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Congratulations! You put in the time physically and emotionally preparing for your surgical procedure and now you are on your way to recovery!
How do you avoid surgical complications?
Your surgeon did exactly what you and her discussed during the pre-operative visit. You did well under anesthesia and did not have any immediate surgical complications. You made it without issues to the recovery area and are now eating, drinking and using a bathroom without assistance. Your surgical site is protected with bandages and some sort of special offloading/protective modality that you expected to be there. You know exactly what to do when you get home and are ready to start on the last phase of healing.
How do you avoid surgical complications?
You optimized your body nutritionally.
You conditioned your muscles in preparation for rehabilitation program and offloading.
Your prepared your mind emotionally and spiritually to deal with pain and discomfort.
You organized your life and involved a group of people who care about you to help.
If complications do occur, it is essential to know how to deal with them timely and efficiently.
How do you prevent the disaster of surgical complication?
Now is the time to concentrate on ensuring success by avoiding complications. To avoid complications, you need to know your enemy. If you learn what complications may arise, you will be prepared to address them before they escalate into disasters.
The most common post operative complication results from wet bandages.
This can occur for a myriad of reasons like not using cast guard plastic bag system during showering, getting soaked in the rain, gardening accidents, or even accidentally peeing on the bandages.
When the bandages are simple like gauze and athletic wrap, they are easy and relatively painless to change. However, when one has a cast, this may become a real problem. Wet bandages under the cast do not dry up. In the world of podiatry, I frequently use non-removable casts to protect surgical site. When the water gets inside of the cast, it saturates cast padding and then travels to the lowest point gravity will take it. This usually results in itchy, irritated, fragile, macerated skin around the heel and bottom of the foot. Of course, the fluid crosses the ankle as well on its way down. Allowed to sit for several hours, the skin will start looking like it does when you have your foot in the water for several hours.
Because the incisions are fragile as is, this will quickly result in incision site weakness and wound dehiscence/opening. This will allow bacterial that traveled with the water and also bacteria that normally lives on the surface of the skin to cause an infection as it invades through the surgical wound. If not changed fairly quickly, serious infection may develop. Virtually all emergency rooms have cast supplies and employ specially trained cast technicians who are skilled with cast placement or exchanges.
DO NOT try to dry the cast by shoving towels inside or blowing inside with a hair dryer. These approaches are not sufficient to evaporate or dry up the water that collects inside of the cast. If your surgeon is on staff at the hospital where the Emergency room is located, she can meet with you there and perform wound exam and cast exchange herself.
Another common complications that interferes with successful surgical outcome is trauma.
This usually occurs due to poor preparation but can be purely accidental as well. Falls is the most common reason I see people develop complications. Improper offloading devices, poor muscle conditioning, improper use of offloading device, or lack of house prep and organization lead to falls. One can cause a complication but simply putting too much weight on operated foot and ankle without realizing that they are creating damage to the surgical site. Frequently, orthopedic and sports related surgery utilizes special stitching techniques, plates, screws, anchors etc. With excessive pressure, weight and torque on surgical site, these implanted devices may fail by breaking, bending, twisting, tearing or backing out. If this occurs, you will have to face a very real need of going back to surgery and will likely have to prepare for a prolonged period of recovery.
No matter what or who caused the trauma, it is essential that you alert your surgeon immediately if this happens. Active recovery can be resumed, once the trauma is addressed.
If unable to reach your surgeon, you should go to the nearest Emergency room for x- rays, laboratory testing and surgical site dressing change. I would recommend asking your surgeon if he or she is affiliated with any community area hospitals prior to your surgical procedures. This way, the emergency room doctor can call your surgeon when you arrive in the ED and your surgeon can come visit you at the hospital emergency room. Surgeon will be able to review all the records and will be able to place any required orders for you right there. If you get admitted to the hospital, the surgeon will be able to see you on the hospital floor in your room. On the other hand, if you end up going to the Emergency room of the hospital where your surgeon is not a member of the staff, he or she will not be able to come and evaluate you. They will also not be able to see your records such as x rays, lab results, MRI, CT scan or other data immediately. Instead, they would have to rely on their colleges to take care of you.
What can you expect during post-traumatic exam?
Skin over your surgical site will need to be examined for evidence of bruising, active bleeding, torn stitches, excessive wound drainage, or signs of infection.
Bruising may result from blood accumulating underneath the skin or in deep areas of the body. This is called hematoma.
This condition may be dangerous as it may result in wound dehiscence/opening, delayed skin healing, skin breakdown, as well as dangerous condition called compartment syndrome. This condition frequently occurs as a result of active bleeding filling a compartment in the limb. Compartment syndrome will be discussed in a separate blog as it is a complex topic deserving special attention.
Torn stitches may be due to rubbing of the bandages on the skin incision or from skin being pulled apart during trauma. If possible, these will be re stitched. If re-stitching is not an option because the wound edges pulled apart too much or have become contaminated, you may have to deal with a period of wound care.
Excessive wound drainage an may occur due to insufficient elevation of surgical limb.
This results in pulling of fluid around the surgical wound and then escaping through the weak point, which is skin incision. Persistent drainage will weaken the skin and will ultimately result in skin delayed healing requiring wound care.
After the skin has been examined, X ray or CT scan or MRI test will be done to further investigate patency of the surgical site.
X ray is a two-dimensional representation of bones, their quality/density and alignment. Metal and metal alloy are visible on x ray. If plates, screws, or anchors are broken or bent, a simple x ray will provide the surgeon with much information needed to fix the breaks. X ray will also show if the alignment of bones, if those were repositioned in surgery, is intact.
CT scan is a 3D x ray. It is a very helpful modality for complex traumatic cases when an injury needs to be evaluated from multiple angles. Even though CT scan will provide significantly more detailed information, it also results in significantly greater dose of radiation being administered.
X ray and CT scan do not allow for high quality of visualization of structures outside of hardware, bones, and to a certain degree cartilage.
MRI test on the other hand does not use any radiation to obtain high quality results. The benefits of the MRI test also include the fact that one can see all structures including muscles, bones, cartilage, blood vessels, nerves etc. The downside of the MRI is the fact that it is a more expensive test and a more time-consuming test. In addition, MRI results will come out “blurry” if the area being scanned has any metallic objects in the exam field.
Surgical site infection is another great concern that must be addressed.
If the surgical site becomes red, warm, swollen with increased wound drainage and starts to smell unhealthy, infection should be high on the suspicion for problem radar. If you see any of these signs, it is imperative that you have these evaluated and treated immediately. It is important to realize that “time is tissue”. Infectious organisms release toxins which destroy healthy tissue resulting in potentially irreparable trauma which may lead to delayed wound healing, wounds that do not heal, infection of structures near to and deep to the wound. If this goes unaddressed, the infection may involve your whole limb. If this happens, you may end up with limb amputation. If infection spreads into your blood, it can use it as super high way and spread all over your body resulting in sepsis (total body infection) and death.
Post-surgical pain and stiffness are commonly reported issues that should be discussed with your surgeon.
Pain after surgery is expected. Even with the use of strong pain medications, some degree of pain is expected.
Pain medications help mask the pain. They interrupt natural pain pathway and do not allow your brain to perceive that a real pain stimulus exits. Pain medications, just like anesthesia, help us deal with severe pain associated with surgical procedure. However, it is important to remember that all they do is mask or cover it. Pain is expected to be most severe in the first 3-5 days after surgery. In addition to pain medication, your surgeon may order anti-inflammatory medications to reduce pain related to excessive inflammation around surgical site. It is important to note that some inflammation is needed for healing.
Another important fact is that pain medications such as opioids are highly addicting and relatively quickly lose their potency in reduction of pain requiring higher doses or high frequency in administration.
Pain medications should be taken exactly as prescribed. If you are doing that and are still experiencing pain, it is important to contact your surgeon right away. Frequently the pain can be reduced by the use of ice behind the knee for lower limb surgery. Elevating the limb is also very helpful as it reduces pressure and swelling around the surgical site. The surgeon may choose to loosen up bandages which may become tight as a result of tissue swelling. Sometimes, there is bleeding through the skin at the end of the surgical procedure. This blood accumulates and then dries up on top of the incision site resulting in painful pressure point. Changing the dressing usually reduces the pain in this situation.
Post-surgical stiffness is also common after surgery but tends to be a temporary phenomenon which improves or resolves with physical therapy and joint motion.
The stiffness is there because of swelling of structures around the joints due to post-surgical inflammation resulting in decreased range of motion. Use of muscles, elevation, passive and then active range of motion all help to alleviate this issue.
However, one must be aware of the type of stiffness and swelling that may be life threatening. Some patients who experience limb immobilization due to casting, use of fracture boot, prolonged surgery etc. may experience sudden onset swelling to the area of the calf muscle. This swelling can be associated with increased pain, tightness and redness around the calf muscle.
This condition is called DVT or deep venous thrombosis.
DVT results because of blood clot forming in deep veins of the leg muscles resulting in obstruction of flow through the vein and back to the heart and lungs. If the clot dislodges, it may travel to any area of the body. If it travels to the heart, lungs, brain or other vital organ, it may result in death or permanent injury to that organ. If you think you have a DVT, you should head to the nearest Emergency room and then notify your surgeon. Diagnosis if DVT is usually done through a non-invasive ultrasound test with or without a blood test called D-Dimer. Treatment for DVT will be started in the emergency room and will likely continue for next several months by your primary care doctor or surgeon. Treatment will likely involve the use of blood thinning agents which will predispose you to bleeding and bruising but should protect you from life threatening blood clots.
Are all complications avoidable? Absolutely not. Some may happen because of your actions and some will be caused by accidents.
The most important thing to remember is to avoid panicking and to be proactive when they occur. Call your surgeon and then call your friend to help you get to the hospital Emergency room or your surgeons office.
Close communication with your surgery team and your support network is your number one resource to prevent and address any and all complications!
DO not let your feeling of fear or embarrassment lead to a delay in care!
Your friends and your surgery team want the best for you and are rooting for your success!
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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!