Recovering from Midfoot Fusion Surgery. Graham’s Story

Graham had a foot operation to fuse the midfoot as well as correct the forefoot. It was a major operation that needed him to be non weight bearing for 6 weeks followed by weight bearing for 4 weeks.

He wrote some notes for a close friend who was due to have similar surgery to help guide them through the recovery process. I found it really interesting reading and Graham was happy for me to share his words with others. The recovery times and restictions would be similar if you are having an Ankle or Subtalar Fusion. There are fewer restrictions in those having surgery for a very diseased tibialis posterior tendon or complicated achilles tendon surgery

Graham’s Story: Graham writes about his experience with some pointers which he would like to share with you.

PREPARATION BEFORE THE OPERATION

Much can be done to prepare you and your home for your return from the hospital

There are various bits of equipment that can be hired or purchased that can make life easier:

My surgeon recommended that I Google “knee scooter”. On doing this there were quite a few results but I thought the one available from www.strideon.co.uk was the best – it’s easy to steer around tight corners at home and is not too heavy to lift over threshold steps, up curbs etc when out. You just lift the front handlebars and manoeuvre it over any obstacles while hopping alongside it! Essentially, it costs £15.50 a week to hire plus £28 delivery. I hired it for 8 weeks although the surgeon said I only needed it for 6 (ie the non-weight bearing period). The firm itself is easy to get hold of and talk to on the phone – I did this to extend my hire period from the original six week non-weight bearing period to cover the next two weeks as well, because I thought that although I was then able to put my foot down and walk around the house (in the boot), I thought making the ¾ mile trip to the shops and back would be too much (even in the boot and with a crutch or two for assistance).

I used the scooter around the home as my main means of moving about– it makes moving around and holding stuff (eg a cup of tea) easy. Note: on crutches it is difficult/impossible to carry anything. I also used it to go down to the shops and have a Costa coffee (most days). I don’t know whether or not you have shops/cafes close enough to “scoot” to or not, but getting out under my own steam was a “lifesaver” – especially on days when my wife was out all day at work! I got many comments from all sorts of people saying what a good idea it was and that they wished they had known about it when they had a foot op. I found that women (of a certain age!!) in particular wanted to have chats with me……… which was somewhat disconcerting!

I also used it for ironing (standing side on), cooking and washing up from about two weeks post op. This is probably not strictly advised but it seemed to work ok for me – providing you put the handbrake in the ON position. CAUTION – I never tried to lift pans of boiling water or anything else heavy or hot, for example from cooker to sink when using the scooter.

I had the scooter delivered two days after the op. This was probably a slight mistake. In hindsight, two days before the op would have been better, giving me a chance to assemble it (not too difficult but requires a little patience) and have a practice eg scooting on uneven pavements and getting over the front door step.

One of my golfing pals spotted a new Canadian invented product – www.peglegs.co.uk.

This product can only be purchased outright – about £165 including delivery. I had (only) a quick look at the website and this looks good if you plan to be on your feet all day, for example working in a shop. However, the fact that you have to strap it on to your leg in three places means it might be a bit of a nuisance if you keep getting up and sitting down. There is a money back guarantee if you happen to be undecided?? I did ask my surgeon about this product – he didn’t seem awfully impressed but didn’t say why, saying only that he thought a scooter was better.

You will probably need a pair of crutches even if you get a knee scooter as you will not want to carry the scooter up and down the stairs daily. Also, useful for quick trips out where you don’t want to go to the trouble of folding up and packing the scooter.

If anyone in your family or friends has a pair of crutches I suggest you get hold of them beforehand and have a practice – again I suggest Googling “How to use crutches” and putting the same phrase into YouTube. There are many websites, including the NHS one, and lots of clips on YouTube that show how to use them. The good advice (that I can remember) for stairs, is “good foot to heaven, bad foot to hell”!! The physio will explain.

NOW, THIS IS IMPORTANT………….. AND PROBABLY THE BEST PIECE OF ADVICE IN THIS WHOLE DOCUMENT……..WHILE MAKING A MANOEUVRE ON CRUTCHES CONCENTRATE SOLELY ON THAT MOVE. DO NOT ALLOW ANYONE TO TALK TO YOU AND DO NOT THINK ABOUT ANYTHING ELSE, because it’s all too easy to lose concentration, make a mistake and fall over – I did this once. I was trying to get over the front door step and into the house whilst talking to a golfing pal who had given me a lift home! You will have to be determined and single minded on this and if necessary tell the person to shut up. I did a parachute roll (yeah right, well almost) and only put a little bit of weight on my bad foot – see later for my thoughts on this slightly worrying occurrence.

Other stuff you may wish to consider getting:

Seal tight plaster cast protector for when having a shower (essential) – see

http://www.physiosupplies.com/sealtight-showerproof-leg-bandage-protector.html

Both my initial cast and the one I had applied at the two-week post op visit went from just above my toes (the toes were always exposed) to a couple of inches below the knee, so I needed the version that finished just below the knee. This is called the “short leg version” and costs £22.50 and was brilliant at keeping my plaster cast dry in the shower. You may want to wait until after op to see which one you want to order or ask at the pre-op consultation. Certainly for the first week I was happy to have an all-over wash at the sink, rather than attempt the “leap of faith” required to get into the shower.

Picker- upper – see website below – especially useful if you are not good at the golfer’s bend – ask physiotherapist if you can’t find a demonstration online – or cannot bend easily from the kneeling position whilst kneeling on the scooter to reach the floor.

Sock/stocking putter on-er – see website below. Although there will be lots of sites covering this and other useful stuff, you could look at site below as your “starter for ten”.

http://www.amazon.co.uk/s/?ie=UTF8&keywords=medical+aids&tag=googhydr-21&index=drugstore&hvadid=25754127176&hvpos

Raised toilet seat – Not sure, but I think this is only/mainly recommended for hip ops. However, as you will, almost certainly, be non-weight bearing on your operated foot, I think this would make life easier. Perhaps worth asking the physio you see after the op (who will make sure you are safe enough on crutches to be allowed to go home) and/or the surgeon.

Spare toothbrush and toothpaste – to keep downstairs. You will not want (believe me) to go up and down the stairs more than once a day until you become weight bearing, and this will allow you to clean your teeth after breakfast without making that trek!

A couple of pairs of, one size larger than normal, socks. This is for when the cast comes off completely and your foot is swollen – as I think it will almost certainly be – if in doubt ask your surgeon. Two pairs will give you socks (for the operated on foot) for four days, which should allow plenty of time for laundry!!

Physio Freeze packs – for when the plaster cast comes off. These will help reduce the swelling. Or you could use packs of frozen peas

Stools (as in sitting/kneeling on variety!) – basically as many as you have/can acquire/borrow/buy, positioned anywhere you normally stand for more than half a minute or so eg in shower, in front of sink washing or washing-up, cleaning teeth, brushing hair, applying make-up. Note: if the activity is on a different floor (ie up or downstairs) or even on the same floor you won’t be capable of moving these stools yourself whilst using crutches. The stools should ideally be at a height that allows you to keep your hips (more or less level) whilst kneeling your bad foot side on the stool. I also recommend that you have a towel, folded at least three times, or cushion, on each stool to rest your knee on – this really makes a difference to comfort. In the shower in particular I suggest you buy/acquire a purpose made, height adjustable, waterproof stool with suction cups on the feet. The only time I felt really vulnerable was showering (and mainly the process of getting in and out of the walk-in shower). Initially, I used an upturned plastic dustbin to kneel on whilst showering. This was not a good idea. A very good idea, however, will be to practice getting in and out of the shower using crutches – mine has a step and a lip. This means a hop (my so-called “leap of faith”!) and not that easy to do. Have someone close by, at least when first trying this manoeuvre.

A slip proof mat to go on the floor of the shower or a towel may help. Also practice getting out of the cubicle and back on to terra firma – you’ll want a (preferably non-slip) floor mat here too because the bottom of the crutches will probably be wet.

Make sure you have a shoulder bag/satchel – in other words a bag that you can use, hands free, to carry the needs (eg meds, book, glasses, empty cup) of the day/night, up and down the stairs. You won’t want to go back upstairs for anything once you have come down in the morning.

You’ll need to raise the bottom end of the bed – about the height of three x 2/3 inch encyclopaedias. I found the best way was to use them between the mattress and the base of the bed. In this way you won’t (overly) affect P’s side of the bed. Then as you start to recover, two weeks..ish post op, you can slowly remove one layer of books per week…ish until the bed is back to normal.

I also found it handy to have a spare pillow in the bed on which to rest the injured foot, or between your lower legs if sleeping on your side – the cast obviously weighs a bit and is hard!

Foot cream – when the plaster comes off completely (after six weeks in my case) – the foot is not very pretty (although I’m sure the shape will be lovely) as it will probably be covered in dry skin. I used Palmer’s Cocoa Butter Formula cream – available from Supermarkets– which I found very to be good.

You may want to get some wide-legged and stretchy tracksuit bottoms – see Operation Section below

Projects. You are going to be sat around a lot and after the first week to ten days (when you will still be recovering from the general anaesthetic – nothing too serious but you will probably get tired quickly) you are almost certainly going to want to do something other than watch TV (although you may want to get a box set in). Getting ready for this may well need some pre-thought but should give you a sense of achievement at the end of your recuperation. I, for example, studied some golf training videos I had acquired, making notes and typing them up, ready for (yet another!!) glorious comeback. I also sorted out and shredded lots of old work and finance/tax documents. So, whether it’s something to do with your art course, sorting old photos, or reading the combined works of Thomas Hardy (good lad, highly recommended) it will pay to be prepared and have all the bits you’ll need for your project/s readily to hand.

Exercise. I found that getting as fit as possible before the op helped. I did cycling, swimming and some gym work. After the op I really didn’t want to do much at all for a couple of weeks. After that I started doing seated exercises with dumbbells (or could start with cans of beans) and just lifting one leg at a time, for increasingly longer periods of time etc. I am sure you could find something that suits you via Google and acquire any necessary bits of kit. I am sure the physio in the hospital will be able to advise on what’s both good and safe to do.

Stairs. Tricky things stairs!! I spent the first six (non-weight bearing) weeks going up AND down stairs on my bottom. I am sure the physios would not approve but I found it easier (so, incidentally, did my sister-in-law who had two bunionectomies recently). The physios will show you how to do it “properly”, with crutches, before they let you out from hospital. Whether going up or down on your bottom it’s the top two stairs that are the trickiest. Briefly, when going up, I shuffled up one stair at a time whilst sitting on my bottom, using my arms to raise me up onto each next stair. I eventually sat on the landing, then I turned and levered myself up onto my good leg which was placed one or two steps from the top. I then used one crutch on one side and holding on to the banister on the other side to hop the remaining one/two stairs. You’ll also need to ensure that a second crutch is to hand or you’ll have to hop everywhere on just one crutch! Sometimes I flipped over and crawled on my hands and knees to the nearest bit of solid furniture and then hauled myself up, and all done without putting any weight on my operated on foot. This takes a bit of upper body strength and a little (pre-)practice, but maybe worth a try.

Coming down was the reverse. Again, worth a practice before you have the op – always have someone nearby when practising any of these manoeuvres. NOTE: you will need to make sure that there are always two crutches placed near the top of the stairs.

Food. We got in quite a lot of frozen meals ready for those evenings in the first couple of weeks when my wife was back at work and I was only capable of turning the oven on!

HOSPITAL & THE OPERATION

This was the quick bit. My op was at 7.30pm and I was home by 10.30am the next day. Not nice, obviously, but I had a general anaesthetic so I didn’t know much about it and the whole experience was much better than I had anticipated. You will be allowed to go home once you have passed water and convinced the physiotherapist that you are safe on crutches. I had a light-ish plaster cast put on during the operation that went from my toes (the toes themselves were open to the air) to a couple of inches below my knee.

My surgeon (and separately, the anaesthetist) came to see me before the op to check if everything was ok and to ask if I had any questions. I didn’t do the following but I suggest you do. Type up any questions you may have and print off copies- one for your surgeon, yourself and your partner. Doing this may seem overkill but has three advantages:

– You won’t forget to ask something that is important to you (I found that you are so busy thinking of the next question that you don’t hear what is said to you and then have a minor panic and forget to ask the right follow up question/s – it’s what I call “medical brain freeze”!!

– You’ll have someone else there to listen to……………… and remember/write down the answers

– The surgeon will be pleased because he will know you are organised!

I recommend that all questions are fitted onto one side of A4 and are, preferably, one-liners (examples are attached at the end of this document).

After the op, a DVT compression sock was put on my non-operated on leg – you should get given this and at least one spare on to take home. This was required to be kept on 24/7 for two weeks and you may well also need a daily injection for four weeks to further cut this risk. It was a small jab (nothing too painful) in the morning applied on alternating sides of my tummy button. I was told I could have done it myself but my wife made a special request to be allowed to be in charge!!

Questions I wished I had asked before the op:

– When I am in a sitting position (eg on chair or loo), do I have to have my leg up on another chair/stool or can I rest my foot lightly on its heel? This question also applies to getting up from a seated position.

– If I should inadvertently put weight on my foot (for example by overbalancing on my crutches) how will I know if I have done any permanent or serious damage? Or, how do I know if I need to come back in and see you? NOTE: when I accidently put some weight on the foot it felt a bit uncomfortable for a couple of days and I was very undecided as to whether to go back to the hospital or not. I didn’t and got away with it – but not a nice feeling to have that worry for the two days.

I found that (with my size 8 ½ shoes and with my foot/cast being “set” at right angles) I was able to put on trousers that were 8 ¾ inches wide. For the hospital I played it safe and went in with a pair of very baggy and stretchy tracksuit-type bottoms from M&S – these will also be useful for all further hospital visits.

FIRST TWO WEEKS ( Day 0 to 14 post-op) NON WEIGHT BEARING

When I came home I was given several types of painkillers. Ibuprofen, Paracetamol and a strong one, called Codeine Phosphate. I took a couple of the latter on my first night home, mainly to help me sleep. I found I didn’t need the codeine ones after that. You may well do………..the point is, the pain was nowhere near as bad as I was anticipating…………providing you don’t do anything physical during the first two weeks and keep your foot up all the time (see below). After about a dozen days I found that, providing my mind was busy, I didn’t need any pain meds. The foot remained uncomfortable (2 to 3 out of 10 on a pain scale), but no more than that.

You’ll be advised, I’m sure, to keep your operated foot “above your hips” or “level with your heart” as much as possible. This is sound advice and certainly kept down my pain levels.

CONSULTANT VISIT – TWO WEEKS POST OP

At this appointment I had my cast cut off with a pair of surgical scissors. The consultant examined his handiwork and made sure the stitches were dissolving nicely and that there was no infection. There was no x-ray taken. He then put on a stronger cast. This was done by soaking a bandage in warm water and wrapping it around the leg. Again, it went from the (slightly exposed) toes to a couple of inches below the knee.

I did have typed questions for this visit. I’ll attach a copy, which I’ve updated with the answers given – as far as I can remember them anyway.

You may be measured for a boot which will be supplied at the next visit. Mine was made by AirCast – see website below

http://www.physioroom.com/product/Aircast_AirSelect_Short/2247/35950.html?gclid=CjwKEAiAt4mlBRDXwt_m9ICU4DcSJAAS_X0WfC7-C-3Dd_zl0myRL4PuWEft6QQmfNlxQvLx3g2sRhoCqcLw_wcB
It was this, ie the shorter version and it cost me £93. It is suitable for both feet, so if you need it in future………….

NEXT FOUR WEEKS – (Weeks 2 to 6 post-op) NON WEIGHT BEARING

You’ll start feeling much better………but a bit bored. Nothing much happens. I suggest you get a programme of stuff organised for each day, with projects, grandchildren visits etc.

No driving for me because, even with an automatic car, it was my right foot that was operated on….so no weight or pressure could be placed on it and I had a big plaster on it!. If it is your left foot that is being operated on it may be worth asking the surgeon when you can start driving an automatic car.

CONSULTANT VISIT – SIX WEEKS POST OP

Here, the cast comes off, needing to be cut off using a small medical, powered circular saw.

I then had an x-ray and was fitted into the boot by the physios. This allowed me to walk with weight on the foot, although at first you may well need a crutch or two, or a stick.

I had some typed-up questions for the consultant – copy of these and answers attached

You always need to put your trousers on first, before the boot, but I found I needed 9-inch wide trousers to slip down over the boot once it was on.Weeks 6 to 10 post op)

WEEK 6 TO 10.BOOT WEARING & FULL WEIGHT BEARING

Got around reasonably well, using one crutch or a stick. Not going too far on any one occasion.
Again, beware boredom. But it will be much easier to get about.
Your foot is likely to be swollen, dry and rough, and therefore in need of foot cream and a larger sock.
The toes were also swollen and I couldn’t get a towel between them – so I used a hankie (linen or paper) for drying purposes.
The boot was ok to walk on around the house but I didn’t go very far outside. And when I did I used a crutch and then a stick. It’s probably not a good idea to walk too far anyway because the boot is high and makes you walk lopsided, which is probably not good for hips etc.
The operated leg was a bit thin and wasted but not too bad. In my case my calf (above the top of boot line) became quite swollen during the day but this always went down overnight and this was, apparently, not unusual.
Keep putting the foot up as much as possible, or at least in the evening. This will help to reduce the swelling. And according to my physio you should keep doing this for several months post op.

CONSULTANT VISIT – TEN WEEKS POST OP

Again, x-rays are taken and if all is well the boot can be discarded but still used if/when foot becomes tired or starts to ache or become uncomfortable. I used the boot occasionally for the first three or four days but then discarded it completely.

My typed up questions for this visit and answers given, are attached.

My and your foot is still likely to be swollen (and could be apparently for up to another four months) especially across the top. This may mean getting a pair of shoes to accommodate this temporary change – none of my existing shoes/slippers fitted very well or at all. Clark’s shoe shop was able to provide a solution to this problem, but little point going there until this stage is reached because you won’t know what shoes will fit and what wont.

I don’t like to mention the V word, but………….. you may even want to consider getting some Velcro fastening shoes and/or slippers.
On asking, the surgeon said it would be five months from the date of the operation before I was back to complete normal in terms of walking, golfing, bicycling etc

A new appointment was made for two months hence which would be almost five months after the op – ie the time period where I/you should be back to normal or at least as normal as I have ever/might be!

The consultant also said I needed physiotherapy and that he would write to me with a named recommendation of a guy who specialised in physio rehabilitation after foot ops. I realise that the surgeon wants to send medical notes to the physio but I suggest you ask for the recommendation and contact details there and then at the meeting – what with Christmas and the New Year, there was a slight delay in the physio starting.

NEXT – WEEKS 11 TO 13 WEEKS POST OP

After a week of “walking” unaided and unbooted but not far on each occasion (a couple of hundred yards max) the foot was slightly uncomfortable on the base and in the ankle (??) and along the top occasionally, but apparently this is all quite normal. You need to remember that you will not have not walked on either leg properly/at all for best part of three months and so it is bound to lead to the odd twinge or two.

Also the bottom half of the leg and the toes remained quite swollen, although I could now get a towel between my toes.

PHYSIO – APPOINTMENT – POST OP

I felt my first session was very good and worthwhile – the big toe was stretched and moved around a bit as was the whole foot. This had the immediate effect of reducing the swelling in the leg and foot. Apparently I should also be putting my foot up every evening to help reduce the swelling. I was also given several exercises to do. They were “rock back and forth”, “deep squats” and “calf stretch”. They are difficult to describe here. I asked about pains that I had either side of my foot, underneath and where the big and small toes end – the pain felt liked the bones there were bruised and was worse when standing on hard surfaces. I was told that this was normal and indeed it is like bruising in so far as I had not put any real weight or work on to this foot for three months and the padding here had become a bit soft and therefore felt “bruised”.

I have just had my third, weekly physio appointment. The guy seems quite pleased with my progress and has now given me a number of walking exercises. It’s almost like the ministry of silly walks. He also said that I could be walking up to 2 miles a day, but in ½ mile sessions. Walking is now much better and I think I am walking (give or take) normally – well, as normal as I ever did?!

I have one more session booked and this may well be my last

Thanks Graham- I am sure other will appreciate it. Sam S

About Sam Singh

As a fellow of the Royal College of Surgeons and Harvard University, and a fully qualified Orthopaedic and Trauma Surgeon, Sam Singh stays on top of the latest surgical techniques and practices.

As well as his position as a Consultant at Guy's and St Thomas' NHS Foundation Trust', Sam Singh privately consults at the London Bridge Hospital, the Lister Hospital in Chelsea, the Sloane in Beckenham and Chelsfield Park in Orpington.

Sam Singh is recognised by all the major insurance companies including AXA PPP, BUPA, AVIVA, PRU Health, Simply Health and WPA. All his charges fall within their guidelines.