What should prospective patients know and what is different about this type of surgery?
“Conventional” orthopaedic management holds that it is necessary to divide and realign bones surgically and to fuse joints to correct the common age-related deformities of the foot.
I feel that this is irrational, since bone cannot produce deformity in an adult – only the soft tissues can produce deformities. It is a sad loss where perfectly normal bones are cut and angled, normal joints are excised and toes are fused.
Although surgery to bone produces what might look like a nearly normally shaped foot, that foot does not necessarily function better.
Incapacity. Surgical interference with the bones usually necessitates plaster of Paris casts, plates, screws and pins. Incapacity might last eight or more weeks, and full recovery take up to one year. Even if the cast or splint is removed earlier driving is not advisable for six weeks [August 2008 issue of The Journal of Bone and Joint Surgery,]
Perhaps worse is that the underlying problems are not solved and surgery to bone merely disguises the factors which are producing the pain and misalignment. Because of this relapse or progression is not unexpected.
The techniques which I use are based on the principles of conventional orthopaedics: However basic principles are applied in what I believe to be a more constructive (and less destructive) fashion.
These concepts began when I was an Anatomy Fellow at a Canadian university, and have evolved with subsequent research. Over the ensuing quarter century I have infrequently needed to perform surgery on bone, and functional improvement of even the most grotesque of deformities (by micro-surgical, minimally invasive corrections of deforming soft tissue) has been possible.
In the majority of patients this surgery is painless.
If you have been selected for this form of surgery, you should note the following: Feet which have reached the stage of requiring surgical intervention are no longer normal. The joints and their surface cartilage have frequently been damaged: Capsules, sinews and other structures have stretched, degenerated, migrated, or in other ways been disturbed. Surgery does not give the patient a “new” foot. What it aims to do is to make walking easier and reduce pain. An equally important aim is to stop further deformity.
1. Cinderella’s sisters’ syndrome: It is unrealistic to expect a surgical procedure to rejuvenate feet to their youthful condition, and anyone who so expects will be disappointed. Individuals who have been damaging their feet with inappropriate footwear should not expect surgery to make their feet immune to further damage by insisting on wearing particular types of fashion footwear.
3. “Secondary changes“. A common abnormality which results from long endured clawing deformity is a dislocation of the joints at the base of the toes (metatarso-phalangeal joints), usually the second toe. The appropriate sequence is to perform the soft-tissue release initially, in the expectation that the dislocation will slowly correct itself over the following nine months. Occasionally it does not correct itself and a second procedure (of minor dimension) may be necessary.
4. The lower limbs will age and deteriorate as do all parts of the body. This procedure will stop the age related degeneration of the forefoot but will not prevent all future degenerative changes, in all parts of the lower limb.
5. I usually suggest that surgery, under local anaesthesia is done on one
foot at a time.
Rarely difficulties can be encountered with local anaesthesia, and a light general anaesthetic might be substituted. The patient should therefore starve from the previous mid-night. Water and any necessary medications, should be taken in the morning before surgery. Do not substitute other beverages for water.
6. Most people should remain in bed in hospital until late afternoon. The reason is that standing too soon may cause bleeding, which can influence the healing process.
7. It is usually fairly easy to walk on the foot on the afternoon of surgery. Once home the patient should ideally remain in bed with the foot elevated until the following morning. Obviously it will be necessary to walk to the bathroom after returning home. It is very unusual to have post-operative pain. This procedure is as near as it is possible to get to pain-free surgery.
8. From midday on the first post-operative day walking should be attempted, beginning on the heel and the outer border of the foot.
9. The dressings should not be wetted or changed. That increases the chance of infection. If there are difficulties with the dressing, please telephone me.
If the dressing becomes stained with blood, which may form a hard pad, it should still not be removed. Blood is a good sealant, a good antibacterial and this hard pad will form a good splint.
Do not try to bathe or shower with the foot in a plastic bag. Leaks are inevitable, and the combination of plastic with soap and water is dangerously slippery.
10. Sutures are usually removed on the 6th post-operative day, after which, within a day or two, the normal footwear will probably be worn.
11. Following this kind of surgery, the toes, now straighter, might not curl down as well as they did previously. Although progressive improvement for about 6 months after surgery is expected, if the curling does not return, this is seldom regarded as a problem and must be considered an acceptable “trade-off” for the benefits of the surgery.
12. Occasionally one of the toes become slightly numb after this procedure. The reason is that by straightening the toes, nerves which have been shortened in the past, (when the toes were curled or crunched up), become stretched. This loss of sensation usually recovers and is seldom considered important.
13. Since it is impossible to exactly judge the “balance” of the many tendons in the foot, which inter-relate to one another in a complex harmony of movement, a small proportion of individuals might require further, minor surgery subsequently. This is usually done as an office procedure.
14. Some individuals require a larger size of shoe after surgery. Trying to use too small shoes is by far the most common cause of problems following surgery. Not only must the shoe be long enough, but wide enough, and the toe box must be high enough. Wait about three months before buying new shoes.
15. It is function and painlessness which are important. Although the cosmetic appearance of the feet is usually improved in these surgical procedures, no attempt is made to reinstate the “cosmetic normality” of the feet. Therefore, if the feet function well, and progressive deformity is arrested, the surgical procedure will be considered successful, irrespective of the appearance of the feet.
16. Smoking. Even one cigarette can delay or prevent appropriate healing.
17. Aspirin should be stopped two days before surgery. Please discuss other coagulants (eg Warfarin)