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Department of Trauma and Orthopaedics Surgical procedure information leaflet Diagnosis: Forefoot pain (metatasalgia) and/or Hammer toe (claw toe) 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 or soft tissue of the forefoot. Lesser toe procedures PIPJ (proximal interphalangeal joint) fusion This is to correct ‘claw toe’ and involves straightening and fusing the middle joint of your toe. This will be held in place by a wire which will be removed in clinic after approximately four to six weeks. You will have a bandage and will have to walk on your heel for approximately four to six weeks. Distal Phalanges Proximal Phalanges 1st Metatarsal 1st, 2nd 3rd Cuneiform Medial, Intermediate, Lateral DIPJ (distal interphalangeal joint) fusion This is to correct ‘hammer toe’ and involves straightening and fusing the end joint of your toe. This will be held in place by a wire which will be removed in clinic after approximately four to six weeks. We may also need to cut the tendons to straighten your toes. You will have a bandage and will have to walk on your heel for approximately four to six weeks. Stainsby procedure This procedure involves removing the joint altogether and reattaching the tendon. This will be held in place by a wire which will be removed in clinic after approximately four to six weeks. After stainsby procedure you may be in plaster for four to six weeks and will be able walk on your heel during this time. Weils osteotomies Weils osteotomy is used to treat rheumatoid arthritis and prominent metatarsal heads. It involves cutting and repositioning of the metatarsal heads, which will be held into place with Surgical information procedure leaflet Hammer Toe Surgery 1 of 9 Version 1.5 Expiry date:21/05/2017 WAHT-CG-029 a screw. After Weils osteotomy you will be in plaster for six weeks and may walk on your heel during this time. After this time you may walk normally but may require an orthotic insert in your shoe. Shaving of the metatarsal heads This procedure is done to treat rheumatoid arthritis and prominent metatarsal heads. It involves shaving (cutting) the bone of the metatarsal heads. After this procedure you will have a bandage for approximately two weeks and you may walk on your heel during this time. After this time you may walk normally but may require an orthotic insert in your shoe. 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 Blood clots (for example, in the legs or occasionally in the lung). Those specifically related to forefoot surgery include problems with: o Damage to the small nerves or blood vessels in the foot (neuro vascular damage resulting in numbness or delayed healing). o Failure of procedure (resulting in further surgery). o Non-union of bone (only applies to fusion). o Complications during surgery resulting in loss of toe. o Weight transfer to the second toe (a corn under the second toe). o Floppy lesser toes o Malunion – poor position of toes after surgery. o Slightly high riding toes. 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 management of Hammer toe include: Surgical information procedure leaflet Hammer Toe Surgery 2 of 9 Version 1.5 Expiry date:21/05/2017 WAHT-CG-029 Modify foot wear (allowing more toe room) Orthotics (placing pads over the calluses to relieve the pressure) 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. 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 Surgical information procedure leaflet Hammer Toe Surgery 3 of 9 Version 1.5 Expiry date:21/05/2017 WAHT-CG-029 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. 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. Surgical information procedure leaflet Hammer Toe Surgery 4 of 9 Version 1.5 Expiry date:21/05/2017 WAHT-CG-029 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 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. Surgical information procedure leaflet Hammer Toe Surgery 5 of 9 Version 1.5 Expiry date:21/05/2017 WAHT-CG-029 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 or 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. 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 Surgical information procedure leaflet Hammer Toe Surgery 6 of 9 Version 1.5 Expiry date:21/05/2017 WAHT-CG-029 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 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. 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. Surgical information procedure leaflet Hammer Toe Surgery 7 of 9 Version 1.5 Expiry date:21/05/2017 WAHT-CG-029 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. 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). Bengali Urdu Surgical information procedure leaflet Hammer Toe Surgery 8 of 9 Version 1.5 Expiry date:21/05/2017 WAHT-CG-029 Portuguese Polish Chinese 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. Name of leaflet:________________________________________ Date:______________ Comments: Thank you for your help. Surgical information procedure leaflet Hammer Toe Surgery 9 of 9 Version 1.5 Expiry date:21/05/2017 WAHT-CG-029