Pain

18 Steps to Minimize Post-Op Pain
By Dr. Brian Richman

Most patient’s come to a podiatric physician’s office for a painful foot condition. Patient’s are reserved about painful treatments including injections and surgical procedures. If a podiatric physician can minimize a patients pain experience preoperatively and post-operatively, the patient will be ecstatic about the podiatric care they receive and will be an excellent referral source back to the podiatric physician.In this article, I have included 18 steps to eliminate post-op surgical pain following bunion surgery. These surgical techniques have been preformed on over 300 patients with very minimal pain post-operatively. These steps can be applied to any foot or ankle surgery with some modifications, depending upon procedure and surgeon preference.

18 Surgical Steps to help reduce post op pain for
hallux abducto valgus surgery.

1. Good pre-operative planning, (good history and physicial exam, x-rays, templates, consults help in deciding which is the best surgical procedure for each indiviual patient.)

2. Mac anesthesia with IV Sedation (patient has less pain, nausea, and vomiting, easier recovery and less expensive than general anesthesia.)

3. Prophalatic IV antibiotics ( usually 1 gram of Ancef IV unless the patient is PCN allergic)

4. Pre-op injection of 9 to 1 mixture of 9 cc 0.5 % Marcaine plain + 1 cc of dexamethasone - total about 20 to 30 cc in a Mayo block and if desired a posterior tibial nerve block. ( Local Anesthesia from this mixture may last up to 24-36 hours post -op.)

5. Ankle tourniquet time less than 1.5 hours ( less tourniquet time decreases chance of blood clots, decreases post op pain and possible complications.)

6. Atraumatic Dissection ( good dissection decreases chance for hematoma, swelling, and pain.)

7. Excellent position and bone compression of osteotomy ( good compression helps bone healing

8. Secure stable fixation ( I use a 2.7 mm cortical screw ) (stable fixation avoids motion at the osteotomy site which helps with bone healing.) If you do not have stable fixation intra-op you will not have stable fixation post-op.

9. Excellent ROM intra-op ( good ROM decreases pain post-operatively.)

10. Use TLS Drain in interspace to reduce risk of hematoma and swelling. ( take TLS Drain tube out 24-48 hours after surgery, when the tube has stopped draining.)

11. Avoid using excessive sutures (use only necessary for closure) Excessive sutures cause excessive scar formation. I close capsule with horiztonal mattress 3.0 vicryl sutures, SQ with 4.0 vicryl deep buried knot sutures, Skin with running subquticular 4.0 prolene with bridge in a middle to allow easier removal post operatively.

12. Use steristrips with no mastizole ( cut suture at the middle of bridge and remove both sides in 2 -3 weeks, keep steristrips in place.) Do not get dressing or foot wet until incision is healed.

13. Use a modified Jones compression dressing ( after bandage apply cotton roll, 4” ace wrap, fiberglass splint, an another 6 “ ace wrap, tuck TLS drain tube under 6 “ ace wrap, tape TLS drain tube so that it is not accidentally pulled out.)

14. NWB with crutches of involved foot times 4 days

15. ice ½ hour on ½ hour off while awake to back of knee, above dressing x 3 days

16. use post op analgesics as needed ( I give them Mepregan Fortis preoperatively, so they don’t have to worry about filling the prescription post-op.) Most patients only use about 3-4 pain pills post-opertatively

17. Profile walking cast given after x-rays and dressing change on first post -op visit usually 4-5 days after surgery. ( I usually keep them in a low profile walking cast boot for 5-6 weeks until swelling is gone, and then they can go back into a regular shoe)

18. I only do surgery on one foot at a time, the reason being is that the patient gets around a lot better on crutches and in a walking cast with 1 “good foot” and one surgical foot. Most insurance companies will reduce the surgeon fee for bilateral foot surgery to about 1.5 times plus with the write off the surgeon is already taken, you are basically doing one foot for free.