A procedure

Day of the procedure

Admission:

You will be admitted to the orthopaedics department. A team including the orthopaedist, senior nurse, nursing staff, care providers and logistic assistants are at your service to provide medical and nursing care. You can address any questions, comments or suggestions you may have to them.

A number of preparations must be made prior to the operation:

You fill in the case history form together with the nurse
The nurse provides you with general information about the department
The nurse marks the operating area with a permanent marker pen

If you feel anxious or nervous, ask the nurse during the admission procedure in the department for a tranquilliser, so you can prepare for the procedure more comfortably. The time the operation will be performed depends on the day’s operating schedule, which makes it difficult to provide you with an exact time. When leaving for the operating theatre you will be dressed in a hospital gown and hat.

You should leave any rings and other jewellery at home, dental prostheses, lenses and piercings must be removed. Nail varnish is not allowed and must be removed in advance.

Anaesthetic:

In principle, we perform the procedure under local anaesthetic (popliteal nerve block) in which only the leg is anaesthetised. However, if you are too nervous it is always possible to receive calming medication or have a general anaesthetic. You will be called to the operating theatre earlier and after the local anaesthetic is administered you will have to wait a short time before the procedure is performed to allow the anaesthetic enough time to work.

Procedure:

One or a combination of techniques is used. During the procedure a tourniquet will be applied around your upper or lower leg. This means the operation is performed using bloodless surgery. Depending on the procedure performed you will be fitted with an open cast or compression bandage immediately after the procedure. In the case of a cast you must not put any weight on the limb for the first ten days, in other cases you will receive a special shoe and can start putting weight on the limb and walking sooner. Following the procedure you will remain in the recovery room for a while and usually be taken back to the department later on. The local anaesthetic will work for between ten and sixteen hours and will gradually wear off. In the meantime you will be given painkillers to suppress the pain in time. If you still experience too much pain, it is possible to administer additional pain medication. The nursing staff will check your blood pressure, pulse, temperature and blood circulation at regular intervals. An intravenous drip will also be inserted in your arm to supply you with the necessary fluids and any pain medication. Place your leg in an elevated position and make sure you keep the operated foot and leg straight.

Day after the procedure = day you are discharged

In the morning you can wash in a wash basin or at the sink. If you find this difficult ask for assistance. If necessary wound care will be carried out by a nurse. If there are no problems the intravenous drip can be removed. Today you are encouraged to move around. The physiotherapist will teach you how to walk using crutches. If you have been fitted with a cast, you must not put any weight on it, but can put some weight on the limb if you have been given a walking boot. You can usually go home in the afternoon, after your treating doctor has visited you. Don’t forget to prepare the necessary documents such as a certificate for work, for your health insurance company, and so on, so that he or she can fill them in during the visit. You will need to come for a consultation two weeks after being discharged. The nurse will arrange the appointment for the consultation with you when you are being discharged. The nurse will also provide you with a prescription for home care as well as a prescription for medication. At home you may continue to take paracetamol 1g up to 4x/day (every six hours) and possibly extra Ibuprofen 600 mg up to 3x/day during the first two or three days if necessary. The stitches used are almost always dissolvable, which means the thread will dissolve after a certain period of time and does not need to be removed. Important aspects for you: your daily phlebitis injections, frequently apply ice and elevate the leg to prevent swelling of the lower leg. If you want to change the bandage, do it properly (or have it done by a specialist) because the bandage is important for the recovery of the soft tissue.

Complications

As in any surgical procedure these involve:

Infection
Post-operative bleeding
Thrombophlebitis: you will receive injections in the abdomen to prevent this

More specifically for hallux valgus procedures:

Hallux valgus relapse: this is usually the result of an inadequate correction during the operation or of wearing inappropriate footwear after the procedure
Hallux varus: the big toe now points away from the little toe (inwards), which is caused by an overcorrection
Shortening of the metatarsus of the big toe, possible dorsiflexion (the big toe bends upwards).
Swelling of the foot: very common and will usually persist for between two and four months. The swelling usually increases during the course of the day.
Non-union: failure of the corrected bone to fuse. If you stop smoking you will considerably reduce this risk!

Recovery

The duration of your recovery period largely depends on whether or not you were fitted with a cast. The cast stays in place for between three and six weeks, and you must not put any weight on it for the first ten days. The cast is removed ten days later and you will be fitted with a walking boot. From this point you can put weight on the limb (first partially and after a while your full weight). An X-ray is taken when the walking boot is removed to check the results. Afterwards we recommend you wear an open shoe or trainer. If you received a special post-operative shoe you can put weight on it quickly, and we also advise you wear open shoes or trainers when this shoe is removed. It is also important to train the mobility of the toes. It is particularly important to devote attention to moving the big toe upwards (this means: moving it towards you = dorsiflexion). Once the wound has healed and the cast has been removed, we also advise you to practise moving the toes in water twice a day. Alternating hot and cold baths (alternating placing the foot in a hot and cold bath, for one minute each time) can help limit any swelling. Nevertheless, you must bear in mind that swelling of the foot is not abnormal the first two to four months. After the cast or bandage has been removed you can hydrate the foot by applying a foot cream or moisturiser once a day (blue pot of Nivea cream). This will make the skin supple and improve the scar’s appearance.

When you start walking without your cast or walking boot, it is important you roll the foot properly. Place your heel down and transfer the weight to the mid foot and finally completely roll off the forefoot and come to rest on the toes. Practise this gait barefoot, using short steps and a slow pace. Due to it being immobilised in the cast the ankle joint may be stiff. Stretching the Achilles tendon and cycling (on a home trainer) can resolve this.
Some patients are advised to follow physiotherapy during their rehabilitation. The physiotherapist can administer additional lymph drainage and make the corrected joint mobile more quickly.
Lastly, it is important to keep the scar out of direct sunlight for between eight and twelve months.

This content was written by : Dr. Stijn Muermans, Dr. Mark van Dijk, Dr. Jan Van Oost