Decompressive osteotomy: A guide for patients

A decompressive osteotomy is a joint reconstructive procedure used in the management of osteoarthritis. This procedure can be used when the first metatarsal is longer than the second and the osteoarthritis is not too severe. When the first metatarsal is longer than the second this may produce “overloading” of the articular cartilage, which can lead to damage. The articular cartilage is the shiny material on the end of bones; the cartilage allows the joint to freely move. In hallux limitus, the articular cartilage becomes damaged which causes the pain and stiffness.

The aim of this procedure is to slow the progression of the arthritis, reduce the pain, increase the motion of the joint and re-establish the normal length of the metatarsals relative to one another.

The decompressive osteotomy acts as a bridging procedure. This means that it will help in reducing the symptoms associated with the condition and extends the life of the joint. However, arthritis may still continue to progress and further surgery may be necessary in the future. If this is the case, joint destructive procedures may be needed, for example a joint fusion or implant.

The procedure involves making an incision along the inside part of the foot over the joint. Any bony prominence on the top of the first metatarsal and the base of the big toe is removed. The head of the metatarsal is then cut and a block of bone is removed to decompress the joint. The size of the block of bone will be determined from your X-ray. Once the final position has been obtained, the osteotomy is fixed with a screw. An additional procedure at the big toe may also be required – Kessel-Bonney procedure. If this is the case, a leaflet about this procedure will be provided.

Specific complications of this procedure include:

• stiffness in the joint (4.94 per cent)
• fixation problems (screws/pins) (1.23 per cent)
• transfer of weight to other joints of the ball of the foot (2.06 per cent)
• non-union of bone (0.41 per cent)
• pain around surgery site (5.76 per cent)
• recurrence of symptoms.

About day case surgery under local anaesthetic

Surgery is carried out under local anaesthetic as a day case procedure, and takes about 30 to 40 minutes to complete. Local anaesthetic means that you are awake during the operation but a screen will prevent you from seeing the operation.

To numb your foot, you will either be given some injections around your ankle or behind the back of the knee. You can eat and drink on the day of surgery; there is no need for fasting.

The operation may take up to 40 minutes but you should be prepared to be at the hospital for some time before the surgery and afterwards to allow for preparation and recovery.

If you decide on surgical management you will be invited back to attend a pre-surgical clinic. A member of the nursing team will take a medical history. If you are on any medication please bring a list with you. This is a good opportunity to ask questions and discuss any concerns you may have about the procedure.

You must have a competent adult at home for the first day and night after surgery.

Recovery after your operation

The first two to three days

• You must rest with your foot elevated.
• You should restrict walking to bathroom visits only. You may be able to bear a little weight on the foot.
• You should take the pain killers that have been prescribed. If you experience pain it is usually worse for the first two days.
• If you are still experiencing pain after three to four days that is not relieved by the painkillers, you should contact the department directly.
• If you have any concerns regarding your foot you should contact the department directly.
• The department is closed at the weekend. Out-of-hours you should contact your GP or go to your local accident and emergency (A&E) department.

Two weeks after surgery

• Two weeks after the operation you must attend for removal of the dressing.
• The skin should be healing well by this time and any non-dissolvable stitches will be removed.
• You should no longer need a bandage and will be able to wear a normal shoe again. This shoe does need to be roomy, ideally a trainer, because your foot will be quite swollen. If you do not have any you will need to buy some before surgery.
• At this stage you can gently increase your activities. You will still need to rest between your activities.
• You will also be given a rigorous regime of exercises to regain strength and flexibility of the big toe joint.

Between two and eight weeks after surgery

• You can normally start bathing the foot one to two days following stitch removal.
• During this time the foot gradually returns to normal and you may be able to vary your footwear a little.
• 60 per cent of patients have returned to roomy shoes at six weeks, and 90 per cent in eight weeks.
• There will still be noticeable swelling, especially towards the end of the day. This is quite normal at this stage.
• You may also return to work after six weeks, depending on the type of work and footwear in which you are allowed to return. For certain jobs this could be an unrealistic expectation.
• At six weeks you can generally return to driving. However, you must feel able to perform an emergency stop. Please check with your insurance company about when your policy covers you to drive.
• Although normal everyday activities will be possible, sporting activities are still restricted at this stage.

Between eight and 12 weeks after surgery

• The foot should now be comfortable and returning to normal but there may still be some slight swelling.
• You can return to high-impact sporting activities around 12 weeks after the operation.

Six months after surgery

• The residual swelling should now be very slight, although the healing process continues for a year. You should be getting full benefit from the surgery.

Twelve months after the surgery

• All healing is now complete.

Complications following foot surgery are rare but can occur. It is important to remember that if a complication arises, you will be need to visit the hospital more frequently and there could be a significant impact on your recovery and return to work time. Foot surgery should be avoided if it is for cosmetic gain only.