Common misconceptions about foot surgery

While I was writing my last post on hammertoe surgery it occurred to me to write a post on common misconceptions of foot surgery.

(Don’t feel like reading a long post? Skip to the last paragraph for a quick summary.)

1) The first one was one that I mentioned in my last post: that extra skin left behind in surgery reabsorbs. This is preached by many foot surgeons but is entirely untrue. Skin left behind remains extra skin after the swelling and scar tissue go down. It is true in the short term that you may not notice it because the area is swollen and the skin is expanded but once the size of the area goes down you still have extra skin.

A small exception to this is when we do hammertoe surgery for corns, sometimes we have to leave part of the corn behind because the skin incision would be too large to close if we cut out the whole corn. After the hammertoe surgery, the pressure and rubbing on the shoe that caused the corn is gone. In this case, the thick hard skin that makes up the corn will go away after surgery. However, this assumes that the correct amount of skin was removed, including the corn. If extra skin remains at the incision, even though the hard part will go away, the extra skin will not go away.

2) The next misconception is also somewhat of a cosmetic one. Many foot surgeons say they put the incision for bunion surgery on the top of the foot because if they put it on the side where it is hidden more, it will rub on the shoe and cause discomfort. Last time I looked at a shoe it encountered the foot on four sides not just one. The real reason doctors put the incision on the top of the foot for bunion surgery is just because they were taught that way when they learned surgery. It also makes it slightly easier to do the surgery, so the surgeon can more easily access the side of the great toe joint closer to the second toe in order to release the soft tissue contracture there. This creates an unsightly scar when looking down on the foot. A much more cosmetic way to do it, is to put the incision on the side of the foot so when looking down you don’t see the scar. With some finesse, I can still easily access the other side of the joint and if I need even more access, I can make a tiny incision between the first and second toe that is barely noticeable.

3) The next misconception: minimally invasive bunion surgery (or other minimally invasive foot surgery) is superior to regular open surgery. The truth is quite the opposite! Minimally invasive surgery entails using a small drill to cut the bones through small stab incisions while visualizing the drills under real time x-rays (Fluoroscopy). This type of surgery is very imprecise as to how much bone is removed and where the cuts are made. I have seen many of these patients have complications due to taking out too much bone and shortening the metatarsal too much, or even not taking enough bone. In addition it is impossible to fixate the cut bone with screws in order to get the bone to heal in the proper place. Some of the doctors that do this type of surgery use ‘percutaneous pins’ in order to hold the bone. This means the pins go through the skin and into the bone. The pin remains sticking out of the skin for 4 to 6 weeks after surgery in order for the bone to heal. The downside to this is that you need to keep the foot dry the whole time the pin is sticking out. Also, the pin exit point creates an additional scar. Additionally, as long as the pin sticks out through the skin, a patient may get a “pin tract infection”. This is when the bacteria from outside the body goes down the pin and into the foot, and into the bone. When you get bacteria or infection in the bone you have a serious problem and need the bone removed, the use of IV antibiotics and usually requires hospitalization. When a screw is used it is completely inside the foot and a patient may get the foot wet after about one and a half to two weeks. Most doctors that perform minimally invasive surgery tell their patients that they will be back to wearing shoes and back to activity faster than traditional open surgery. This is usually not true as they recovery in a similar amount of time.

4) Next misconception: if your doctor tells you that you’ll be back to normal shoes and normal activity in anything less than three or four weeks when he/she is doing bone surgery (and mostly any other foot surgery), he/she is lying to you. It takes 4 to 6 weeks for bones to heal and be strong after they are cut during surgery (or when they are fractured in an injury). After bone surgery, the patient should be immobilized in a boot or a surgical shoe for this 4 to 6 week period in order to allow the bones to heal properly. Occasionally, people wear a brace for only 3 weeks, but that is more unusual, as almost all of my patients wear it for 4 weeks. Whenever bones are cut, and with any other surgeries, there will be scar tissue that forms in the operative site. The doctor will call this “induration”. This induration will be present for 3-6 months and many times up to a year. During this time, the surgical site will feel hard and stiff. Your doctor may prescribe physical therapy after surgery to break up some of these adhesions. All surgeries produce this scar tissue. It does not mean that you will not be able to perform activities or not wear shoes, but I tell my patients that this will be present and they will not be able to wear all shoes or perform all activities due to it.

5) The last misconception that I hear patients talk about is that foot surgery is extremely painful and even more painful than other types of surgery. The truth is that foot surgery is unique compared to surgery on other parts of the body because you have to walk on your foot postoperatively. This weight bearing and not elevating the part of the body does cause slightly increased pain and throbbing. There are surgical techniques that I employ in order to reduce the amount of pain postoperatively. The amount of pain that patients experience starts with how the surgeon handles the tissue during the surgery. In my residency I was fortunate to work with plastic surgeons that taught me unique tissue handling skills that reduce postoperative pain and swelling. Most of my patients experience moderate to no pain after surgery. While I cannot guarantee that for everyone, I invite potential patients to read my reviews in Google. Many of them state that they had little to no pain, or experience less pain than they expected to have after foot surgery. Additionally, I often prescribe a cold therapy device to be used postoperatively. I also prescribed painkillers that reduce the discomfort after surgery greatly. Most people only take these for 1-3 days after surgery. Having less pain really enhances the surgical experience and lets patients return to more normal activities sooner. For example, most of my patients that have desk jobs are able to go back to work on Monday after doing surgery on Friday.

As you can see, there are many misconceptions about foot surgery. I have generalized my descriptions, however, many variables will affect each individual patient. When patients come in for their preoperative appointment, I am very thorough and go over the following: Alternatives to surgery, risk versus reward of surgery, benefits of surgery, pre-operative planning, postoperative course, potential for further surgery in the future, preventative care against recurrence of the deformity, and any other unique characteristics for the individual patient. I will answer all of your questions and make you feel comfortable about having surgery prior to moving forward with the actual surgery.

To summarize the most important points of this blog: 1) Don’t do minimally invasive surgery. (Yes, it is THAT bad that I can generalize). 2) There are ways to reduce postoperative pain. 3) Have realistic expectations about recovery. 4) There are ways to reduce surgical scarring. 5) There are surgical techniques to make foot surgery more cosmetic while getting rid of painful foot deformities.