Complications are a part of surgery and it is important for patients and their families to understand that complications can and do occur during some surgical procedures. The decision to do surgery should not be taken lightly and multiple consultations are beneficial with all questions asked and answered. When necessary, other opinions outside of our office will be encouraged. Patients and their families need to go into these procedures with their eyes wide open and their expectations expressed. We clearly outline what we can and cannot do surgically and hope to be sure that our expectations as well as our patients are perfectly aligned. This allows a very smooth surgical procedure with good to excellent short and long-term outcomes.
Any surgical procedure has inherent risks that include poor healing of the skin requiring wound care or special procedures to close the wound. Infections are rare and are treated with antibiotics. The incidence of a deep infection is even more rare but it can occur. This would necessitate intravenous antibiotics and possibly a surgical debridement. Nerve damage or sensory impairment is also rare but can occur. We always go through the risks and complications of surgical procedures as listed on our consent form in our office at the time that we perform a surgical consent. Wound healing problems, nerve damage and superficial or deep infection are exceedingly rare in our hands. Other complications specific to the procedures we perform are as follows:
- Achilles tendon lengthenings are performed through three small incisions in the back of the foot. These usually need to be lengthened surgically to get the best long-term outcome. It is rare for us to need to open the Achilles to do an open procedure if during the procedure the tendon snaps. If necessary, the small percutaneous incisions are lengthened and the tendon is repaired. When the tendon is lengthened properly the chances of recurrence are very small. When the tendons are over lengthened it is a significant complication and causes the patient to have weakness with push-off. These usually need to be repaired surgically.
- Gastroc recessions are performed just below the calf muscle. When sutured properly the incisions look perfect and show no signs of “dimpling”. Dimples can occur within the incisions, which are small little areas that look imperfect just below the calf muscle. They have nothing to do with function. Incisions could also scar more readily. Recurrence of tightness to the calf muscles are more common with lengthening the gastroc. However, over lengthenings are relatively rare.
- Arthroeresis implants are titanium and patients will almost never have an allergy to them. They are small implants that block abnormal motion in the joint and over time we have found that they do slightly shift and move. Rarely do they shift and move to a position that causes them to pop out of place. It can and does occur infrequently. Implants placed can be too big, causing a significant loss of motion of the subtalar joint. They can also be too small, limiting the amount of correction desired. They can also shift into a position towards the outside of the foot and function perfectly well despite their shifting. Although x-rays do show a shift in the implant, this movement typically is not symptomatic. Although some surgeons have found that implants are removed in one-third to 40% of the cases, we have found this to be a total failure of the physician who has evaluated and treated the patient. A failure to understand the function of the foot and the need to create a “tripod” causes failures. Our removal rate is less than 5%.
- Naviculocuneiform joint fusions are procedures in which the cartilage is taken out of the bones so that the bones can heal together and help the patient develop an arch. Delayed healing can occur, necessitating a longer period of immobilization. Nonunions can occur in which the bones do not unite and another surgical procedure may be necessary. If there are concerns during the healing process, bone stimulators are utilized to accelerate the healing process. Malunions occur when the bones are not placed in their proper position and the bones do not heal correctly. They may or may not be symptomatic. If symptomatic, the bones can be later corrected to be placed in a more correct and anatomical position. Hardware that is utilized includes screws most commonly, and occasionally staples. Screws and staples can cause irritation below the skin, necessitating later removal. It is relatively uncommon for this to be necessary.
- A Cotton is a procedure which is an opening wedge osteotomy of the medial cuneiform in which a bone graft is placed on the top of the foot. In most cases we will use a small pin to hold the position of the bone graft in the bone. This pin is usually placed through the skin and is removed in the office in a completely pain free procedure. With a Cotton, bone graft has to be incorporated into the bone, which may take many months. A bone graft can subside and a loss of correction can be seen. Rarely will there be subluxation of the joint in front of or behind it.
- A Calcaneal osteotomy is a procedure in which the back heel bone is cut and shifted down and in so that the heel bone is parallel into the lower leg bone called the tibia. Complications with this procedure are rare as this bone is very well vascularized and heals within 6-8 weeks. Screws are placed directly on the bone from an incision on the back of the heel. Rarely will these screws become irritating and require removal. A malunion of the heel bone can occur if the shifting of the bone is not correctly placed. This is very rare and if it did occur it can be corrected surgically to realign the heel bone in a more correct fashion.
- In an Evans calcaneal osteotomy the outside of the heel bone is opened to help realign the outside of the foot relative to the inside and equalize its length. Complications of this surgical procedure are a little bit more common than in others. This can include injury to the nerve (sural) around the outside of the foot. This would cause some numbness to the small toe. Placing bone graft on the outside of the foot may necessitate utilization of small plates and screws. If so, this could become irritating to the tendons (peroneals). This may be temporary. Placing too large of an implant can cause stress to one of the outer joints (calcaneal cuboid joint), which could increase pressure in the joint causing later arthritic changes. While cutting the heel bone, shifting of the front part of the bone relative to the back can occur, causing misalignment of the calcaneal cuboid joint. Misalignment of the joint can likewise cause arthritic changes in the future. Bone grafts when placed can subside losing some of the correction. Placing small bone grafts may not give full correction to the problem. Malunion or nonunion of the heel bone after an Evans is uncommon and if it occurs can be corrected with additional surgical procedures.
- A first tarsal metatarsal joint fusion (Lapidus) is a procedure that is performed in the arch region. Any time cartilage is removed and bones are placed together with hardware, complications can occur. Complications can include a malunion in which the fusion site does not heal in the perfect position that we would like. A delayed union can occur in which the bones do not fuse as quickly as we would like and in such cases the patient may be kept nonweightbearing for a longer period of time and a bone stimulator may be utilized. A nonunion can occur in which the joint does not fuse and consolidate completely. In some cases this may become asymptomatic. In other cases if there is pain, then another fusion may be necessary. This secondary procedure may necessitate bone graft to augment the healing potential. Screws and plates when placed can always cause some irritation to the soft tissue requiring later removal.
- A plantarflexory wedge osteotomy is a relatively straightforward procedure that we use infrequently to reestablish a tripod when we do not want to sacrifice any other joints and prefer not to use any bone graft. Delayed union, nonunion and malunion can occur, which all may require care that would include further surgery if the bone does not unite or bone stimulator to help healing. Patients may also be kept nonweightbearing for a longer period of time.
It is critical to have a full evaluation of the patient to determine what is the best treatment option. In many patients that are flatfooted, the natural history may be perfectly benign. In others we are able to evaluate the patient and see where the natural history of their problem will become progressively worse and in those patients intervention is necessary.
Combinations of procedures are utilized to help our patients. Every patient is different and we do individualize their treatment accordingly.