Surgical Information

The following are lists of protocols for post operative care. These protocols are meant to be used as general guidelines; clearly, each surgical case is unique and may require individualized care.

Post Op CT scans @ 12 weeks for TTC Fusion, Pantalar Fusion, Triple Arthrodesis, Talus ORIF, Pilon ORIF, Ankle Fusion, Midfoot Fusion, Any bone block fusion

NWB = no weight bearing
PWB = all weight-bearing advancement: start 25% weight-bearing in boot; increase 25% each week until 100% weight-bearing in boot
POS = post-op shoe

Having surgery, no matter how “small” or “minor” the procedure, is a significant event. First, you must find time in your already busy lifetime to have the surgery and to recover afterwards. In addition to scheduling the surgical date itself, there also will be various pre-operative appointments so that you can meet the anesthesiologist and undergo appropriate medical tests.

It’s important for you to understand the nature of your surgery and to know exactly what’s going to be done during the procedure. You should be able to answer such questions as: What is the procedure I will be having? How long will it take for me to recover and get back to my usual activities? What kind of care will I need after I leave the hospital?

You must also prepare emotionally for surgery. Having an operation can cause considerable anxiety. During your recovery you may find yourself more dependent on others than you’ve ever been in the past. It’s important to remember, though, that you’re not alone. Preparing yourself physically and mentally is important for both the surgery and a smooth recover.

We know that you have many questions about your surgery and what to expect. The following pages contain answers to the questions most commonly asked by our patients and their families.

• Call your primary care physician’s office to set up an appointment for your preoperative physical and lab tests within 30 days of surgery. In addition, if you are followed by a cardiologist or pulmonologist, you will need to see him/her prior to surgery to be cleared for the procedure.* All preoperative testing results should be faxed to (703) 810-5420
• Consult your primary care physician about the use of medications, especially routine prescriptions for heart conditions, high blood pressure, asthma and seizures. If instructed, take these medications with a small sip of water on the day of surgery.
• Ask your primary care physician about when to stop taking blood-thinning medications, such as aspirin, Ibuprofen, Coumadin, Plavix or Lovenox.
• Do not take diabetic medications on the day of surgery unless instructed to do so by your primary care physician.
• Do NOT eat or drink anything after 12 midnight the night before surgery, including no mints, gum or candy. You may brush your teeth, but may not swallow any water. Your surgery will be cancelled if you eat or drink after midnight. The reason for this is to minimize the risks of aspiration. Aspiration is when stomach contents enter the lungs during anesthesia, causing irritation and even pneumonia. During your pre-operative visit, you will be told which, if any, medications to take on the morning of surgery. Do so using only a sip or two of water.
• Do not consume alcohol for 24 hours prior to your surgery. Smoking and recreational drug use prior to surgery can lead to serious side effects under anesthesia.
• Use the scrub brush that was provided to you by the surgical coordinator the night before or morning of surgery. Clean your leg from your knee to your toes, being sure to scrub between the toes as well
• Plan how you will get around and care for yourself in your home after surgery. This includes practicing using crutches and deciding where you will be sleeping.
• You will need a responsible adult (18 years or older) to drive you home and to stay with you for at least 24 hours to assist you if you are having outpatient (day) surgery.
• You will receive a phone call from our staff prior to surgery telling you what time to arrive for surgery.
• Any work release, FMLA forms, or disability paperwork will be taken care of by our office staff. Do not give any of this paperwork to your physician. There is some turnaround time for this forms so take this into account and plan ahead. Your patience is appreciated.

Attention!

Nicotine

If you routinely use any nicotine-containing products (cigarettes, cigars, chewing tobacco, e-cigarettes, etc.) chewing tobacco, e-cigarettes, etc.), you need to stop prior to your surgery. Using nicotine places you at a higher risk of complications and is essential to help you achieve the best outcome possible. Depending on the nature of your operation, you may be tested, and your surgery may be cancelled if you continue to use nicotine-containing products

Nonsteroidal Medication

If you are undergoing bone surgery (osteotomy, fusion, or fracture) you are not allowed to take any nonsteroidal/anti-inflammatory medications following surgery until otherwise instructed by your surgeon. Taking these medications following surgery inhibits bone formation. This does not apply to soft tissue or ligament surgeries.

Common over-the-counter NSAIDs include Advil, Motrin, Ibuprofen and Aleve. Prescription NSAIDs include Naprosyn, Ibuprofen, Mobic, Celebrex, Relafen (nabumetone), Lodine (etodolac), Daypro (oxaprozin), Voltaren (diclofenac), Clinoril (sulindac), and indomethacin. If you are unsure about whether a medication you are taking is an NSAID, please ask your nurse or physician.

On the day of surgery, you will need to arrive at the hospital about two hours before your scheduled procedure.

After checking-in, you will be escorted to an area where you will change into a hospital gown and be helped onto a bed. A family member or friend can keep your belongings, or we can store them for you. They can also stay with you until it is time for you to go to the Operating Room. When you are taken to the Operating Room, your friend or family will be directed to the surgical waiting area.

Please note that you will meet with Dr. Switaj on the day of surgery, prior to going into the Operating Room. At this time, he will be able to address any remaining questions that you have.

Please remember that your procedure time is approximate. On some occasions, due to emergencies, we may need to delay your procedure. Our goal is to stay on schedule, but if your procedure is delayed, we will keep you informed and as comfortable as possible

• Wear loose, comfortable clothing that can fit over a bulky dressing. Wear shorts, sweat pants, pajama pants, skirt or dress. Do not wear jeans.
• Do not wear barrettes, hair pins or hair pieces.
• No make-up is preferred, especially mascara. Remove all fingernail and toenail polish
• Do not wear jewelry or bring valuables to your surgery.
• A photo ID, insurance cards and prescription cards should be brought and left with a family member during surgery.
• Bring a list of your current medications and dosages. Include over-the-counter medications.
• Bring a list of your drug and/or food allergies.
• If you have crutches/walker or Roll-a-Bout, leave them in the car. You will not need them for discharge from the hospital, but you will need them to get inside when you get home.
• Bring glasses (leave contact lenses at home) and hearing aids. They will be removed prior to surgery and given to a family member or secured in your belongings bag.
• If you have imaging studies, please bring the CD with them on it, as well as the report, on the date of your operation

Weight Bearing and Mobility Aides

• After surgery, you may be non-weightbearing for a period of time, varying from a day or two to several weeks. The length of time will depend on the kind of surgery you have and your compliance with post-operative instructions.
• Non-weightbearing means that your foot may not touch the floor, even in a splint or boot. Any weight put on the healing bones or joints will adversely impact your recovery. It is essential that you follow these directions carefully and 100% of the time. Putting weight on your foot, even just once, can jeopardize healing and the results of surgery. If you have questions regarding your weight-bearing status, please call the office.
• For mobility during this time, your doctor will recommend crutches, a walker or a Roll-a-Bout to help you get around.
• If your doctor recommends crutches, they will be provided, adjusted to your height and you will be instructed in the proper way to use them. If you already have crutches at home, you might want to practice with them prior to your surgery.
• A walker is another option as a mobility aide. A prescription for this may be needed to ensure insurance coverage. This can be provided to you prior to your surgery.
• Instead of crutches or a walker, your doctor may recommend, or you may prefer to use a rolling knee walker. This is a wheeled support for your leg that enables easier mobility than crutches. These can be rented or purchased and delivered directly to your home—do not have it delivered to the hospital/surgery center. Clinic staff can provide information when you schedule your surgery or you can contact the company at 888-736-6151 or www.roll-a-bout.com. You can also search online at websites such craigslist, ebay, etc. to purchase “used” ones if you so choose.
• You should decide which mobility aide you will be using and make arrangements for it before your surgery. If necessary, we can prescribe physical therapy prior to your surgery to help better assess which mobility aide you prefer. You will need to bring it with you on the day of surgery, but leave it in the car. Clinic staff will take you to your car when you are discharged, but you will need your mobility aide to get from the car when you get home.

• After your surgery, you will be taken to the recovery area while your anesthesia wears off. Most patients receive oxygen at this time. As you wake up, you may be especially sensitive to lights, noise and temperature.
• The recovery area nurse will be checking your blood pressure, pulse and breathing frequently. This is routine and does not mean anything is wrong. You may experience some side effects from the anesthesia, such as nausea, shivering, sore throat or headache. Let the nurses know is you experience these or any other side effects and they will do what they can to assist you.
• Most patients receive a nerve block during surgery, which will numb the nerves that do down to the foot/ankle area. This block will last approximately 8-10 hours on average. However, some patients will still experience some discomfort after surgery. Your nurse is there to help assess your pain and give you the most effective medication that has been prescribed for you.
• When your nurse and anesthesiologist think you are ready, you will be discharged from the recovery area. If you are being admitted to the hospital after your surgery, you will be taken to your room at this time. You will receive your discharge instructions when you are ready to go home.
• If you are an outpatient and going home after your surgery, the nurse will help you to sit up and give you fluids to drink prior to discharge.
• Please understand that the post-operative course varies from patient to patient, and these are meant only as guidelines to a smooth recovery. These instructions may not cover all aspects of your post-operative care and recovery. Please feel free to call the office if you have further questions.

Circulation

• If you have had toe surgery on the toes, it is important that you check the circulation to the toes more frequently. By pressing lightly on the toe, you will note that the color of the toe changes and gets a little pale (blanches). When you release the pressure on the toe returns to a more normal pink color (this is called capillary refill).

The toes must not be dusky, pale or blue. If you notice any adverse changes, contact the office immediately

Wound Care and Bleeding

• Drainage and bleeding after surgery is normal. You may notice bleeding through the dressing or splint—this is quite common It is OK to place extra gauze over the dressing to reinforce it, but do not remove the entire dressing.

If the blood or drainage continues to drip and the dressing is saturated with wet blood after the first 24 hours, call the office

• Do not remove your dressings, cast or splint unless you are specifically told to do so. Doing so could lead to skin problems, infection, and lack of healing.
• The type of dressing you will have post-operatively depends on the type of surgery performed. On the day of surgery, you will receive specific verbal and written instructions about your dressing. If you have a splint, you will not have to do anything. Occasionally, if you have a small dressing, you may be instructed on how to change it prior to you first post-operative appointment
• Regardless of the type of dressing, you should not get the incision wet for 10-14 days. This interferes with proper healing and may result in infection.
• BATHING INSTRUCTIONS: Do NOT get bandages wet. Cover your leg with a plastic wrap (usually 2 small / medium trash bags) with the open end taped water tight around your leg and a clean dry washcloth inside the bag covering the top of your bandage, and KEEP IT OUT OF THE TUB / SHOWER.
  • When bathing, either take a sponge bath or hang the foot over the side of the bath. One safe technique is to get into the empty tub with your foot out of the tub, then fill the tub. It may help to sit on a stool in the tub / shower with the leg out.

Elevation and Ice

Swelling is to be expected after any surgery. It is difficult to specify what constitutes an abnormal amount of swelling. Unfortunately, a minor amount of swelling can remain for up to a year after your surgery.The more you elevate, the less pain you will have.

• When you return home, you should rest and keep the foot elevated.Elevation helps to minimize post-operative swelling and is recommended for 7-10 days after surgery. Often the easiest locations are to lie on the couch and place your foot on the top of the couch, or at the kitchen table with the foot on pillows resting on the table.
• Do not do any excessive or unnecessary walking during the first few days after surgery. Each operation is slightly different, and you may be told specifically not to put any weight on your foot at all. Under these circumstances, you will need to use either crutches or a walker. This does not mean you need to lie in bed all day, and should move every few hours if able, but restrict the time the foot is “down” to 10 minutes or less at a time.
• Use ice over the foot for 24 hours after surgery. If you do not elect to use a cold therapy unit, we recommend filling a large plastic bag with ice and propping the bag over the foot. Ice your foot for approximately 10-15 minutes every hour while you are awake. Do not ice your foot while you are asleep. Do not let the dressings get wet from the condensation on the ice bag. Placing a towel between the foot and the ice will help to prevent this. Do not place ice directly on your skin.

Medications

Pain Management

Unfortunately, everyone experiences some degree of pain after surgery. For some this is worse than others. You will be given a prescription for pain medication before you leave, but often this just “takes the edge off” during the immediate postoperative period. You will not be pain-free, and the first night will be painful and uncomfortable. This will improve with time. Please let the staff know if you are allergic to any medications. If you have had local anesthesia, it is important to start taking the pain medication when the anesthetic begins to wear off.

• RATING PAIN – Using a pain scale to describe your pain will help the staff understand your pain level so it can be managed effectively. “0” means you have no pain; “5” means moderate pain and “10” is the worst pain possible. While you WILL have pain after the operation, we strive to keep your pain at a “4” or below.
• NERVE BLOCK – This is an injection administered during your surgery, which will numb your foot/ankle after surgery. The duration of the block will be variable, but in most cases will last 8-10 hours. In some cases it might last longer.
• TAKING YOUR PAIN MEDICATION – It is advisable to begin taking your prescribed pain medication before your nerve block completely wears off.Our goal is to make you as comfortable as possible; however, you will still experience some pain. Pain medication should not be taken on an empty stomach.
• PAIN PROTOCOL –
  • Tylenol 500mg by mouth every 6 hours x 5 days IF no liver disease
  • Celebrex 200 mg by mouth twice a day x 14 days IF no cardiac history, no sulfa allergy, and no fusion procedure
  • Oxycodone 5-10mg by mouth every 4 hours as needed for pain
  • If bad reaction to Oxycodone, Dilaudid 2-4mg by mouth every 4 hours as needed for pain
  • If prescribed, take Oxycontin ER 10mg by mouthtwice a day x 5 days
• WEANING OFF MEDICATION – After your pain begins to diminish, begin to taper your medication by taking fewer pills or taking them less often, as needed.
  • Stop Oxycontin first, then Oxycodone, can then be prescribed Tramadol if still needed for pain
• MEDICATION REFILLS – It is important that you don’t wait too long to call for new prescriptions of narcoticpain medication. These prescriptions can no longer be called or faxed to your pharmacy, and we are not allowed to give refills. If you will need a refill in 3-4 days please call our office and speak to one of our staff that you had surgery with Dr. Switaj, your specific procedure you had done, and your surgery date. We will then coordinate to either mail you the prescription or you will need to have someone to pick up the prescription at our office.

Other Medication

• VENOUS THROMBOEMBOLIC (VTE) PROPHYLAXIS – There is a risk of developing a symptomatic blood clot following any lower leg surgical procedure. Although this risk is low, you will be prescribed a medication to help prevent the development of blood clots following your surgery. The type of medication, and duration of its use, will be a shared decision-making process between you and your physician.
• POST-OP NAUSEA – You will be prescribed a medication for the prevention of nausea during your post-op course (Zofran). This medication is to be used as needed.
• CONSTIPATION – A side effect of narcotic pain medications is constipation. Senokot-S (over-the-counter) is recommended, if taking narcotics. Drinking plenty of fluids and eating fresh fruits and vegetables will also help.
• Vitamin C 500mg PO once daily x 50 days. This is to help diminish the chance of developing a rare, but severe complication called Complex Regional Pain Syndrome (CRPS)

Physician’s Orders

Weight Bearing

• You will be told one of these three options:
  • Weight bearing as tolerated
  • Weight bearing HEEL ONLY for a specific amount of time
  • NO weight bearing for a certain amount of time
• You will be told one of these three options:
  • Use crutches
  • Use walker
  • User knee scooter

Post-Op Shoe / Boot

• You will be told one of these two options:
  • Wear post-op shoe / boot at all times for a specific amount of time
  • May remove post-op shoe / boot to sleep only

Driving

• You will be told one of these two options:
  • Driving as tolerated wearing option below
  • NO driving for a specific amount of time
• If you are allowed to drive, you will be told one of these two options:
  • Regular shoe
  • FLAT back shoe only (no wedge shoe)

Dressing

• Do NOT REMOVE bandages
• Dressing changes:
  • Wash hands prior to dressing change
  • Remove dressing in a specific number of days
  • Clean incision with alcohol
  • Place smear of antibiotic ointment over incision site
  • Cover incision with gauze
  • Once dressing is changed, change daily and follow instructions above
  • Keep dressing clean and dry for a specific number of weeks
  • May shower after a specific number of weeks
  • Apply smear of antibiotic ointment to site prior to showering

Sutures

Return to Dr. Switaj’s office for suture removal / wound check. You will be told when to return.

Circulation

• Check circulation of toes. Notify your doctor’s office of changes in color or temperature. Toes should be warm and pink.
• Use Cryocuff (cooling) device as instructed. Do not start until nerve block has worn off and sensation has returned.

Additional Information

1. The medicine used for anesthesia / sedation will be acting on your body for the next 24 hours, so you may feel sleepy. This feeling will slowly wear off.
2. While you are taking pain medication (narcotics), you should not drive a car, operate machinery or power tools, drink any alcoholic beverages (including beer) or sign any legal documents.
3. You will need a responsible adult (18 or older) to stay with you for the next 24 hours for your safety and protection.
4. You WILL have pain or discomfort after this procedure. Your doctor will prescribe pain medication for you. This should be taken as directed, and if it does not improve the pain, contact your doctor.
5. After general anesthesia, start with a light diet such as liquids (soft drinks, tea, gelatin or broth), then soup and crackers and gradually increase to solid foods as tolerated. It is very important to drink liquids during the next 24 hours.
6. If unable to urinate within 12 hours of your surgery, contact your doctor and proceed to the nearest Emergency Room for a void trial, an evaluation of post-surgical delay in urination.
7. A low grade fever following surgery is common. If you do feel warm, take your temperature. If the temperature is 101.5 F (38.5 C) or higher, call your doctor.
8. ELEVATE your foot above the level of your heart as much as possible for the first 5-7 days to reduce swelling and discomfort.
9. Do NOT remove bandages unless specifically instructed to do so.
10. Some blood soaking through the bandage may be expected. You can reinforce with clean gauze and ace wrap as needed. If bleeding doesn’t stop after two (2) days, contact your doctor’s office.
11. Do not get bandages wet while bathing. Cover your leg with a plastic wrap with the open end taped around your leg and a clean dry washcloth inside the bag covering the top of your bandage, and KEEP IT OUT OF THE TUB / SHOWER. If may help to sit on a stool in the tub / shower with the leg out. If your splint gets wet please call clinic immediately.
12. If you have any questions or concerns, call your doctor.

A follow-up appointment will be scheduled.

Complications

While the following discussion is usually one of the most intimidating and frightening aspects of surgery, it’s also one of the most important. All surgery is associated with certain risks that something can go wrong. When this happens, the problem is called a “complication.” Sometimes patients think that doctors tell them about potential complications for legal reasons. This is incorrect. There are two main reasons why it’s important for you to know about potential complications. The first is so that you can be fully informed and educated as you decide whether or not to have surgery. I rarely tell patients that they “need surgery.” Rather, I tell them how surgery might help, and that they must weigh this against the potential risks of surgery. The second reason to be familiar with potential complications is that if a complication does occur, it can be recognized and addressed as soon as possible. Big problems usually start as smaller ones, and it is often much easier to treat a complication sooner rather than later.

Infection

So, what can go wrong? For starters, there is always the risk of infection. The skin is an amazing barrier that protects us from bacteria. With any surgical incision, the inner body is exposed to bacteria and an infection can develop. Most infections are shallow, or “superficial”, and are treated with antibiotics. Less commonly, the infection is “deep,” and requires another surgery to clean the infected tissues. Before any operation, numerous steps are taken to protect against infection. Nevertheless, there will always be some risk of infection. Fortunately, for most foot and ankle procedures, this risk is very low, and less than 5%.

Nerve Injury

In addition to infection, there is also a risk of nerve injury during surgery. Down towards the ankle, where the circumference is smaller, the two nerves in the upper leg split into five smaller nerves. As such, there is a greater chance that these nerves can be stretched, bruised, or even cut during surgery. Such injuries can result in loss of sensation, weakness, and the formation of a neuroma. A neuroma is a region of an injured or irritated nerve that becomes hypersensitive and painful. In order to minimize the chance of nerve injury, several steps are taken, including careful positioning of incisions and delicate handling of soft-tissues.

CRPS

Along these lines, surgical patients can infrequently develop a syndrome called Chronic Regional Pain Syndrome (CRPS). CRPS is characterized by pain that lasts much longer and is more severe than normally expected. It may also be accompanied by painful sensations to touch or other non-painful stimuli, as well as changes in skin temperature, color, vascularity, and hair growth. The ultimate cause of CPRS is unknown, as is an understanding of which patients will be affected by it. Please be reassured that CRPS is relatively uncommon (it is estimated to be less than 1%). Nevertheless, we watch for it carefully as in the vast majority of cases it can be successfully treated.

In addition to these complications, there are unfortunately other risks associated with surgery. These include bleeding, drug reactions, and blood clots. It is very important that you inform the surgical and nursing staff if you have had any drug reactions or allergies in the past. It is also important to inform the staff if you have had a blood clot in the past.

Finally, with any procedure, there is always the possibility of an unexpected complication, and no guarantees or promises can be made concerning the results of any operation. Please be assured, however, that we do everything possible to prevent complications. We also strive to treat them as aggressively as possible should they develop. And again, the potential complications listed above are not reviewed for legal reasons. Rather, they are reviewed to help you make an educated decision with regard to surgery and to familiarize you with these complications so that they can be identified as soon as possible.

In today’s world we all tend to look for guarantees. If you’ve read the last section about what can go wrong with surgery, you’ll understand that it would be unfair for me to guarantee you a perfect surgical outcome. Of course, the odds weigh heavily in your favor. Be wary of a doctor who promises a perfect result.

While I cannot guarantee the outcome of your surgery, I can, however, guarantee one thing: my 100% effort. If your case is challenging and takes longer than expected, I can assure you that nobody will rush and we’ll stay as long as it takes. If you have a problem after the surgery, you can be seen any time of day, any day of the week.

People often ask me, why feet? Feet are not glamorous, and by most standards are dirty and downright ugly. If you have found your way to this office, however, you likely have a sense of how disabling foot and ankle pain can be. You probably understand how much a dysfunctional foot can interfere with your life.

Foot and Ankle Surgery is a complex and challenging field. No one, including myself, can guarantee that you will have a good result. Nor can anyone guarantee that you will not have a complication from treatment. However, there is one guarantee that I can make, and that is my 100% effort and devotion to your care. This is my pledge to you.

Paul J. Switaj, MD