Considerations around Surgery

Having an operation to treat a condition should generally always be seen as a last resort, reserved for situations where conservative options (i.e. non-operative treatments) have failed to resolve symptoms to a satisfactory, manageable level. Outlined below are some of the alternative treatments commonly used in managing conditions of the foot and ankle, with some of the shared risks of surgery detailed in the subsequent section.

options other than Surgery

In most conditions of the foot and ankle there is common ground in terms of the conservative options available to try prior to considering surgery. The options for treatment will be discussed on an individual basis and include (but are not limited to):

  • Being pro-active with painkillers, taking them on a regular basis in anticipation of a busy day rather than “chasing your tail” after the event as would be normal with a headache for example.

  • Physiotherapy. This is the mainstay for many foot and ankle conditions where balance, stretching and strengthening etc can be very condition-specific. Targeted physiotherapy is therefore crucial in many cases and will often obviate the need for surgery. In cases where surgery is still required outcomes can be more favourable having already been through physio - the importance cannot be over-emphasised!

  • Insoles. Many conditions are related to the mechanics of how the foot is working including the forces going through different parts of the foot when you walk. This is easily demonstrated with the fact that many people notice certain shoes help their foot pain while others aggravate it; this is due to the different mechanical properties of different shoes. In the same way insoles that alter the mechanics of the foot can be integral to the treatment of many conditions of the foot and ankle.

  • Weight-loss. Easier said than done but for the same reasons as mentioned above body-weight directly affects the force going through different parts of the foot. In some cases therefore it can be very difficult to alleviate foot pain if the loads applied are very great; equally, pain can improve greatly as the forces come down so it is always a sensible part of trying to alleviate pain before considering surgery where possible.

  • Injections. Injection therapy is very condition-specific and its use therefore is very variable depending on individual circumstances. Steroid injections can be very helpful both in diagnosing and treating certain types of pain but they have risks such as thinning and depigmentation of the skin (chronic), temporary pain flare, and rarely even rupture of tendons. Mr Rudge will discuss the relative merits of injections in individual cases during the clinic appointment in order to agree a plan going forward.

  • Activity modification. Sometimes a simple change can make an unmanageable situation manageable and this is always worth considering rather than surgery.

  • Simply living with it! Many conditions can be helped without surgery to the point where symptoms are low-level and manageable rather than needing to proceed with invasive treatment and the option of "simply living with it" is important to bear in mind.

The risks associated with surgery

There is a lot of common ground when it comes to the risks associated with surgery in the foot and ankle (and orthopaedics in general). Obviously it is unfortunately not possible to eradicate all risks from surgery but knowledge of their existence allows surgeons to mitigate them as best as possible and allows patients to make an informed decision around whether or not to proceed with surgery.
Listing all the risks can appear daunting and (pessimistic!) however it is important to maintain a sense of perspective - most risks are low otherwise we wouldn’t ever do operations. This topic has been researched extensively and most operations can be considered to have a success rate of 80-90% overall. Below are some of the risks inherent to many orthopaedic operations however the individual circumstances will be discussed in detail during the consultations prior to surgery.

Some common-ground risks associated with surgery:

Infection. The overall risk of developing an infection after surgery is in the region of 2%. When indicated (e.g if metalwork is being implanted) a dose of antibiotics may be given at the time of surgery to keep this risk low. Extensive steps are always taken in theatre to minimise the chance of acquiring an infection yet it still occurs on occasion. If infection does occur it is often purely superficial and easily treated with tablet antibiotics. Rarely however the infection can be deep (including around metalwork) in which case prolonged antibiotics (weeks to months) may be required as may further surgery.

Stiffness and Swelling. These are common to any foot and ankle operation and can take a long time to settle. After surgery you will often be advised to keep your foot elevated as much as possible (even 55 minutes out of every hour?) for the first two weeks while the wounds heal. Gravity doesn’t help unfortunately and swelling can take many months to settle, perhaps even up to a year in some cases. Swelling per se is not usually problematic but it can be an inconvenience with shoes in the weeks and months after surgery until it settles. Stiffness is again common and it is important to maintain movement with regular exercises - you will be advised at to the specifics in your case and physiotherapy may be necessary in addition.

Nerve Injury. There are many important nerves around the ankle and foot which can routinely become bruised and swollen due to surgery in the nearby vicinity. The way in which nerves respond is variable including areas of skin numbness or hypersensitvity but things will usually settle in the weeks to months as the local inflammation dies down. Nerves can unfortunately become permanently damaged during surgery but steps are taken to minimise this risk such that it is fortunately incredibly rare. Very occasionally patients can experience an unusual pain response to surgery (or injury) called CRPS (Complex Regional Pain Syndrome). This will often settle with time but can require multifaceted treatment by Pain specialists for many months.

Blood Clots (Thrombosis). There is a risk of blood clots occurring in the leg (deep vein thrombosis) or lung (pulmonary embolism) in patients undergoing some types of surgery. Some patients have an inherent increased risk (e.g. a prior history of thrombosis in you or your family) and some operations carry higher risk than others (for instance achilles tendon repair). Individual cases are therefore assessed as to the potential risk of thrombosis and steps are routinely taken to keep the risk to a minimum. In some instances additional mitigating steps will be discussed in the form of medication to further reduce the risk; this is usually in the form of a daily, self-administered injection during the higher risk period after surgery (which can even run to 6 weeks or more). Most simple operations do not warrant this however and simple measures such as remaining mobile and hydrated will suffice. The individual circumstances will be discussed and an appropriate plan agreed, it is an important part of the pre-operative discussion as while clots in the leg can be problematic, clots in the lung can be life-threatening so any additional risk factors need to be assessed and acted upon.

Pain. Whilst post-operative pain is an understandable source of concern for patients undergoing surgery the essence of pain relief is to be ahead of the game. Patients will often be given numbing nerve blocks and pain killers during surgery such that they are not in significant pain after the procedure. Some discomfort is however inevitable and regular painkillers may be required for a period after surgery. This will be discussed and advice given according to individual circumstances. Keeping the limb elevated whilst recovering at home is also an effective method of controlling post-operative discomfort.

Summary

There are many other procedure-specific risks associated with different types of surgery which will be covered on the relevant pages on this website with links to further information as well.

It is important to remember that whilst, unfortunately, success cannot be a guarantee with any form of surgery, the vast majority of patients do very well and most of the risks mentioned have solvable solutions even if that means another procedure. This will be discussed in the consultations prior to proceeding with surgery and is the main reason why surgeons and patients should see surgery as a viable option only once the alternative (non-operative options) have been exhausted.