Forefoot Deformity Correction

This leaflet aims to answer your questions about having forefoot deformity correction surgery under the care of Mr Rajiv Limaye . It explains the benefits, risks and alternatives, as well as what you can expect when you come to hospital. This leaflet covers surgery for Bunions, hammertoes and other non-arthritic forefoot deformities.

What is forefoot deformity correction surgery?

Most forefoot deformity surgery is to treat bunions (hallux valgus) and/or lesser/smaller toe deformities.

What happens during forefoot deformity surgery?

Forefoot deformity surgery can be done as a day surgery procedure, unless you have other significant medical problems that mean you may need to stay in hospital overnight, or if several toes are being corrected at the same time. You will usually have a general anesthetic. A cut is made over the bunion on the inner side of big toe . The soft tissues around the bunion are released. The bunion is removed and a cut (osteotomy) is made in the long bone at the base of the big toe. The bunion is correctes and repositioned bones are held in place with one or two screws or staples. The wound is closed with stitches. Other procedures for the smaller toes may be performed at the same time through separate cuts over those toes. Occasionally these toes may need a temporary wire or screw down the length of the toe to hold everything in the right place. The foot and ankle are then bandaged up.

The screws in the big toe are small and usually can be left in forever. They are like internal scaffolding that holds the bones in the correct place and the bone mends around them. After that they are superfluous to needs but we leave them in as they seldom trouble you.

The different types of bone cuts have different names that you may hear in clinic or when signing your consent form: ‘Scarf osteotomy’, ‘Akin osteotomy’.

Why should I have forefoot deformity surgery?

The surgery is required for bunions and lesser/smaller toe deformities place after simple measures have failed to relieve the pain that include wide fitting shoes, simple painkillers and padding. Even after the surgery, wearing high or medium heeled shoes may still be painful. So you might have to be realistic and wear comfortable shoes after surgery.

What are the risks?

In general, the risks of any operation relate to the anesthesia and the surgical procedure itself. In most cases you will have a general anesthetic. You will be able to discuss this with the anesthetist before surgery and he/she will identify the best method for your individual case.

The main surgical risks are listed below: (the full list of risks will be explained to you by your treating consultant Mr Rajiv Limaye)

Infection - approximately 2% risk in our unit
Blood clots (thrombosis) – Normally the risk is small.But if you are in high risk category 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
Stiffness - this improves over time and helped by physiotherapy
Scar sensitivity - can be improved with scar massage
Gait: There can be a change to the way you walk (‘gait’) as your big toe is back in alignment. Usually it improves your walking, but it can cause pain in other areas of the foot.
Recurrence: Occasionally the deformity may recur and need further surgery. This is higher in younger patients, those with generalized laxity (looseness) of joints and those with more severe deformities. With more modern techniques significant recurrence is rare. Rarely the deformity is over corrected (Hallux Varus), it may not be symptomatic but if it is, it can be complex to treat.
Pain: It is usually painful for the first week after surgery. After recovery, some patients experience pain under the heads of the smaller toes after bunion surgery as the weight is transferred this way (‘metatarsalgia’). This is often helped with a simple shoe insole. A small number of patients may experience Chronic Regional Pain Syndrome, a disease characterized by severe pain, swelling, and changes in the skin, which may persist beyond the first few weeks following surgery.
Scar: The scar on the inside of the foot usually fades with time but sometimes can become prominent especially in darker skinned individuals.
Numbness: Sometimes the nerve supplying the inner edge or web space of the big toe can be damaged causing patches of numbness. This is not always permanent, although it may take six to twelve months to recover.
Non-union: There is an approximately 1% chance that your bones will not heal together (unite). This may need further surgery but is usually managed by keeping the foot in the post-operative shoe for longer. This risk increases if you smoke and is higher in patients with diabetes.

Are there any alternatives?

Simple non-surgical measures, such as wider shoes made of softer leather must be tried before undergoing surgery. You can try toe spacers but this will not correct the deformity.

How can I prepare for forefoot deformity surgery?

You should make arrangements to be collected from the hospital. Someone should stay with you overnight if you have a general anesthetic and your operation is a day case. You will need some time off work after the surgery. This will be at least 10-21 days but maybe longer if you have a manual job. Mr Limaye will discuss this with you. We advise you speak to your employer before surgery to make plans.

Giving my consent (permission):

Mr Limaye needs to ask your permission to perform forefoot deformity surgery. You will be asked to sign a consent form that says you have agreed to the treatment and that you understand the benefits, risks and alternatives. This states that you agree to have the treatment and you understand what it involves. If there is anything you don’t understand or you need more time to think about it, please tell the staff caring for you.

Remember, it is your decision. You can change your mind at any time, even if you have signed the consent form. Let staff know immediately if you change your mind. Your wishes will be respected at all times.

Will I feel any pain?

There will be some pain after the surgery. While you are asleep local anesthetic may be injected into your foot to reduce the pain after the operation even if you go to sleep for the surgery. You will be given medicines to take home to control the pain. The nurse will go through the medicines with you, including how often and when to take them. There will be a combination of strong and weak pain killers.It is essential that you maintain an adequate level of pain relief after your surgery so make sure that you regularly take your prescribed painkillers.

If your pain does not settle, then you can either be reviewed in your scheduled outpatient appointment or you should seek further advice and management from your consultant Mr Limaye or call your local GP.

The Day of the Surgery:

Mr Limaye will see you before and after your operation. The anesthetist will also see you before your operation either on the ward if you are early on the list or in the theatre suite. Any queries about the anesthesia are best discussed with him/her directly on the day.

Waiting for your operation:

Please note that you may not be the first patient on the operating list and therefore have a variable amount of time during which you will be waiting to go to theatre; how long will depend in your place on the list. If you are the last patient to be scheduled for surgery, it may be up to three or four hours; you should therefore come prepared for a wait. Some reading material is provided by the day case unit but we appreciate a wait of several hours can be tedious; as such you may wish to bring a book, some work or other material to keep yourself occupied.

During your operation:

An ankle block will be administered in the operating theatre. This numbs the small sensory nerves around the foot, helping to control the pain and to minimize the dose of general anesthetic. You can still bend the toes. Your foot will be heavily bandaged to protect it and reduce the swelling. The gauze bandage which is applied in theatre in a sterile environment will stay on for 2 weeks. There will be no plaster cast.

After your operation, prior to discharge:

The physiotherapist will issue you with crutches and a special surgical sandal to wear. If you already have either of these, please bring them with you. The crutches are not essential, but as the foot is sore when weight bearing you may find it helpful to use them.

After you have been discharged from the ward, you will be presented with a bill for any incidentals from the hospital for the crutches, surgical shoe, shower cap and any medications.

You will be given medications to take home to control the pain. These will be a combination of strong and weak painkillers. A nurse will go through the medications with you, confirming how often and when to take them.

When you feel comfortable and ready you will be allowed to go home. You should have made arrangements to be picked up from the hospital and have someone staying with you at least overnight if you are a day case.

As a day case patient, you can normally go home about 3-5 hours following surgery. As an overnight, patient you will be discharged around 10 am the next day.

What do I need to do after I go home?

This is a general guide only. Patients will progress and recover from their surgery at different rates. If your surgeon Mr Limaye gives you different advice, then you should follow that.

First two weeks:

The local anesthetic in the joint will start to wear off, so you will need to start taking painkillers. You should keep the foot elevated when not walking or exercising for the first week after the operation. Whenever the foot is put down, it will swell and become sore. It is normal to see mild bruising and some dry blood on the foot. By the end of this week the post-operative pain will have significantly reduced.

Continue to elevate the foot as much as possible. You may walk short distances within your home or to a car from this week, ensuring you are wearing the special sandal. In week two you can start working from home, but you must try and keep the foot elevated. If you have a heavy manual job it will be at least six weeks, and possibly three months, before you can return to work.

You will be seen approximately two weeks (10 – 17 days) after your operation in the outpatient clinic.

You will first see the team nurse and then Mr Limaye . At this appointment, the bulky dressings are removed. The stitches are removed, and the scar will look raised due to the dry skin, suture material. For larger corrections, a toe alignment splint will be applied which you must try to wear for at least 16 hours a day. Simple toe bending exercises will be demonstrated to you. You will leave with the same surgical shoe on.

He will advise you at this appointment regarding your return to work.

3-6 weeks:

It will be 4 - 6 weeks before you can drive. Motor insurance companies vary in their policies. It is best to discuss your circumstances with your insurance company to be sure that you are covered.

The Drivers Vehicle Licensing Agency (DVLA) regards it as your responsibility to judge when you can safely control a car. You should contact the DVLA and your insurance company if you are concerned about this.

All dressings can be removed by you by day 18 - 21. You should remove all the remaining wound dressings at home, it is best to soak them off in the shower. You can consider flying short distances at this stage; however, do expect some swelling and pain in the foot.

You should apply moisturizer around the healing wound, once the wound is completely healed. Skin emollients may be applied around the healing wound. These lotions may be applied over the wound once it has totally closed.Bunion wounds often have a thick scab which can take more than 2 months to fall off. The final scar does usually fade.

If you require Physiotherapy, Mr Limaye will refer you for it at this stage. He will write the referral in the clinic and send the referral directly to the physiotherapist or osteopath. The big toe joint becomes very stiff after bunion surgery. This can be corrected by regularly performing the recommended range-of-motion and stretching foot exercises. These exercise routines will help speed up the recovery process after surgery, prevent permanent stiffening of the big toe joint and prevent painful adhesion internal scarring. You should begin with the following mild assisted range-of-motion exercises. To perform this exercise, grab the big toe and hold the fingers close to the big toe joint. Make sure you are not holding the interphalangeal joint; the joint in the middle of the big toe, closest to the toenail. Gently flex this toe upwards until you feel some resistance and mild discomfort hold this for a count of approximately 10 seconds. In a similar manner, perform the exercise by flexing the toe downwards. Remember it is the joint closest to where the bunion was that you need to maintain movement in. This exercise routine should be performed 6 times per day from the 3rd week following surgery.

Please continue to perform the range-of-motion exercise 6 times per day, as prescribed in week 3. Swimming can be started if all the wounds are dry and healed.

If you have had a "re-do" surgery or if the procedure was complex, you may need to wear the surgical sandal for six weeks.

6 weeks after surgery:

You will have a further appointment to see Mr Limaye in clinic. Please arrive 20 mins early for your appointment to collect an x-ray form from the receptionist for you to go to the x-ray department and have an x-ray. This is to check the bones are healing.

Milder corrections may have already full weight bearing in a more regular shoe. The bone has not fully mended but is ‘sticky enough’ that walking short distances should not be a problem.

At this stage, the foot is still swollen and you should not expect to fit into your existing shoes. It is not easy to find a shoe that fits as your foot is still swollen. Some suggestions I can make:

Buying a larger soft “sketcher” type shoe to wear for 2 months.
Crocs.
Suede “UGG” style boots.
A soft wide fit men’s trainer made of soft fabric material.
Your old gym trainers with the far end laces and (if possible) insoles removed to make more space for the big toe.
“FITFLOPS” (NOT FLIP FLOPS) are supportive and work well in summer. You will struggle with your normal shoes, so you may have to pick up a cheap pair to get you through the next 2 months.

6- 12 weeks after surgery:

Your mobility will continue to improve, although you should avoid walking long distances. You can usually return to work after six weeks. You can start gentle exercises and activities after 6 weeks and gradually increase your activity level with time. You should speak to your surgeon about this if you are uncertain.

Low impact exercise, such as exercise bike and cross trainer can be started. You may now drive a manual vehicle in addition to an automatic. However, motor insurance companies vary in their policies please check with your insurer first.

Week 12 Onwards:

Now you start enjoying the foot but the final shape of the foot in terms of the swelling and fading of the scar can take 6-9 months. Running can be started at 10-12 weeks. Other high impact exercise can be started at the same time. A gentle heel can be introduced, and you can move into higher heels with time. Please note that heels should be limited to a reasonable height as they are not great for your feet.

For short haul flights you will be able to fly after 2-3 weeks. For long haul it is 6 weeks. Flying is associated with a slightly higher risk of thrombosis especially with long haul flights. We do make exceptions if your home is abroad.

What should I do if I have a problem?

If you experience any of the following symptoms, please contact Mr Limaye, the ward or your GP:

Increasing pain
Increasing redness, swelling or oozing around the wound site
Fever (temperature higher than 38°C).
suspect you have DVT (deep vein thrombosis) - symptoms include pain and/or burning in the back of your lower leg. You may also feel unwell and have a temperature.

If, at any time in your post-operative recovery, there is any sign whatsoever of infection, either suspected by you or diagnosed by your GP, please contact your Mr Limaye’s secretaries at the hospital.