In medicine a complication is defined as an “unanticipated problem that arises following, and is a result of, a procedure, treatment, or illness”.
Complications are typically associated with surgery but it is important to note that they can occur even with non operative treatment and doing nothing at all. With every operation and procedure there are risks of complications. There is no such thing as a 100% risk free operation, and there is no surgeon with 0% complications.
Fortunately, the majority of complications are uncommon and not serious, and those that are serious are rare. However it is important that your surgical team are made aware of any issues as soon as possible. Early identification of these complications is important so that they can be treated appropriately and effectively.
At the London Foot & Ankle Clinic we have an extremely low complication rate. Mr Malik has personally performed over 5000 procedures. As a dedicated specialist in Foot & Ankle conditions who is constantly updating his skills and knowledge he keeps his complications to a minimum.
Many patients fail to factor in a potential complication into their post operative recovery plan. Complications typically prolong a recovery sometimes by months. This should be borne in mind when considering an operation.
Below is a list of the frequently occurring and/or serious complications related to most surgical procedures. If you suspect you have a complication please do not hesitate to contact us.
As with all invasive surgical procedures there is the risk of infection. The risks of infection are increased in patients who are diabetic, suffer from rheumatoid disorders, smoke, do not keep their foot elevated, get their wound wet and are immunosuppressed for example.
This would manifest as redness and increasing pain, tingling or burning sensation following surgery. There may be associated wound breakdown/discharge. It is important to notify your surgeon Mr Malik or general practitioner immediately if you have any concerns. In the first instance the wound must be examined, a microbiology swab taken (and sent to the laboratory) and only then antibiotics commenced. The wound swab will take at least 48hrs to culture and reveal any evidence of infection. It is important to get a swab of the wound prior to starting antibiotics as it informs your surgeon of the nature of the potential bacteria and once antibiotics are started it is difficult to get any meaningful results. The risk of developing a superficial infection is 1-2%.
This is a more serious complication but fortunately very rare. In this instance the use of antibiotics on their own is usually not sufficient. Surgical washout of the wound and debridement of any unhealthy tissue maybe required. Mr Malik’s deep wound infection rate is currently 0.15%.
Remember any increasing pain or irritation around the site of surgery several days after the operation is abnormal. Contact your surgeon Mr Malik if you have any concerns.
If you are unable to contact your surgeon please call the ward or contact your general practitioner. If you do see your general practitioner and they recommend antibiotics, please make sure the wound is swabbed by and a sample sent to microbiology before etching any antibiotics. This will help us to identify what organism if any has grown.
This is important as sometimes the bacteria are resistant to antibiotics and you may not respond to the initial medication. Only by knowing what organism has infected the wound and its sensitivities will we be able to treat the infection properly.
Sutures are used by surgeons to close wounds. Deep sutures are made of bio-absorbable material, as are knotless skin sutures. These sutures have advantages such as not requiring any suture removal following surgery and arguably better cosmetic results. The disadvantage is that in a small percentage of the population the body struggles to breakdown the suture material. White blood cells accumulate around the suture material in attempt to break it down.
This manifests clinically as increased redness and pain around 4 to 6 weeks post surgery. Occasionally a small abscess forms and small area of wound breakdown. These abscesses are typically sterile (not caused by infection) but the area of skin breakdown can become secondarily infected. Contact your surgeon if you develop any problems with your wound.
Surgery of the lower limb coupled with a period of immobilisation increases the risk of blood clots in the lower limbs. You should mention to your surgeon if you feel you may be at higher risk. The following are additional factors that increase your risk:
Patients with a blood clot of the lower limb typically complain of increased pain and swelling in the leg with a tense and painful calf. However a significant proportion of clots can be “silent” and completely asymptomatic with many patients not even knowing that they had one. In patients with blood clots in the lower limb a small percentage can develop a pulmonary embolism (PE). Patients with PE complain of chest pain and breathlessness and can be fatal if not treated as an emergency.
A post-operative anti-embolism stocking (provided by the ward) should be worn on the un-operated limb until you are fully mobile. This will help reduce the risk of blood clots following surgery. Wriggling your toes, massaging your calves and regular movements of your lower limbs (as able) will help maintain healthy circulation during periods of reduced mobility. It is also important to drink lots of water and remain well hydrated. If your foot and ankle are in any form of plaster cast, injections to thin your blood will be prescribed to help reduce the risk of clots. This also applies if you are deemed to be high risk,
Between 2011 and 2014, Mr Malik performed over 1400 procedures. During that period 1 patient developed a deep venous thrombosis (0.06%).
Any type of surgery will leave a scar, even keyhole surgery.
This occurs in some individuals when the body heals with too much scar tissue. If you have previous hypertrophic scars then you may already be aware of this. If this results, you should massage the scar tissue regularly with cream (any will do such as E45) and apply silicone patches (readily available at most high street pharmacists) to the scar.
In patients with darker complexion and particularly of Afro-Caribbean origin, there is an increased risk of developing keloid scarring. In this condition the excess scar tissue forms beyond the original surgical scar.
Certain areas of the body heal quicker than others. Take for example a cut to the hand, which heals very quickly, compared with an injury to the front of the leg (shin), which can take several days if not a few weeks to heal. Wounds in the lower leg and foot tend to take longer to heal and this is especially the case if one does not keep the leg elevated and well rested. In some patients the wound may take longer to heal than average or actually breakdown without any obvious underlying cause such as infection. Risk factors include:
In the event of a wound breakdown you should notify your surgeon immediately. Remember any increasing pain or irritation around the site of surgery several days after the operation is abnormal. The wound will be swabbed, cleaned and redressed. Often the only treatment required is careful wound management. Antibiotics maybe commenced as a precaution or if there is suspicion that there is an underlying superficial infection.
All scars should be kept away from direct sunlight for at least 6 months or until the scar has matured. This is to avoid sunburn as the new skin is highly sensitive and it will also affect the final cosmetic result.
Acute and chronic injuries typically result in swelling of the affected part. This is because swelling is a normal part of the inflammatory response, which is the body’s way of healing. In most cases this swelling is unhelpful and if the underlying problem is left untreated, can become chronic.
Surgery to correct the underlying problem may or may not resolve the swelling itself. It is less likely to do so if the swelling is chronic in nature. Surgery itself is a form of trauma to the body. The body will heal with an inflammatory response, resulting in additional swelling. As the feet and ankles are the most dependant (lowest) part of the body one can expect a lot of swelling. It is therefore crucially important that following most operations to the foot and ankle that one rests and keeps the foot elevated.
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 the level of 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.
Once the wound has healed, your surgeon will advise you when you can commence regular wound massage and range of motion exercises. Application of an ice pack will also help reduce swelling and assist with pain relief. It is important to protect the affected area with a towel prior to the application of ice; often a bag of frozen peas is very effective (it is important to remember that these peas are not safe to eat as they will have been defrosted and refrozen). Apply for 10 minutes several times a day. These measures will help reduce any soft tissue swelling.
It will take several months before the swelling returns to normal levels but there is a small risk that there may persist a degree of chronic swelling especially if poor compliance with post-operative guidelines and instructions.
Remember any increasing swelling, pain, pins & needles or irritation around the site of surgery several days or weeks after the operation is abnormal and you should contact your surgeon, Mr Malik. If you are unable to contact your surgeon please contact your general practitioner.
This occurs because tiny nerves that supply the skin have been injured at the time of surgery. This is unavoidable as the nerves are invisible to the naked eye. These nerves typically heal without any problem however in some patients it may manifest as increased sensitivity around the scar. Once all the dressings are off and the wound is dry and fully healed it is important to desensitise the scar. Touching the scar will often be the last thing you might want to do as it feels uncomfortable, but that is exactly what you have to do. Massage the scar with cream and touch it as often as possible. This dampens the nerve response and eventually the scar will no longer be sensitive. Think about what you do when you bump the funny bone around your elbow, you rub it!
This can result when there has been some trauma to a nerve supplying an area of skin. This trauma maybe when a nerve has been cut (typically very small branches invisible to the naked eye). It can also result from pressure, bruising or stretching of a nerve during the operation, typically when retracting the nerve and soft tissues out of the way. In all these cases sensation typically returns completely but can take several months if not up to a year.
Very rarely a nerve may have been cut deliberately during surgery, typically to gain access and this will result in permanent loss of sensation. Risks are increased in revision surgery where there is increased scar tissue and the nerves are difficult to identify.
This results when a nerve has been cut and in an attempt to heal results in a growth of nerve endings, which are sensitive and painful. Referral to a pain specialist may be required as well as further surgery, which involves burying the neuroma in deeper tissue. Fortunately this is an extremely rare complication.
This is a poorly understood condition. Most cases of CRPS are triggered by an injury, which is often innocuous in itself. Some people develop it after surgery. CRPS most often starts soon after an injury but there may be a delayed onset.
Patients typically experience severe debilitating pain far beyond what would be expected normally. The most common symptoms are pain sensations and include: burning, throbbing and stabbing. Touching and moving the affected area can be intolerable.
The pain can be confined to one limb but can spread to other parts of the body. The skin of the affected part can become so sensitive that the slightest touch, breeze, or temperature change can illicit severe pain. Affected areas can become swollen, and the skin typically has a tight, shiny appearance to it. Joints can become stiff, and the affected areas can fluctuate in temperature and change colour (white blanching, bright red, purple or blue).
The pain can be severe and constant, and can be heightened by emotional and physical stress.
No one knows why it occurs but it is thought to be an abnormality in the body’s response to injury. There is increasing evidence to suggest that it is a systemic disease. Most patients with CRPS have no actual injury to a nerve and this is classified as type 1, also previously known as reflex sympathetic dystrophy (RSD).
Anybody can get CRPS but it typically affects women three times more commonly than men. It can affect all ages but the average age symptoms start, is around 50.
Evidence suggests that CRPS has both physical and psychological factors. Patients with CRPS may have associated depression and anxiety.
Diagnosis is difficult and made when there is spontaneous pain or pain resulting from a stimulus that would not normally cause pain, and is disproportionate. There is also evidence of swelling, skin blood flow changes and abnormal sweating in the region. Finally no other identifiable cause for the symptoms can be found. There is no specific test for CRPS.
Treatment is multi-disciplinary. The key is physiotherapy with the important goals being desensitising the affected part, restoring movement and improving function. Contrast warm/cold water baths, desensitising massage, gradual weight bearing and the use of a transcutaneous electrical nerve stimulator (TENS) are some of the ways that physiotherapy will help. A referral to a pain specialist (doctor specialising in pain) will also be made. They may prescribe specific pain medication.
Prognosis is usually good as this is a self-limiting condition although the duration of symptoms is very variable. Early diagnosis and treatment is important.
During most operations while you are asleep the surgeon will carry out nerve blocks to minimise pain and discomfort post operatively. Very rarely <0.5% injury to a nerve can occur. This is almost always temporary. The Royal College of Anaesthetists have issued this document which provides further information.
If you suspect any form of nerve injury, please contact your surgeon, Mr Malik. You may have to be referred to a pain specialist if a serious nerve injury is suspected.
It is normal to bleed a little following an operation. It is therefore normal to expect a degree of bruising, which is simply blood in the soft tissues. It is also 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, Mr Malik. 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.
The treatment for certain conditions involves either breaking a bone and resetting it into a more favourable position or fusing one bone to another. Delay in the bone healing or fusing is called delayed union. Bones typically heal within 3 months. If there is some radiological evidence (x-rays) of bone healing, but it is beyond 3 months since the surgery, then a diagnosis of delayed union can be made.
Failure of the bone to heal or fuse clinically and radiologically is called non union. Some people heal slower than others and those who smoke are at a greater risk of this occurring. The surgeon may decide not to perform surgery unless you refrain from smoking.
Risk factors include:
In the case of established non union confirmed on CT scan Mr Malik will discuss with you the possibility of revision surgery. In some instances a stable fibrous non union can develop which is pain free and from a patient perspective completely asymptomatic. In such cases it is important to treat the patient and not the X-ray!
If the non union is symptomatic further surgery typically involves the use of bone grafting and more hardware in situ and a longer period in cast.
Between 2011 and 2014 Mr Malik carried out 1300 procedures and had 5 non unions which required further surgery (0.38%).
Stiffness is a reduction in the normal range of motion in a joint. Following surgery it is common to get stiffness in several joints. This is typically due to a combination of immobilisation post-operatively (particularly if the foot and ankle have been in a plaster cast) and swelling of the affected limb.
Fortunately in the vast majority of patients, it is only temporary. With elevation, ice and rest the swelling will subside. Regular, daily range of motion exercises (particularly in conjunction with physiotherapy) will also help regain the normal joint suppleness and movement.
In patients with pre-existing joint stiffness, a full return to normal range of motion may not be possible. With certain operations, some degree of stiffness may be inevitably and a recognised complication of surgery. In such instances your surgeon may recommend either a manipulation under anaesthesia, a steroid injection to reduce inflammation in the joint or further surgery to remove the scar tissue and free up the joint. However surgery does carry with it risks and the possibility of further scarring.
Prevention is always preferable to treatment. Adhering to the post-operative guidelines can reduce the risk of stiffness. In summary, high elevation for the first two weeks post-operatively, to reduce swelling. Early active range of motion exercises of all joints not immobilised, for example moving toes and ankle if possible. Passive range of motion exercises as soon as the wound has healed. Regular physiotherapy to help regain full function and normal range of motion.
Orthopaedic Outpatient Department 30 Devonshire Street, London, W1G 6PU
tel: +44 (0) 203 7956053
Mon - Fri (8am-8pm) Sat (9am - 5pm)
info@lfaclinic.co.uk
