Post Surgical Issues
Patients undergoing surgical procedures on their feet may encounter any of the following post-surgical issues:
Patients who undergo a general anesthetic may be disoriented while awakening from the anesthetic, as well as for a period of time afterwards. This may last anywhere from less than 10 minutes to a few hours. During this time, the patient may have associated amnesia. For example, if your surgeon speaks to you immediately after surgery you may have no recollection of the discussion.
Confusion related to the anesthetic is often due to the anesthetic gases and narcotics that are given during the operation. It can sometimes take anywhere from a few hours or longer for these metabolites to “clear” a person’s system after surgery. During this time, confusion can be common. There may be increased confusion in some overweight patients, since it may take longer for the “fat soluble” anesthetics to clear their system.
A small percentage of patients will either stay confused or become confused in the first day or two after surgery. When this happens, a cause needs to be identified. The most common cause of confusion is a medication that the patient receives during anesthesia or in the recovery process. Often the narcotics that are given to help control post-operative pain will induce some confusion.
Constipation is a common problem after surgery. It often takes about 3-5 days to manifest. Constipation occurs because patients are given narcotics to control their post-operative pain. Narcotic medication slow the motility of the bowel. Also, events that usually stimulate your bowel, such as eating and being active, are constrained. Treatment includes taking a stool softener daily after the surgery. Laxatives can be added if stool softeners are ineffective.
Fortunately, hiccups are not that common after surgery. Generally, hiccups occur due to irritation of the diaphragm – a muscular area that separates your lungs from your abdomen. Occasionally, the combination of taking medications and laying down (supine) can cause patients to develop hiccups. Hiccups are self-limiting and will usually settle on their own.
Heel pain is a common complaint 6-12 weeks after major foot or ankle surgery. The pain is usually self-limiting. There can be a couple of causes, but the most common is that the heel tissue gets irritated when a person begins to increase their walking and general weight-bearing after being off their foot for an extended period of time, recovering from the surgery. The heel becomes accustomed to not being walked on during the time the patient is “non-weight-bearing” (often 6-10 weeks). The heel tissue atrophies a bit during this time and does not appreciate the relatively sudden increase in activity that occurs when patient start weight-bearing again. The heel often lets the patient know that it is angry with this increased workload by becoming symptomatic with pain and irritation. The solution in this instance is to slow down the recovery a bit and to realize that the heel symptoms will get better (usually in 3-6 weeks) – once the heel tissue toughens ups a bit.
The other potential cause of heel pain following surgery is pain from a prominent screw head (hardware). If this is the case, it can be padded (heel gel pad from a local drug store) but ultimately the screw will need to be removed once the bone has healed.
Driving must be avoided for a period of time after many foot surgeries. Driving is an activity where safety is paramount, so any activity that affects the safe operation of the vehicle should be avoided. Therefore it is critical that patients NOT drive right after a major surgery. Patients who undergo surgery on their right foot, or patients who have a manual transmission will have to avoid driving for a prolonged period of time. For major surgery, such as an ankle fracture, this is often 10 weeks or more. Patients should not return to driving until they have been cleared by their surgeon. Once comfortable, patients should ease back into driving, and if driving skills are of a concern after surgery, a driving class should be considered. Patients should never drive with a walking boot or any other device that restricts their motion.
A low-grade fever which is below 38.5 C (101.3 F) within the first 2 to 3 days after surgery is surprisingly common. The most common cause of a low-grade fever after surgery is a condition called atelectasis. Atelectasis occurs when your lungs do not fully expand, causing the base of the lungs to clump up a bit. This tends to occur in situations where a patient is lying down and not taking deep breaths – both common situations after foot surgery. Treatment of atelectasis involves taking a full deep breath a couple of times every hour to help expand your lungs. Patients should also be encouraged to get out of bed and sitting upright so gravity can assist in expanding the lungs. A low-grade fever may last until the atelectasis is gone.
Patients should always be concerned about a fever in the post-operative period, however, they should be particularly concerned if the fever:
- occurs more than three days after surgery
- is quite high – above 38.5 C (101.3 F)
- is associated with intense pain at the site of surgery
- is associated with other symptoms (e.g. chest pain, abdominal pain, urinary tract infections)
These situations may be associated with an infection or other potentially serious medical problem.
All foot surgery creates some initial pain that will make walking and moving around challenging. After surgery, depending upon the type of operation that was done, the surgeon will allow patients to have one of three limitations:
- Weight-bearing as tolerated;
- Non-weight-bearing, or
- Partial weight-bearing.
Weight-Bearing as Tolerated
For surgeries that do not require major bone, tendon, or ligament healing, the surgeon may deem it acceptable to bear full weight on the operated foot. However, even though patients may be allowed to bear weight as tolerated, it is still important to continue to wear appropriate footwear and minimize the amount of time that the foot is down (elevate the foot). Footwear, such as a post operative shoe or a Cam Walker, is designed to protect the surgical area by evenly dispersing force up the leg, thereby helping to protect the operated area. It is also important to limit walking. Walking will cause more swelling to the operated area than is there already, which will create increased discomfort. Also, patients will often limp after surgery. A limp creates an asymmetric gait and therefore too much walking will often lead to overload of other parts of the body with resulting symptoms (e.g. lower back pain, knee pain, hip pain).
For many operations that require healing of major bones, tendons, or ligaments, your surgeon will instruct you to be non-weight bearing. Sometimes a patient will be allowed to be touchdown weight-bearing (i.e. letting the foot gently rest on the ground – 10-15 lbs of weight). No or limited weight-bearing through the foot is done with the use of crutches, walker, knee walker, or wheelchair. If instructed to be non-weight-bearing, it is critical that patients remain non-weight-bearing until their surgeon instructs them otherwise, since loading through a healing bone or ligament may cause inappropriate tissue healing or lead to non-unions of bones or fusions.
Some surgical procedures, particularly around the front and mid part of the foot (e.g. some bunion procedures), can be treated with partial weight-bearing. Weight-bearing can be done through the heel while using crutches or other devices that limit the weight through the foot. It may be important not to load through a part of the foot (ex. the front of the foot) as this may disrupt the healing process.
If crutches are used, they should be fitted properly. In addition, many people will find that knee walkers are helpful since it allows patients to apply weight through the knee and not the foot. It’s also important to keep the foot elevated at or above the level of the heart, minimizing swelling that naturally occurs after a major foot surgery. It is very important that patients follow surgeons’ recommendations. If recommendations are not followed, patients are likely to have increased swelling, increased pain, and an increased risk of non-union.
Unfortunately, nausea and vomiting are a relatively common side effect of surgery. The most common cause immediately after surgery is related to the reaction of the anesthetic agent. However, some of the narcotic pain medications that are given to treat post-operative pain may cause nausea and vomiting. The main treatment for nausea and vomiting is to remove the cause if possible. For example, if patients are sensitive to narcotics, then they may, if possible, limit their narcotic use or switch to another narcotic that is less sensitive. Another option for treating nausea is to take an anti-nausea medication (antiemetic), such as diphenhydramine (Benadryl).
Moving around after surgery can be difficult and may place patients in an increased risk of falling, which can injure another area of the body. Also, if patients are on pain medication, the chances of falling also increases. Therefore, it is important to limit activity and be very careful when mobilizing after foot surgery.
Edited November 16, 2015