Guide to Foot and Ankle Surgery and Recovery

PART 1: BEFORE SURGERY

Use this three-part guide to help make your orthopaedic foot or ankle surgery and recovery go smoothly. You achieve the best results when you work with your surgeon to prepare for surgery and post-surgical recovery. Part 1 will focus on what to do before your surgery.

How do I prepare myself for surgery?

Make a list of questions and discuss them withe your surgical team at your pre-operative visit. You should understand what your surgery will entail as well as the expectations after surgery. Bring a complete list of your medical conditions and medications (including prescription, over-the-counter, and herbal/nutritional supplements) with the dosage for each one.

Will I need medical testing before surgery?

Your health conditions and your planned surgery may require that you undergo testing before surgery. Testing may include blood work, radiographs, EKGs and in some cases medical clearance by your primary care provider or specialists such as a cardiologist.

Do certain medications need to be stopped before and/or after surgery? If so, which ones?

Some medicines can be dangerous when taken just before or after surgery. Your surgeon will tell you which medicines must be stopped before or after surgery. Your surgeon may tell you to stop taking:

• Aspirin before surgery. This drug can increase bleeding during surgery.
• Non-steroidal anti-inflammatory drugs (NSAIDs) including ibuprofen (Advil and Motrin), naproxen (Aleve), Celebrex, and Mobic. These drugs can increase bleeding during surgery by decreasing one’s ability to clot blood. They may also slow down bone healing after surgery.
• Certain steroids as they may slow down wound and/or bone healing after surgery.
• Hormone replacement therapy and/or birth control pills after surgery. These may increase the risk of having blood clots after surgery.
• Metformin or diabetic medications related to metformin at least 24 hours before surgery. These medications can cause a reaction to anesthesia.
• Certain over-the-counter (OTC) supplements and/or herbal preparations (fish oil, St. John’s Wort, etc.) before surgery. Many of these agents can increase bleeding during surgery.

Does the use of nicotine affect surgery?

Nicotine and other chemicals are contained in cigarettes, electronic cigarettes, cigars, and chewing tobacco. Nicotine slows down the flow of blood to and from the surgical foot and ankle. This effect of nicotine can increase the risk of developing bone, soft tissue and wound healing problems and/or infections after surgery. Slowing down the blood flow in one’s leg may also increase the chance of getting a blood clot or deep vein thrombosis (DVT). To get the best results from orthopaedic foot and ankle surgery, you should stop using nicotine-containing products well before surgery. You should discuss quitting with your surgeon and/or primary doctor.

What devices do I need to get to use after surgery?

After orthopaedic foot or ankle surgery, you will not be allowed to put weight on your operated leg for a period of time. To avoid putting weight on your surgical foot or ankle, you will need to use an assistive device like crutches, a walker, a knee walker, or a wheelchair.

Other devices/equipment may be considered to help in performing daily activities in the home, including a bedside commode, shower chair/stool, or transfer board (especially if you are non-weightbearing on both legs). Many of these devices may be covered by your insurance company.

Is physical therapy (PT) needed before surgery?

To walk smoothly and safely with an assistive device, you may need to receive training from a physical therapist. The surgeon may schedule a PT session for you before surgery to get you familiar with assistive devices, fit the assistive device if needed, and improve balance, arm strength, and opposite leg strength.

When should I stop eating and drinking?

Typically, you will be instructed to not eat or drink after 11:59 pm on the night before your surgery. This means no coffee, chewing gum, or water in the morning. If your surgery is later in the day, you may be allowed to drink clear liquids until about 6-8 hours before your surgery.

Why is this important? You should have as little food, drink, or stomach acid in your stomach as possible at the time of anesthesia. After eating or drinking, it takes at least 6-8 hours for food and/or drink to leave the stomach and enter the intestines. If you do not eat or drink after 11:59 pm on the night before your surgery, your stomach should be empty by the time anesthesia is administered. This decreases the chances of nausea, vomiting, or an upset stomach with anesthesia or aspiration.

If you take certain medicines regularly in the morning, exceptions may be made to allow you to take the medication with small sips of water on the morning of surgery. Review your medications with your surgeon and anesthesiologist before surgery.

PART 2: THE DAY OF YOUR SURGERY

Use this three-part guide to help make your orthopaedic foot or ankle surgery and recovery go smoothly. You achieve the best results when you work with your surgeon to prepare for surgery and post-surgical recovery. Part 2 will focus on what to do the day of your surgery.

When do you have to arrive at the hospital or surgical center?

A physician, nurse, or administrator will usually call you the day before their surgery. Please note that if the surgery is on a Monday, you will likely get the pre-surgical phone call the previous Friday. If you do not receive this call, you should contact your surgeon.

The purpose of this pre-surgical phone call is to ask preadmission questions and tell you when and where to go on the day of surgery. While each hospital or surgical center has different policies, most will ask you to come in one to a few hours before your scheduled time of surgery and to bring all your medications in the original bottles.

What should you bring with you?

While each center has different policies, it is highly recommended that you bring the following with you on your day of surgery:

• Medical insurance card
• Passport or driver’s license as legal identification
• List of medications that are regularly taken (or the original bottles if requested)
• Immunization record if patient is a minor
• Credit card and small amount of cash
• Copy of pre-surgical test results. This is very important to have if these tests were done at a location different from the place of surgery.
• Assistive devices, such as crutches or a walker, to be used after surgery
• Small bag for personal belongings

While each hospital or surgical center may have different policies, it is not recommended for you to bring jewelry (including rings and piercings), large amounts of cash and more than one credit card on the day of surgery. Small items like these can be misplaced at a busy hospital or surgical center.

What should you wear?

On the day of surgery, you should wear loose, comfortable clothing. You often will have a bulky dressing and/or plaster splint on your operated leg, ankle, and/or foot after surgery, and your clothes must fit around your dressing and/or splint. Examples of such clothes include shorts or sweat pants without elastic bottoms.

Due to the post-surgical dressing and/or splint, you cannot wear normal shoes on the operated foot until it is healed. This means that you should bring a supportive, non-slip shoe with rubber soles to wear on your non-surgical foot.

Just before surgery, you will be asked to change into a hospital gown. Depending on the policies of the hospital or surgical center, you may be asked to remove your underwear while wearing the hospital gown. You will continue to wear the hospital gown until you leave the hospital or surgical center. If you stay in the hospital after surgery, it is recommended that you bring a short robe to wear over the hospital gown.

Who will you meet with?

Once you are dressed in your gown, you will meet with a pre-surgical nurse or physician’s assistant (PA). They may review notes and tests, shave and cleanse the part of the body to receive surgery, and perform a physical exam . They will also place an IV in one of your arms. This IV allows you to receive fluids and/or medicines without eating or drinking.

After the IV is placed, you will meet with the surgical team. This team includes the surgeon, surgical nurses, PAs, and possibly assisting surgeons in training. Such assisting surgeons are common at university or academic hospitals and are known as orthopaedic surgical residents and fellows. While patients will meet with many people that are important parts of the surgical team, it is important to recognize that the foot and ankle orthopaedic surgeon is the leader of the team and will be performing the actual surgery. Nurses, PAs, and assisting surgeons help the surgeon during surgery.

As the leader of the team, the foot and ankle orthopaedic surgeon will speak with you again about your surgery. Many surgeons will have already discussed what to expect from surgery, but this lets you ask any last-minute questions or express concerns to the surgeon. At this time, the surgeon will mark your surgical area with his/her initials via pen or marker and verify with you that it is correct. To ensure the entire team is aware of the plan, other members of the surgical team will check that the correct area on the patient has been marked for surgery.

You will meet with the anesthesia team before having surgery. This team includes the anesthesiologist who will make sure that the patient feels neither pain nor discomfort during surgery, nurse anesthetists (CRNAs), and possibly assisting anesthesiologists in training. Such assisting doctors are common at university or academic hospitals and are known as resident anesthesiologists. While you will meet with many people that are a part of the anesthesia team, it is important to recognize that the anesthesiologist is the leader of the team and will be administering the anesthesia. Nurses and residents assist the anesthesiologist and are an important part of the team providing patient care.

What is anesthesia and what are your options for anesthesia during surgery?

Anesthesia is a condition where you experience no pain and limited memory from a situation. Some form of anesthesia is needed to safely receive any kind of foot or ankle surgery. Anesthesia options include general anesthesia, sedation, regional anesthesia (block), or local anesthesia.

With general anesthesia, you are completely asleep during surgery. You receive medicine through your IV to make you fall asleep. Once asleep, you receive a tube in your mouth (laryngeal mask airway or LMA) or windpipe (endotracheal tube or ETT) to protect your lungs and keep you breathing during surgery.

Regional anesthesia allows you to breathe on your own by numbing the surgical area. This may include a spinal or epidural where numbing medicine is injected into the back and spinal cord, near the spinal nerves.

Another example of regional anesthesia is a nerve block where numbing medicine is injected into the thigh, back of the knee, or leg, near large nerves above the surgical foot and ankle. Whether the numbing medicine is given in the back, thigh, or leg, the regional anesthesia works by affecting large nerves above the involved foot and ankle. One advantage that such regional anesthesia has over general anesthesia is that you may have pain relief many hours after surgery when the nerves above the operated foot and ankle are left numb. Another advantage of regional anesthesia is that you often do not experience the nausea, vomiting and sore throat that are more common after general anesthesia.

How long will you have to stay in the hospital after surgery?

Your surgery will be scheduled either as outpatient or inpatient. If you are outpatient, you will go home on the same day after becoming fully awake in a recovery room after surgery. The amount of time from surgery to being fully awake is typically between three and six hours.While each hospital or surgical center may have different policies for when a patient is ready to go home after surgery, you should be able to:

• Safely stand and walk independently without feeling dizzy or lightheaded, losing balance and falling.
• Urinate without problems.
• Eat and/or drink small amounts without nausea or vomiting.

If you are inpatient, you will stay at the hospital after surgery for several nights. Your surgeon will decide if you are an inpatient based on how complex your surgery is, the amount of pain anticipated, the rehabilitation needs, or your medical conditions. Insurance companies often have criteria that determine whether you will be an inpatient or an outpatient.

Where will your family members wait or stay during your surgery?

While each hospital or surgical center may have different policies, all medical staff will provide as much comfort for family members at this time. Some hospitals and surgical centers will allow family to stay with you in the pre-surgical area until you are brought to the operating room. Many hospitals and surgical centers have an assigned waiting room where family members can stay while you receive surgery.

After your surgery is done, some hospitals and surgical centers will allow family to briefly visit you in the post-surgical recovery room. Many hospitals and surgical centers have an assigned post-surgical discharge area where family can be formally reunited with you when you are awake and ready to go home. If you are to be admitted to the hospital after surgery, family members may have to wait until you are brought to your hospital room before they can see you.

PART 3: AFTER SURGERY

Use this three-part guide to help make your orthopaedic foot or ankle surgery and recovery go smoothly. You achieve the best results when you work with your surgeon to prepare for surgery and post-surgical recovery. Part 3 will focus on what to do in the days immediately after your surgery.

What kinds of symptoms can I expect after surgery?

Surgery can be a big stress to the body, so it is normal for you to experience the following symptoms after surgery:

• Pain, which will be worst in the first few days after surgery. As time passes and the body starts to heal, post-surgical pain lessens.
• Swelling of the surgical foot and/or ankle
• Bruising and discoloration of the surgical foot and/or ankle. Normal skin colors after surgery include blue, red, pink, purple, and brown. Skin colors that may be a sign of problems with circulation are pale white and dark black. Tell your surgeon immediately if you suspect circulation problems.
• Blood or fluid leakage from the surgical foot/ankle incisions. This tends to occur when one’s foot swells after surgery.
• Low-grade fevers (less than or equal to 100.5 degrees) during the first week after surgery. Low-grade fevers that last after one week or those that are above 100.5 degrees at any time after surgery may not be normal. The surgeon should know about this immediately.

What modifications or accommodations are needed at my home after surgery?

After foot or ankle surgery, you will have restrictions placed on your operated foot or ankle and overall activity level. Due to this change in your activity level, you will have to make adjustments to your daily routine at home. While every patient has a different living situation, some things can be done at home to make the post-surgical recovery time easier.

• If you live alone, it can help for a close friend or relative to stay with you during the first several days after surgery. This friend or relative can help you get your home organized for doing things around the house.
• It is best to keep the entire home clean and organized to avoid injury. This includes decreasing clutter, removing loose wires and cords, securing rugs to the floors, and cleaning up spills immediately.
• At night, you should have the lights on as you move through the house. A nightlight can be very helpful in certain rooms like the bathroom and bedroom.
• For the bathroom, organize toiletries you use often so that they are in easy reach and not in cabinets or shelves that are either too high or too low.
• For the bedroom, organize clothes you wear often so that they are in easy reach. When getting dressed, place the surgical leg into clothes before the nonsurgical leg. When getting undressed, place the nonsurgical leg out of clothes before the surgical leg. Tight pants and/or socks can be uncomfortable against your post-surgical dressing and/or splint and should be avoided at this time.
• For the kitchen, organize foods you eat often so that they are in easy reach. The best types of foods to eat after surgery that help with healing include fruits, vegetables, nuts, lean meats and dairy items like milk and yogurt. It also helps to drink plenty of water and electrolyte drinks (e.g., Gatorade) to stay hydrated after surgery. It can also help to prepare meals before surgery and store them in the freezer to be thawed out and eaten after surgery.
• When bathing, the surgical leg must be placed outside the bathtub. When showering, you must keep your post-surgical dressing and/or splint clean and dry. Covering the surgical leg with a large, snug plastic bag or commercial cast cover can do this. (Of note, Saran wrap or plastic wrap does NOT work). To keep weight off your surgical leg in the shower, you may need to use a shower bench or chair, which can be prescribed by the surgeon and purchased from surgical supply stores.
• When resting, keep the surgical leg iced because this helps to decrease pain after surgery. The ice should be placed in thin, but tight, bag and over a thin sheet which itself will be placed over your surgical dressing and/or splint. This is done to prevent your dressing and/or splint from getting soaked from the ice. In a pinch, frozen foods (peas/corn) can be used to cool the leg instead of ice. Mark them so they are not eaten after been frozen/thawed a number of times.
• When resting, keep the surgical leg elevated to decrease pain after surgery. If possible, it is best for the surgical leg to be positioned above the level of your heart. This can be done by placing a few firm pillows placed under the surgical leg.
• When sitting, use firm chairs and place them in every room in the house. While sofas and recliners are good for resting, they are not as supportive for sitting or getting up to stand.
• Stairs can be challenging to use after foot or ankle surgery, but handrails can help provide body support. When going upstairs, the nonsurgical leg goes first and the surgical leg follows. When going downstairs, the surgical leg goes first and the nonsurgical leg follows.

Do I need to take blood-thinning medication after surgery?

The known risk of getting a painful blood clot or deep vein thrombosis (DVT) in your leg after orthopaedic foot or ankle surgery is very low. However, the orthopaedic foot and ankle surgeon may instruct you to do several things to make the chances of DVT occurring even lower. Such actions include:

• Avoiding medicines like hormone replacement therapy and birth control pills, which can increase the risk of getting a blood clot.
• Avoiding nicotine-containing products, which can increase the risk of getting a blood clot.
• Staying relatively active after surgery. While you may not be allowed to place weight on your operated leg after surgery, you may be encouraged to move around the house often. If allowed by the surgeon, you may also exercise your hips and knees with regular movements and stretching. Staying inactive and/or in bed can increase the risk of getting a blood clot.

When does your surgeon next see you after surgery?

While every foot and ankle orthopaedic surgeon has different instructions, you will usually return to the office between one and three weeks after surgery for your first post-surgical visit. You should call your surgeon’s office to schedule this appointment if you did not schedule before surgery.