Post-Operative Care of the Podiatric Patient

Andrew J. Meyr, DPM

TUSPM Department of Surgery
January 21, 2013 Class of 2015
Rich Derner says: Nothing ruins good surgery like follow-up.
Not good post-operative care

READ!
Recommended Reading:
McGlamrys text
Post-operative complications and considerations section (pg 1997)

Usually small sections at the end of specific surgical chapters Clinics in Podiatric Medicine and Surgery editions Residency Interview Study Guides
Presby manual Crozer manual Goldfarb board review PRISM

Good Post-Operative Care begins Pre-Operatively

Management of patient expectations
Post-operative recovery process Post-operative outcomes
Good post op care begins pre operatively. You should not be surpised in the post operative period. A good surgeon can handle anything that happens after the surgery.

You are not a used car salesman! You should never attempt to sell a patient on surgery. In just about all situations, elective surgery is a last resort.

Good Post-Operative Care begins Pre-Operatively

Management of patient expectations
Post-operative recovery process Post-operative outcomes You are not a used car salesman! You should never attempt to sell a patient on surgery. In just about all situations, elective No one has ever died from a surgery is a last resort.
bunion!; But people have died from bunion surgery.

Good Post-Operative Care begins Pre-Operatively

Management of patient expectations
Post-operative recovery process
Many patients expect that as soon as the surgery is over, they have a brand new foot ready-to-use. Provide a conservative range until that they can expect to be in a regular shoe and back to normal activities: Patients do not understand the concept of

healing process. They think that right away they Hammertoes: 1-6 months will be getting better. Bunions: 2-6 months This is the range where they are back to normal Achilles tendon surgery: 6-12 months Charcot reconstruction: A full year

Good Post-Operative Care begins Pre-Operatively

Management of patient expectations
Post-operative recovery process
Give a specific list of activities that they will be unable to perform:
Give patient idea of what external xation device looks like before the surgery.

Showering, Driving, Working, Walking, etc. Pre-operative PT (dispense crutches/walker)

Give a specific example of what restraining devices to expect: Need to break it down and be
Put on a cast for a week! Any pins sticking out of the foot?
basic with your patients. give them a specic list of activities they are not going to be able to perform.

Good Post-Operative Care begins Pre-Operatively

Management of patient expectations
Post-operative recovery process
Be blunt and be specific!
People generally understand the concept of scar tissue
important

Mrs. Feynman, I have to make the commitment to perform the surgery and you have to make the commitment to allow it to heal in the correct position.

Good Post-Operative Care begins Pre-Operatively

Management of patient expectations
Post-operative outcomes
Paint a bad picture both pre-operatively and post-operatively!
If you give them low expectations they will be happy if anything happens. Give them the idea that this is something serious and we are taking it seriously. Over exaggerate everything to manage expections. If you tell it it will be a breeze that is how they are going to think. If you say it will take a while to heal that is how they will think.

Good Post-Operative Care begins Pre-Operatively

Management of patient expectations
Post-operative outcomes
Paint a bad picture both pre-operatively and post-operatively! Informed consent with discussion of all alternatives, risks and potential complications.

Alternatives, Risks and Potential Complications

Mrs. Feynman, thank goodness no one has ever died from a Alternatives: bunion before.its not a fatal diagnosis. You dont need bunion surgery, and there are lots of things that can be done besides surgery.

very rarely the rst time you meet someone they will do surgery. elective surgery should be the last resort.

Alternatives, Risks and Potential Complications

Mrs. Feynman, thank goodness no one has ever died from a Alternatives: bunion before.its not a fatal diagnosis. You dont need bunion surgery, and there are lots of things that can be done besides surgery.

6 months: General rule of thumb for conservative

interventions. Should certainly at least try some conservative intervention.
if patient is not willing to try conservative measure you should not be willing to do surgery

Alternatives, Risks and Potential Complications

Mrs. Feynman, thank goodness no one has ever died from a Alternatives: bunion before.its not a fatal diagnosis. You dont need bunion surgery, and there are lots of things that can be done besides surgery.

100% ~10% <1%

Alternatives, Risks and Potential Complications

Mrs. Feynman, thank goodness no one has ever died from a Alternatives: bunion before.its not a fatal diagnosis. You dont need bunion surgery, and there are lots of things that can be done besides surgery.

100%:

-Temporary pain and swelling,

-Scar -Chance that it will change your life forever.

Alternatives, Risks and Potential Complications

Mrs. Feynman, thank goodness no one has ever died from a Alternatives: bunion before.its not a fatal diagnosis. You dont need bunion surgery, and there are lots of things that can be done besides surgery.

100%

~10%:

10% chance of something going wrong with the surgery

Painful and/or ugly scar (keliod), More pain

than when we started, Chronic pain state, Infection requiring antibiotics or surgery, Skin healing problems, Bone healing problems, Need for future surgery, Overcorrection, Undercorrection, Recurrence, Need for removal of hardware, Nerve damage, Stiffness, Decreased motion, etc

Alternatives, Risks and Potential Complications

Mrs. Feynman, thank goodness no one has ever died from a Alternatives: bunion before.its not a fatal diagnosis. You dont need bunion surgery, and there are lots of things that can be done besides surgery.

100%

~10%:

Painful and/or ugly scar (keliod), More pain

come up with a list as many potential complications as possible when doing surgery

than when we started, Chronic pain state, Infection requiring antibiotics or surgery, Skin healing problems, Bone healing problems, Need for future surgery, Overcorrection, Undercorrection, Recurrence, Need for removal of hardware, Nerve damage, Stiffness, Decreased motion, etc
Be extraordinarily careful and basic with your language when explaining surgery to a patient. Always remember your very first day in clinic!

Alternatives, Risks and Potential Complications

Mrs. Feynman, thank goodness no one has ever died from a Alternatives: bunion before.its not a fatal diagnosis. You dont need bunion surgery, and there are lots of things that can be done besides surgery.

100% ~10%

Patients will always be like you the rst day of clinic

<1%:

-You having a reaction or allergy to the anesthesia that we didnt know about and it kills you. -You developing a blood clot that goes to your heart or your lungs and it kills you. -You developing an infection so bad that we have to amputate your toe or your foot.

Alternatives, Risks and Potential Complications

Mrs. Feynman, thank goodness no one has ever died from a Alternatives: bunion before.its not a fatal diagnosis. You dont need bunion surgery, and there are lots of things that can be done besides surgery.

100% ~10%

<1%:
The chances of these things happening are about the same as you getting into a fatal car accident driving to or from the surgery, but they are a risk that you wouldnt take by not having surgery.

-You having a reaction or allergy to the anesthesia that we didnt know about and it kills you. -You developing a blood clot that goes to your heart or your lungs and it kills you. -You developing an infection so bad that we have to amputate your toe or your foot.

Good Post-Operative Care begins Pre-Operatively

Management of patient expectations
Post-operative outcomes
Paint a bad picture both pre-operatively and post-operatively! Informed consent with discussion of all alternatives, risks and potential complications.

Development of mutual expected outcomes.

Cartesian model
What exactly is a hammertoe?
make sure before the surgery that both me and the patient has an idea of what we want from the surgery

Good Post-Operative Care begins Pre-Operatively

Management of patient expectations
Post-operative outcomes
Paint a bad picture both pre-operatively and post-operatively! Informed consent with discussion of all alternatives, risks and potential complications.

Development of mutual expected outcomes.

Cartesian model
What exactly is a hammertoe? At what point should I get surgery, doctor?

Post-Operative Considerations: Weight-Bearing Status

How much (if any) weight can be placed on which part of the foot using which type of immobilization device (if any)?

Post-Operative Considerations: Weight-Bearing Status

How much (if any) weight can be placed on which part of the foot using which type of immobilization device (if any)?
"there always has to be air between your foot and the ground"

Do not underestimate the concept of non-weight bearing!

It is extremely easy to label a patient as noncompliant, but a lot harder to appreciate that you may be making an unrealistic order and/or not explaining yourself appropriately.

Post-Operative Considerations: Weight-Bearing Status

How much (if any) weight can be placed on which part of the foot using which type of immobilization device (if any)?

READ!
Austin DW and Leventen EO.

A new osteotomy for hallux valgus: .

Clin Orthop Relat Res. 1981 Jun;(157): 25-30. (Pubmed ID#: 7249456)

What type of internal fixation for the osteotomy is recommended for this procedure?

Post-Operative Considerations: Weight-Bearing Status

Non-weight bearing (NWB)
Partial weight bearing (PWB)
Not enough to just say non weight bearing

With crutches; With walker; With wheelchair, etc.

To heel; To heel for transfers; To forefoot 20%; 50%; 75%; etc.

Partial weight bearing needs to be more specic.

Full weight bearing (FWB) Weight bearing as tolerated (WBAT)

Post-Operative Considerations: Weight-Bearing Status

Non-weight bearing (NWB)
With crutches, With walker; With wheelchair, etc

Partial weight bearing (PWB) To heel; To heel for transfers; To forefoot 20%; 50%; 75%; etc. Full weight bearing (FWB)

Cast Know what the acronym for CAM stands for CAM walker Posterior splint Surgical shoe
Full; Half; Rockerbottom

Post-Operative Considerations: Weight-Bearing Status

Non-weight bearing (NWB)
With crutches, With walker; With wheelchair, etc

Partial weight bearing (PWB) To heel; To heel for transfers; To forefoot 20%; 50%; 75%; etc. Full weight bearing (FWB)

Cast CAM walker Posterior splint Surgical shoe

Full; Half; Rockerbottom
Rockerbottom.

Post-Operative Considerations: Weight-Bearing Status

Non-weight bearing (NWB)
With crutches, With walker; With wheelchair, etc

Partial weight bearing (PWB) To heel; To heel for transfers; To forefoot 20%; 50%; 75%; etc. Full weight bearing (FWB)

Cast CAM walker Posterior splint Surgical shoe

Full; Half; Rockerbottom

Post-Operative Assessment
Documentation: NORMAL Ms. Feynman returns 2 weeks s/p right 2nd digit hammertoe surgery NWB in an intact posterior splint.
First line of post op note. Must be very specic in the note. What is the weight bearing status and hiow are they being

Post-Operative Assessment
Documentation: NORMAL Ms. Feynman returns 2 weeks s/p right 2nd digit hammertoe surgery NWB in an intact posterior splint, or Ms. Feynman returns 2 weeks s/p right 2nd hammertoe surgery PWB in a surgical shoe with an intact dressing.

Post-Operative Assessment
Documentation: NORMAL ABNORMAL
Ms. Feynman returns 2 weeks s/p right 2nd digit hammertoe surgery NWB in a posterior splint, or Ms. Feynman returns 2 weeks s/p right 2nd hammertoe surgery PWB in a surgical shoe with an intact dressing, or

Ms. Feynman returns 2 weeks s/p right 2nd digit hammertoe surgery WBAT in her regular sneakers and without a bandage.

Post-Operative Considerations: Weight-Bearing Status

Situations for NWB immobilization in the forefoot:
Arthrodesis: 1st MPJ (McKeever arthrodesis; 1st met-cuneiform articulation (Lapidus arthrodesis)

Post-Operative Considerations: Weight-Bearing Status

Situations for NWB immobilization in the forefoot:
Arthrodesis: 1st MPJ (McKeever arthrodesis; 1st met-cuneiform articulation (Lapidus arthrodesis) Fractures:

possibly cc--tired

3,4,5 are fractured. if there is some type of fracture the patient is going to be weight bearing.

Post-Operative Considerations: Weight-Bearing Status

Situations for NWB immobilization in the forefoot:
Arthrodesis: 1st MPJ (McKeever arthrodesis; 1st met-cuneiform articulation (Lapidus arthrodesis) Fractures: Metatarsal osteotomies?:

Post-Operative Considerations: Weight-Bearing Status

Situations for NWB immobilization in the forefoot:
Arthrodesis: 1st MPJ (McKeever arthrodesis; 1st met-cuneiform articulation (Lapidus arthrodesis) Fractures: Metatarsal osteotomies?: MPJ pinning?:
cc this page

Post-Operative Considerations: Weight-Bearing Status

Situations for NWB immobilization in the forefoot:
Arthrodesis: 1st MPJ (McKeever arthrodesis; 1st met-cuneiform articulation (Lapidus arthrodesis) Fractures: Metatarsal osteotomies?: MPJ pinning?: Plantar incisions

Post-Operative Considerations: Weight-Bearing Status

Situations for NWB immobilization in the forefoot:
Arthrodesis: 1st MPJ (McKeever arthrodesis; 1st met-cuneiform articulation (Lapidus arthrodesis) Fractures: Metatarsal osteotomies?: MPJ pinning?: Plantar incisions

How long?

Usually at least 2 weeks, and a maximum of 6-8 weeks.

Post-Operative Considerations: Weight-Bearing Status

Situations for NWB immobilization in the forefoot:
Arthrodesis: 1st MPJ (McKeever arthrodesis; 1st met-cuneiform articulation (Lapidus arthrodesis) Fractures: Metatarsal osteotomies?: MPJ pinning?: Plantar incisions
NO

How long?

If a patient is NWB, then should you cut off the cast and walk them to x-ray?

Post-Operative Considerations: Weight-Bearing Status

Other situations: Usually WBAT in a surgical shoe for forefoot.

How long?
Somewhere between 2-8 weeks. Usually at least until the sutures have been removed, edema has resolved, and all pins have been removed from the foot. And not any longer than after you have radiographic evidence of osseous consolidation.

Post-Operative Considerations: Sutures

How long are sutures left in place?
Until the tensile strength of the wound is greater than the tensile strength of suture.

Post-Operative Considerations: Sutures

How long are sutures left in place?
Until the tensile strength of the wound is greater than the tensile strength of suture.

10-14 days for podiatric procedures.

Maybe a bit longer for plantar incisions. Maybe a bit longer for diabetic or other immunocompromised patients.

Post-Operative Considerations: Sutures

Clinic Considerations:
ALWAYS ask before removing sutures! important Start out by removing every other suture and checking the wound if unsure. Usually we apply steri-strips afterwards which just fall off on their own.
Benzion?

use your nger to move skin around to see what the strength is. just gently move it back and forth and see if it stays together or if it doesnt stay together.

Post-Operative Complications: Wound Dehiscence

when incision gaps open before it is ready to

distally it is gaped open incision has opened before it is healed

Post-Operative Complications: Wound Dehiscence

Partial thickness vs. Full thickness
Resuture, has to do with how deep it goes. if it is in the deep fascia it is full thickness. Steristrip, dermis or sub q = partial Keep clean with dressing intact, or Betadyne to dry it out a little bit.
Maceration
white material around foot is maceration use betadine

Post-Operative Considerations: Vascular Status

Specific for Amputations and Plastic Surgical Flap Procedures:
suture dorsal ap to plantar ap. want to see if capillary rel is immediate or not. we want to check the color of the ap and the integrity of the sutures.

Want to assess for capillary refill of the dorsal and plantar flaps, as well as a subjective assessment of temperature of the flap, color or the flap, and the integrity of the sutures.
this looks good compaired to the other slides

Post-Operative Considerations: Vascular Status

Specific for Amputations and Plastic Surgical Flap Procedures:
Want to assess for capillary refill of the dorsal and plantar flaps, as well as a subjective assessment of temperature of the flap, color or the flap, and the integrity of the sutures.

Post-Operative Considerations: Vascular Status

Specific for Amputations and Plastic Surgical Flap Procedures:
Want to assess for capillary refill of the dorsal and plantar flaps, as well as a subjective assessment of temperature of the flap, color or the flap, and the integrity of the sutures.

Post-Operative Considerations: Vascular Status

Specific for Amputations and Plastic Surgical Flap Procedures:
Want to assess for capillary full thickness refill of the dorsal and plantar flaps, as well as a gangrene subjective assessment of temperature of the flap, color or the flap, and the integrity of the sutures.

Post-Operative Considerations: Edema

Although swelling can be an expected result of any surgical intervention, there is a difference between normal edema and abnormal edema.
Assess whether edema is localized or generalized. Assess whether edema is soft or firm.
Localized, firm and painful? Suspect hematoma.

Objectify!: Measure circumference to compare edema to the contralateral side and between visits.
Metatarsal heads Metatarsal bases Malleoli

Post-Operative Complications: Deep Vein Thrombosis

cc?

Specific unilateral calf edema:

in post op examination look for calf pain.

Homans sign: Calf pain with ankle dorsiflexion Pratts sign: Calf pain with calf compression

Diagnostic test: Venous Duplex Ultrasound

Post-Operative Complications: Deep Vein Thrombosis

Specific unilateral calf edema:
Homans sign: Calf pain with ankle dorsiflexion Pratts sign: Calf pain with calf compression

Diagnostic test: Venous Duplex Ultrasound

know these

Virchows Triad: Hypercoaguable state, Immobilization, Vessel Wall Injury I AM CLOTTED: Immobilization, Afib/CHF,
Malignancy/MI, Coagulopathy, Longevity (age), Obesity, Trauma, Tobacco, Estrogen/BCP, DVT/PE History

Post-Operative Complications: Deep Vein Thrombosis

Specific unilateral calf edema:
Homans sign: Calf pain with ankle dorsiflexion Pratts sign: Calf pain with calf compression

Diagnostic test: Venous Duplex Ultrasound

Pulmonary Embolism:
know this

Classic triad: Shortness of breath, Chest pain, Hemoptysis Diagnostic test: Spiral CT scan

READ!
Shibuya N, Frost CH, Campbell JD, Davis ML, Jupiter DC.

Incidence of acute deep vein thrombosis and pulmonary embolism in foot and ankle trauma.
J Foot Ankle Surg. 2012 JnaFeb; 51(1): 63-8. (Pubmed ID#: 22196459)
Recommended Reading

Post-Operative Complications: Infection

inammation vs infection all infection is inammatory but not all of inammation is infectious

If there is a hole in your body the natural response is to be inammed. a little bit of erythema surrounding an incision is normal.

cellulitis is erythema that is coming from infection. erythema is usually just 1-2cm around a wound. more pinkish than red and it is relatively small. cellulitis is a lot deeper of a red and it is more 'deeper'.

Erythema

Vs.

Cellulitis

Post-Operative Complications: Infection

Erythema

Vs.

Cellulitis

Post-Operative Complications: Infection

Potentially Normal:
Erythema Warmth Swelling

Potentially Abnormal:
Cellulitis
Lymphangiitis/Streaking Mark it and date it!

Hot foot
Sensitive Hands/1 C

Edema

Post-Operative Complications: Infection

Potentially Normal:
Erythema Warmth Swelling

Potentially Abnormal:
Cellulitis
Lymphangiitis/Streaking Mark it and date it!

Hot foot
Sensitive Hands/1 C

Edema 5 Cardinal Signs of Inflammation/Infection: Dalor (pain) Calor (heat) Rubor (redness) Tumor (swelling) Functio Laesa (loss of function)

know this

 Infection is a clinical diagnosis: Systemic signs of infection

Nausea, Vomiting, Fever, Chills, Diarrhea, Night sweats, etc.
ask this to the patients every morning. these are review of systems questions.

Local signs of infection

5 cardinal signs of inflammation Drainage (purulent, sanguineous, serous) Odor

Laboratory work
Complete Blood Count (WBC)

Post-Operative Complications: Fever

Fever generally defined as >101.5F Everything else is low-grade fever
this is a ballpark range not a science.

Post-Operative Complications: Fever

Fever generally defined as >101.5F Everything else is low-grade fever

5 Ws of Post-Operative Fever

know this

Wind: Atelectasis, Aspiration Pneumonia, PE Water: UTI, dehydration, constipation Walk: DVT Wound: Surgical site infection, Thrombophlebitis (IV site), pain Wonder Drug: Usually antibiotics and heparin

Post-Operative Complications: Fever

Fever generally defined as >101.5F Everything else is low-grade fever

5 Ws of Post-Operative Fever
Wind: Atelectasis, Aspiration Pneumonia, PE Water: UTI, dehydration, constipation Walk: DVT Wound: Surgical site infection, Thrombophlebitis (IV site), pain Wonder Drug: Usually antibiotics and heparin

Find the source!

Post-Operative Considerations: Pain

Find the source!:
Is the patient taking medications appropriately? Is the patient taking any adjuvants? Are they icing, elevating and immobilizating appropriately? Do they have realistic expectations with respect to pain management?

Is the bandage too tight? What type of pain is it (aching?, sharp?, spasming?) Is something else going on?

100% chance that there is some pain after surgery

Post-Operative Interventions: Multimodal Pharmacology

-Percocet 5/325mg. 1 tab PO q6 hours pain. -Percocet 5/325mg. 2 tab PO q6 hours prn severe pain. -Morphine 2mg IV q2hour prn breakthrough pain.
PO Severe Pain Options:
Dilaudid 2mg (up to 8mg) PO. 1 tab q6 hours prn pain. Morphine 10mg (up to 30mg) PO. 1 tab q6 hours prn pain. Oxycontin 10mg PO q12 hours (not a prn!)

on test

Other in-house IV options:

Dilaudid 0.5mg IV q2 hours prn 0.5mg (up to 1mg) severe pain

PCA (Patient controlled analgesia)

World Health Organization (WHO) Analgesic Ladder

Post-Operative Assessment
Documentation: NORMAL
learn how to write a real note not just EMR

The bandage is clean/dry/intact on inspection. The incision is clean and coapted with all sutures in place. There is mild periwound erythema, but no cellulitis, drainage, nor malodor. There is moderate edema, but within normal limits of post-operative course. Calf is soft and non-tender.

Post-Operative Assessment
Documentation: ABNORMAL
Bandage: Absent, Dirty, Dishelved, etc Incision: Dehisced, Gapped, Open, etc Partial or Full thickness? Where? Sutures: Pulled out Peri-incision: Maceration, Cellulitis, Drainage, Edema, etc
Where and to what level? Streaking? What type of drainage?

Calf: Firm, edematous, painful, Positive Homans, Positive Pratts

Questions?
Please do not hesitate to contact Dr. Meyr if there is anything at all that that he can do for you:

AJMeyr@gmail.com

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