic/admissions nurse. It is your responsibility to ask, if you feel you need more information about your foot condition or any proposed treatment.

What is the purpose of this information

This information has been designed by a working party of podiatric surgeons.   It is intended to provide you with additional information about your proposed treatment and assist you in making an informed choice. Information specific to your own planned operation will be provided separately (as on my WebPages and clinical information provided at the time of your consultation).

Who is responsible for my care?

Your treatment / surgery will be undertaken by me as a podiatric surgeon. Podiatric surgeons non-medical specialists.
Titles: Consultant Podiatric Surgeon
I use the title podiatric surgeon to avoid confusion with podiatrists. Please see my biographic details under ‘About’.

Does the hospital employ trainees?

No training occurs at Spire Little Aston Hospital and if anyone attends to observe we will inform you and you have the right to decline such observation.

Do I have a choice with regard to my anaesthetic for foot surgery?

You should discuss your preferences with both Mr Tollafield and Dr Akinwale 

What will I wear on my foot after my operation?

We provide most patients with a special postoperative shoe after their foot surgery which will accommodate the bandages.

Will I be in a cast after surgery or have to use crutches?

This will depend on the type of operation you have had.  You will be told beforehand if crutches or a cast are required following your operation. You will be shown how to safely use crutches if these are necessary by our physiotherapists.

What do I need to do before I come in for my operation?

Our hospital will contact you with an admission pack once you decided to have surgery. This will inform you where to go, what time to arrive, what to bring and how to prepare yourself for surgery. You will be provided with advice regarding your regular medicines when attending for a pre-surgical check up with our nursing team.

What will happen on the day of my operation?

  • When you arrive you will be welcomed by one of the team who will escort you to the your room
  • The consent form will be counter signed, and you be able to ask any further questions.
  • The operation site will be marked and you will agree the location of your surgery
  • My physiotherapist will go through use of crutches before and after
  • Dr Akinwale or one of my other anaesthetists will talk to you about your anaesthetic and general health
  • The nurse will take you upstairs to one of our three operating theatres and you will meet the rest of the team
  • We will make you comfortable, ensure we help any anxiety away and I will place a local anaesthetic in your foot to make it numb. You should not feel this or remember the injection.
  • After your operation your foot will be bandaged you will be find yourself in recovery where the recovery team will keep you comfortable and pass you onto the nurse to take you back to the ward. We may apply some ice on your foot to assist swelling.

What will happen after I have my operation?

  • Once back in your room each of the team will see you again and make sure you are comfortable.
  • A special post-operative shoe will be applied to the foot
  • You can eat once you feel well enough or awake and provided with a drink which is welcome after a period of starvation
  • I will talk to you about the operation and answer any questions
  • X-rays are usually taken in theatre so you don’t have to go for this.
  • If you stay in overnight we will of course make your staff comfortable and provide for your hotel needs
  • You will be discharged home with an escort (who must be a responsible adult) and we expect you to have someone stay with you over night. You cannot of course drive and we like to convey you to a car by wheelchair for your safety

Can I go home the same day?

Most foot surgery can be done as a “day case operation” which means that are able to go home the same day. 

What happens if I have a problem after my operation?

You will be provided with postoperative instructions, and useful information including any contact numbers for the ward (Wyndley). We have a 24 hour service and a nurse will see you if you need to come back in. Our Resident Medical Officer (RMO) will examine you and contact me. In 99% of cases we can deal with the problem on the ward.

If you can come back during the day to outpatients it is sometimes easier in case we need arrange other services (Monday to Friday 8.00am – 19.30pm; Saturday 8.0 am– 12.00pm)

I will always try to see you at the earliest but be reassured we have staff trained and able to deal with most problems and if I am on annual leave I will inform you another colleague (orthopaedic surgeon) will be on standby. We try to cover all aspects by planning ahead.

Will I need to take time off work after my surgery?

You are advised to rest after surgery.  The amount of time required varies according to the type of operation and your own circumstances.  Please follow the advice provided by your podiatric surgeon. Fitness to work  forms will be issued from the ward for a limited period.To extend the note please see you own GP. We will send a discharge letter to your GP so he knows when you have left our care                                                                                                                                      

Will I have to come back to Spire Little Aston hospital after my surgery?

Follow-up after podiatric surgery will be clearly marked on your appointment card by our ward staff.  You you will be reviewed between 2-4 days initially by one of the nursing staff.

Things to consider before having a foot operation

When considering whether or not to have an operation, you need to carefully ensure you have booked no holidays close to the date of surgery and allow plenty of time for recovery.

If you have animals, especially a dog, try to make arrangements for a sensible period for their management. You will not be able to manage an animal until fully recovered

Be wary of holidays in hot climates. Sun can affect the foot and the surgery significantly even a month after you have healed.

You can fly to a holiday destination depending up the length of flights but discuss this in advance of surgery.

Activity

You will be required to rest after your operation. How much rest and how much activity you are allowed to undertake will be discussed with you before and after your surgery. Postoperative recovery times vary between patients.

Alcohol

You are advised to avoid alcohol after your foot surgery, whilst on medication. Alcohol may interact with one or more of your medicines in addition to increasing the risk of falls postoperatively

Altered Walking Pattern

Foot surgery may affect the way you walk. Following foot surgery, patients naturally favour the other foot. This is usually temporary, until the foot settles and you become accustomed to walking normally again. An insole is often recommended after some operation

Avascular Necrosis (AVN)

This is where part of the bone loses its blood supply. This may occur after an operation or even from simple trauma. The bone may ‘weaken’ and change shape. Usually the blood supply will return to the bone with time. Sometimes the bone is damaged resulting in problems such as secondary arthritis. This is rare.

Bleeding

There will be some bleeding postoperatively but the majority of this is controlled during the operation.  Infrequently, a small collection of blood in the deeper tissues may form.  Avoid direct pressure on the operation site by using your crutches or walking shoe.

Chronic Regional Pain Syndrome (CRPS)

This is a rare condition, which may occur even after any injury. The condition is uncommon and can occur after any type of operation. Persistent / chronic pain develops as well as swelling / colour changes and changes to bones of the affected limb. Treatment requires early diagnosis and referral to a pain specialist. Complete resolution of the condition may not always be possible. This is not a predictable event (see clinical information for further details).

Crutches

Are provided by us for your personal use. These are not recycled.

Risk of fatal consequence

Anaesthetics are very safe and we take all precautions during surgery. Please advise us if there is any change in your health.  Our hospital is equipped to deal with emergencies. Serious problems following surgery can arise from pulmonary thrombosis sometime after surgery and you will need to go to an hospital with an A&E department. Please call an ambulance if you have chest pain.

Delayed healing

Although you will be given an estimate as to how long the recovery process will take delays in healing can affect the soft tissue or bone. Poor eating, smoking, too much standing can all add to a delay.

Driving

Do not drive after foot surgery until recommended.  Start by trying the foot pedals on the driveway where it is safe. For your first journey do not travel too far and it is best to have a competent driver with you to take over. You cannot drive with casts and if you fail to follow advice you may invalidate your insurance or have an accident. Always check with you own insurance if you use an automatic but do not drive before any wound has thoroughly healed.

Failure of the operation

In some operations (e.g. bunion surgery) full correction may not be achieved although symptoms are usually improved.

Fixation problems

If we have to utilise metal work (pins / screws / plates / implants) these are normally left in place. In about 10% of patients we may have to remove these if they work loose or cause irritation to the surrounding tissues. Once the bone has healed the metalwork is not required.

Infection

We will screen you for some bugs e.g MRSA before operating. Tell us if you have had recent surgery, or if you are susceptible to infections following surgery. Please remember even recent dental treatment can place you at risk as bugs (bacteria) travel to damaged areas.Infection rates are estimated at less than 5%. If infection does develop it is generally superficial and can usually be treated with antibiotics.  Deeper infection is very rare although more serious.  Infected bone may need removing which could affect your foot permanently.  Any infection has the potential to be fatal and foot surgery is no exception.  Fortunately, this is rare.

Joint stiffness

Surgery near joints e.g. bunion surgery can lead to some joint stiffness. The immobilisation following surgery and healing of the deep tissues near to the joint may be the underlying cause. Gentle exercises will minimise the risk under the care of our skilled physiotherapists.

Keloids

Keloids are large unsightly scars which are raised up and may extend beyond the margins of the original wound. This is a rare type of scar. Patients will often have a history of poor scar formation / keloids. We know that certain ethnic backgrounds may predispose to this type of scar but white skin is no exception.  In patients who have a history of ‘keloids’ we need to weigh-up very carefully the real risk of ‘keloid’ developing after surgery. If a scar is raised it will usually settle within 24 months. Further surgery is rarely needed and will often seek a second opinion from one of our plastic surgeons if you are worried.

Loss of sensation

It is possible for you to lose some sensation around or away from the surgical site after surgery. Care is taken to avoid damage to nerves and it is rare for a major nerve to be damaged. If nerve damage does occur it is more often the tiny nerves to the skin which may leave an area of skin with reduced or altered sensation. This may recover after 9 months after which time it is usually permanent but should not trouble you.

Loss of tissue / part of foot / limb

This would be a very rare complication for the vast majority of patients having foot surgery.  However it is possible for injury to blood vessels and or serious infection to lead to loss of tissue which can involve some or all of the foot.  The risk of this for healthy patients would very low indeed.

Metatarsalgia

(discomfort under the ball of the foot often called transfer pressure)
Foot surgery may alter the pressure under the forefoot causing discomfort (or making existing discomfort worse). This may need to be treated with insoles and rarely by further surgery.

Non-Union

This term refers to the situation where bone fails to fuse (join) together as planned. The percentage risk varies greatly depending on the bone or joint in question e.g. hammer toe correction or after bunion surgery. If this situation occurs we may:

    • Allow more time for the bones to knit together
    • Place you in a cast
    • Re-operate on the bone using a graft of bone from your body
    • Do nothing if there are no symptoms as a result

Numbers of Operations Performed

As an experienced consultant in my field I only undertake surgery I have experience in. If I feel you need a different surgery that I do not carry out I will offer you an appointment with one of my local orthopaedic colleagues who I know specialises in feet as well. We want you to be confident at our hospital your care is of utmost importance.

Oral Contraceptive medication

Certain (oestrogen containing) oral contraceptive medications are associated with a slight increased risk of thrombosis (blood clots). You may wish to discuss the implications of this with me or your own GP.  Stopping oral contraceptives means you are at risk of pregnancy unless alternative contraceptive measures are taken.

Pain

It is difficult to predict how much pain you will suffer after the operation as this varies between patients. You may experience more discomfort in the first two days. My local anaesthetic block and pain medication will minimise this.

Pain Medication

You will be advised to take medicines after your operation to help control postoperative pain.  Remember some preparations may upset your stomach. Always try to step down to a low grade pain killer that you are used to and does not cause side effects.

Rest

You are strongly advised to rest after your surgery. Resting with your foot elevated and regular use of an ice pack over the ankle will greatly reduce pain and swelling.

Shoe difficulty

You may have difficulty with shoes after surgery due to swelling. Do not expect to return to all your shoes after the operation.

Smoking

Smoking has the following adverse effects in relation to surgery:

      • Delays wound healing
      • Is associated with failure of bones to fuse [‘knit together’]. Risk increase 2.7 times more compared with a non-smoker
      • Is associated with increased risk of thrombosis

Swelling

Swelling is always present after surgery as it is part of the normal healing process.  A swollen pain free foot usually offers no concern. Some patients experience prolonged swelling of the foot after surgery (15%) until 4 months.  Most swelling will have decreased by 12 months.

Thrombosis

A thrombosis is a clot which most often forms in veins of the lower legs e.g. ’Deep Vein Thrombosis’. Risk factors for thrombosis are:

      • Previous history of thrombosis
      • Family history (genetic)
      • Obesity
      • Smoking
      • Certain drugs (e.g. some types of oral contraceptives)
      • Prolonged rest periods without muscle activity

The post surgery thrombosis risk is 1% in my practise. If you are at risk we will treat you with a medicine to think your blood. We will provide you with T.E.D stockings on your non operated foot which you will need to wear until you are active again.

Preventing an uneventful recovery

The vast majority of patients who undergo foot surgery have few problems. We prevent most complications by

      • GP providing a summary of your medical history
      • Consultant informing you of what you must expect and can do
      • Planning surgery to meet your specific needs medically and socially
      • Pre-operative Sister trained in assessment prior to surgery
      • Organising tests from urine sample, blood, ECG (heart)
      • Asking for second opinions before elective surgery
      • Anaesthetist assessment
      • Admission assessment by nursing (double checks)
      • Anaesthetic staff checks
      • WHO or (world health organisation) international patient checking
      • Operative monitoring and standard care models

I hope by sharing this information that has been put together by colleagues and tailored to our hospital you will realise serious problems are few and that we take good care of our patients. It is hoped that this information has answered most of your questions about your proposed operation. Please discuss any concerns with me before you agree to surgery

October 2013

Thanks for reading: Useful Pre-operative Information. Consulting Foot Pain – David Tollafield, Birmingham