Podiatric Surgery

Your pre-operative information

This information is intended as a guide only and needs to be considered with the information concerning your particular operation.

Please take time to read this information before your foot operation. You might want to discuss it with a relative or carer.

If you feel you need more information about your foot condition or any proposed treatment please ask us.

Common questions about podiatric surgery and foot surgery

1. Who is responsible for my care?

Your treatment and/or surgery will be carried out by and supervised by a podiatric surgeon who is a Fellow of the Faculty of Surgery, College of Podiatrists. Podiatric surgeons are not registered medical practitioners but are non-medical specialists in the surgical and non-surgical management of foot problems.

The team

The Podiatric Surgery Team consists of several different professionals, all dedicated to your care. The role of each professional is explained below.

Podiatrist

A podiatrist has studied for three years to obtain a degree in podiatric medicine. They are independent clinicians, qualified to diagnose and treat foot problems. Podiatrists may specialise in particular areas, for example caring for diabetic patients or sports medicine. With the exception of nail surgery, podiatrists treat foot problems with non-invasive methods.

Trainee in podiatric surgery

A podiatrist who has studied for a further two or three years and is undertaking a formal surgical training programme under the supervision of a consultant.

Specialist registrar in podiatric surgery

A podiatric surgeon who is qualified in the practice of podiatric surgery and is working to complete their three-year post specialist training as part of a continued programme.

Podiatric surgeon

A podiatric surgeon is a non-medically qualified specialist in the diagnosis and treatment of foot problems by both surgical and non-surgical methods. A podiatric surgeon has completed the training process and may have their own caseload.

Consultant podiatric surgeon

After some years of practice within a podiatric surgery department, a podiatric surgeon may be appointed as a consultant. They may be the lead clinician appointed by an NHS trust providing a podiatric surgery service.

2. Do you employ trainees?

Yes. Many departments are registered podiatric surgery training centres. All training centres must be approved by the Faculty of Surgery, College of Podiatrists. Training clinicians is essential for the future care of patients.

3. Will I need an anaesthetic?

Foot surgery is performed under a local anaesthetic. This is by injection into the toe, foot, ankle, or near the knee, depending on the area which needs to be made numb. This means you will be awake during your operation, though your foot will be numb and the operation will be screened so you cannot see what’s happening. You will be able to listen to music or watch television using headphones, or read during your operation.

4. Can I eat and drink before my operation?

As your surgery is going to be undertaken using a local anaesthetic, you are able to eat and drink as normal.

5. What shoes can I wear after my operation?

We provide most patients with a special post-operative shoe after surgery which will accommodate the bandages. You will not be able to wear normal shoes or trainers.

6. 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 before if a cast or crutches are needed following your operation. You will be shown how to safely use crutches if these are necessary. You will also receive ongoing advice and support regarding your mobility needs.

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

• Check your appointment letter to make sure you know what time to arrive and where to go.
• If possible, cut your toenails and clean under the nails well the day before surgery.
• Remove all nail polish.
• Remove jewellery except for a wedding ring, if you wear one.
• Wear loose clothing as a large dressing will be applied after the operation.
• You may bring an iPod with headphones and a book if you wish. You will not be able to take a recording device into theatre such as a mobile phone.
• Please make sure you arrange transport to and from the hospital or day-surgery unit.
• A fit and responsible adult must stay with you for at least one night after your operation.
• You should rest for the recommended period after your operation, as advised by your podiatric surgeon.
• If you need to take your regular pre-prescribed medication during your time in the department, or if you may need to use an inhaler, angina spray or EpiPen, please remember to bring these with you.
• If your podiatric surgeon has asked you to arrange any tablets or medicines please remember to get these before your operation. If you have been asked to get these from your own doctor please arrange this well in advance.
• Take any prescribed medicines as normal, unless you have been told differently.
• Read any additional information you may be given regarding your admission for surgery.

8. What will happen on the day of my operation?

• You will be asked to come to the hospital or day-surgery unit.
• When you arrive you will be welcomed by one of the team who will escort you to the admission area, where you will be asked to change into a theatre gown.
• Your medical history will be assessed for any changes and some routine observations such as blood pressure will be undertaken.
• Your consent form will be checked and signed by the podiatric surgeon. The foot to be operated on will be marked with a pen. If you have any questions these can be answered at this time.
• If you are going to be provided with crutches after your surgery, you will be shown how to use these either before or after your operation.
• A local anaesthetic will be given before you are taken into theatre.
• Your local anaesthetic will be checked for effectiveness by one of the team before you are taken into theatre.
• When the team is ready, you will be taken into the operating theatre for your surgery.
• Your foot will be cleaned with surgical scrub and sterile sheets will be placed around the area.
• Your local anaesthetic will be re-checked to make sure the area of foot is still numb.
• A tourniquet (like a blood pressure cuff) may be used around your ankle during your operation. This may be uncomfortable for a short while, but most people find it acceptable after about five minutes.
• After your operation your foot will be bandaged up carefully and you will be transferred to a ward or recovery area.

9. What will happen after I have my operation?

• You will be transferred from theatre back to the ward.
• One of the team will make sure that you are comfortable and check your blood pressure, general wellbeing and dressing.
• It is usual for you to be monitored for one hour after your operation. You will be offered a drink and something to eat.
• A special post-operative shoe or boot will be applied to the foot. Sometimes a cast is needed.
• You will go home in the post-operative shoe if provided and you must wear this until told otherwise.
• If you have been placed in a non-weight bearing cast you must follow the instructions given to you.
• One of the team will check you are pain-free, read through and explain your post-operative instructions, including any contact numbers to use in case of a problem. They will discuss your painkillers and how to take them.
• You will be discharged and allowed home with your responsible adult.

10. Can I go home on the same day?

Foot surgery can be done as day surgery, which means that you are able to go home on the same day. A fit and responsible adult must stay with you for at least one night after your operation.

11. What happens if I have a problem after my operation?

You will be provided with an advice sheet to take home after your operation detailing your post-operative instructions and useful information including contact numbers to use in case of a problem.

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

You will need to rest after surgery. The amount of time required varies according to the type of operation and your own circumstances. Please refer to the specific operation information provided by your podiatric surgeon or ask one of the clinical staff.

13. Will I have to come back to hospital or a clinic after my surgery?

You will have to come back to have your dressing changed and your stitches removed. The number of re- dressing appointments is often dependent on the type of surgery.

The number of follow up appointments will be outlined at the consultation and consenting appointment.

It is important to note that if a post-operative complication occurs you will need to be seen more frequently. A complication can impact on your return to work date.

Things to consider before having a foot operation

The intention of any podiatric treatment or surgery is to reduce your foot pain or deformity; however, it is an unfortunate fact that all treatments and operations carry risks. This information is not intended to worry you, but is provided to make sure that you are fully informed about the problems that can occur after surgery.

Patients rarely have problems following podiatric surgery and most are pleased with the result. Surgery should not be carried out for cosmetic reasons or when there are no restrictions on personal activities, daily living or quality of life. If a complication does occur, you could find yourself worse off than you were prior to the surgery.

When considering whether or not to have an operation, you need to carefully compare your level of pain or discomfort and its impact on your quality of life, against the likely risks as well as intended benefits from any proposed surgery.

The risks and benefits of your proposed surgery will be fully discussed with you. We hope that all of your pre- surgery questions will have been answered, however if you have additional questions please do not hesitate to ask a member of the team.

Changing your mind

Following diagnosis, a treatment plan will be discussed and agreed by you and your podiatric surgeon. If you feel that the suggested plan does not fully meet your needs, values or wishes, you do not have to agree to treatment. You can withdraw your consent at any time before the surgery. Other options for treatment are generally available and it is important that the plan suggested suits you.

Second opinion

We are very happy to arrange for you to have a second opinion regarding your diagnosis or proposed treatment at any stage. Please tell one of the team if you feel you would like a second opinion. Seeking a second opinion does not mean we will refuse to treat you if you decide you wish to continue to receive care from us.

Risks and benefits

This section details further information that may be helpful when making your decision about surgery. It is organised in alphabetical order. Where we discuss risk with you we will use the following terms:

Activity

You will be required to rest after your operation. How much rest and how much activity you are allowed to do will be discussed with you before and after your surgery.

Alcohol consumption

You are advised to avoid alcohol after your foot surgery and while on medication. After surgery you are more likely to fall and alcohol may interact with one or more of your medicines, increasing this risk.

Altered walking pattern

Foot surgery may affect the way you walk. Following surgery, patients naturally favour the other foot. This is usually temporary, until the foot settles and you become accustomed to walking normally again. Sometimes we provide a foot splint to help with symptoms.

Avascular necrosis

This is very rare. It occurs when 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.

Being awake during the operation

Electing to have your operation under local anaesthetic, means you will be awake during your operation. You will not be able to see anything during the operation and you will not feel any pain. Your foot and leg will be tested before you enter theatre to make sure you are pain free. We check this again once you are in theatre. In the rare event you feel any discomfort, tell the nurse and we will deal with it immediately to make sure you are comfortable. This is very rare and most patients are able to chat to one of the nursing team or listen to their music or watch television while the operation is being performed.

Bleeding

There will be some bleeding after surgery but the majority of this is controlled during the operation. Uncommonly, a small collection of blood in the deeper tissues (haematoma) may form. This occurs less than one per cent of the time and can be managed by draining the blood. It generally settles without problems.

Chronic regional pain syndrome (reflex sympathetic dystrophy - RSD)

This is a rare condition, which can even occur after minor injury and is not always associated with surgery. Symptoms include persistent chronic pain, swelling, skin colour changes and changes to bones of the affected limb. Treatment requires early diagnosis and referral to a pain specialist. Complete recovery from the condition may not always be possible. This is not a predictable event but is fortunately uncommon and occurs in approximately three in 4,000 people (rare).

Crutches

Some operations will require you to use crutches afterwards. You will be made aware of this before your surgery and you will be shown how to use them safely. If you think you will have difficulty using crutches please let one of the team know, so that alternative walking aids can be arranged.

Death

This is extremely rare and most unlikely to happen, but as with all surgical procedures it remains a remote possibility. The Podiatric Surgery Team is trained and the department is equipped to deal with clinical emergencies.

Delayed healing

Although you will be given an estimate as to how long the recovery process will take sometimes delays in healing of the soft tissue or bone can occur. Generally, the soft tissue will heal although bone sometimes does not heal properly (see non-union). It is important to remember that the information you have been given is a guide and you should allow for this when planning your recovery.

Smoking can increase your risk of delayed wound healing so if you are able to stop or reduce the number of cigarettes you smoke each day, your chances of delayed wound healing will reduce.

Deterioration of symptoms

The vast majority of patients having foot surgery have less discomfort following their operation. Occasionally however, some patients have no improvement of symptoms and more rarely, some patients have more discomfort. It is for this reason that foot surgery for cosmetic reasons is not recommended.

Driving

The time that you are not allowed to drive following your foot surgery varies between procedures. We will advise you of the timescale. Do not drive after foot surgery, until confidently back in normal footwear, otherwise you may damage the operation site. It may also invalidate your insurance and be an offence under the Road Traffic Act.

Failure of the operation

On average the majority of patients are pleased with result of their surgery. The success of any procedure depends on the type and complexity of the operation and health of the patient. Despite the very best efforts of the team we cannot guarantee outcomes. In some operations, for example bunion surgery, full correction may not be achieved although symptoms are usually improved. The risks of failed procedures will be fully discussed with you during the consent process, where you will have the opportunity to ask questions and discuss alternative options.

Fixation problems

If we have to use metalwork, such as pins, screws, plates or implants, these are normally left in place. In about one in 10 of patients we may have to remove these if they come loose or cause irritation to the surrounding tissues. If the metalwork is removed, it will not affect the long-term prognosis.

Infection

Infection rates are estimated at less than two per cent for all surgeries. If infection does develop it is generally superficial, usually treated with antibiotics and resolves very easily. However, although uncommon, infection can get deeper into the bone which is a much more serious complication. This may require a period of hospitalisation, possibly further surgery and a longer course of antibiotics. In rare instances, the infected bone may need removing which could affect your foot permanently. Any infection has the potential to be fatal, fortunately this is extremely rare.

Joint stiffness

Surgery near joints, for example bunion surgery can lead to some joint stiffness. Not moving the foot following surgery and healing of the deep tissues near to the joint may be the underlying cause. In most cases you will be provided with some gentle exercises to minimise this risk. If the exercises are not carried out as advised it may lead to a painful stiff joint.

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. It may affect patients from certain ethnic backgrounds or those with a history of poor scar formation. If you are at risk this will be discussed with you. There are some things we can try to minimise the risk but they are not always effective. These include:

• use of corticosteroid injections prior to surgery
• careful incision planning
• use of zinc creams after the operation.

Local anaesthetic

Local anaesthetics are medicines which when injected near nerves stop pain. Most of us have experienced a local anaesthetic at the dentist. Foot surgery is readily performed under local anaesthetic and involves injections placed either around the ankle or behind the knee. After the injection has had time to work, which can take several minutes, you will not be able to feel pain in that area. Local anaesthetics are extremely safe drugs, however as with any drug, there is a risk associated with their use (toxic effect is about 15 in 10,000).

Failure of the local anaesthetic

A small number of patients do require additional local anaesthetic during surgery. In rare circumstances some patients do not respond to local anaesthetic injections and we cannot proceed with surgery (less than one in 100). In these situations surgery may have to be postponed. While local anaesthetic drugs are considered very safe there are some potential side-effects such as:

• allergic reaction to the anaesthetic (less than one in 10,000)
• toxic reaction to the drug (less than one in 2,000 across all injections)
• irritation or damage to the nerves at the injections sites
• bruising around the injection site (one in 20).

Loss of sensation

It is possible for you to lose some sensation around the surgical site after surgery. Great 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 loss of sensation can sometimes recover with time but this is not always the case.

Loss of tissue, part of the foot or a 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 for healthy patients is less than one per cent.

Metatarsalgia

This refers to discomfort under the ball of the foot (metatarsal heads). Foot surgery may alter the pressure causing discomfort or making existing discomfort worse. This may need to be treated with shoe inserts and although rare, 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, for example bunion surgery risk is less than one in 100 and major joint fusion such as talo-navicular joint (big joint near ankle) risk is around one to two in 10.

Smoking has been shown to increase the risk of non-union by 2.7 times in comparison with a non-smoker If this situation occurs we may:

• allow more time for the bones to knit together or use treatments which can encourage bony healing
• re-operate on the bone or joint using a graft of bone from another part of your foot or body
• do nothing if there are no symptoms.

Numbers of operations performed

In most cases your consultant or podiatric surgeon will have performed a large number of the same operation. In some circumstances however, the consultant may have only performed a very small number of those operations. This might be because the operation is not something that is commonly performed or because combinations of different operations required to fix your foot may not be common.

Oral contraceptive medication

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

Out-of-hours arrangements

This may be provided via your GP out-of-hours service, hospital accident and emergency department, or via another arrangement. This information will be provided when you are discharged from hospital or day-surgery.

Pain

It is difficult to predict how much pain you will be in after the operation as this varies between patients.

Generally, the first night is the worst, but advances with local anaesthetics and pain medication means that this can be managed, if not avoided. Pain usually lasts for three to four days and is made worse by activity, so resting with your leg elevated is important.

If you are still experiencing pain which is not being relieved by rest or medication please contact us. You will be provided with instructions on what to do should you have any problems immediately after your surgery.

Pain medication

You may be advised to take medicines after your operation to help control post-operative pain.

Recurrence of the original problem

It is possible for a problem to recur after a number of operations. For example, a bunion which is correct and looks to be healing two weeks after surgery may deteriorate over time. Recurrence varies for individual operations.

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 help to reduce pain and swelling.

Scars

All surgery will create scars. Great care is taken to minimise the scar you will have by carefully placing the incision and taking great care during your operation. Some people will have a discomfort, nerve entrapment or thickening of the scar. This is uncommon, generally short-term and, if it does happen, often relates to post- operative infection or to a predisposition to problem scars (see keloids). The vast majority of patients have minimal cosmetic defect from their scars. If you have any concerns please speak with one of the team for further advice.

Secondary arthritis

Some operations, generally joint fusions, lead to an increased risk of arthritis developing in adjacent joints. This is termed secondary arthritis. Fusion operations are generally performed to deal with pain from arthritic joints or because of instability in the foot. This can place more stress on adjacent joints increasing the risk of secondary arthritis.

Shoes

Although every effort is made to give as good a result as possible, you may still have difficulty finding and wearing shoes and, in rare cases have less shoe choice after the operation. This can be a particular problem if the foot persistently swells or the scar is painful.

Smoking

Smoking has the following effects in relation to surgery:

• delays wound healing
• is associated with failure of bones to fuse (knit together). Smokers are 2.7 times more likely to have this problem compared with non-smokers
• is associated with increased risk of thrombosis.

Swelling

Swelling is always present after surgery as it is part of the normal healing process. Swelling may be minimised by following the post-operative instructions issued to you by the team. Some patients experience prolonged swelling of the foot after surgery (five to 10 in 100). Smaller operations usually have minimal swelling whereas larger operations may be associated with greater swelling for a longer duration. In a few cases, swelling may be present in the long-term but this is usually painless although it can affect shoe fit.

Thrombosis (DVT)

A thrombosis is a clot which most often forms in veins of the lower legs. Risk factors for thrombosis include:

• previous history of thrombosis
• individual health
• smoking
• certain drugs or medications, for example some types of oral contraceptives
• damage to vessels and tissue, for example from surgery
• immobilisation.

The post-surgery thrombosis risk has been calculated at five in 1,000. However, the more risk factors you possess the greater the chance of a clot forming. If it develops and is left untreated it can become fatal.

Your DVT risk will be assessed prior to your surgery. Depending on the level of risk you will be fitted with a compression stocking (when on the ward prior to the operation) and may require the administration of an anticoagulant type medication. This will all be discussed with you at your pre-assessment appointment. DVT often presents with a painful swollen calf as well as redness of the leg and prominent veins on the top of the foot. If you suspect you may have a DVT you need to attend your local accident and emergency department immediately.

You should reduce the risk factors you can by:

• stopping smoking at least four weeks before your operation and until you are fully recovered
• avoiding medicines which predispose to clots, for example oral contraceptives (in discussion with your GP who will advise you of alternative measures of contraception)
• following the exercise regime as recommended by your podiatric surgeon or the team.

Trainees

Many podiatric surgery services are approved clinical training centres for the Faculty of Surgery, College of Podiatrists. If you do not wish to have a trainee participate in your care please notify a member of staff. Making this request will not affect the treatment you receive in any way.

Finally, before an appointment, please make a note of any questions you would like to ask us.