Rheumatoid Forefoot Reconstruction

Rheumatoid Forefoot Reconstruction Exceptional healthcare, personally delivered Following your consultation with a member of the Foot and Ankle tea...
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Rheumatoid Forefoot Reconstruction

Exceptional healthcare, personally delivered

Following your consultation with a member of the Foot and Ankle team you have been diagnosed as needing a forefoot reconstruction. This leaflet aims to give you additional information about your condition and the treatment. It is designed to give you some general details about the recovery from surgery if necessary and the common risks and complications. This leaflet is not for self diagnosis. Please ask your surgeon if you have any further questions

What is it? This is an operation to correct the severe toe deformities that occur in the feet of people with rheumatoid arthritis and similar conditions. Occasionally it is done for deformities caused by other conditions.

Why would it be performed? The surgery is carried out for severe toe deformity with pain and problems with shoe wear. Usually people have pain under the ball of their feet that is often described as “walking on pebbles”. Surgery would only be advised if the use of wide shoes with plenty of toe-room and insoles have not been helpful. One foot can be operated on at a time or, if both feet are affected, both can be operated on at the same time if that is your preference.

What does the operation involve? The main joint of the big toe is fused. This makes the toe straight, stronger and able to take its share of weight in the foot. A cut is made on the side of this joint, the arthritic joint is cut out and the bones fixed together, usually with two screws. The joint is stitched up.

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There are 2 ways to reduce the pain under the ball of the foot: „„ Each small toe is straightened by a method called the “Stainsby operation”. Cuts are made over the tops of the toes. A piece of bone is removed from the base of the toe to relax it and allow it to drop into the correct position. The ligaments and tendons of the toe are then repaired and the toe is usually held in position with paper stitches. Occasionally a pin is required to hold the toe in position. „„ An incision is made across the ball of the foot and the metatarsal heads from the small toes are removed. The skin is then stitched up. At the end of the operation a soft, firm dressing is applied.

How long will I be in hospital? Your foot will probably swell up after the operation and we will keep you in until the swelling is going down, the wounds are clean and you are comfortable enough to start getting about. You will be in hospital for at least an overnight stay and may be longer depending on your mobility.

Will I have to go to sleep (general anaesthetic)? The operation can be performed under general anaesthetic (asleep). Alternatively, an injection in the back, leg or around the ankle can be given to numb the foot while you remain awake. Your anaesthetist will advise you about the best choice of anaesthetic for you. In addition, local anaesthetic may be injected into your leg or foot while you are asleep to reduce the pain after the operation even if you go to sleep for the surgery. You will also be given pain-killing tablets as required. Rheumatoid Forefoot Reconstruction

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Will I have a plaster on afterwards? You will usually have a firm bandage on your foot for the first 2 weeks. At this stage, the sutures will be removed at the nurseled clinic at the hospital. You may require a plaster or splint to be applied, but this will be discussed with you.

What will happen afterwards? The big toe is fixed in one position. This will limit your choice of shoes, especially heel heights and your surgeon will agree the position of the toe with you before surgery. The small toes will be straighter and rather floppy, especially at first. The calluses on the sole of your foot will gradually disappear, usually after about 6 weeks. If you have pins in your toes, these will be removed after 6 weeks.

How soon can I.... Walk on the foot? You can start to walk on your heel straight away but as little as possible. You must elevate it as much as possible. The stitches are removed 2 weeks after your surgery in the nurse-led clinic and you can then be more active, but you should still walk putting your weight through the heel.

Go back to work? Most people find they cannot work until the splint or plaster has been removed after 6-8 weeks. This is not a hard and fast rule. If you only have an operation on one foot, can get about on crutches, do a desk job and can get to work, you could probably go back to work after about 3 to 6 weeks. 4

Rheumatoid Forefoot Reconstruction

Drive? Once your splint or plaster has been removed, you may be able to start driving again. You must be comfortable and not too stiff before trying to drive. Start by sitting in the car and trying the pedals. Then drive round the block. Drive short distances before long ones. If you cannot safely make an emergency stop your insurance will not cover you in the event of an accident. Ask your surgeon or foot and ankle nurse when it is safe for you to drive again.

Return to normal activities? You can start gently exercising your foot and walking further each day when you no longer need to use a splint or have a plaster. When you are comfortable doing this, you could start increasing your activities. Most people with severe arthritis will have some limitations on the kind of exercise they can take, but a well-corrected foot will not add to your limitations.

What can go wrong? „„ Infections in the wound, plaster problems and minor damage to the nerves of the toe can occur in any foot surgery. Usually these are minor problems that get better quickly. After a forefoot reconstruction, the wounds on top or bottom of the foot tend to look quite messy for 2-4 weeks because of the amount of stretching of the skin, but usually settle well after this time. „„ The foot tends to swell up quite a lot after surgery. Swelling is part of your body’s natural response to any injury and surgery is no exception. Your foot is at the bottom of your body, so fluid tends to collect in its tissues (“at the bottom of the slope”) and cause swelling. People vary as to how quickly this swelling disappears after an operation and 6 months is not unusual. If you are not having undue pain or inflammation there is probably nothing to worry about and you can afford to give it time. Rheumatoid Forefoot Reconstruction

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„„ In 1 in 20 forefoot reconstructions, the big toe fusion fails to fuse. Only half of these cause problems, but, if they do, you may need another operation. „„ The big toe is now fixed in one position. Sometimes the stiff toe rubs a bit on shoes or puts stress on the small joint in the middle of the toe. „„ In cases of severe deformity, it may not be possible to obtain complete correction of the toes but significant improvement in symptoms is often achieved. „„ All patients will be assessed for the risk of Deep Vein Thrombosis before going to surgery and preventative precautions will be taken, based upon this assessment.

References and Further Information The figures for complications given in this leaflet have been taken from information produced by the British Orthopaedic Foot Surgery Society using audits from all areas of the UK. The British Orthopaedic Foot Surgery Society web site is available at: http://www.bofas.org.uk/PublicArea/PatientAdvice/tabid/85/ Default.aspx [Last Accessed March 2011] Mann, Coughlin and Saltzman (2007) Surgery of the Foot and Ankle 8th edition , Elsevier, Philadelphia Myerson , S (Ed) (2000) Foot and Ankle Disorders, Saunders, Philadelphia NHS Constitution. Information on your rights and responsibilities. Available at www.nhs.uk/aboutnhs/constitution

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If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice. © North Bristol NHS Trust. This edition published May 2014 . Review due May 2016. NBT002473