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FOREFOOT
RECONSTRUCTION

FOREFOOT RECONSTRUCTION

DEFORMED OR DISLOCATED 2nd TOE

 

The most common reason for a forefoot reconstruction is severe deformity of the 2nd toe which can even dislocate. The toe may sit on top of the foot and often crosses over the hallux. Most patients have a very painful lump in the ball of the foot and feel like they are standing on a pebble every time they stand.

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The surgery to rebuild the front of the foot and is referred to as a forefoot reconstruction.

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What can I expect on the day of surgery?

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  • The surgery will normally be under a general anaesthetic.

  • Normally patients stay overnight. Some elderly patients may even opt to book into a rehabilitation centre to convalesce for the first two weeks

  • I will numb the ankle and foot with local anaesthetic so that you will be comfortable when you wake.

  • There will be a big bandage on your foot and ankle which you will keep dry and intact for 2 weeks

  • You will be given crutches and a post op shoe to wear

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What are the risks and complications?

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The vast majority of patients do extremely well. A small group of patients need extra physio due to swelling or stiffness. Rare complications include infection, DVT, nerve damage, fracture, non-union, stiffness, recurrence, deformity, flexor tendon injury, further surgery (ranging from removal of screws to repeat surgical correction and extremely rarely fusion of the 1st MTP joint) and CRPS

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Clear Advice About DVT

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A DVT is a Deep Vein Thrombosis or a blood clot in the leg. A blood clot occurs after this forefoot surgery for about 1 in every 100 patients. You can help prevent a blood clot by keeping your knee and ankle and toes moving. Keeping yourself hydrated is also helpful to prevent a DVT. Finally elevating your leg to the level of your heart will minimise the amount of swelling you have which will also help to prevent a DVT.

 

If you were the unlucky patient who developed a DVT you would likely have some symptoms:

  • The leg (above the dressing/foot) would become hard, heavy, swollen, painful and/or red

  • If you were to have any of the above symptoms you would have to have a scan to look for a blood clot and then be treated with blood thinners

If the blood clot were to move to the lungs you would have a pulmonary embolism which is a medical emergency

  • The symptoms of a pulmonary embolism are breathless & chest pain- Call 911

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When can I drive?

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The best guide that you are safe to return to driving is that you are able to walk well without crutches and without the surgical shoe. The usual time scale also depends on whether you had surgery on your right or left foot and whether you drive a manual or an automatic.

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  • Right side surgery and all car types: 6-8 weeks

  • Left side surgery and manual car:     6-8 weeks

  • Left side surgery & automatic car:     2 weeks

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How long will I need to off work?

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The time you require off from work depends on what type of job you do. The first two weeks of healing are critical and so you must have this time off work. Many people are able to work from home and so if you avoid commuting in the first six weeks, you will find that your foot does better. If you work on your feet all day, do a manual job, or are required to wear dress shoes you may need 8 weeks before you are back at work.

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What instructions will I have for the first 2 weeks after surgery?

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  • Elevate leg level to heart (above if swollen)

  • Keep foot dry for 2 weeks

  • Keep dressing intact

  • Move Toes and Ankle

  • Touch Weightbear in post-op shoe

  • Keep the big toe flat and don’t walk with the toe sticking up in the air

  • Please remember that standing and walking in the first 2 weeks puts pressure on the healing wound. The more you stay off your foot, the better your wound will heal.

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SELF EXERCISES

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Start immediately (Day 1) post op and repeat as often as you can.

(Please don’t remove your dressing these photos are just to illustrate clearly what you should do)

  1. In your dressing wiggle your toes up and down as much as you are able to do

  2. Grip the entire big toe and move the toe as far down as it will go and then as far up as it will go

      Passive Dorsiflexion                                                                                    Passive Plantarflexion

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What happens at 2 weeks in clinic?

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  • You will attend my foot & ankle clinic to check your wound

  • If your wound has healed well you will be put into a hallux valgus splint and shown how to apply it

  • If you have K-wires in the toes they must stay dry

  • Continue with postop shoe for another 4 weeks whenever standing or walking

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  • It is crucial that you learn how to do special exercises in this clinic appointment to teach the big toe and lesser toes to work normally (see below)

  • Reteach your big toe to rest on the floor (and not stick up in the air)

  1. Sit in a chair no splint THEN:

  2. Practice pushing your whole hallux down into the floor (Figure1)

  3. Once you are doing this well, lift your heel and start to push up onto tip toes (Figure 2)

   FIGURE 1                                                                   FIGURE 2

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  • Another wonderful exercise, though often not loved by patients, is to practise picking up a tissue by scrunching up the toes

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Physiotherapy and instructions for the period from 2 weeks to 6 weeks following surgery

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  • You must use the post op shoe and splint whenever you are standing and walking

  • From 2-4 weeks you may put up to 50% of your body weight through the foot

  • This is called partial weight bearing and your physio therapist can help to make sure you are doing this correctly (you still need your crutches)

  • From 4-6 weeks you can weight bear fully in the post op shoe

  • Gradually increase the amount of time you spend standing and walking

  • Continue to elevate your foot when it is swollen

  • Continue to do the exercises to move the toe up and down regularly

  • Now add in exercises (shown to you in clinic) which work on ensuring your big toe can push down into the floor and then lift your heel off the floor

  • You may do pilates exercises/ abdominals and core (but only those exercises where you are laying on a floor mat and no standing exercises)

  • Also stretch gastrocs, & hamstrings with theraband or towel wrapped around foot

  • Contrast bathing in hot and cold bowls of water (If no K-wires) otherwise you will be able to start contrast bathing after 6 weeks when the wires come out

  • If K-wires, clean foot with a moist flannel but do not wet the wires

  • Wound massage with Bio Oil

Clinic Appointment 6 weeks following surgery

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  • You will have a set of weightbearing radiographs

  • If you have K-wires in any of your toes these will be removed

  • Once the K-wire site has had a day to heal over you will be able to start wetting the foot

  • Gradually increase the amount of time you spend standing and walking

  • Continue to elevate your foot when it is swollen

  • You will then be able to go into a roomy lace up shoe

  • Work on walking slowly, heel through to toe off so that you are using your foot well

Physiotherapy and instructions 6 weeks+ following surgery

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‘SURREY STAGES’

The Surrey Stages is a Foot & Ankle Rehabilitation Program designed to continue to strengthen the healing tissues while preventing injury as healing takes place

 

BRONZE AWARD

  • DOUBLE HEEL RISES (DHR)

  • You can go up and down on tiptoes in sets of 3, slowly and 15 reps in each

  • You are working towards a normal gait (perhaps slightly slower to start)

  • All pilates exercises & gym equipment with foot plate (bike, rowing machine, X-trainer)

  • Note: If you and your physio are struggling to help you progress past the bronze award, start to wear a backpack and slowly increase the weight/ number of books in the back pack. Eventually you will be able to discard the back pack and progress to the Silver Award

 

SILVER AWARD

  • DOUBLE HEEL RISES WITH A LIFT

  • You go up on both feet but lift unoperated leg and lower slowly only on operated leg

  • 3 sets, working to 15 reps in each

  • You can stand both feet on a wobble board

  • You can hold a solid DHR for 20 seconds

  • You can skip on the spot (low height) with both legs

 

GOLD AWARD

  • SINGLE HEEL RISES

  • 3 sets, working to 15 reps in each

  • You can stand on one foot on wobble board

  • You can hold a solid DHR for 40+ seconds

  • Very gentle jogging

 

PLATINUM AWARD

  • Progress to hopping in all directions

  • Double and Triple Hops

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