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This project will, hopefully, turn into a manual that applies generally to any surgery preparation to optimize results and produce best possible outcome with fastest recovery time.
What are the Essential Topicals and Concerns you should discuss with your Surgeon?
My goal is to introduce you to essential conversation to have with you surgeon to achieve clarify and peace of mind to allow for successful outcome with minimal required downtime. To accomplish this, it is important to thoroughly discuss obstacles that stand in the way of successful surgical outcome and to offer proactive solutions.
Obviously, there are times when you have to undergo surgery unexpectedly as in cases of trauma, infection, or other life and limb threatening processes. It is almost impossible to prepare thoroughly for events like these.
What prepares you, in such cases, are your life choices up to this moment. If your body is optimized for healing and recovery, even non-elective surgery will produce a more predictable outcome.
This will depend on the type of injury of course. Vitamin D for example would need to be at the optimum level for bone healing. Iron levels and oxygen carrying capacity would need to be top notch in cases where blood loss is an issue.
Going into non-elective surgery without the diagnosis of conditions like diabetes, rheumatoid arthritis, heart failure, coronary artery and kidney disease, just to name a few, will certainly decrease the chance of negative outcome.
These series of blog posts are not intended to discuss preparation or recovery from such injuries. Instead, I will concentrate on getting ready for elective/semi-elective surgical procedures.
Of course, the emphasis here will be on prep for and recovery after podiatry procedures, as this is what I deal with on daily bases.
However, information presented here can be applied broadly to other surgical specialties.
So when do you start preparing?
Ideally one should start getting ready 3-6 months before surgery. This should give sufficient time to address many of the obstacles interfering with successful recovery.
Obstacle 1: Post-operative weakness and de-conditioning
Many lower extremity surgical procedures, especially those involving bones and joints, require prolonged immobilization or at least limited walking to allow for proper healing. Humans are designed to move, to walk, and to explore and surgery temporarily gets in the way of this drive.
Movement that is generally allowed after surgery involves use of equipment one is likely not familiar with and puts other parts of the body on strain. Just try using crutches, or cane, or knee rolling walker, or even a wheelchair while only being allowed to balance on one foot.
This is a difficult task even for most motivated people, if it is to be done correctly. Now imagine trying to use of these modalities while being in pain and experiencing anxiety about putting the weight down on the foot!
This is why I highly recommend a visit with the surgeon many months prior to surgery date to discuss the details of surgery and post-operative recovery protocol for a specific procedure. Once you know what is expected, you can start getting ready with focus on specific activities and muscle groups.
This is not like training for a marathon!
Obviously, if you are planning to undergo foot surgery, you are likely unable to wear shoes comfortably or walk/stand for a prolonged period of time…this is fine!
Ask you doctor to refer you for formal physical therapy to work on balance, stability, gait training with recommended offloading modality, safe transfers in different circumstances, swelling control, muscle strength to upper extremities, core strengthening, endurance, etc.
If physical therapy is not covered by your insurance, shop around and consider paying out of pocket for a professional Physical therapy or Personal trainer assessment and training session. Go with clear set of expectations and a list of specific questions that should be clear for you after talking with the surgeon.
This way, you will be able to maximize your time during such training session.
Bring a friend with you to record the encounter, so that you can have a truly tailor-made resource to refer to. I do not recommend just looking up videos or reading articles on line on how to prepare for a specific surgery, as individual assessment would provide for best possible outcome for you in light of your overall health and physical abilities.
No online video can substitute for that.
Selection of offloading modality starts with understanding degree of non-weight bearing required, meaning how much weight can be placed on the operated lower limb. I will discuss these from most to least restrictive.
Most restrictive: Absolute Non-Weight bearing
This means that your doctor does not want your foot to touch the ground for any reason at all! As you can imagine, this means your body will be required to undergo significant adjustment in how it moves. Transition to such activity will be exhausting, as you will be required to perform unnatural movements to protect your limb.
In lower extremity, this is a common prerequisite for surgeries for structures around middle of the foot, heel, ankle and above. This can be a short-term restriction (2-3 weeks) or a long-term restriction (several months). During this time, the effected limb is protected with fracture cast, splint, or fracture boot.
As healing progresses, doctor will ask you to start placing some weight on the foot as you progress to moderate level restriction.
Moderate level restriction: Partial weight bearing (heel touch and toe touch)
This level of precaution is the trickiest, as it requires a “feel” for the weight placed on the foot. Here you can put some weight on the designated weight bearing areas of the foot, usually away from surgical site (heel or ball of the foot/toe touch). The most important and difficult part of this restriction is following through on the exact degree of partial weight bearing.
Depending on what your surgeon recommends, this may involve resting the foot on the floor but not putting the weight on it. This is frequently compared to putting the foot on an egg and placing just enough pressure as to avoid breaking its shell. How is that for tricky?
As you can imagine, this will require significant use of core muscles, great balance and upper extremity strength to do successfully. If not done successfully, one can easily loose balance and fall resulting to compromise to surgical sites and injury to other areas of the body.
In addition, if using devices like crutches, one may develop pain under arm pits and tingling/numbness to arms as a result of incorrect crutch use techniques. This is frequently seen in patients who “swing on” their crutches by allowing the crutch handle to press into armpits thereby resulting in nerve injury.
Thus, it is important to remember that the crutch handles are there to be pushed off of and the body weight must be supported through the hands gripping the offloading device.
Minimal level restriction: Full protected weight bearing
This is a type of restriction that allows one to put full weight on the operated limb while wearing an immobilizing device on that limb. Most of the time, this involves the use of fracture boot or a cast.
This is one of the most exciting and also one of the most prone to injury and surgical site compromise times.
The reason is that by this time, most patients are so tired of not using their foot that they find it exceedingly difficult to stick with the gradual transition from putting weight down on limb, to standing, to walking in straight line, to walking all directions, to fast walking, to jogging, to running, to jumping.
As you can see, once you are at this point, gradual transition and graduated loading and stressing of the limb is a must for successful outcome. Those who rush the recovery end up prolonging their rehab process and frequently end up with a complication or lack of full recovery.
This is the time to start actively working with your physical therapist again, so as to learn how to walk pain-free and injury free. All those bones, joints, muscles, tendons etc. have atrophied to a certain degree and must be re-conditioned and strengthened.
This process cannot be rushed as body responds to stress and loading forces by growing in girth. This growth will not occur overnight! I frequently see patients rushing into walking without protective device end up with ankle sprain.
Absence of restriction: Weight bearing as tolerated
This is the final stage of recovery and includes walking without assisting modalities and in supportive shoe gear. Sometimes, this may require use of low-profile supportive modalities like orthotics or braces but weight bearing is full and unrestricted at this time and pain should be virtually absent.
From here, you can start working on ever increasing your endurance, distance, and stamina.
So, should you stop all physical activity before surgery and during this intense recovery period?
Absolutely not! In fact, you should be increasing your activity!
However, this increase in physical exercise must be directed towards muscle groups, bones, joints, and physical maneuvers that are essential for recovery. Thus, one is not expected to sit on the couch with foot up longer than one to two weeks.
Once the pain and swelling are under good control (usually within first 14 days), you should start on activities previously discussed with your physical therapist and surgeon to stay strong, stable, and injury free in other areas of the body.
Even better, you should start working on strengthening those areas before the surgery date to give your body an advantage.
Many of the newer foot surgeries techniques allow the patient to be at the stage of full protected weight bearing almost immediately after surgery. If your surgeon allows this level of activity, you will certainly return to full activity faster and will de-condition less.
Should you concentrate on physical fitness alone during recovery?
Of course not! You must prepare for surgery like you would prepare for a new job or for going into an unknown territory!
In addition to physical optimization and proper pain control, successful social support and spiritual/emotional support is essential. It is easy to get discouraged due to various limitations imposed by recovery process (these will be discussed in future blog posts).
This of course includes prolonged time away from work and potential financial burden if the recovery starts taking longer than expected.
Surrounding yourself with a group of understanding, loving, caring people who are interested in your success. This will allow you to concentrate on recovery instead of fretting about everything you are unable to accomplish.
Just think about being unable to drive, unable to cook, unable to do laundry, unable to climb stairs, unable to carry your child, lift certain weights etc. That is why being able to stand soon after surgery is important not only for faster return to a more normal physical activity but also for emotional and spiritual health.
As you can see, successful preparation for and persevering through lower extremity surgery is no simple task! It requires physical, emotional, financial, logistical, and social preparation for successful outcome.
I hope reading this blog post opened your eyes to this complex yet very doing task!
With the right equipment, groundwork and team of friends, surgeons, personal trainers, and physical therapists, you can almost guarantee a good outcome!
In the next blog, I will discuss importance and tips on psychological preparation for surgery!
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Author bio:
My name is Dr. Marat Kazak. I have been working as a professional Podiatrist serving Northern California community since 2014. My extensive medical and surgical knowledge combined with an ongoing curiosity to learn about the latest trends define my success in the field of foot, ankle and leg medical and surgical care.
The goal of this website is to give you the tools to better care for yourself, to dispel medical myths, and to empower you with information to save time and money! If you are looking for an answer on foot and ankle pain, this is the place to find it. If you do not see your topic of interest covered, please send me a message and I will do my best to discuss it thoroughly in my next upcoming post.
Visit this blog often to learn about latest developments, treatments, and approaches to healing and recovery!