Dr. Eduard Rabat is an orthopedic surgeon, traumatologist and specialist in foot and ankle surgery. He develops his activity in his practice at Hospital Quirón Barcelona, ??where he is responsible for the Foot and Ankle Surgery Unit. He dedicates 90% of his time as a doctor to this specialty. Today we talk to him about pain in foot surgery and how to avoid it.
Dr. Rabat, foot surgery has always had a reputation for being very painful. To what is due? Is this true?
It is true that foot surgery has a reputation for causing excruciating pain and enormous mobility difficulties. This has its historical origin in the type of surgery and anesthesia that has been practiced throughout the world for most of the 20th century, well into the 1990s, especially in relation to bunion surgery, the most common. And really, it was that horrible! All these experiences have been transmitted from one generation to another, settling in the subconscious of patients. This was due both to the type of surgery performed, which was very aggressive with the tissues and with poor aesthetic and functional results, and to the type of anesthesia, general or epidural, with very short-lasting analgesia. This meant that, after the effect of anesthesia had passed, the patient was left in the hands of painkillers that were ineffective in solving so much pain.
What is the current situation? Is this surgery still very painful?
Fortunately, this has changed radically, and it has done so thanks to improvements in surgical technique and anesthesia. We can say that our society, our patients and their current lifestyle have made traumatologists evolve in favor of surgeries that, while maintaining their effectiveness or even improving it, have decreased their degree of aggressiveness. Today, patients don’t, patients can’t afford long recoveries or hospital stays. Most of our surgeries are performed on an outpatient basis. This is what we know as minimally invasive surgery, a set of techniques that are designed to minimize the damage that accompanies all surgical procedures. This evolution has been crucial in foot surgery and in all surgery in general.
Does this mean that we have foot surgery and will not have any pain?
90% of the patients we operate on report not having had any pain in the first 24 hours. Obviously, not all foot surgeries are the same in terms of severity. When we anticipate that due to the type of pathology we may face a potentially more painful procedure, we take special measures. I think the most important change is in the mentality of professionals. Before, postoperative pain was considered normal, which was treated with drugs, and today the goal is to achieve zero pain or, if this is not possible, minimal pain. A painless surgical procedure is the first step to achieve a good recovery.
What are the most common minimally invasive techniques in the foot and ankle?
Basically, arthroscopy and percutaneous surgery. Arthroscopy consists of accessing the interior of the joints through a half-centimeter incision. In the foot it is used especially in the ankle, both in the treatment of cartilaginous injuries (osteochondritis), and in chronic injuries of the ankle ligaments (those ankles that are constantly twisted), tremendously frequent. It is also used to repair injuries to the main tendons of the foot, very common in athletes (peroneal tendons) and in certain diseases of the big toe. Likewise, with this method we treat plantar fasciitis and Morton’s neuromas. Percutaneous surgery has its main application in forefoot deformities, such as bunions, metatarsalgia, hammer toes, etc. It consists, also through minimal incisions of half a centimeter, in accessing the bones of the foot to, through osteotomies, correct the deformities by varying their position.
Open surgery or percutaneous surgery?
Personally, in most cases (90%) I apply percutaneous surgery because of the advantages it presents for our patients. With this type of surgery we can apply the same techniques as in open surgery, with the same degree of efficiency. It stands out for causing minimal or no pain, leaving no scars, and because it can be performed through outpatient procedures with rapid return to work and social life. Nowadays, our patients cannot afford to leave their work activity for a long time and for this reason the surgery must be adapted to their needs. Obviously, there is still a significant percentage of foot pathologies that cannot be operated using this minimally aggressive surgery. In these cases, good anesthesia will ensure a painless postoperative period, even if this entails measures such as hospital admission for at least the first night.
How is the surgical process in a standard bunion surgery?
The patient arrives at the surgical block the same day of the intervention and is received by the nursing team, who reviews the preoperative period (analysis, electrocardiogram, etc.). Shortly after, he enters the operating room, where he is given sufficient sedation so that he does not experience any suffering with the anesthesia. Next, the anesthetist completely numbs the foot by means of two or three punctures in the ankle – the sedation prevents pain. Immediately afterwards, the surgery is carried out in the operating room and under the control of a portable X-ray device and the bunion and the rest of the forefoot deformities are corrected through small 0.5 cm incisions through which we can work on the tendons, the bone (either lowering the exostoses or cutting them –osteotomies–) and even, on many occasions, we insert screws through these small cuts.
The use of screws is necessary in approximately 80% of cases, especially in the most severe ones. After surgery, the patient is transferred to the Major Ambulatory Surgery (CMA) unit, where he usually stays between 2 and 5 hours before authorizing the transfer to his home.
And from here, how does the procedure continue?
When the patient arrives home, they are invited to rest for the first week, although in most cases they are allowed to walk with support and with the help of a specific shoe for forefoot surgery, which is usually used for a week. From then on, he can go outside and, if he wishes, go to his regular job as long as it does not involve special physical activity. At home, the pain is controlled with simple medication. Let’s not forget that the foot remains “asleep” during the first 24 hours, which is when the pain can appear. Later, thanks to this type of surgery, it should no longer occur. After a month, the patient starts wearing comfortable or sports shoes and, from then on, begins a process of re-education.
