354 Forefoot Reconstruction
Postoperative Management
First, as we use special instruments and implants for forefoot surgery, we have to use special post- operative footwear. All our patients wear the heel support postoperative shoe, which not only
preserves the operative results, but also allow immediate postoperative walking. Similarly, our postoperative Type II and Type III system allow an early functional recovery and return to social activities [20, 21]. This is an opportunity to thank Romans Industrie (Romans, France) which manufactures these shoes.
Fig. 44a. Postoperative management 1) Special footwear.
1. Sole and last of the Type I heel support shoe.
2. Elasticity of the distal part of the sole allowing to have correct gait. Note that the metatarsal heads are out of support.
3, 4. The shoe: Walking one week postoperative.
5, 6. Specifications of postoperative variable volume shoe (Type II): Correct place for the great toe and adaptable top.
7. At 15th postoperative day.
355 Surgical Management – Postoperative Management
The postoperative period has to be taken in charge and completely controlled by the sur- geon himself, because he knows better than anyone the foot operated and what we have to expect from the performed surgery. I particu- larly think that the surgeon has to apply the bandage and strapping himself and has to control the foot “self-training” of the patient [15, 129].
This is an opportunity to emphasize the role of the patient in the success of the surgery and to write that foot surgery is not like hip surgery which is low demanding from the patient in the postoperative period. On the contrary, the role of the patient is critical in the post foot surgery period: The patient has to be disciplined.
During the first postoperative days, he must ele- vate his foot and stay in this position for a long time. The foot must not just lay on a chair while sitting, but must be upper than the heart in a decubitus position. The patient must also perform self-training that is accurate with foot and leg position and handlings for several weeks and every day particularly in case of invasive
forefoot surgery (moderate hallux valgus correc- ted by scarf osteotomy is not demanding from the patient).
The role of the physiotherapist is also criti- cal. The first postoperative days, he has to mas- sage the entire lower limbs to decrease the oedema. He must also show the patient exer- cises to increase the blood circulation, at last he teaches and controls the patient self-training.
I thank my physiotherapists team A. Zandi, A. and T. Gouzland.
The RSDS is more frequent in invasive sur- gery like the five rays osteotomies: However, it is significantly decreased or avoided by the large shortening of the metatarsal. When it occurs, the Thyrocalcitonin injections are a good solu- tion.
At last, what about insoles? I think that in most cases the surgery can resolve the problems to give final results without insoles. However, there are two indications of insole. The first one is temporary: This may be in the preoperative period, or in the postoperative one. Secondly, there are some cases where surgery is contrain-
Fig. 44b. Postoperative management 2) Avoiding edema.
1. Foot must be elevated during the 48 postoperative hours. It is necessary to stop the edema. In our practice, both feet operated on the same day, and two days staying with elevated feet.
2. Once back home, 500gr of frozen green garden peas is certainly the best means to cool the foot! Set on the dorsal part of the ankle and of the middle foot, it is long-lasting cool (> 2 hours) and takes the correct shape around the foot, thus it is stable from the beginning. It is easy to take another bag. This is for only three days postoperative.
356 Forefoot Reconstruction
Fig. 44c. Postoperative management 3) Toes strapping and mobility recovering (training).
1. Toes strapping in MTP plantar flexion (3 or 4 weeks postoperative).
2. When there is no K-wiring, strapping of the DIP in dorsal flexion. This is not necessary in case of toe K-wiring (3).
4. The best position to reach the foot with the hands and to make self-training.
5. Plantar flexion of the MTP joints (passive and active).
6. The husband should be useful too!
7. Tiptoes and training of toe ground contact (after one postoperative month).
dicated. In these cases, the role of insoles is cri- tical. However, insole has to be in the shoe and not in the cupboard! So that insoles have first to be the most simple and the less invasive, in
order to leave place for the foot in the shoe. It is an opportunity to thank my chiropodist F. Lan- glois who makes thin and effective soles (which stay in the shoes!).
357 Surgical Management – Postoperative Management
Fig. 44d. Postoperative management 4) Problems occurring in invasive surgery.
1. Reflex Sympathetic Dystrophy Syndrom (RSDS) is more frequent for such invasive surgery with local previous trophic troubles and with anxious patients. It usually occurs after one postoperative month
It is usually well treated by Thyrocalcitonine injections. However, this syndrome may be diminished or avoided by large and harmonized metatarsal shortening and the precautions we mentioned above in the postoperative period.
2, 3. Treatment of remaining postoperative stiffness.
2. Manipulation under anaesthesia: To be performed at 2.5 or 3 postoperative months.
3. If necessary, at 1 postoperative year, MTP surgical release regularly provides good results if there is only stiffness and no remaining static or anatomic problems. Percutaneous or mini invasive MTP release or/and section of the tendons is extremely effective in revision for stiffness. Once again, stiffness now rarely occurs since we perform large harmonized shortening in severe forefoot disorders.
These problems (CRPS, stiffness) rarely occur for the single first ray surgery (scarf and great toe osteotomy).
