Forefoot Reconstruction

Rheumatoid (and other arthritis) often results in deformities of the forefeet. In most cases there is a large bunion (hallux valgus deformity) of the joint at the base of the 1st toe with advanced degenerative changes of the joint cartilage. The 2nd to 5th toes are frequently malaligned, resulting in painful callosities over the joints of these toes and pain at their bases. A forefoot reconstruction aims to improve the alignment of the forefoot and significantly decrease pain.

Forefoot reconstruction surgery involves a number of steps. These include:

• General anaesthetic, intravenous antibiotics
• Incision along the inside of the big toe
• Fusion of the joint at the base of the big toe
• Two incisions on the top of the foot
• Removal of bone at bases of 2nd to 5th toes
• Straightening of 2nd to 5th toes
• Insertion of wires into toes
• Check x-ray
• Closure of wound with stitches/sutures

All surgical procedures carry some risk. The risk of complications of forefoot surgery is low. Some of the risks with surgery include:

• Infection
• Problems with wound healing
• Nerve injury causing numbness, tingling and/or pins and needles
• Scarring
• Non-union of joint at base of big toe (the bones don't fuse together)
• Deep venous thrombosis/pulmonary embolism (the risk of DVT increases with smoking, the oral contraceptive pill and hormone replacement therapy, immobility and obesity)
• Anaesthetic complications
• Drug allergy
• Ongoing pain

Rest

• You will have a cast on your leg. Keep foot elevated as much as possible, especially for initial 72 hours. Keep dressings dry and intact until post operative appointment.
• Mobilise short distances as pain allows, aim to remain in your own home for the first few weeks limiting long periods of standing or mobilising
• Do not bear weight for the first six weeks

Pain

• Pain relief may be required for up to 2 weeks; depending on your other medications this may include:
• Regular paracetamol, anti-inflammatory drugs and break through opiate type medications
• A regular blood thinning medication will also be prescribed for 2 weeks

Driving

• Any surgery performed on the right foot or both feet will mean no driving for a minimum of 6 weeks
• If surgery was performed on the left foot then driving in an automatic is possible, but Dr Phegan would recommend waiting a minimum of two weeks before attempting to drive

Driving any vehicle with a cast or boot is potentially hazardous and you should consider this before getting behind the wheel.

Follow up

• Keep all dressings dry and intact for the first two weeks
• Removal of stitches/sutures typically occurs at an appointment with Dr Phegan and his in-house therapists at 10-14 days at first post operative appointment. Very occasionally some sutures need to stay in for longer
• Your appointment will be booked by Dr Phegan and a confirmatory SMS will be sent informing you of the time and date for follow up

Typical milestones

• 2 weeks: Wound review and removal of sutures, change from cast to boot, commence rehabilitation
• 2-6 weeks: regular physiotherapy to increase range, continue to non-weight bear
• 6 weeks to 3 months: weight bear as tolerated, work on swelling reduction, scar massage and mobility
• Full recovery 6-12 months

Every patient's recovery is individual and depends on the severity of the injury and the complexity of the surgery.