GSSC Foot Book 2016 (Final)

Boot Camp
Pre and Post Operative Foot Handbook
Mr Paul Rice
9573 9682
Mr Tim Schneider
9521 2882
Mr David Shepherd
9573 9679
9815 2555
Matt Hopkinson
Nick Bridges
Nick Gray
[email protected]
Boot Camp Foot Handbook
This hand book has been developed by Orthopaedic Physiotherapists experienced in foot
surgery. It is developed to assist with your recovery, and we recommend family members
familiarise themselves with its contents too. It has been designed to be informative and is
only a guide. It is not meant to be prescriptive nor replace your Clinicians material. You
should always discuss all relevant care with your surgeon and clinical staff as each case is
different and this information may not be suitable for your individual needs. Its a good
idea to bring this booklet in with you during your admission as it may contain important
information relating to your care. Instructional videos can be found at
glenferriessc.com.au
Pre-Operative Information
What type of foot operation?
So you have
decided to undergo
an operation on
your foot.
What is the
procedure, how
long will it take to
recover, what must I do? These are all questions
commonly asked prior to and following your
operation.
The following pages will hopefully answer these
questions and any more that you may have,
providing you with the information to best
recover and get back on your feet.
*For more information refer to Australian
Orthopaedic Association Handout supplied by
your Surgeon.
Are you fit for your
operation?
You can do a few things
before and after your
operation that can assist
with your recovery.
Exercise - Start your
program as soon as
possible. Outpatient
sessions or classes
should be organised to
get you used to exercising and strong enough to
mobilise following your operation.
Alcohol - Decrease alcohol intake as it can effect
medications you will be taking.
Smoking - Cease smoking; it increases the risks
for anaesthetics and impairs healing of your foot.
There are numerous products that can help you
do this.
Watch your weight - reducing your weight and
healthy eating will assist in the recovery process.
A dietician can assist you to commence a weight
control program pre-operatively.
Medications - If you are on any medications,
this will need to be discussed beforehand with
your doctor and staff in the pre-admission clinic.
Some medications will need to be ceased before
your operation.
Dentist - It is a good idea to get your teeth
checked before your surgery as they can be a
source of infection that may effect your foot.
Pathology - There may be some tests organised
for you in the weeks prior to your procedure.
These will include an ECG, a blood test and
perhaps a urine test. This is to ensure you are
well prior to your surgery.
Physician - Your surgeon may wish for you to
see a Physician before and during your
admission. If you see one of the hospital
Physicians, they will follow you through your
admission. The Physician is a general medicine
specialist who will assist in treating and
monitoring complex conditions.
Essentials to Bring
into Hospital
You should remember
to bring into hospital
with you the
following items. Any
x-rays that may be
pertinent to your admission, all
the
medications that you are required to take
regularly. These should be in their
original packaging to avoid confusion.
You should also bring in a small toiletry
bag including items you would routinely
use.
You only need to bring in a small
amount of change for newspapers etc.
Keep reading material light as it can be
difficult to concentrate for long periods
following your operation. Please do not
bring your valuables into the hospital, or
Equipment
Yo u w i l l r e q u i r e
suitable furniture for
your return home. A
high chair and raised
toilet seat are useful
for 6 weeks
following your
operation as they
make it easier getting
up and down. If you
are uncomfortable
standing in the
shower, or if your
X-rays
Routine Medications
Routine Toiletries
Small Change
Light Reading Material
Walking Aides
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ask staff to lock them away for safe
keeping.
Finally bring in any walking aides that
you routinely use. You will typically go
home on aides and we recommend that
you have a practice before you come
in.Your preadmission nurse can tell you
where to get crutches or a frame.
It is an important part of your
rehabilitation to adopt as normal a
routine as possible soon after your
operation. For this reason, it’s a great
idea to get dressed every day to allow
you to be up and about. Loose and
comfortable clothing is recommended,
with stretch fabrics with elastic waists
ideal.
Men should bring in boxer shorts, tshirts, track suits, underwear and shorts.
Women should bring in night wear,
under wear, track suit and t-shirts.
balance is poor, a shower stool is also
useful. If you do not have these items,
they can be hired from suppliers close to
your home. The case manager can assist
you with this.
Home Visits
If you are unsure about the suitability of
your home for your return following your
operation, a referral to an Occupational
Therapist can be arranged for assessment.
This can usually be arranged through pre
admission.
Underwear
Shorts
Tee Shirts
Track Suit
Pyjamas / Nighties
Foot Wear
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Coming to Hospital
The Anaesthetic Review
It is usual to be admitted to the hospital
on the day of surgery or occasionally the
day prior. Your Surgeon will have
provided you with details about when to
present to hospital.
You will usually be required to fast for
6-8 hours prior to your surgery.
This means nothing to eat or drink.
The Anaesthetist will come and see you
before your operation and discuss the
type of anaesthetic you will have.
You will need to clarify with your
Surgeon what medications you need to
take on the morning of your operation.
These are usually essential heart or
blood pressure medications and can be
taken with a small sip of water. The
nursing staff can discuss this with you.
You will be off the ward for about 5
hours. This includes the time you spend
in recovery after your operation. Your
Surgeon will generally call a nominated
person following your operation to
update them on your progress.
If hair removal is necessary, it will be
attended to before your surgery. Please
do not shave the operation site yourself
as this can increase the risk of
infection
If you have requested a single room,
every effort will usually be made to
accommodate you. However due to
clinical demand and need, these rooms
may not always be available and you
may be asked to share a room until one
becomes free.
These following tables are designed to help you anticipate when certain
activities are likely to commence following your operation. It is a guide
only as each Surgeon will have specific preferences for your care.
Toe Operations
Scarf/Akin Osteotomy
Scarf / Akin osteotomy is a surgical procedure
performed to correct “bunions”.
A bunion (also known as hallux valgus) is a very
common foot deformity. Over time, the bones of the
big toe may gradually become malaligned, leading to
a characteristic bump on the inside of the big toe.
This bump can initially be pain free. Overtime, if the
aligment worsens, pain, skin redness, and even
numbness can develop. It is a progressive condition
which can effect the mechanics and functioning of the foot as a whole.
The scarf/akin osteotomy involves removing the bunion “bump” and correcting any
changes which have occurred in the bone and soft tissues (ligament/capsule). The
goal is to achieve better alignment of the toe, to improve mechanics of the toe and
foot as a whole, and to therefore reduce pain.
Following this operation, as with any other, swelling will occur. The goal in the early
stages of recovery is to minimise swelling by keeping the foot elevated. This means
that walking should be kept to an absolute minimum (i.e. to bathroom or kitchen
only).
Micro Bunion
Similar to the Scarf Akin, the MicroBunion however is performed through a small incision. As a
result of this, following a few days of elevation, patients are able to walk on their foot wearing a
wedge type sandal provided at your surgery. Crutches may or may not be required as comfort
dictates.
Weil Osteotomy
Weil’s Osteotomy is a type of operation typically performed for toe
deformities.
It is performed when “toe clawing” has caused pain in the front part of the
foot. Doctors will often call this pain “metatarsalgia”. The operation seeks
to improve the deformity, lessen pain, and improve mobility.
It is often performed at the same time as a bunion correction (scarf/akin
osteotomy).
DMMO (Distal Minimally Invasive Metatarsal
Osteotomy)
Similar to the Weils Osteotomy, but performed through a small incision, this procedure allows
weight bearing wearing a flat post operative shoe, after a couple of days resting. Crutches may or
may not be required as comfort dictates. Post Operative taping may be required to assist the toe to
sit in the right position.
Moberg Osteotomy
A surgical procedure to realign the bone at the base of the great/big toe (proximal phalanx), aiming
to relieve pain and improve function.
It is typically performed as one surgical option for Hallux Rigidis, a degenerative condition which
causes loss of joint cartilage and the formation of bony osteophytes (bony bumps/protuberances).
These bony bumps/protuberances can jam or impinge, causing pain and restricted movement
effecting one of the joints of the big toe. They can also cause pain by rubbing on footwear.
Cheilectomy
A surgical procedure to remove bone spurs from the base of the great/big toes.
It is typically performed for Hallux Rigidis, a degenerative condition causing
limited motion and pain effecting one of the joints of the big toe.
The aim of surgery is to relieve pain and improve function.
Toe Replacement
Similar to the Ankle Replacement, this operation involves cutting away the
worn joint surfaces and replacing them with artificial surfaces, typically metal
and plastic. The aim is to restore movement and function to the joint.
Achilles Operations
The Achilles tendon is a rope like band at the back of your ankle. It joins your calf muscles to your
heel bone (calcaneus), enabling you to point your foot. It is the largest tendon in the human body
and has a key role to play in activities such as walking, jogging, and jumping.
Achilles Repair
When the Achilles tendon breaks right the way through (i.e. Achilles
rupture), you are no longer able to point your foot down or raise your heel
and you lose power in the ankle. These movements are extremely important
for walking.
In this instance, Achilles repair is required to re-join the two ends of torn
tissue and restore function. Because tendon healing takes time, Achillies
repairs are usually protected for 6-8 weeks before commencing
rehabilitation to allow the tendon to become strong.
Achilles Debridement
When there are signs of wear and tear effecting the Achilles tendon, a
debridement may be recommended by your Specialist. Debridement may
involve trimming worn portions of the tendon or performing surgical
techniques to stimulate healing and regeneration of the tendon.
Haglunds
Haglund’s deformity is a bony protrusion (bump) involving the heel bone (calacaneus), at the point
where the Achilles tendon attaches. The Achilles tendon pulls on the bone, causing local pain and
swelling. There are several ways of managing Haglund’s deformity, one of which is surgery which
seeks to remove the bony protrusion.
This will remove the irritation however, the local area can remain tender for up to six months.
Ankle Procedures
Ankle Arthroscopy
An ankle arthroscope is a form of “key hole” surgery. This means only
small incisions are made - it is a minimally invasive technique. A tiny
camera is inserted into the joint allowing images to be shown on a
monitor. This technique allows Specialists to make an accurate
diagnosis and plan the best cause of treatment.
At the time of performing the arthroscope, the Surgeon may proceed
with cleaning up or repairing tissues within the ankle which are worn
or damaged.
Ankle Reconstruction
Ankle reconstruction is a surgical procedure which
seeks to tighten or repair some of the ligaments of
the ankle. Ligaments are rope like tissues which
connect one bone to another bone giving the joint
stability. If you experience significant or repeated
trauma to your foot or ankle (e.g. rolled ankle), the
ligaments stretch and may even tear completely,
leading to instability and pain.
If at the time of surgery the existing ligaments are
too badly damaged to re-attach or tighten, other
tissues (e.g. tendons) may be used to perform the
reconstruction.
The procedure is performed to improve the stability
of your ankle to minimise the likelihood of
recurrent ankle sprains and joint damage.
Ankle Replacement
Ankle replacement is a surgical procedure which removes damaged tissues
from your ankle, and replaces them with a prosthetic implant. Worn out joint
surfaces are replaced and the joint is re-aligned. In the case of the ankle joint,
the joint surface of the leg bone (tibia) and that of the foot bone (talus) are
replaced with a prosthetic implant consisting of two metallic parts and a
plastic spacer which sits in between. This configuration seeks to mimic the
natural movements typically available at the ankle. The goal of the operation
is to reduce pain and improve function (i.e. walking)
Arthrodesis (Joint fusion Surgery)
Arthrodesis seeks to permanently stiffen a joint
by joining bones which make up the involved
worn out area. The aim of the procedure is to
reduce pain and improve function.
It is typically reserved for more severe cases of
arthritis, and is often considered when other
forms of treatment have been unsuccessful.
Arthrodesis is commonly performed on the
joints of the ankle or toes.
Joint replacement surgery is an alternative
technique which may be more suitable for
some patients.
Pain Relief
It is extremely important that you play an active role to ensure that your pain is well
covered during and after your stay. At no stage should you be in uncontrollable pain.
This means you should be able to comfortably participate in daily care and
Physiotherapy sessions throughout the whole day.You should also be comfortable at
night.
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Pain Relief Options
Initially you will may have an infusion or oral medication to
help control your pain. This may be via an epidural; an
infusion into your spine that blocks sensation to an area, a
regional nerve block; an infusion into a nerve to block its
region of supply and / or a PCA (Patient Controlled
Analgesia). A PCA lets you control how much analgesia you
receive. It is administered via a drip and is controlled with a
button attached to a pump. When you push the button a
small amount of pain medication is released, when you need
more relief, you simply push the button once again for
further doses. Built in timers will prevent you from giving
yourself too much, and Nursing Staff will monitor your pain
and analgesia levels.
Pain Scale
You will experience some pain once your anaesthetic has
worn off - it would be unusual and unrealistic if you didn’t.
To control your pain well, it is important you communicate
with the Nurses. To assist with this, your Nurse will ask you
to regularly rate your pain. A number between 0 - 10 is used
to describe the amount of pain you are experiencing. Ten is
the worst pain imaginable whilst zero is no pain at all.
Inform about pain sooner rather than later. It is your
responsibility to tell the Nurse whether the pain relief is
effective- there are many options that can be used to help
you. It is vitally important to keep your pain constantly
managed post operatively. It allows you to exercise and
move freely and therefore get a better outcome.
Oral Analgesia
You will be offered oral analgesia which will work alongside
any infusions that you may have. These medications will
form the basis of what you will go home with.These
medications are called analgesics and used to treat strong
pain such as what you feel after an operation. Slow release
analgesics will be given which will provide you with
constant background relief. You should routinely take these
when offered. Top up cover can be used too if you are
experiencing discomfort. Side effects of these medications
can be nausea, light headedness and constipation. Please
inform your Nurse if you are experiencing any of these
symptoms.
Patient Complications
Ongoing Pain
Pain after a foot operation usually decreases rapidly during the first month. Pain felt while sleeping
may persist for up to 6 weeks. Stiffness when standing up may be present for as long as 2 years
following your surgery.
Swelling
Swelling in your feet occurs if you keep your legs in a dependent position for long periods of time.
This can be improved by spending time with your feet elevated. Swelling in your foot will remain
until your leg overcomes the trauma of surgery. This type of swelling can be controlled by ensuring
you balance rest and exercise and with the application of ice. Swelling may persist for 6-12 months
post surgery. It is also normal to have a degree of heat in your foot as it heals. Any increasing or
unusual warmth, swelling, redness or discharge should be reported to your surgeon immediately.
Ice Therapy
Ice is really effective in assisting with pain reduction and swelling.
Ice in the form of gel packs, ice in a bag or even a packet of frozen
peas should be placed in a pillow slip or towel to ensure an ice
burn does not occur. Ice should be applied for twenty minutes at a
time; more than this is not beneficial. In the first weeks following
your operation, your foot is well and truely wrapped up, so ice is
unnecessary. As time goes on, you will need to ice less frequently,
but will find it useful to settle your foot after exercise or activity.
Heat Therapy
Heat should not be applied to your leg immediately after your operation. This could cause
increased bleeding and swelling. About a month following your surgery, gentle heat via a heat pack
or hot water bottle can be useful when applied to your ankle to loosen the muscles and assist with
movement. Make sure the pack is warm rather than hot and use a towel to protect your skin from
burning. Discuss with your clinician when its safe for you to use heat.
Teeth
It’s a good idea to have your teeth checked prior to your surgery as any infection from a tooth can
travel to your operation site. Likewise, where you have a prosthesis, inform your dentist prior to
any future invasive procedures as it is likely that a preventative course of anti-biotics may be
prescribed.
Signs to look for when you go home.
When home you need to watch for any undue discomfort or inability to move
your foot. Unusual swelling, sudden discharge from the wound, increasing
redness and fevers should be reported immediately to your clinician .
Exercise
Walking
We do not encourage
exercise in the first two
weeks following your
operation as we wish for the
wound to heal. Do not
compare with others, as
everyone will heal at
different rates and will have
started from different
baselines. Elevation is the
most important thing
initially. Your
physiotherapist will discuss
with you should they wish
you to perform exercises.
Following your review, you
will be told when to
increase your levels of
activity and when to
commence exercises. This
will be gradual and will be
dictated by pain and
swelling. Every one is
different so do not compare
with others.
Following your post op
review your surgeon will
direct you as to when you
will be allowed to increase
your activity.
When you are comfortable
walking around your house,
it is time to venture outside.
Gradually increase the
distance you walk every
day. A good guide is to walk
a few houses extra every
day. If you do this a couple
of times a day, before you
know it you will be walking
around the block. Aim to
eventually have a 20-30
minute walk a couple of
times a day.
Your Physiotherapist will
tell you how long you will
need to stay on your
crutches after your
operation.
Driving
The Australian Orthopaedic
Association (AOA)
recommends that you do
not drive a motor vehicle
following your operation. If
your right foot is operated
upon, then this may be for
up to 12 weeks.This is
because your ability to
concentrate and to react in
an emergency situation will
be impaired in this period.
If you drive an automatic
car and it is your left foot,
then you will be able to
drive after the two week
review and when you feel
comfortable to control a
vehicle..
Your surgeon will be able to
advise you when it is safe to
resume driving.
Swimming
You are not allowed to
commence Hydrotherapy
until your wound has
sufficiently healed. This is
to reduce the risk of
infection. Hydrotherapy is
beneficial following joint
procedures as it allows
strength and range of
motion exercises to be
performed without putting
too much stress through the
joint. Water also offers a
nicely supported
environment to practice gait
technique and balance
exercises safely. Be careful
when commencing
Hydrotherapy programs as
you often feel quite good in
the pool, but can be sore
and tired afterwards. For
this reason, it is
recommended that you keep
initial sessions short and
build your tolerance. Please
check with your surgeon
when it is safe to go in a
pool.
Going Home
Medication
Discharge Goals
You will be independent with
Bed Transfers
Toilet Transfers
Chair Transfers
Showering
Walking Safely
Negotiating Stairs
Precautions
Exercises
Dressing
Transport Home
The majority of patients go home by car.
Your surgeon will discuss with you
should they feel alternative transport is
required
Independence
It must be remembered that you will be
independent when you return home from
hospital. Whilst you may need assistance
with some tasks, you are expected to be
able to bathe and dress yourself, and get
yourself in and out of your bed and
chair. You will need some help with
meal preparation.
You will normally be sent home with one - two
weeks supply of medication. Further medication
can be arranged via your GP and Pharmacist.
Home Support
If you require assistance upon your return to home,
there are lots of things available. Meals on wheels,
home help and District Nursing can be arranged to
make life a little easier. Please discuss with the
hospital Pre Admission Nurse to see if you qualify.
Discharge Time
You will be informed on a likely discharge
day during your hospital stay. Hospital
discharge time is usually at 9.30 am. The
Nursing staff will assist you to be ready at
this time. Please inform your family of this
time.
Walking
You will generally stand on the first day following your operation. Mr Schneider’s patients will
take no weight through their operated side for at least two weeks whilst Mr Rice may allow you to
touch your foot to the ground (like you are stepping on an egg). Your physiotherapist will inform
you as to how much weight you are allowed to take as occasionally due to the type of surgery you
have had, this may alter.Typically, standing is assisted by the use of a walking aide; usually a pick
up frame and progresses to using crutches as your balance and comfort allows in the ensuing days
or weeks.
After the initial healing phase of two weeks, you will be encouraged to gradually increase the
distance you walk as pain and safety allows. Your Surgeon and Physiotherapist will direct you
when to progress from walking with a frame or crutches to a walking stick or no aides. Like
everything with this operation, it’s about a balance of exercise and rest. If you walk too often or
too far before you are ready, you may find pain and swelling may become an issue with other
areas of your rehabilitation.
Crutches/ Frames
You will be shown how to walk with crutches or a frame following your surgery. It’s a great idea
if you have a practice before you come into hospital so you are familiar with the technique.Whilst
the Physiotherapist will make sure your crutches are the correct height when you are in hospital, if
you wish to practice and you are unsure as to how to set your crutches, ask where you hire or
purchase them from, or check with your local Physiotherapy clinic. Don’t be embarrassed if you
cannot manage crutches. Our aim is to make you as safe as possible post operation. We have lots
of tricks up our sleeves, so feel free to contact us to discuss further.
To walk with crutches, make sure you keep the crutches wider than your feet; the closer they are
the more likely you will trip over them and it’s also more difficult to balance. Place the crutches
about a foot in front of your feet and then move your operated foot up to the crutches, keeping it
off the ground.
Push through your hands and then hop your un-operated leg up to join the other leg.You will
need to take a lot of weight through your hands, so no weight will go through you leg. If you are
unable to manage crutches, a pick up frame offers greater support. Generally, if you are over 60,
because your upper limb strength and balance may be diminished, the Physiotherapist will
recommend the use of a frame for safety purposes, until you are allowed to weight bare through
your foot.
As you heal and feel more comfortable, you can begin to walk through the crutches. Your
surgeon will direct you on this at your follow up review.
Stairs
If you are on crutches when going up steps , step your good leg up first, and then follow with
the operated leg and the crutches, To go down steps, put the crutches down first and then the
operated foot, followed by the good foot.If you are unsure you can go up and down on your
backside. Videos of step negotiation can be found on
http://glenferriessc.com.au/instructional-videos/
Scooters
Scooters can be a useful tool to assist with your mobility after
your operation. However, due to the fact that you are basically
resting in bed for the first two weeks, they are generally not
required at this stage. Scooters can be cumbersome around
bedrooms and bathrooms, so you will still need a frame or
crutches. If you are non weight bearing for an extended period,
scooters can be a useful way for getting around outside. Your
Physiotherapist can assess your mobility and balance to suggest
if this is a good idea; otherwise a wheel chair can suffice.
Bolsters
Your Surgeon recommends the use of a bolster post operation to assist
with elevation. Whilst they are available in hospital for your use as an
inpatient, they are not available to take home. Bolsters for home use are
available for hire through the MOG rooms at Windsor at $10.00 cash per
week. It is best to pick this up prior to your surgery. These bolsters are
returned to Windsor, generally at your post op review.
Equipment Hire
We use Pharmore Chemist (03 96467200) as a preferred supplier at Glenferrie Private Hospital.
On site we have a supply of crutches for purchase ($40.00 underarm and $60.00 forearm) and
frames for hire ($25.00 p/w). Arrangements via many suppliers can be made for home delivery
of wheelchairs, bathroom and toilet aides or any other of your equipment needs locally that can
supply your requirements should you like to make other arrangements.
Glenferrie Private Hospital specialises in providing care for private short-stay patients undergoing
orthopaedic and specialist surgery. Our hospital has been designed with the comfort of our
patients in mind as well as providing the best in clinical care.
29 Hilda Crescent
ph: 03 9009 3000
Hawthorn 3123
fax 03 9009 3899
Notes
Pre Operative Exercises
These exercises will help you to strengthen important muscle groups prior to your operation. If you
have any pre-existing injuries you think may restrict your ability to do these exercises, please
discuss with your Physiotherapist before starting.