Patients

Insurance / Self Pay

Self-pay

Initial consultation: £175.00
Follow-up consultation: £125.00

The cost of a surgical procedure is set by the hospital.

Pre-surgery Information

Before you arrive for your surgery

  • Please have a shower or bath.
  • Do not put any creams, lotions or talcum powder on your feet.
  • Please cut your toe nails if they are long
  • Remove nail varnish on fingers and toes

Local Anaesthetic

If you are having a local anaesthetic you will be awake throughout the procedure. You are welcome to bring in a personal stereo, MP3 player or a book to read.

It is important that you continue to take any medication as normal, unless otherwise advised. If you are on medication for asthma or angina (e.g. inhalers or nitrolingual spray) please bring these with you.

Please have something to eat and drink before arriving at the hospital on the day of your operation.

General Anaesthetic

If you are having a general anaesthetic please follow the advice provided to you by the anaesthetic team.

Clothing and jewellery

  • There is no need to bring nightwear as a hospital gown will be provided.
  • Please wear loose fitting clothing, for example a skirt, shorts or wide legged trousers as the dressing applied after surgery will be bulky.
  • We will provide you with a surgical shoe to wear. Please bring a flat heeled shoe or trainer for your other foot.
  • Please remove all items of jewellery (including body piercings) as cautery used during surgery can cause skin burns if metal is left in contact with the skin
  • Remove any nail varnish.

Home support

Please arrange for someone to accompany you home from the hospital. You will not be able to drive or use public transport.

If you are not staying in hospital after your surgery it is pre-requisite that you have someone to stay with you for the first night, you have sufficient home support and a telephone in case of emergencies.

In theatre

If you are having a local anaesthetic you will be awake during the operation but a screen will be placed over the table so that you cannot see. A tourniquet will be applied, usually around the ankle, to keep the blood away from the foot. If you have had an ankle block or injections directly into the foot you will feel the tourniquet as tight around This can sometimes feel tight and slightly uncomfortable to start with but the discomfort usually settles down.

Following surgery

You will be returned to your room and will be discharged later. During this time observations will be taken and a post-operative shoe fitted and painkillers will be prescribed.

When you are discharged you will need to travel straight home sitting on the back seat of the car with your foot elevated.

Bathing

You will need to keep the dressing clean and dry. You can wash by having a bath but only with a limbo cast cover over the foot. These covers will prevent water reaching the dressing; a plastic bag with tape is not a suitable alternative. These covers can be purchased through limbo: https://limboproducts.co.uk/ (01243 573 417). It is not advisable to shower as this would put more pressure onto your foot and there is a risk you could slip and stub the foot which would not only be very painful but could damage the surgery site, fixation etc.

Work

You will need complete rest for two to three days following surgery.

The length of time that you must take off will depend on your recovery and type of work. A period of between two and eight weeks is expected, depending on the type of procedure. A sickness certificate, if required, will be provided. Please inform Mr Larholt on the day of the surgery if one is required

Thank you for reading this fact sheet, we hope it has been helpful. If you have any further questions, please contact us.

Post-surgery Information

Following your procedure it is reasonable to expect a degree of pain or discomfort. The following instructions are for your benefit to help minimise swelling and pain. Please read and follow carefully the advice given.

After your operation

You will need to go directly home after your operation, sit in the back of the car with your foot raised across the back seat.

Once home, you must rest for at least 24 hours on a bed or sofa with your foot raised slightly above the level of your hip with a pillow or cushion placed under the foot and if comfortable your knee. Do not sit with your foot down or your legs crossed, as this will cause your foot to swell and become painful.

No walking is permitted (except to the toilet) within the first 24 hours. This is important to help reduce pain and swelling.

While you are resting with your leg raised you must carry out the exercises described in the preventing deep vein thrombosis (DVT) information sheet.

As the local anaesthetic begins to wear off you may experience some discomfort. Take your painkillers once you get home, if you have not already taken a dose in hospital, do not wait until the anaesthetic begins to wear off and take the medication as directed and do not exceed the maximum dose. You should continue taking them for at least the first three days following your operation. This will considerably reduce the likelihood of suffering undue post-operative pain.

Pain varies with operations and it is normal to have pain for the first three days. It should begin to improve by the third day, however if you experience severe pain or are concerned about your foot please contact the hospital who will contact Mr Larholt.

Ice packs may be placed at the front of the ankle over the bandage or behind the back of the knee for ten minutes, no longer, and if behind the back of knee wrapped in a tea towel. This may be repeated every hour to help reduce excessive discomfort and swelling. You might notice a small amount of blood on the bandage, this is normal. However, if the bandage becomes excessively stained with blood, it will need to be changed so please contact Mr Larholt.

Always wear your post-operative shoe when walking to protect your foot and be compliant if you are non or partial weight-bearing.

Two days after surgery

You may move around the house for a few minutes every hour, resting with your foot and leg raised afterwards. If your foot starts to become painful you are overdoing it and you must rest. Walking may be gradually increased on the following days but it is important that you do not stand for long periods. Continue to rest and raise your foot after walking.
Do not disturb or remove your dressing and keep it clean and dry. If the bandage appears to be slipping off apply a little additional adhesive tape to keep it in place. If the dressing is coming loose it is often a sign you are doing too much.

Do not get the dressing wet. Do not shower or bath unless a Limbo or equivalent dressing protector is used (Cast or dressing covers can be obtained by phone 01243 573 417 or online at www.limboproducts.co.uk). Do not try to attempt this with plastic bags wrapped around the foot. If you get the dressing wet, you run the risk of introducing an infection into the wound, should this happen please contact Mr Larholt.

You will be reviewed one week or sooner following your surgery.

After seven days

The dressing will be changed and the wound checked. Following he wound check you must continue to keep the dressing clean and dry.

After fourteen days

By this time the skin has healed (for stitches on the sole of the foot these stay in place for up to three weeks). The stitches are removed or trimmed if absorbable stitches have been used.

After some surgical procedures you may be able to return to wearing normal footwear, however this is not always the case and you will be advised at your dressing appointment.

Four to six weeks

Four to six weeks after surgery your foot should be more comfortable and begin returning to normal. Depending on the type of operation you should be able to wear a lace-up running trainer. There may be some swelling, particularly towards the end of the day. This is normal and to be expected as feet and legs are more prone to swelling.

The procedure dictates your recovery time and it is advisable to re-read the information sheet about your operation.

After six months

The residual swelling should be slight, if not completely resolved and the scar line beginning to fade. However, you will continue to heal for up to 12 months after surgery.

Returning to work

Ask your surgeon about the most suitable time to return to work, as this varies depending on the type of procedure you have had and the nature of your job.

Emergency out of hours contact information

Please telephone 0207 205 2928

IF YOU DEVELOP

  • Severe pain, swelling or redness in your calf, of either leg
  • You develop pain away from the site of surgery (e.g. in the calf or chest)
  • You develop flu-like symptoms (e.g. high temperature, lethargy etc).

GO DIRECTLY TO YOUR LOCAL A&E DEPARTMENT

Extracorporeal Shockwave Therapy (ESWT)

Shockwave therapy is a non-invasive treatment that passes shockwaves through the skin to the area of damage to stimulate a healing response. Within the foot and ankle ESWT is indicated in the management of plantarfasciits and tendon pathology especially the Achilles tendon.
Shockwave treatment is performed once a week over three consecutive weeks with each treatment lasting approximately ten minutes.

ESWT is safe but the treatment can be painful and following treatment bruising and discomfort, which may last a couple of days can develop.

For both conditions significant improvement can take up to three months to occur

The treatment code for planatarfasciitis is T5780
The treatment code for Achilles tendinopathy is T7250

It is important to know that not all insurers cover this treatment so you may wish to check with your provider.

Video of shockwave for plantarfasciits

The Surgery

In most cases surgery can be performed under local (awake) but for certain procedures general anaesthesia is required. The type of anaesthetic is entirely at your discretion. For a general anaesthetic a local anaesthetic will also be given so that when you wake your foot / leg will be numb and allow you to start your pain killers well before the anaesthetic wears off.

As with all types of surgery complications can occur and whilst the risks of developing a complication are low they do still occur and can affect the recovery time and therefore the return to activity and work. Some complications are more serious than others and certain complications require further surgery. With this in mind surgery for cosmetic reasons should be avoided. Surgery is indicated when there is such an effect on a person’s activities of daily living and quality of life that it prevents them from undertaking activities etc. that they enjoy.

The recovery from an operation is dependent on the type and number of procedures and this is also the case for the complications.

Below are the complications that can occur following foot surgery:

Complications Associated With Surgery

Complications following podiatric surgery are infrequent but it is important that you understand they can occur and if they do can influence your return to work, sporting activities etc. Most complications are short term and resolve with non-surgical care, however some complications can be long term and require long term treatment with medication e.g. Complex Regional Pain Syndrome (CRPS), chronic pain syndrome. Other complications may require reoperation e.g. prominent fixation, haematoma, painful non-union. Complications can be divided into general (associated with all types of surgery) and specific (related to the procedure that you are having).

Infection

Infection rates are estimated at less than 2% of all surgeries. If infection does develop it is generally superficial, usually treated with antibiotics and resolves very easily. However, although uncommon, infection can get deeper into the bone which is a much more serious complication. This may require a period of hospitalisation, possibly further surgery and a longer course of antibiotics. In rare instances, the infected bone may need removing which could affect your foot permanently. Any infection has the potential to be fatal and foot surgery is no exception. Fortunately, this is extremely rare.

Delayed healing

Although you will be given an estimate as to how long the recovery process will take delays in healing of the soft tissue or bone can occur. Generally, the soft tissue will heal although bone sometimes does not heal properly (see non-union). You should remember that the information you have been given is a guide and you should allow for this when planning your recovery. Smoking can increase your risk of delayed wound healing so if you can stop or reduce the number of cigarettes you smoke each day your chances of delayed wound healing will reduce.

Swelling

Swelling is always present after surgery as it is part of the normal healing process. Swelling may be minimised by following the post-operative instructions. Some patients experience prolonged swelling of the foot after surgery (5-10%). Smaller operations usually give rise to minimal swelling whereas larger operations may be associated with greater swelling and for longer. In a few cases, swelling may be present long term but this is usually painless although can affect shoe fit.

Scarring & Keloids

Following any deep incision to the skin scarring occurs. At first the scar is often a different colour from the surrounding skin but over time the colour fades and it blends with the surrounding skin. On occasion the scar can become enlarged, lumpy or even keloid in type (a scar which is raised and extends beyond the margins of the original incision). A keloid scar is rare but is associated with a history of poor scarring as well as black skin. It is important that you let Mr Larholt know if you have had problems with scarring as certain types of suture material can be used to reduce the risk, however it can never be completely mitigated.

Fixation problems

Any metalwork (pins, screws, plates or metallic implants) used is normally left in place, but once the bone is healed the metalwork has done its job and is no longer required. In approximately 10% of patients the metalwork backs out of the bone and becomes prominent beneath the skin. If this is the case and it produces irritation it needs to be removed.

Avascular Necrosis

This is a rare event and occurs when part of the bone loses its blood supply. This may occur after an operation or even from simple trauma. The bone may ‘weaken’ and change shape. Usually the blood supply will return to the bone with time. Sometimes the bone is damaged resulting in problems such as secondary arthritis.

Bony Non-Union

This term refers to the situation where bone fails to fuse (join) together. The percentage risk varies greatly depending on the bone or joint in question e.g. Bunion surgery risk is less than 1% but this risk increases with fusion of the joints of the rearfoot.
Smoking has been shown to increase the risk of non-union rate by 2.7 times in comparison with a non-smoker. Non-union is reduced by being compliant, especially if you have been advised to be non-weight bearing

If a non-union occurs it can be managed in several ways:

  • Allow more time for the bones to knit together, use treatments which can encourage bony healing e.g. bone stimulators
  • Re-operate on the bone / joint using a graft of bone from another part of your foot / body
  • If there are no symptoms monitor the foot

Bony Malunion

This is where the fusion of the bones is in a suboptimal position and can be associated with over or under correction of the deformity. Malunion can produce problems with transfer pressure and possible recurrence of deformity

Joint stiffness

Surgery near joints e.g. bunion surgery can lead to some joint stiffness. The immobilisation following surgery and healing of the deep tissues near to the joint may be the underlying cause. Postoperative exercises will be given to you at your redressing appointment to reduce the risk of joint stiffness developing.

Bleeding / haematoma

There may be some bleeding postoperatively. Infrequently, a collection of blood may form in the deeper tissue (haematoma) this can produce pain and is often managed by expressing the haematoma, on occasion further surgery may be required. This problem is infrequent and occurs in less than 1% of patients.

Loss of sensation

It is possible for you to lose some sensation around or away from the surgical site after surgery. Great care is taken to avoid damage to nerves and it is rare for a major nerve to be damaged. If nerve damage does occur it is more often the tiny nerves to the skin which may leave an area of skin with reduced or altered sensation. This loss of sensation can sometimes recover with time but this is not always the case.

Transfer pressure

This refers to discomfort under the ball of the foot (metatarsal heads). Surgery to the foot may alter the pressure under the forefoot and increase discomfort here. Sometimes this is treated with shoe inserts and rarely by further surgery.

Altered Walking Pattern

Following foot surgery, patients naturally favour the other foot and often walk on the opposite side of the foot which had the operation i.e. outside of the foot if the operation was on the inside and vice versa. This is usually temporary and once the foot becomes more comfortable you begin to walk normally.

Deterioration of symptoms

The vast majority of patients undergoing foot surgery have less discomfort following their operation. Occasionally however, some patients have no improvement of symptoms and more rarely, some patients have more discomfort. It is for this reason that foot surgery for cosmetic reasons is not recommended. It is always possible to have a straighter toe or foot which hurts more.

Failure of the operation

On average at least 90% of patients are pleased with result of their surgery. The number would depend on the type / complexity of the operation and health of the patient. The important point to note is that despite the very best efforts of the team we cannot guarantee outcomes. This is true of any patient undergoing any surgery. In some operations (e.g. bunion surgery) full correction may not be achieved although symptoms are usually improved.

Failure of the Local Anaesthetic

A small number of patients do require additional local anaesthetic during surgery. In rare circumstances some patients do not respond to local anaesthetic injections and we cannot proceed with surgery (< 1 case per 100). In these situations surgery may have to be postponed. Whilst local anaesthetic drugs are considered very safe there are some potential side-effects such as: o Allergic reaction to the anaesthetic (< 1 person per 10,000) o Toxic reaction to the drug (< 1 person per 2000 across all injections) o Irritation or damage to the nerves at the injections sites o Bruising around the injection site (1 person in 20)

Postoperative pain

Most people find they have mild to moderate pain following their surgery. The level of pain experienced varies greatly between individuals and can somewhat be dependent on the type of painkillers a person is or is not able to take. Pain generally lasts for the first three to four days and is made worse by activity (resting with your leg elevated is important). After this period your pain should improve, if however, you are still experiencing pain which is not being relieved by rest or analgesics you need to contact the department. You will be provided with instructions on what to do should you have any problems immediately after your surgery.

Deep Vein Thrombosis (DVT)

Deep vein thrombosis is a condition where a blood clot develops in the veins of the leg. In foot surgery this is an uncommon event 0.5% of patients. However, if it develops and is left untreated it can become fatal. Your DVT risk will be assessed prior to your surgery. The majority of patients are low risk and do not require any preventative measures during the operative period. Patients at risk of DVT will be fitted with a compression stocking (when on the ward prior to the operation) and may require the administration of an anticoagulant type medication. This will all be discussed with you at your consultation prior to your surgery. DVT often presents with a painful, swollen calf as well as redness of the leg and prominent veins on the top of the foot. If you suspect you may have a DVT you need to attend your local A&E department immediately.

Complex Regional Pain Syndrome (CRPS)

This is a rare condition, which may occur even after even minor injury. It is not always associated with surgery. The condition is very uncommon and can occur after any type of operation. Persistent / chronic pain develops as well as swelling / colour changes and changes to bones of the affected limb. Treatment requires early diagnosis and referral to a pain specialist. Complete resolution of CRPS may not always be possible. This is not a predictable event but fortunately uncommon (0.1%).

Loss of tissue / part of foot / limb

This would be a very rare complication for the vast majority of patients having foot surgery. However, it is possible for injury to blood vessels and or serious infection to lead to loss of tissue which can involve some or all of the foot. The risk of this for healthy patients would be much less than 0.5%.

Death

This is extremely rare and most unlikely to happen, but as with all surgical procedures it remains a remote possibility e.g. result of an anaphylactic shock (severe allergic reaction) to an injection. The podiatric surgery team is trained, and the department equipped, to deal with such an emergency.

Recurrence of the original problem

It is possible for a problem to recur postoperatively for a few operations. For example a bunion corrected and looking perfect at two weeks postoperatively may deteriorate over time. Recurrence varies greatly for individual operations.

Shoe difficulty

Although every effort is made to give as good a result as possible, you may still have difficulty with shoes and, in rare cases have less shoe choice after the operation.

The vast majority of patients who undergo foot surgery under the care of a Podiatric surgeon have an uneventful experience and are pleased with the result of their surgery. This information is designed to make sure that you are fully aware of the potential for complications, despite their low frequency, and the impact that they can have on your recovery and return to work/activities. Foot surgery for cosmetic reasons should be very carefully considered.

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