When you arrive back on the ward from theatre, you will either have a padded bandage or backslab plaster of Paris cast. Your operated leg will be elevated on pillows. It is important to keep your leg elevated in order to reduce bleeding, swelling and pain. You may be in slight discomfort, but usually you should feel no pain and instead numbness in the foot as a result of the local anaesthetic block.

Your anaesthetist will discuss pain control with you in your room prior to the surgery. This will usually involve a combination of pain relieving medications and local anaesthetic injected either by your surgeon or the anaesthetist, to make the area of the operation numb.

Just after the anaesthetist has put you to sleep and before the operation has actually begun, a local anaesthetic block is typically carried out which will numb the affected foot and ankle for roughly 6-24 hours. For forefoot and midfoot procedures, Mr Malik your surgeon, undertakes his own ankle blocks, which are 95% effective in obtaining a pain free foot for roughly 24 hours. For surgery involving the ankle and midfoot you will have a popliteal block which involves numbing the nerves behind the knee and this is performed by the anaesthetist either under ultrasound guidance or using a nerve conductor to help guide the injection to the correct spot.

It is important to start taking the painkillers that have been prescribed every 6 hours, even before your block wears off. It is also important to keep the limb elevated, as swelling will increase the amount of pain. For certain operations non-steroidal anti-inflammatories such as Voltarol (Diclofenac) and Brufen (Ibuprofen) are not advisable as they can delay bone healing. Please discuss with your surgeon and anaesthetist which painkillers you can and cannot take.

Consultant Anaesthetist – Dr Matthew Size carrying out a popliteal block under ultrasound guidance

Once you are awake in recovery we will check that you are comfortable and give you any extra medications that are necessary. We will also provide you with pain relieving drugs to take home.

It is important that you start taking these drugs as soon as you are eating and drinking and before the effects of the numbing medicines wear off.

Modern anaesthetics are short acting with relatively little hangover effects. Many foot and ankle operations are done as ‘day case’ procedures, meaning you do not have to stay overnight. Most people will be awake within approximately 30 minutes of the end of the surgery and can usually eat and drink straight away.

Before you go home we will check that your observations (heart rate, blood pressure etc.) are stable, you are comfortable, you have someone to look after you at home and you have a way of contacting the hospital. We will make sure you have pain relieving medications to take home.

You should not drive or operate machinery for 48 hours after an anaesthetic. Some pain relieving medications can also make you feel drowsy so you should not drive whilst taking them. Exact timings for recovery are difficult to estimate as it depends on the patient, the operation and other factors.

This depends entirely on what procedure you have had. A plaster is used as a splint and protects the bones, joints and soft tissues. The initial plaster applied is called a backslab. This is because the plaster is not complete (to allow room for post operative swelling). The backslab will be removed at the two week postoperative clinic appointment at the time the wound is checked. Depending on the operation you may either then go into a brace, removable surgical boot or complete cast.

A Backslab (Incomplete Plaster)

A Complete Cast (Fibreglass)

Advice To Patients With A Cast

• Elevate your foot to above groin level as this helps to prevent swelling
• If your foot becomes too swollen, your cast will become tight, restricting circulation
• Move your toes up and down at regular intervals throughout the day, as this helps to increase blood flow and aids circulation
• Move your hip and knee regularly as this prevents them from becoming stiff and the muscles from wasting
• Keep the plaster cast dry (protective waterproof covers are available to purchase for bathing/showering – see Limbo bags)
• DO NOT poke objects inside your cast as this can cause sores to develop and subsequent infection

You should contact your surgeon or General Practitioner if you develop:

• Extreme pain
• Increasing pain
• Tightness unrelieved by HIGH elevation for one hour
• Progressive swelling of toes unrelieved by HIGH elevation for one hour
• Localised painful pressure
• New or progressive numbness or tingling (pins and needles)
• Breakage or damage to your cast
• Offensive smell or discharge from under your cast

For minor operations, surgery of the forefoot and where early movement is important a padded bandage will be applied.

Foot in post operative bandage

If your foot is in a bandage you will also most likely be given a post operative shoe. This shoe is designed not to bend as it has a very stiff sole, and therefore protects the foot and site of operation. If you have had a 1^st MTP joint fusion or fracture fixation you will be asked to be non weight bearing for a period of time (see specific conditions). In these circumstances the shoe is simply worn for protection in case you fall or stumble. It is not an indication that you are advised to walk and weight bear on the foot. For other procedures such as bunion and toe deformity correction you will be allowed to weight bear for short periods post operatively but the shoe must be worn at all times when weight bearing. It does not need to be worn in bed or when resting. Post-operative shoes are usually provided by the ward staff or physiotherapist and should be worn until instructed otherwise.

Post operative stiff soled shoe

It is important to keep both the bandages and plaster cast completely dry following the surgery. If the wound gets wet in the first two weeks following surgery, you increase the risk of wound breakdown and infection. Wear a Limbo bag when going for a shower and please avoid any DIY efforts (such as using bin liners) as they usually result in some water seeping through and compromising the wound healing.

Following an injection you will have spot plaster over the injection site, which you can remove after an hour.

After a proximal medial gastrocnemius release you will have a dressing over the wound. Please do not remove this dressing until seen by your surgeon in the follow up clinic. You are advised to keep the wound dry for 10 to 12 days.

The following is a rough guide of what to expect when you come out of surgery for some common procedures (note this may change depending on individual considerations).

• Achilles tendon debridement – Bandage and post-operative shoe/Backslab
• Achilles tendon reconstruction – Backslab
• Achilles tendon repair – Backslab
• Ankle arthroscopy (simple) – Bandage and post-operative shoe
• Ankle arthroscopy (complex) – Bandage and post-operative shoe/Backslab
• Ankle fusion – Backslab
• Bunion correction – Bandage and post-operative shoe
• Bunionette correction – Bandage and post-operative shoe
• Fusion of major joints – Backslab
• Injections – Spot plasters
• Lesser toe deformity correction – Bandage and post-operative shoe
• Ligament reconstruction – Backslab
• Morton’s neuroma excision – Bandage and post-operative shoe
• Nail surgery – Bandage and post-operative shoe
• Proximal medial gastrocnemius release – Wound dressing
• 1^st MTP joint cheilectomy – Bandage and post-operative shoe
• 1^st MTP joint fusion – Bandage and post-operative shoe (strict non weight bearing)
• Tendon surgery – Backslab
• Tibialis posterior tendon/Flat foot reconstruction – Backslab

The degree of mobility allowed following your surgery depends on the type of procedure that has been performed

It is important to note that only after an injection or proximal medial gastrocnemius release are you expected to walk normally following the procedure.

A walking assessment by a physiotherapist will be carried out either before or after your surgery. If crutches are required, you will be instructed on their correct use. The crutches are adjusted for each individual and are not intended for use by others. You will be told how much weight if any can you put through your operated foot.

If you are in a backslab then you are NOT to put any weight on your foot. If you are in a full cast you are again NOT allowed to put any weight on the foot. Despite detailed post operative instructions several patients each year walk on their plaster and this often results in complications such as poor wound healing, infection and non union. Please follow your surgeon’s guidance as it is in your best interest.

Picture of a Non weight bearing cast that a patient walked on

Full weight bearing (FWB)

You may walk as normal, taking the weight through the operated foot. The physiotherapist will give you instructions on the correct and safe use of your crutches if you require them after your operation.

Weight bear as tolerate (WBAT)

You may walk with as much weight as you can tolerate through the operated foot as pain and discomfort allows. Do not force yourself to walk normally if it hurts. Instructions will be given on the correct and safe use of crutches by the physiotherapist.

Partial weight bearing (PWB)

You may walk taking a partial degree of weight through the operated foot, using a walking aid. You will be instructed on the degree of weight that is acceptable.

Touch weight bearing (TWB)

You may walk, taking most of the weight through the non-operated foot and crutches and only touching the ground with the affected foot for balance.

Non-weight bearing (NWB)

You are not allowed to put any weight through the operated foot. The foot has to be off the ground the whole time. Instructions will be given on the correct and safe use of crutches by the physiotherapist.

The following is a rough guide of weight bearing status post surgery for some common procedures (note this may change depending on individual considerations).

• Achilles tendon debridement – Non-weight bearing (NWB) for two weeks followed by full weight bearing (FWB) in removable boot for 4 weeks
• Achilles tendon reconstruction – NWB for two weeks followed by weight bearing as tolerate (WBAT) in removable boot (with 4 wedges) for 5-6 weeks
• Achilles tendon repair – NWB for two weeks followed by WBAT in removable boot (with 4 wedges) for 5-6 weeks
• Ankle arthroscopy (simple) – Touch weight bearing (TWB) 48 hours and then WBAT, bandage to be removed 48 hours post surgery
• Ankle arthroscopy (complex) – see individual post-operative instructions
• Ankle fusion – NWB for up to eight to twelve weeks in plaster cast
• Bunion correction – TWB for 48 hours and then WBAT in post-operative shoe for at least 6 weeks
• Bunionette correction – TWB for 48 hours and then WBAT in post-operative shoe for at least 6 weeks
• Fusion of major joints – NWB for up to eight to twelve weeks in plaster cast followed by FWB in a removable boot
• Injections – FWB
• Lesser toe deformity correction – TWB for 48 hours and then WBAT in post-operative shoe for at least 6 weeks
• Ligament reconstruction – NWB for two weeks followed by WBAT in either a removable boot or ankle brace for at least 4 weeks
• Morton’s neuroma excision – TWB for 48 hours and then WBAT in post-operative shoe for at least 6 weeks
• Nail surgery – TWB for 48 hours and then WBAT in post-operative shoe for at least 2 weeks
• Proximal medial gastrocnemius release – FWB
• 1^st MTP joint cheilectomy – TWB for 48 hours and then WBAT in post-operative shoe for at least 6 weeks
• 1^st MTP joint fusion – NWB in post-operative shoe for 6 weeks
• Tendon surgery – NWB for two weeks followed by weight bearing in either a removable boot or ankle brace for at least 4 weeks
• Tibialis posterior tendon/Flat foot reconstruction – NWB in cast for 6 weeks followed by WBAT in either a removable boot or ankle brace for at least 4 weeks

Swelling

Surgery around the foot and ankle can result in massive soft tissue swelling. Unchecked this can result in pain, delayed healing and possible wound breakdown and subsequent infection. It can also delay the healing time and result in increased complications. It is important to minimise the swelling by keeping your foot elevated at the level of your heart. This can be done by making sure that you recline with pillows and cushions underneath the foot and ankle. It is advised to stay housebound for the first two weeks to allow for sufficient elevation. If you have previous or existing problems with your back or hip(s), elevate to just above your groin. Get up for five minutes out of every hour to do necessary tasks, for example, going to the toilet then ELEVATE your limb.

Pain Control

It will become obvious to you that when you stand up and put your foot down it will start to throb and hurt. Elevating the foot & ankle will alleviate the pain and discomfort post-operatively.

Bleeding

It is not unusual for some blood to ooze through the bandages, especially when you first get up and have your foot in a dependant position. Elevate the foot and the bleeding should stop.

If you have continued bleeding, please contact your surgeon. If you are unable to contact your surgeon please call the ward or contact your general practitioner. Keeping your foot elevated will help minimise this risk.

Rest

We recommend that you remain housebound during the first two weeks post surgery for most major procedures. Mobilising only to go to and from bed or the sofa and to the toilet. Avoid prolonged standing indoor or outdoors to minimise pain, swelling and post operative complications such as wound breakdown and infection.

High elevation

When the affected foot is at the level of your heart. This position can only be achieved with the body reclined at least 45 degrees lying in bed or on a sofa (length ways) with pillows behind your back and under your foot. This is usually required for the first two weeks post-operatively.

Horizontal elevation

When the affected foot is in a horizontal position. This position can be achieved with the patient sitting in a chair with the foot on another chair or table (with cushion). The foot should be kept elevated until the swelling has subsided.

All patients leave hospital once it has been deemed safe to do so. The nursing staff will ensure you have eaten and drunk without problems. All patients undergoing a general anaesthetic or sedation should NOT drive on the day of their operation and ensure they have someone who can take them home. Most foot and ankle procedures are now done as a day case procedure. If you have an evening operation or a major procedure expect to stay in hospital for one night.

You will be sent home with a discharge pack including your painkillers and any blood thinning medication. You should also go home with details of your follow up appointment.

You will be discharged with a copy of your operation note, which will have detailed post-operative instructions. It will also outline the follow-up after your surgery.

The majority of patients require 2-3 follow-ups but each operation has an individual post-operative course and every patient heals differently. Your follow-up will be tailored individually as necessary.

Please see further details under foot & ankle conditions regarding weight-bearing status, schedule of clinic follow-ups and post-operative x-rays and physiotherapy.