Department of Trauma and Orthopaedics Surgical procedure information leaflet

Department of Trauma and Orthopaedics Surgical procedure information leaflet Diagnosis: Bunion (Hallux Valgus) It has been recommended that you have f...
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Department of Trauma and Orthopaedics Surgical procedure information leaflet Diagnosis: Bunion (Hallux Valgus) It has been recommended that you have forefoot surgery. This leaflet explains some of the benefits, risks and alternatives to the operation. We want you to have all the information you need to make the right decision. Please ask your surgical team about anything you do not fully understand or want to be explained in more detail. We recommend that you read this leaflet carefully. You and your doctor (or other appropriate health professional) will also need to record that you agree to have the procedure by signing a consent form, which your health professional will give you.

About forefoot surgery This type of surgery would include an operation to your toes, bunions or soft tissue of the forefoot. A bunion is not a bump on the bone itself, it is caused by a change in the angle of the bones in the foot. Sometimes, it is painful, but can cause symptoms by pressure on footwear or, by crowding or crossing of the smaller (lesser) toes. Occasionally the second toe can become so crowded that it becomes clawed, and can cross over the big toe. This causes two problems: 1. Your big toe is bending towards your second toe. 2. The bump on the joint of your big toe sticks out and may be red and sore (it usually makes finding comfortable shoes difficult). The decision to have surgery for your bunion is usually made based on the level of pain and inconvenience caused by the bunion. You may find it difficult to find shoes wide enough to accommodate your bunion. In general if your bunion is not painful we would not recommend surgery. However, should you choose to have surgery the following operations may be suitable to treat your bunion: 

Simple bunionectomy Your surgeon would make a small incision (cut) over the bunion and shave the bone to take away the lump. This is the simplest procedure but does not correct the deformity. Some patients may find the bunion returns over a period of time.



An osteotomy (chevron, scarf or proximal) This is an operation in which the bone (metatarsal) is cut and placed into the correct position. Any bony lump is usually trimmed at the same time. The aim of the operation is to straighten the big toe, and hopefully narrow the forefoot. Because the operation involves cutting the bone, this has to be held in position by small screws, wire or staple while the bone heals together again.

Occasionally, the big toe is osteotomised (broken) as well, a procedure known as the Akin procedure. The cut made in the bone allows the bones to be repositioned, so that the big toe is straightened. What can I expect after these operations? After the operation, you will wake up with your foot in plaster. The foot is always painful, but Surgical information procedure leaflet Bunion Surgery

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painkilling tablets usually control this. In order to minimise swelling, you will need to keep your foot up after the operation. You would be in plaster for four to six weeks after any of these procedures. You can walk on your heel. After your surgery you should elevate your foot above your bottom as much as you can for approximately two weeks. This helps reduce pain and swelling. Benefits of the procedure The aim of your forefoot surgery is to reduce pain and correct deformity. Serious or frequent risks Everything we do in life has risks. Forefoot surgery has some risks associated with it. The general risks of surgery include problems with: o The wound (for example, infection); o Breathing (for example, a chest infection); o The heart (for example, abnormal rhythm or, occasionally, a heart attack); and o Bleeding (following surgery there may be some bleeding). Those specifically related to forefoot surgery include problems with: o Pain, the procedure does involve moving soft tissue and will hurt afterwards. o Damage to the small nerves or blood vessels in the foot (neuro vascular damage resulting in numbness or delayed healing). o Scarring, the operation will leave a thin scar on the side (or top) of the big toe. o Thick/Keloid scar, these are scars which grow excessively. o Failure of procedure (resulting in further surgery). o Non-union of bone. o Drifting back of hallux deformity. o Recurrence of the bunion. o Over-correction of the bunion, so that the big toe points inwards. o Stiffness of the big toe. o Weight transfer to the second or third toe (a corn under the second toe). o Malunion – poor position of toes after surgery. o Slightly high riding toes. o Implant irritation Sometimes, more surgery is needed to put right these types of complications. 

Most people will not experience any serious complications from their surgery. The risks increase for elderly people, those who are overweight, smoke and people who already have heart, chest or other medical conditions such as diabetes, kidney failure. As with all surgery, there is a very small risk that you may die.



You will be cared for by a skilled team of doctors, nurses and other health-care workers who are involved in this type of surgery every day. If problems arise, we will be able to assess them and deal with them appropriately.

Other procedures that are available The options with non-operative (Orthotic) management of bunions include:  Wider shoes.  Softer leather shoes (or sandals in summer).  Custom wider box shoes and silicon spacers between the first and second toes. Surgical information procedure leaflet Bunion Surgery

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  

If you have a flat foot as well (a recognised association) an arch support or rocker may also be of help. Foot splints or braces. Corn plasters can relieve symptoms of local pressure.

These will not treat the underlying problem but may make bunion symptoms tolerable. Your pre-surgery assessment visit We will ask you to go to a pre-admission clinic where you will be seen by members of the medical and nursing teams of the surgical unit. The aim of this visit is to record your current symptoms and past medical history, including any medication you are taking. It is important to let us know in the pre-admission clinic if you are taking any of the following as these may have to be discontinued before surgery:  Anticoagulant drugs (for example, warfarin, aspirin or clopidogrel).  Non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen and diclofenac.  Contraceptive pill. Please bring to your pre-operative assessment visit a list of the medications you are taking or have recently taken, including medicines prescribed by your family doctor and those bought “over the counter” without prescription, and also any herbal medications. Keeping an up-todate list of medications with you is highly recommended. You may have a full examination and the following tests may be done:  x-rays of your foot and chest if required;  ECG, a tracing of your heart beat;  blood tests;  urinalysis (urine test); and  MRSA (Methicillin Resistant Straphylococcus Aureus) swabs, this is a test for bacteria that can be carried in your nose, throat and groin. It is harmless in these areas, but if it reaches an open wound, it can be very serious. It is relatively uncommon but if you will be given a treatment pack and instructions. Your operation will be postponed until it is cleared. A patient information leaflet is available on MRSA. Please ask about this at your preoperative appointment. The members of the surgical team will check that you agree to have the planned surgery. If you have been given a consent form please bring it with you, alternatively you will be given a consent form in clinic. Make sure that you have read and understood this information before your clinic visit. If you have not understood any part of the information, you will be able to ask any questions you may have about your planned surgery. Important: If you have any kind of infection or skin wound (such as a cut, graze, leg ulcer or broken skin) please inform the medical team of this at your pre-surgery assessment or early health screen. Being admitted to the ward You will usually be admitted on the day of your surgery so you and we can prepare for the surgery. We will welcome you to the ward and check your details. We will fasten an armband containing your hospital information to your wrist.

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Your anaesthetic We will carry out your surgery under a general anaesthetic. This means that you will be asleep during your operation and you will feel nothing.

Before you come into hospital There are some things you can do to prepare yourself for your operation and reduce the chance of difficulties with the anaesthetic.    

If you smoke, consider giving up for at least six weeks before the operation. Smoking reduces the amount of oxygen in your blood and increases the risks of breathing problems during and after an operation. If you are overweight, many of the risks of anaesthesia are increased. Reducing your weight will help. If you have loose or broken teeth or crowns that are not secure, you may want to visit your dentist for treatment. The anaesthetist will usually want to put a tube in your throat to help you breathe. If your teeth are not secure, they may be damaged. If you have long-standing medical problems, such as diabetes, hypertension (high blood pressure), asthma or epilepsy, you should consider asking your GP to give you a check-up.

Your pre-surgery visit by the anaesthetist  After you go into hospital, the anaesthetist will come to see you and ask you questions about: o Your general health and fitness; o Any serious illnesses you have had; o Any problems with previous anaesthetics; o Medicines you are taking; o Allergies you have; o Chest pain; o Shortness of breath; o Heartburn; o Problems with moving your neck or opening your mouth; and o Any loose teeth, caps, crowns or bridges. 

Your anaesthetist will discuss with you the different methods of anaesthesia they can use. After talking about the benefits, risks and your preferences, you can then decide together what is best for you.



Also, before your operation a member of the theatre nursing staff may visit you. He or she will be able to answer any questions you may have about what to expect when you go to theatre.

On the day of your operation Nothing to eat and drink (nil by mouth) It is important that you follow the instructions we give you about eating and drinking. We will ask you not to eat or drink anything (including chewing gum or sucking sweets) for six hours before your operation. This is because any food or liquid in your stomach could come up into the back of your throat and go into your lungs while you are being anaesthetised. You may take a few sips of plain water up to two hours before your operation so you can take any medication tablets. Surgical information procedure leaflet Bunion Surgery

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Your normal medicines Continue to take your normal medicines up to and including the day of your surgery. If we do not want you to take your normal medication, your surgeon or anaesthetist will explain what you should do. It is important to let us know, before you are admitted, if you are taking anticoagulant drugs (for example, warfarin, aspirin or clopidogrel). We will need to know if you do not feel well and have a cough, a cold or any other illness when you are due to come into hospital for your operation. Depending on your illness and how urgent your surgery is, we may need to delay your operation as it may be better for you to recover from this illness before your surgery. Your anaesthetic When it is time for your operation, a member of staff will take you from the ward to the operating theatre. They will take you into the anaesthetic room and the anaesthetist will make you ready for your anaesthetic. To monitor you during your operation, your anaesthetist will attach you to a machine to watch your heart, your blood pressure and the oxygen level in your blood. General anaesthesia usually starts with an injection of medicine into a vein. A fine tube (venflon) will be placed in a vein in your arm or hand and the medicines will be injected through the tube. Sometimes you will be asked to breathe a mixture of gases and oxygen through a mask to give the same effect. Once you are anaesthetised, the anaesthetist will place a tube down your airway and use a machine to ‘breathe’ for you. You will be unconscious for the whole of the operation and we will continuously monitor you. Your anaesthetist will give you painkilling drugs and fluids during your operation. At the end of the operation, the anaesthetist will stop giving you the anaesthetic drugs. Once you are waking up normally, they will take you to the recovery room. Pain relief after surgery Pain relief is important as it stops suffering and helps you recover more quickly. We may give you tablets or injections to make sure you have enough pain relief. Once you are comfortable and have recovered safely from your anaesthetic, we will take you back to the ward. The ward staff will continue to monitor you and assess your pain relief. They will ask you to describe any pain you have using the following scale. 0 = No pain 1 = Mild pain 2 = Moderate pain 3 = Severe pain A local block may also be used. This is an injection of some local anaesthetic near the nerves that supply the lower half of your body. This will numb the part of your body being operated on and give good pain relief during and after your operation. It is important that you report any pain you have as soon as you experience it. What are the risks of anaesthetic? Your anaesthetist will care for all aspects of your health and safety over the period of your operation and immediately afterwards. Risks depend on your overall health, the nature of your operation and how serious it is. Anaesthesia is safer than it has ever been. If you are normally fit and well, your risk of dying from any cause while under anaesthetic is less than one in 250,000. This is 25 times less likely than dying in a car accident. Side effects of having Surgical information procedure leaflet Bunion Surgery

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an anaesthetic include drowsiness, nausea (feeling sick), muscle pain, sore throat and headache. We will discuss with you the risks of your anaesthetic. After your surgery  Once the medical team are happy with your progress, we will usually take you from the recovery room to the general ward. You will need to rest until the effects of the anaesthetic have passed. You may have a drip in your arm to keep you well hydrated.  Your anaesthetist will arrange for you to have painkillers for the first few days after the operation, as we mentioned earlier.  We will encourage you to get out of bed and move around as soon as possible, as this helps prevent chest infections and blood clots. Usually, the physiotherapy or nursing team will help you with this.

Leaving hospital Length of stay How long you will be in hospital varies from patient to patient and depends on how quickly you recover from the operation and the anaesthetic. Most patients having this type of surgery will be in hospital for day case surgery, but occasionally an overnight stay might be required. Medication when you leave hospital Before you leave hospital, the pharmacy will give you any extra medication that you need to take when you are at home. Rehabilitation How long it takes you to recover from your surgery varies from person to person. It can take up to six months. You should consider who is going to look after you during the early part of this time. You may have family or close friends nearby who are able to support you or care for you in your home during the early part of your recovery period. The First 5 Days Following Your Operation Following your operation to your foot you will be able to stand and take weight on your heel only, but you must rest with your feet up as much as possible. You should try to restrict your walking to just going to the bathroom / toilet. After five days you can increase your walking but you should elevate your foot if swelling increases. At About 14 Days Following Your Operation At about 14 days after your operation you will be seen, in the outpatients department for follow-up the stitches will be removed (or trimmed if absorbable). Depending on the operation you have had, the plaster may be renewed or plaster may be left off. If there are no wires and the wounds have healed, you may return to normal footwear. However, this may be a problem due to swelling. At About 4-6 Weeks Following Your Operation If you are not in plaster: At about 4 weeks after the operation swelling should reduce further and you should be able to start wearing more normal footwear. Any wires may be removed and you may return to work around this time (depending on your work and the type of footwear you wear at work). For a job where you are on your feet all day, return to work in less than 4 weeks would be an unrealistic expectation. If in plaster: The plaster should be removed at this stage and any wires removed. You will then usually be allowed to mobilise as you wish. You can start to wear more normal footwear although this is often not possible due to swelling for about another 2-3 weeks. Usual return to work is about 8 weeks – depending on your type of job.

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Other factors such as the severity of the deformity, tissue quality, smoking, circulation and general health can also make a difference to wound healing and recovery rate. Although the foot should now be comfortable and returning to normal, there will still be noticeable swelling particularly towards the end of the day. This is normal and to be expected. Physiotherapy is not automatically organised and will be arranged as needed. Depending on the surgery you have had a follow-up appointment may be made for 3 months after surgery. Running and contact sports should be avoided for up to 12 weeks depending on the type of surgery After 6 Months The residual swelling should now be slight if not completely resolved. You should now be starting to get the full benefit of the surgery. You should be able to wear most shoes. The swelling may however continue until about a year following surgery. Sometimes the forefoot remains permanently slightly swollen. We do not recommend buying new shoes until about 6 months after surgery due to the swelling. Stitches / Wound You will have your dressing (with or without plaster) on for about two weeks. A small amount of oozing is to be expected. We will take out stitches that seal the wound after about 14 days at your outpatients appointment. Personal hygiene Your wound dressing (and plaster if you have one) need to be kept dry. If showering or bathing, we recommend that you cover your foot with a plastic bag, which you will be given details of in the plaster room. Diet You do not usually need to follow a special diet. If you need to change what you eat, we will give you advice before you go home. Exercise When you can exercise depends on your individual operation. You consultant will discuss this with you. Sex You can continue your usual sexual activity as soon as you feel comfortable. Driving You cannot drive with a plaster on. When the plaster is removed you should not drive until you feel confident that you could perform an emergency stop without discomfort – probably at least six weeks after your operation. It is your responsibility to check with your insurance company. Work How long you will need to be away from work varies depending on: o how serious the surgery is; o how quickly you recover; o whether or not your work is physical; and o whether you need any extra treatment after surgery. Most people will not be fully back to work for eight weeks. Please ask us if you need a medical sick note for the time you are in hospital and for the first three to four weeks after you leave. You should contact your family GP or Primary Care Centre if:  Your wound continues to bleed. Surgical information procedure leaflet Bunion Surgery

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 

Your wound becomes increasingly painful or you get reduced sensation or pins and needles, which is not relieved by elevation. You become unwell (including a high temperature) following your operation or notice any foul smell from beneath the plaster.

Outpatient appointment Before you leave hospital we may give you a follow-up appointment to come to the outpatient department, or we will send it to you in the post.

Contact details If you have any specific concerns that you feel have not been answered and need explaining, please contact the following. Worcestershire Royal Hospital  Hazel Unit Nursing Staff (phone 01905 760266) Alexandra Hospital  Ward 16 Staff (phone 01527 512104) Kidderminster Treatment Centre  Ward 1 Nursing Staff (phone 01562 512356) Other information The following internet websites contain information that you may find useful.  www.patient.co.uk Information fact sheets on health and disease  www.rcoa.ac.uk Information leaflets by the Royal College of Anaesthetists about 'Having an anaesthetic'  www.nhsdirect.nhs.uk On-line health encyclopaedia  www.worcsacute.nhs.uk Worcestershire Acute Hospitals NHS Trust Patient Services Department It is important that you speak to the department you have been referred to (see the contacts section) if you have any questions (for example, about medication) before your investigation or procedure. If you have any concerns about your treatment, you can contact the Patient Services Department on 0300 123 1733. The Patient Services staff will be happy to discuss your concerns and give any help or advice. If you have a complaint and you want it to be investigated, you should write direct to the Chief Executive at Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD or contact the Patient Services Department for advice.

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Please contact Patient Services on 0300 123 1733 if you would like this leaflet in another language or format (such as Braille or easy read).

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Comments We would value your opinion on this leaflet, based on your experience of having this procedure done. Please put any comments in the box below and return them to the Clinical Governance Department, Finance Department, Worcestershire Royal Hospital, Charles Hastings Way, Worcester, WR5 1DD.

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