CHAPTER 11

Foot Surgery

Foot surgery has undergone tremendous changes in the past few decades. In the first half of the twentieth century the emphasis was on correcting the physical manifestation of the problem with little effort made toward addressing the forces behind the deformity -- in much the same manner that a mechanic may replace a tire with uneven wear without realigning the wheels.

This tendency contributed to unacceptably high failure and recurrence rates in foot care. Also a factor was the lack of sophisticated instruments available. As recently as 1970 many surgeons were still utilizing modified hammers and chisels to perform foot surgery. Today, most foot surgery is performed with high-speed power equipment that enables the surgeon to make precise bone incisions.

Today's foot surgery focuses on getting the patient walking as soon as possible, sometimes immediately after surgery. This is in sharp contrast to foot surgery of the past, which too often left the patient immobilized for long periods of time. Still, the decision to have foot surgery is not one to be taken lightly. If you are considering having foot surgery, keep the following information in mind:

1. Almost all foot surgery is elective. You should have your foot operated on only after you have tried more conservative therapies. A heel spur, for example, will often respond to strapping, steroid injections, or to the wearing of orthotic devices (customized sole inserts), so you owe it to yourself to try these therapies first. Do what is best for you, not what is most expedient for the surgeon.

However, in the case of certain conditions, such as painful bunions or hammertoes, the conservative option, such as wearing a molded shoe, may be unacceptable to you. If this is the case, surgery may be the only alternative.

2. Avoid "same day" surgery. Most foot conditions develop slowly. This gives you the time to make a careful, sound decision. Don't let yourself be pressured while you're "in the chair." If you have doubts, go home and sleep on it. You may also want to get a second opinion. Most health insurance companies will be more than happy to send you to a qualified doctor, often at no charge to you.

The only type of surgery that should be performed during your first visit is minor skin surgery, such as the removal of an infected ingrown toe nail or the removal of a skin tumor such as a wart.

Occasionally emergency surgery is necessary, as in the diagnosis of osteomyelitis (bone infection), but this is a rare occurrence. There is no valid reason why corrective bone surgery can't be scheduled at your convenience.

3. Elect a time that is best for you. Since foot surgery is elective, plan to have it done when you will be least inconvenienced. Swelling results from most foot surgery and necessitates the wearing of a surgical shoe for a few weeks. If you have to attend a wedding, you'll probably want to delay the procedure until after the festivities. If your job requires the wearing of stylish shoes, you may want to delay the surgery until your vacation.

Weather may also be a factor in the choice of your surgery date. Most people who live in a cold climate prefer to have their feet operated on in warmer weather because it is easier to fit a swollen foot into a sandal than a winter boot.

4. Cosmetics alone is not a good reason to have foot surgery. You may consider your foot problem unattractive but, unless you model your feet for a living, it's usually best to leave them alone. Good reasons for having foot surgery are to relieve pain, to help you walk better, or to help you fit into normal shoes.

5. Select the best foot surgeon available. Find out the qualifications of your surgeon. Every podiatrist or orthopedist is legally permitted to operate on your feet, but the training and experience of individuals varies widely. While there is no one criterion by which to judge an individual's competence, you should look for the following attributes: a) completion of a surgical residency; b) board certification; c) hospital surgical privileges; d) satisfied patients; and e) a good reputation among other specialists.

A doctor who over-advertises to obtain surgical patients should be considered suspect -- a top foot surgeon needs only his or her track record as his advertisement. Your surgeon should not be offended if you ask for a second opinion or a copy of your X- rays.

There are first-rate surgeons in every large city, so invest the time and energy to seek these individuals out. You deserve the best.

6. Foot surgery is not painful. Many procedures can be performed under local anesthesia. Your foot can be numbed with a Novocaine-like substance: Marcaine(r) is popularly used because it keeps the foot pain-free for about twelve hours. More extensive foot surgery is usually done under general anesthesia.

If you are in pain after the anesthetic wears off, many analgesic tablets, ranging from aspirin to narcotics, are available to keep you pain free.

7. Allow time for your foot to heal. Modern surgical techniques now allow you to walk on an operated foot shortly after surgery. But don't expect to be running a marathon the following week.

Nature needs time to fully heal the foot and this can vary with the individual. Some "fast healers" return to work a few days after surgery. Others need a week or more to recover. The duration and extent of the surgery are also factors. In general, the more extensive the surgery, the longer the recovery time.

The foot's healing process occurs in two stages. In the first phase, known as the "primary" healing stage, the body actively heals the incisions. This period lasts three to four weeks and you will be aware of the process. In the "secondary" healing stage, your body gradually remodels the bones which have been operated on. This stage can take from several months to several years, and you will rarely be aware of the underlying changes. Gradually you will be able to resume all normal activities but you may occasionally feel a funny numbness, twinge, tingling or other sensation. When these disappear you know that the healing process is complete.

Office Versus Hospital Surgery

Where to have your surgery is an often controversial subject. Simply put, minor foot surgery should be performed in a doctor's office and major foot surgery should be performed in a hospital. But there are complicating factors. Some surgeons' offices now contain operating suites as elaborate and well prepared as those in hospitals. And some procedures previously thought of as being major are now considered minor. So, where your procedure should be done depends ultimately on how much support care you need.

Most doctors' offices are not equipped for such ancillary services as general anesthesia, attending physicians, or nursing. Nor are they equipped for overnight stays. If your surgery is extensive, if you have a medical problem such as a heart condition, or if you have no one to care for you at home, you will be better off in a hospital. If your procedure is minor, you are in good health, and you have someone to take care of you at home, you're better off having your surgery performed in a well-equipped doctor's office.

Conventional versus Minimal Incision Surgery

Two distinct techniques of foot surgery are currently being utilized and there is a great deal of controversy over the advantages and disadvantages of each method.

Conventional foot surgery is the predominant style used by hospital-based surgeons. In this technique, the surgeon makes a lengthy incision over the area to be operated on and proceeds to "open up" the area. The surgeon can then visualize the internal structures and proceeds to cut and remove bone using power drills and saws. Scalpel blades are often used to cut and reposition soft tissue structures such as tendons and capsules. This type of surgery is often referred to as "open" surgery.

Minimal incision surgery is performed predominantly in doctors' offices. In this technique a small incision is made over the involved area. A small dental-type drill is used to "grind off" bone. This method is often referred to as "closed"' surgery since the surgeon cannot visualize the actual bone.

It is this inability to literally see the bone which fuels the vigorous opposition of many surgeons to "closed" surgery. They argue that due to the comparatively "blind" technique many unidentified structures are cut. This argument has somewhat lessened with the advent of portable imaging devices such as the Lexiscope(r). Opponents also point out that often necessary ancillary procedures such as the insertion of a joint implant or repositioning of tendons and joint capsules are simply not possible with minimal incision surgery.

Minimal incision surgeons contend that their technique offers the following advantages:

1. It can be performed in a doctor's office, thus saving considerable expense to the patient.

2. The patient does not have to remain in the hospital overnight. He may immediately ambulate, and often return to work within days.

3. The scar is usually smaller. Minimal incision surgeons also argue that with the use of X-rays during the actual surgery, they do know what structures they are cutting. It is probable that advances in technology which will improve the ability of the "closed" surgeon to see the structures he or she is cutting will in turn enhance the scope and safety of procedures. The photon image intensifier, which acts like a portable fluoroscope to make the underlying bones "visible," is just one of the many devices holding such promise.

The technique performed on your foot will depend on both the training of your surgeon and the severity of your foot condition. Small procedures such as the elimination of bone spurs on the toes are most easily corrected by minimal incision surgery. Major foot deformities involving the replacement of joints can only be corrected using "open" techniques. There are some conditions such as metatarsal deformities and minor bunion operations in which either technique can be utilized.

Soft Tissue Procedures

These procedures do not involve the cutting of bone. They range from the simple removal of a wart to the more complicated removal of a deep nerve tumor (neuroma).

Wart Surgery

As discussed, warts are benign skin tumors caused by a virus infection. They are commonly found on the bottom surface (plantar) of the foot and therefore are usually referred to as plantar warts. Technically warts are known as verrucae and papillomas. Surgical excision of a wart is indicated in cases when the growth is large, or when non-surgical therapy such as the use of acid has not been successful.

The surgeon first applies local anesthesia to numb the wart area and then uses an instrument known as a curette to "scoop out" the entire growth. No sutures (stitches) are needed to close the wound, and usually no significant scar results. Sometimes a cauterizing agent such as phenol is used to help prevent the wart from recurring.

This procedure is not debilitating. The area where the procedure was performed may feel sore for a few days, and there may be some bleeding, but you should he able to return to your job the next day.

Nail Surgery

Nail surgery is also a relatively minor procedure. The most common indications are chronically ingrown and infected nails, in which case a small section of the side of the nail is usually removed. If you have a history of repeated infections of the same nail, the growth portions (nail root and matrix) at the back of the nail may also be removed. This can be accomplished by surgically removing these "growing" sections.

More commonly a caustic phenol solution is applied to these areas to prevent regrowth. The result is that the major portion of the normal nail will continue to grow, while the offending ingrown section will not. This procedure is both simple and highly effective. Occasionally, however, the offending portion of nail will regrow and the procedure will have to be repeated. In some cases of severely deformed or fungus-infected nails, it may be necessary to remove the entire nail. Again, you and your doctor will make the decision as to whether the procedure should be temporary or permanent (removal of the entire growth plate).

Permanent removal of a nail is not as drastic as it sounds. Your toenails serve little function and you can do very well without them. After this procedure is performed, a "nail-like" tough skin forms where the nail originally was. This can be covered with nail polish or an artificial nail.

Removal of a nail portion is not debilitating. You may, however have to wear loose-fitting shoes for a few days after the procedure.

Morton's Neuroma

Morton's neuroma is a fairly common benign nerve growth usually developing between the third and fourth metatarsals and most often found in women. It is caused by the irritation of branches of the medial and lateral plantar nerve as they cross between the metatarsal bones.

Wearing tight shoes pushes the metatarsals together squeezing the tumor between them, and this friction causes the nerve to enlarge. Symptoms of a neuroma vary but may include a sharp, tingling or burning sensation that radiates to the toes.

The conservative treatment of a neuroma includes injections of steroid into the neuroma as well as changing to wider shoes. If these measures are not successful, surgery may be necessary.

The procedure for neuroma removal requires an incision over the neuroma site. The surgeon then must carefully dissect and remove the entire tumor. Often the ligaments attaching the adjoining metatarsals are cut. This allows these metatarsals to separate and helps prevent recurrence of the tumor. Neuroma removal can be performed in either an office or hospital. This procedure requires sutures and you will have to wear loose shoes or sandals for about two weeks afterward.

Toe Procedures

Most toe procedures are designed to eliminate painful corns. These accumulations of extra skin develop because of excessive friction on the skin of the toe as it gets pressed between the bone on the inside and the shoe on the outside. This is usually caused by two structural conditions: most commonly, the tendons of the toe gradually contract causing the toe to "buckle up" and rise. As the "knuckle" of the toe rises higher it is likely to rub against the top of the shoe. thereby causing a corn. When this condition occurs at the middle of a toe it is known as a hammertoe. Mallet toe results when the buckling occurs at the end of the toe.

The second condition which may cause a corn is the presence of a bone spur on a toe. A bone spur - - technically known as an "exostosis" -- is a calcium deposit which forms on an area of bone subject to great friction. Bone spurs usually form at the ends and the sides of toes. The most common location for this type of corn is on the outside of the little toe, where friction against tight shoes is the greatest.

Corns due to bone spurs can also occur in between the toes as the skin gets rubbed between two toe bones. These corns become soft and rubbery due to the presence of moisture between the toes and are known as "soft" corns. Another place that corns caused by bone spurs are likely to occur is at the end of a toe. Occasionally these bone spurs occur underneath a nail causing a painful condition known as a subungual exostosis.

"Soft Tissue" Toe Surgery -- Tenotomy

A tenotomy is a simple procedure available for the correction of a hammertoe. Tenotomies are useful only in hammertoe cases where the problem is being caused by a contracted (tightened) tendon. The tendons going to your toes are located just below the skin. Look down at the top of your foot. If your tendons are tight, you can probably see them as "cordlike" structures. In a tenotomy, the surgeon uses a tiny blade to sever a tight tendon on the top of your foot, beyond your toes. Occasionally the tendon on the bottom of the toe is also cut. Sometimes the surgeon will also perform a capsulotomy in which he cuts the joint capsule just below the tendon as well.

Tenotomies are only useful when a hammertoe deformity is "flexible." By "flexible," we mean that the toe can be manually straightened. When a hammertoe has progressed to the point where the "knuckle" joint becomes rigid, a tenotomy to relax the tight tendon will be of little value. If you have a hammertoe, reach down and try to straighten the toe. If you can easily straighten the toe, a tenotomy may be indicated. If the toe is "stiff" and unbending, a tenotomy (or capsulotomy) by itself will be virtually useless. If your corn is a result of a bone spur, it is also unlikely that you will benefit from a tenotomy.

Perhaps the most compelling limitation to the tenotomy is that its benefits tend to be temporary. After the procedure you will need to stretch the corrected toe daily for many months to prevent the tendon from reshortening.

Bone Procedures for Toe Problems

The most effective long-term cures for corns due to hammertoes and bone spurs are procedures that either straighten the toe or remove the offending spur. When the corn occurs near the "knuckle" or joint, a procedure known as an arthroplasty is performed using either the open or closed technique. In the open method, an incision is made on the top of the toe and a section of bone at the raised area of the "knuckle" is removed. In the closed method, a small incision is made on the top or the side of the toe and a burr is inserted into the bone, and rotated by a dental-type drill. The excess bone is pulverized into bone paste which is then squeezed out of the small hole on the top of the toe.

The advantage of the closed technique is that only a tiny scar will remain after the toe has healed. The advantage of the open method is that there is less chance of subsequent stiffening of the joint. In the open procedure, the offending bone is cleanly removed from the joint space. In the closed or minimal incision technique, bone paste can be left in the joint and this paste can regrow to form bone which may result in a stiff or arthritic joint. Each procedure takes about thirty minutes and can be performed in a doctor's office under local anesthesia. If you have this procedure done on a Friday, expect to be back to work on Monday (albeit in loose or cut-out shoes).

As in any procedure performed on the foot, it is important that no pressure be put on the operated area. Your doctor may give you wooden "post-op" shoes, or you may choose to wear loose fitting sneakers or an old pair of shoes with a hole cut in the top. If the weather is warm, sandals are also acceptable. Whatever you select, remember that no pressure is to be put on the healing wound for several weeks.

Surgery for "Spurs" on Toes

Bone spurs are actually calcium deposits which result from increased pressure or friction on bone. The body "lays down" this calcium for protection in the same way that the skin develops callus to protect itself from excessive force. Technically known as an exostosis, this is basically a permanent condition which cannot be helped by reducing the amount of calcium in your diet.

Bone spurs can occur anywhere on your foot. You may be able to feel them as small lumps and bumps. Often these lumps are painless. If this is the case, leave them alone. Sometimes they may result in corns, particularly when they develop on the outside of the little toe or between the toes, where they result in "soft" corns. Surgery is indicated when you can no longer get relief from wider shoes,

A subungual exostosis occurs when a bone spur develops underneath a toenail. Surgery is indicated for this painful condition when you can no longer get relief from wearing a shoe with a higher toe box (the part of the shoe above the toes).

In the case of a simple exostosis, in which there is no joint involvement, closed surgery can be used to easily grind off the extra bone. This procedure is done in an office under local anesthesia and usually requires no sutures. An exostosis can also be removed via open surgery. Ultimately it is up to your surgeon to choose the method, but it is important for you to be aware of the options.

Metatarsal Surgery

The metatarsals are the "long" bones of your feet. The "ball" of the foot is the area located below the front part of the metatarsal bones. Metatarsal problems range from the bunion, which is the deformity occurring at the first metatarsal, to a "tailor's bunion," which is found on the fifth metatarsal. Plantar-flexed or "dropped" metatarsals are a condition which often results in painful callus formation on the bottom of the foot.

Bunion Surgery

A bunion is a deformity found at the first metatarsal-phalangeal joint, behind your big toe. It is a condition that develops slowly and results from the gradual dislocation of the metatarsal-phalangeal joint which has become "unstable" during the propulsive phase of walking (a time when the joint should be stable). As the deformity progresses, the big toe itself will shift toward the outside of the foot. In severe cases, the big toe will actually overlap or underlap the second toe. Bunions are often painful and they can make shoe fitting very difficult. Contrary to what many people believe. tight shoes do not cause bunions, but they will aggravate them and accelerate their development. The tendency for bunion formation is hereditary and surgery is the only way to correct them. Exercises, splints, and other devices look good on paper but they just don't work. The forces causing a bunion are simply too great for any known device to correct. Orthotics designed to stabilize the foot during gait are custom-made inserts which fit into your shoes. While these devices do not correct a bunion, they may be useful in providing relief and slowing down bunion development.

If your bunions don't hurt and you don't have difficulty finding shoes, there is no need for surgery. You should, however, see a podiatrist about having orthotics made to counteract deforming foot forces. If your bunions are painful, bunion surgery is indicated.

Most of the recent advances in foot surgery have been directed at bunion surgery. In the past, emphasis was placed on the removal of the "exostosis" or lump, and straightening of the big toe. The reasoning was "if the toe looks straight, it will function properly." Each surgeon had his own favorite procedure. Today, we know that there are many different types of bunions and that no single procedure will give the best results. Your surgeon must first X-ray your foot to determine the type of joint you have. He or she will then measure the various angles of your foot. Only then can it be determined which procedure is best for your bunion. Procedure selection is very important. No matter how expertly the surgery is done, your results are only as good as the procedure selected.

In a "simple" bunion, where the toe is straight, only the exostosis need be removed. This procedure can be done either in an open or closed manner. Most bunions, however, are not simple and require either cutting of capsular tissue, or cutting of bone (osteotomy). These procedures are generally best done using the open technique. in which there is less chance of traumatizing the first metatarsal-phalangeal joint.

Depending on the nature and severity of the bunion, your surgeon and you will decide whether to perform the procedure in an office or hospital and whether to have the operation done under local or general anesthesia. If you have bunions on both feet, you'll want to decide whether or not to have them corrected at the same time. Each choice has its own advantages and disadvantages.

You'll initially have a longer recuperation time when you have both feet operated on at the same time, but you may feel that this is preferable to having one foot operated on and then having to go back and do the other foot later. The recovery period from bunion surgery will vary depending on the specific procedure and your body's healing rate. Most people can walk satisfactorily within a few days after surgery. Again, you will have to wear modified footgear until the post-op swelling subsides. Some people need a couple of months to return to normal shoes. Don't expect to be a "cripple" after bunion surgery, but don't expect to go dancing the week after either.

If you work at a desk job, expect to return to work the week after surgery. If you have a walking job or have both feet operated on at the same time, your disability time will probably be two weeks or more. Keep in mind that these are general guidelines which your surgeon may modify. Don't be misled by advertisements for "lunch-hour" bunion surgery -- you may turn out to be "the slowest healer" the doctor has ever had!

Prevention of Bunion Recurrence

After bunion surgery you must take measures to prevent the recurrence of this deformity. The best way to do this is with orthotic devices, which act to control the faulty biomechanics responsible for the instability of the first M-P joint.

"Bunion-Like" Conditions

The joint involved in bunion formation (the first metatarsal-phalangeal or M-P joint) assumes more weight than any other foot joint in the propulsive phase of gait and is more likely to be affected by osteoarthritis, a condition resulting from excessive "wear and tear" in which extra bone is deposited near the joint. This extra bone restricts the motion of the joint and causes severe pain during walking.

While bunions result from a gradual dislocation of the joint, painful bunion-like conditions can occur in which there is no dislocation of the first M-P joint. In these cases, the big toe and joint will look straight, but will hurt when moved. In the early stages of osteoarthritis of the big toe joint, a small bone spur forms at the top or side of the joint. This spur causes a limitation of motion, creating a condition referred to as hallux limitus. If left untreated, eventually the condition progresses to the point where there is virtually no motion left in the joint. This is referred to as hallux rigidus.

The early stages of hallux limitus should be treated with physical therapy to maintain as much range of motion as possible. When normal ambulation is no longer possible, surgery is necessary to "remodel" the joint. This is an open procedure in which the excess bone surrounding the joint is excised and it is often necessary to replace the entire joint with an artificial inplant.

After this procedure it is important that vigorous physical therapy be instituted to maintain normal joint motion. Osteoarthritis can also affect the lesser metatarsals. In these cases. therapy and treatment parallel that of osteoarthritis of the first M-P joint.

Tailor's Bunion

A tailor's bunion or "bunionette" is a bunion-like condition of the fifth M-P joint (the area behind the little toe). It derives its name from the old belief that tailors developed this condition as a result of working at their sewing machines with their legs crossed and the outside of their feet touching. This condition is caused by faulty foot mechanics and, like a conventional bunion, tends to be hereditary.

Two procedures are commonly used to correct the tailor's bunion. In some cases, an angulated incision is made in the bone, which is then slid inward. Other times the front or side part of the bone is removed. Regardless of which method is elected, this is generally a highly successful procedure, and post-op ambulation and healing are rapid.

Surgery for "Dropped" Metatarsals

Ideally, all five metatarsal bones should hit the ground at the same level. Often, however, one or more metatarsals can be structurally lower than the others. This condition is referred to as plantar-flexed or "dropped" metatarsals. The increased pressure of one metatarsal hitting the ground with more force than the others often results in the formation of a painful callus-like lesion known as an intractable plantar keratoma (IPK).

The conservative treatment of an IPK involves using an accommodative orthotic with a built-in depression below the dropped metatarsal. While this device will not correct this condition, it will allow the dropped metatarsal to functionally hit the ground at the same level as the other metatarsals. In an older, less effective treatment, metatarsal pads were placed behind the affected bone. The theory was that these pads "raised" the dropped metatarsal.

Experience has shown, however that it is better to let a plantar-flexed metatarsal drop harmlessly into a small hole, than to attempt to "lift" it. When conservative therapy has not been successful, surgery is indicated. This highly successful procedure, known as an osteotomy, involves surgically raising the dropped metatarsal. This can be accomplished easily using either the open or closed method. In both cases, an incision is made into the metatarsal causing a precise surgical fracture. The patient is allowed to walk immediately in wooden post-op shoes which "float" the fractured bone and let it heal in a new raised position. Healing from an osteotomy takes about three weeks.

Heel Spur Surgery

A heel spur is a painful bone formation on the heel caused by the gradual "pulling off" of bone from the heel by the stretching of the ligaments of the arch. These ligaments originate in the heel and terminate in the metatarsal bones. Surgery is indicated only after all other conservative treatments have been unsatisfactory.

Heel spur surgery is performed through a small incision on the inside back part of the foot. It is no longer considered absolutely mandatory to remove the entire spur. Often detaching ligaments attaching to the spur (the plantar fascia) is sufficient to make this condition asymptomatic.

Major Foot Surgery

Major foot surgery is also available for the correction of foot deformities such as flatfeet, high arched feet, clubfoot, and ankle instability. Many of these procedures require the use of wires, screws and extensive casting to fixate bones. This type of surgery should therefore not be considered as "ambulatory." The procedures for these "reconstructive" surgeries are complex and are best discussed with your own surgeon.

What To Expect After Surgery

Foot surgery is unique -- in what other type of surgery are you required to walk on a healing wound? The foot, though, is a sturdy structure which responds well to this challenge, and most foot surgery heals uneventfully. But you should be prepared for any of the following possible post-op complications:

1. Post-op Swelling (edema). Some swelling should be expected following your operation. Generally, the more extensive the surgery, the greater the swelling will be. Elevating your feet will help reduce this swelling. One way you can do this is to place a large book such as an encyclopedia or Sears catalog under the base of your mattress. Remember that the more you're on your feet after surgery, the longer it will take for the swelling to go down. Most edema should be gone after one month. Some residual swelling. However, may remain for the next few months. This residual swelling should not be painful. but may restrict you from wearing tight-fitting shoes.

2. Black and blueness. This is a normal sequela of surgery and results from small internal bleeding in the wound site. Sometimes this discoloration may even appear in other parts of the foot. Bunion surgery, for example, might result in black and blue adjoining toes. Post-op discoloration will gradually fade and completely disappear within a month.

3. Soreness. This will also vary with the extent of surgery and your own pain threshold. Many people require little or no pain medication after surgery-often the application of ice is sufficient. Others use aspirin or Tylenol(r). If you are in discomfort, your surgeon can prescribe medication ranging from codeine to stronger narcotics. Generally it makes sense to take as little medication as needed following surgery. Still, you don't have to be a hero. Take as much medicine as you need to feel comfortable.

The soreness you feel after surgery will peak in about forty-eight hours and will decrease every subsequent day.

4. Infections. Your foot surgery was performed under sterile conditions, so the risks of infection are minimal. Keeping your bandages clean after surgery will also decrease the chances of an infection developing, but unfortunately, even under the best of conditions infections may occur. Fortunately, modern antibiotics make infections much less of a problem than they once were. Be aware of the "cardinal" signs of an infection: throbbing pain, increased temperature, redness, swelling, pus.

Infections take a few days to develop. If you notice any of these signs, call your doctor immediately. The sooner an infection is detected, the faster it can be resolved.

5. Numbness. This is a normal post-operative finding that results from the cutting of small nerves during surgery. You may experience "funny" feelings such as a pins-and-needles sensation or an occasional sharp pain. These feelings are signs that your wound is healing and that the nerves are regenerating. Normal feeling should return to the operated part of your foot within a few months.


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