Surgery on the Rheumatoid Forefoot
Surgery is performed under general anesthetic. The stay is usually 1 to 2 nights. The procedure takes about 90-120 minutes. The aim of surgery is to realign the toes, remove the pain and so allow improved function. It is not possible to make the foot look completely normal again.
Technique
An 6 cm incision is made on the inner side of the foot over the base of the great toe.
The joint surfaces are removed and then the toe is correctly aligned, and plate and screws are used across the joint to hold it solidly
If the lesser metatarsal heads are to be removed an incision is made across the sole of the foot. If only a section of bone from the toe is to be removed there will be several smaller incisions on the top of the foot. The skin is stitched, and a wool and crepe bandage applied with a plaster strip within it.
Risks
All surgery carries potential risks. The risks are minimized by having the surgery meticulously performed by an expert in foot and ankle surgery. Risks include
- Infection - approximately 2% risk in our unit
- Blood clots (thrombosis) – You will be put on Low molecular weight Heparin prophylaxis to reduce the risk of blood clots in calf, thigh or rarely in lungs.
- Numbness – can occur over the outer border of the foot, and usually improves over time
- Pain and swelling - This can occur after any foot and ankle surgery. You have to keep the limb elevated for 48 hours to avoid swelling and you will be given pain killers.
- Stiffness – this improves over time and helped by physiotherapy
- Scar sensitivity - can be improved with scar massage
- Delayed or non-union - the non-union rate (bones not healing together) is approximately 5% and is higher in people who smoke.
- Incomplete correction or recuurence
Discharge advice following forefoot surgery in Rheumatoid Arthritis
Dressings
Your foot has been dressed in a wool and crepe bandage which has a plaster strip around the great toe to give it support. This dressing should not be changed until you are seen at your first follow-up appointment after 2 weeks. The dressing must be kept clean and dry.
Elevation
It is very important that you rest as much as possible and keep your foot elevated for the first 48 hours after surgery. Try to avoid letting it hang down when sitting as this will lead to swelling and pain. This is most apparent within the first 2 weeks but swelling may occur for up to 6 months after surgery, especially after sitting or standing for long periods. In bed, put the foot on a pillow.
Analgesia
You will receive a prescription for pain medication on discharge. Pain is often due to swelling, and this is eased by rest and elevation of the foot.
Walking
A special shoe has been supplied for you wear over your dressings which should be worn during the day for 6 weeks. A physiotherapist will show you how to use crutches and apply the shoe. It is necessary for you to walk by taking the weight on your heel so that you don’t put pressure on the great toe. It is not necessary to wear this shoe in bed.
Follow-up
You will be seen approximately 2 weeks following surgery. At this time the dressings and sutures will be removed, and a plaster technician will put a fiberglass slipper around your foot. You will be seen again after 6 weeks when you will have an X-ray and the slipper will be removed. The foot is often slightly swollen at this stage and so a comfortable pair of loose-fitting shoes or trainers will need to be worn and should be brought to the out-patient appointment. You will then be seen about 3 months after the surgery.
Driving
You should not drive a manual car for 6 weeks following surgery. After this you should start gradually to see if you are comfortable. It normally takes a few days to feel confident.
Work
If you have an office-based job, then you should be able to return after 6weeks. If you have a more physical job, then it may take 8-12 weeks.
Recovery
It often takes 6 months for all swelling to resolve following surgery and so minor swelling late in the day is not unusual and should not be a cause for concern.