Soft tissue surgery guide for patients

In the foot and ankle many types of soft tissue lesions can occur. It is important to remember that it is very rare for these lesions to be or become malignant. The most commonly presenting lesions are listed below.

Ganglion

These are a relatively common and look and feel like a smooth, soft lump under the skin. They are made up of a thick jelly-like fluid, called synovial fluid, and they are often on the top of the tarsal joints, which is known as the midfoot. They vary considerably in size and arise from a weakness of the joint capsule or tendon sheath. This weakness causes the fluid to balloon out. Draining the ganglion reduces its size, but once the capsule repairs it often begins to fill with fluid again. Surgery involves removing the ganglion, identifying and repairing the underlining weakness of the joint capsule or tendon sheath, where possible.

Bursa

A bursa is a superficial fluid filled sac. There are two types of bursas: anatomical and adventitious. Anatomical bursas are meant to be there and are often between tendons and joints. Adventitious bursas form when an area of skin is exposed to excessive friction or a joint becomes prominent and rubs on your footwear, which is the case with bunion deformities. Adventitious bursas are the ones that often cause problems in the foot and ankle. The treatment for a bursa is the same as for a ganglion but in addition, any deformity or prominence that is causing the bursa may need to be reduced.

Plantar fibroma

A plantar fibroma is a fibrous nodule in the arch of the foot. It is embedded within the plantar fascia, a band of tissue that extends from the heel to the toes on the bottom of the foot. A plantar fibroma can develop in one or both feet and may be singular or multiple. It is a benign (non-malignant) condition with a very low incidence of malignancy. Over time, the fibroma may increase in size but may never produce any problems. Problems experienced include pressure from footwear and discomfort within the lesion itself, which is less common. Definitive causes for this condition have not been clearly identified.

Plantar fibroma surgery involves excision of the fibroma and part of the normal plantar fascia. The reason for this is that if any of the abnormal fibroma cells remain, there is an increased chance of recurrence. The plantar fascia is an important structure in the foot and acts as a beam, preventing collapse of the arch.

Following removal of the fibroma you may notice a reduction in the height of the arch, as well as some discomfort on the outside of the foot. Following this surgery, it can take time to settle and it is not uncommon for patients to have some residual discomfort three to six months following the surgery.

Following this procedure, you may be placed in a non-weight bearing below knee cast or a heel walker for three weeks.

Future treatment may require a shoe insole to help support the arch/foot.

Inclusion cyst

These are caused by a foreign body, such a splinter, getting under the skin and causing a reaction. They can become very hard and sore and often have to be removed.

Digital myxoid cyst

A digital myxoid cyst, sometimes called a mucous cyst, is an entirely benign swelling that occurs on the fingers or toes. They are skin-coloured, reddish or slightly translucent. The cyst is often connected to the lining of the joint and is usually found between the joint and the nail.

Treatment of a myxoid cyst means removal of the associated joint- an arthroplasty. A specific information sheet will be provided to you around digital arthroplasties.

About day case surgery under local anaesthetic

Surgery is carried out under local anaesthetic as a day case. This means that you are awake during the operation, but a screen will prevent you from seeing what is going on.

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

Depending on the site and size of the lesion the operation may take up to 40 minutes, but you should be ready to be at the hospital for some time before the surgery and afterwards to allow for preparation and recovery.

The tissue that has been removed may be sent for analysis. This is done to confirm the diagnosis.

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

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

Recovery after your operation

Surgery for each of the conditions and their locations varies the recovery. Specific detail will be provided to you by the podiatric surgeon.

Ganglions/cysts/bursa

The first two to three days

• You must rest with your foot elevated to hip level.
• You should restrict your walking to bathroom visits only. If you have been given crutches, you must use them in the way shown. You may be able to bear a little weight on the foot.
• You should take the prescribed painkillers. 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 over 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

• One to two weeks after the operation, you must visit for the dressing to be removed.
• 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 may be swollen. If you do not have any you will need to buy some before the surgery.
• At this stage, you can gradually and gently increase your activities. You will still need to rest between activities.
• Once the stitches have been removed, you can begin driving and return to work unless you have been advised otherwise. Please check with your insurance company if you wish to start driving again.

*If the operation involves an incision in the sole of the foot, the stitches will be removed three weeks after surgery and you will need to use the post-operative shoe until then.

Between two and six weeks after surgery

• You can normally start bathing the foot once again 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.
• Sixty 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.
• Although normal everyday activities will be possible, sporting activities are still restricted.

Between four to six weeks after surgery

The foot should now be comfortable and returning to normal, but there may still be some slight swelling.

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.

Please be aware this is general recovery advice and specific details around your personnel recovery will be discussed at the consultation.

Frequent or serious occurring risks

All operations carry a small risk of complications. In foot surgery, complications are uncommon and most resolve without permanent disability or pain.

General and specific complications of this procedure include:

• infection (two in 100)
• delayed healing of the skin (eight in 100)
• non-compliance of patients (four in 100)
• prolonged swelling post operatively (four in 100)
• thick or sensitive scar formation (four in 100)
• blood clot deep vein thrombosis (DVT)
• recurrence of ganglion, bursa, cyst or fibroma.

Complications following foot surgery are rare, but can happen. It is important to remember that if a complication arises you will 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 only for cosmetic gains.