Where to look for information after your bunion surgery?

When a colleague (HFP) sought out this question, she was generous and mentioned her surgeon was busy and thought it an oversight as she left the hospital without some of those basic questions answered. I am both an ex-patient and a foot surgeon, and I’m afraid I have to disagree. We often confuse nice with good, and all clinicians have a blip – but then don’t we all? So we have a patient leaving the hospital after bunion surgery. No post-operative information is apparent, so what does she do? Call a friend! This, in fact, is Facebook and jolly good it is as there is a heap of friendly advice, not least foot surgeons. Not only that, I see the post and write, talk and realise my site ConsultingFootPain is missing post-operative advice. Okay, I wrote a book, but not everyone wants to read a book, even though it is crammed with real patient advice. There was one confusing response, though, and I will make this clear.  It said – “Contact the surgeon for post-op advice as only he knows if there were any intra-operative issues which may change post-op regime.”

On the surface, that makes sense, but HFP should have had all of this and was now a little flummoxed. These conversations are not for after surgery but before. Why? Because busy people have to plan their lives and know what to do for the best. Of course, she should speak to the team when she can, but then unusual times have set unusual precedence over what we might have expected. ConsultingFootPain is about supporting all clinicians and their patients with trusted advice. I am not entirely sure that seeking advice for a basic set of instructions as one would expect to know is the same as ‘complications’ dressed as intra-operative issues. The latter of course must be for that surgeon and the service to deal with. The absence of such discussion is less than ideal. So let’s delve into this a bit more and look at some basic information. REMEMBER – no one can give precise information, only a guide as the best fit. You can view the quick summary and then read the expanded information. 


Here is a quick summary as a guide

  • Pain reaches a peak at around 16 -24 hours, reduces over 72 hours, and can be fairly negligible by 5 days.
  • Swelling reduces slowly from 2 weeks, then 4-6 weeks, then 3-4 months, then 6 months. 
  • Footwear may be tolerated by 6 weeks to be tolerated but don’t be surprised if it takes longer. Some shoes don’t fit because the foot shape has changed.
  • Mobility commences slowly after 5-7 days. Two weeks should allow some walking, better with aids. Normal activity can take time 6 weeks to 6 months. Returning to heavy industrial work with risk no earlier than 8-12 weeks and for active work, e.g. teaching 8-12 weeks. Sedentary office work 3-6 weeks. 
  • Wounds take 2-3 weeks to stabilise but may take 6 months to reach their optimum strength.
  • Hygiene can be maintained by careful showering using a special cover rather than a plastic bag.
  • Numbness may persist for up to 9 months, gradually improving. Massage to reduce the delay in recover

The consent

https://www.dreamstime.com/photos-images/signing-consent.html

The consent form provides limited information and, ideally, in today’s currency, supportive information material should be digested before surgery. This aspect of care is not new. A list of do’s and don’ts make sense. Clearly, you cannot drive, go shopping and should not fly or take any transport that exposes you or others to risk. You may want to familiarise yourself with the concept of risk and what this really means in another article released by ConsultingFootPain. The range of different operations will determine what you can and cannot do. And it will also determine to have much latitude you have. HFP has a scarf-akin osteotomy to which is a  successful technique rated amongst orthopaedic and podiatric surgeons alike. A great site to go to for more information on this condition is footeducation.com. You can read this article in tandem with the scarf-akin above or purchase my book on Bunion Behind the Scenes, which has tons of personal information.

Let us look at the big five areas of post bunion recovery. 

The big five WHAT you really need to know

Pain (the lion)

You can expect anything from little pain to a lot of pain. Now that’s just as helpful as using a bent penny in a slot machine. I guess you could say that we want to avoid that ‘roar’ of the pain stab that stops you from thinking, sleeping or even eating.  The truth is we all have different pain thresholds. More complicated surgeries may be more painful, but the Scarf-akin is moderate. Take the painkillers regularly as guided—anti-inflammatories with or after food. Paracetamol (acetaminophen) and codeine are useful but watch out for codeine. It is good, but it can make you feel dizzy and give you hallucinations in rarer cases. The big downside is constipation – and this can be nasty. Eat loads of fruit and vegetable, keep hydrated to avoid the worst effects. Forty-eight hours is the time when pain should be descending, but it can hang on in there, giving you the odd surprising jip for a week or more. 

Swelling (the water buffalo)

Swelling is good, and swelling is bad, a contradiction that needs some explanation. Swelling reminds us of hurt and the need to rest. It stops movement. We do less damage with rest. Swelling goes down in time. Sudden swelling after surgery, when all seemed well, is bad. We must think about infection for up to 72 hours. Obviously, an infection can happen later on, but we need to talk about this when we get to the wound. 

To reduce swelling, we must elevate the limb – the higher, the better. This practical act stops nerve endings in tissue from being excited as pressure builds. Keep the pressure down, and the nerves are kept calmer. Next, ice or cooling methods stop excessive swelling and slow down nerve conduction. The benefit provides more comfort. There are heaps of methods available, but try out the download here for more information. There is a warning. Make sure you do not use ice for too long or on fragile skin. Place ice around the ankle rather than the toes. Allow time to recover from your surgery. Use ice after periods of movement and when pain escalates. Icing and elevation can achieve 40% pain control – now that’s impressive. 

Exercise & mobility (the cheetah)

The cheetah is well known for bursts of speed. This is not you, and after bunion surgery, gentle movement is important, so you need to take your time and be realistic. (1) Use those alphabet exercises. This means you need to draw an imaginary figure A, then B, then C and so on, all the way to Z. Move from the ankle, and you will exercise every muscle. Maybe three times a day, but make sure you do something while rested. (2) Cycle movement exercises bend the knee and hip and rotate. To do this, lay on your back and pedal first one leg, then the next. Do five pumps each hour while you are not on your feet. Squeeze your buttock cheek muscles as this is good for venous blood movement. Once the wound is healed and pain controlled then you can press the toe against the ground and lift the heel to help create more upward movement. Toe joint mobility can take over six months to return and in many cases does not fully flex because it has been placed into a new position after being dislocated for so long.

Stop clots before they happen.

Exercises are for when you are not moving and are important to stop clots. In some cases, you may have been given an anti-clotting injection and have to follow up at home, but don’t stop exercising. The risk of a leg clot after foot surgery is small, but it can happen. If you get sudden chest pain and breathing problems, then DO phone 111 or 999. Lung clots are life-threatening.

Standing

Standing after foot surgery is a NO-NO. Why? Pain, more swelling, and remember you probably have had a fair amount of surgery, which needs to heal. It is not helped by standing up, cooking or driving, going shopping or caring for others in the family. It would be best if you were cared for. How long should you rest for? We want you to exercise then build up with short walking periods, but during the first week (5 days), any standing or walking should only involve visits to the bathroom. Once you pass the first week, then gentle walking can be increased, but you need aids. 

Aids to help mobility

Remember, you have been temporarily disabled. This means you are vulnerable and can fall over. The first thing you should have are crutches, and these should be demonstrated with practical instructions for correct length and stride when in use, how to go up and come downstairs. Now you can use a walker boot. Chances are you will have a post-op shoe. This allows you to cope with that big dressing, but once it is stripped down at around 2 weeks, the shoe is loose. A walker boot is great, and I have found Aircast both secure and adjustable. Some services provide these others don’t. Many will say you don’t need them but take it from me, as a patient, you will advance far quicker with a boot than not. My neighbour had a scarf-akin, and she was stuck with not be able to get around until I recommended she had one. If you can move around and build up active walking, three things will happen that are positive.

  • circulation increases and flows around the foot and limb
  • swelling reduces as the calf pump is activated
  • wounds heal better with less swelling and better circulation

The downside is –

  • you can over-exercise and increase your pain
  • swelling can increase with overuse
  • the wound opens up and becomes infected

One set of bullet points cancels out the other. But as patient HFP says, she knows her limits and will be sensible. Put it this way, non-compliant patients delay their recovery and fail to benefit.

Return to work and normality

Everyone wants to return to normal, and this is as expected. How long does a scarf-akin take to settle? If you are lucky within a month, if you are unlucky, 4 months. What is normal?

  • return to walking 1/2 mile
  • returning to the gym
  • shopping
  • going back to work
  • standing all-day
  • wearing most shoes in your cupboard
  • flying to a holiday destination 
  • swimming in water
  • driving a car with clutch and gears 

Let me level with you. Bunion surgery and some other types of foot surgery take 6-12 months for some, but not for everyone. Younger people do recover better. Heavier people have the added problem of weight and gain in body size during recovery. Normal will be different for everyone. Don’t go back to work too soon and when you do ease back if you can on a reduced time basis. Don’ forget surgery has a psychological level as well as physical.  After returning to work –

  • Allow your foot to be raised.
  • Do not work or stand for longer than 30 minutes.
  • Reduce your hours for the first 2 weeks when going back
  • use ice if swelling become notable and uncomfortable

Wound (the rhino)

Skin is tough, but not when it fails to heal. If it gets soggy and wet, an infection can thrive. The type of wound for a bunion is either on the side of the joint or top. A wound takes a minimum of 2 weeks to stabilise, even with stitches (sutures). Steristrips are thin tapes and may be used with absorbable stitches. If you cannot see any stitches, they will most likely dissolve on their own. Because this form of closing the wound is invisible and beneficial, the strength of the wound depends upon how long the stitch retains its form. Once an external (visible) stitch is removed, then the wound may open slightly. This is not uncommon but try not to overuse the foot for a further week. By week three, your wound should be ready to be left open and even earlier if all appears well. Air is good and dries out wounds if slightly moist. Dressings are no longer required unless needed to avoid shoe rubbing. Taking care of wounds will be dealt within the next section, but first, let’s be aware of the late infection.

Infection

Infections are characterised by increased pain, swelling and failure of pain medication to work. The wound starts to ooze, perhaps, and the foot feels hot. If you have red streaks going up the leg or feel unwell, this is an emergency and should not be taken lightly as such a condition can be life-threatening. If the wound opens, seek early assistance for assessment. It is not good enough to have antibiotics prescribed over the phone.

Hygiene & bathing (the elephant)

The elephant in the room wants to spray water, keep clean and feel good. Having just discussed wounds, it makes sense that the wound does not become wet and soggy by allowing showers or baths to soak. If you do soak your dressings, these must be changed as soon as possible to avoid infection. Showers are better in many ways for two reasons. Firstly you can sit under a shower, which means you do not have to climb in and out. Secondly, the showerhead can avoid direct soaking of the dressing. If you have not been provided with a shower cover for your limb, invest in buying your own. Limbo Cover(TM) is recommended because you can order them, and they come quickly by mail. They are designed and reinforced for multiple uses. I have used them for hand injuries and foot surgery, and they have a high patient acceptance rate. The version shown is above the ankle, but a lower leg version also exists for extra security. This author does not recommend using tapes up plastic bags because they leak and tear. Why go through surgery and risk problems for the sake of a product that is designed for the job.

Massage and care of the incision line

As soon as the wound is closed and appears calm start massage. Use Bio oils or anything you like for the skin. While this helps moisturise the skin you are really trying to break up adhesions around the scar line. Apply your lubricating oil first. Press down firmly to tolerance and move along the scar forwards and backwards. Now try little circling movements along the scar line. Does it hurt and feel sensitive? If yes continue pushing yourself which may make you queasy or dislike the sensation. You are desensitising the wound and removing tightness which breaks down excessive scar tissue. This will help toe movement. The nerve recovers as it will be released from the scar tissue. Massage promotes circulation enhancing healing. Unpleasant to start with, yes. Benefits almost instant but after a few days, it does get easier. 

If you feel you need more information or have a burning question, why not write below, and ConsultingFootPain will answer your question. Find out more about the author. This article does not replace any information your specialist may feel appropriate but hopefully, it will take you in the right direction. All surgeons have different ways of approaching post-operative care but occasionally patients require a little extra help. 


FURTHER INFORMATION ON BUNIONS & SURGERY

The following information is available on this website click on the highlighted text:


When is surgery indicated for the bunion?
Hallux Valgus known as bunion
Helping your bunion yourself
Jo’ Bunion Surgery
Risks from surgery
Bunion surgery the best age?
Bunion-joint-fact-sheet-2021-3


Thanks for reading this article ‘What you really need to know after bunion surgery?’ by David R Tollafield

Published June 2021 by Busypencilcase Reflective Communications Est. 2015