Surgical Repair of Foot and Ankle Fractures

The following is a general guideline. Keep in mind that post-op care may vary.

As discussed in the “Foot and Ankle Fractures” section, most broken bones involving the foot and ankle can be treated without surgery. The decision to proceed with surgery usually depends on if the bones have been shifted out of place, known as displacement of the fracture. If surgical repair has been recommended, it means that the bones are out of position enough to alter the function of the foot and ankle if healing occurs with the bones in their current position. Surgical repair of a displaced fracture is performed by manually shifting the broken bones bake into place, known as “reduction” of the fracture, and then placing metals screws and plates to hold the broken bones in correct position until the fracture has healed.

Ankle Fracture Repair

The fibula, also known as the lateral malleolus, is the outer bone on the ankle and is most commonly fractured. Less commonly fractured is the inner portion of the tibia, known as the medial malleolus, which may be fractured in isolation or in addition to the fibula. Surgery is achieved by making incisions directly over the broken bones, and repositioning the bones into their proper alignment with special instruments. The fibula is held in position with a very thin metal plate which is placed directly on the surface of the bone, then secured with several metal screws. The medial malleolus is usually held in place with metal screws alone. If there is any damage to the ligaments around the ankle noted at the time of surgery, the ligaments can be surgically repaired at the same time.

Metatarsal Fracture Repair

There are several common breaks that occur to the metatarsal bones, and occasionally surgical repair is recommended, based on the displacement and precise type of fracture. Metatarsal fractures may be repaired with screws alone, or with a small metal place and screws.

Preparing for the surgery

When your surgery is scheduled, you will be given a pre-surgery packet including information on location of the surgery. Most of the time, this operation is performed at an outpatient surgery center. Patients over the age of 50 and those with certain health conditions will require blood work-up and EKG. Blood thinners should be discontinued prior to the surgery. This includes Coumadin, Plavix, aspirin, anti-inflammatory medicines (ibuprofen, naproxen, Aleve, Motrin, diclofenac, etc.), glucosamine, and herbs that may cause thinning of the blood. If you have questions about discontinuing certain medicines, please contact the office at least two weeks prior to your surgery. If you are on prescribed medicines such as Coumadin or Plavix, meet with your primary care doctor prior to discontinuation. Should you have questions about any particular medicine you are on, please address far in advance.

Length of Procedure

These procedures typically take 1 to 1 1/2 hours. You are required to be at the surgery center 1 hour before the scheduled start of the procedure, (or 2 hours ahead of time if the procedure is being performed at the hospital) and will need to stay in the recovery room for approximately 1 hour after surgery.

Anesthesia

Ankle fracture repair requires a general anesthesia for this procedure, and you will also receive a regional block. This is a process in which the anesthiologist injects numbing medicine into a nerve in the back of your knee, providing pain relief for the first 12-24 hours after the surgery. You will have an opportunity to speak with the anesthesiologist about the general anesthesia and block prior to your surgery. Metatarsal fracture repair may be performed with a regional block alone.

Pain medicine

You will be provided with a prescription for pain medicine at the time of surgery or at your pre-operative evaluation. If you would like your prescription before the surgery, contact the office two weeks prior to your scheduled procedure. These types of stronger (narcotic) pain medicines cannot be called into your pharmacy. Most patients are able to wean off of the pain medicine within 2-3 weeks of the surgery and transition to over-the-counter (OTC) analgesics (anti-inflammatory medicines or Tylenol). Most of the pain medicine we prescribe contains Tylenol (acetaminophen or APAP). Therefore, Tylenol should not be taken in combination with the pain medicine. It is recommended that you do not exceed 2 grams of Tylenol/day. The pain medicine we typically prescribe contains either 325 mg or 500 mg of Tylenol (APAP). Some common side effects of narcotics include itching, nausea and constipation. Should you experience these side effects, there are medicines that can be prescribed to counteract them. Because constipation is so common, consider starting an over-the-counter stool softener such as Colace when you begin taking the pain medications.  Also, maintain a high fiber diet (25g/day for women and 35g/day for men) and stay well hydrated.

What to expect during the first two weeks

After the surgery, you will be placed in a non weight-bearing (NWB) plaster splint. You will be given crutches at the surgery center. If it is difficult for you to use crutches, you may want to obtain a knee scooter or roll-about at a local medical supply store.  Most insurance companies do not cover the cost of a knee scooter, though a prescription is often required. Please contact the office well in advance if you would like a prescription for a scooter. It is recommended that you keep your leg elevated above the level of your heart most of the time for the first 72 hours after your surgery. This will decrease both swelling and pain. Keep dressings dry at all times. For showering, consider covering the splint in a garbage bag, duct taping the edges. You may also obtain a cast-cover, available in the office and at most drugstores. They cost around $30 and are reusable. Do not attempt to remove the splint at any time.

What to expect at your first post-operative appointment

10-14 days after your surgery

This appointment may be scheduled prior to your surgery. The post-operative splint will be removed and the incision will be evaluated at that time. If the wound has healed properly, sutures will be removed. X-rays of your foot or ankle will be obtained to evaluate the position of the bones. In most circumstances, you will then be placed in a removable walking cast (CAM boot or walker). You will be given precise instructions as to when you may begin placing weight on your foot in the CAM boot, whether you may remove it at, and for how long you need to wear it (usually until the next postoperative visit). It is very helpful to continue to elevate your leg whenever possible during this time.

What to expect at subsequent post-operative appointments

Additional post-op appointment will usually take place at 3-4 weeks intervals. X-rays will be obtained to evaluate for healing at the fracture site at each visit until the fracture has healed. Once there is some healing noted at the fracture site, your activities will be advanced to allow more weight-bearing on your leg, and eventually transitioning out of the CAM boot. Again, you will be given precise instructions about weight-bearing and removal of the CAM boot, because this varies from individual to individual.

When wearing the CAM boot, consider obtaining a shoe that is of equivalent height for the opposite foot. This will decrease the likelihood of developing back pain caused by shoe height discrepancy. If you do not have a shoe of similar height, you may want to obtain an attachment for your shoe. This may be found out www.evenupcorp.com 

Once you have weaned out of the CAM boot, you may resume physical activity such as walking and riding a stationary bicycle. If you are comfortable on the stationary bicycle after a couple of weeks, you may transition to the elliptical machine (available at most gyms). You may also gradually introduce walking longer distances. Physical therapy is often prescribed, depending on your surgery, and your usual level of physical activities.

Further follow-up appointments may be required and will be determined on a case by case basis. 

Common post-operative findings

• Elevated temperature: It is common to experience a low-grade fever for up to 3 days following surgery. If you think you may have a fever, take you temperature with an accurate thermometer. If it is remains elevated above 101° F for more than 12 hours, or you if are still experiencing a temperature above 100° F more than 3 days following surgery, contact the office. You may take anti-inflammatory medications for the elevated temperature.
• Pain: For the 1-2 weeks after surgery, you may experience moderate-severe pain that responds to the pain medications you have been given. If the pain remains severe despite the pain medications, contact the office or the anesthesiologist at the surgery center. The pain will significantly decrease within 1-2 weeks following the operation. However, it is common to experience some amount of pain for up to 2-3 months after surgery. This pain is usually mild and occurs after increased physical activities. You can apply ice to your ankle or take anti-inflammatory medications of this occurs.
• Calf atrophy (decrease in calf size) due to long period of immobilization. This will improve as you perform rehabilitative exercises and resume activity (unless you have undergone an ankle fusion, in which case you will have permanent calf atrophy.
• Swelling: Ankle swelling may persist for several months after the surgery. Anti-inflammatory medicine, ice, and/or compression with a compressive stocking may help to reduce swelling.
• Foot and Ankle stiffness: Will improve with rehabilitation exercises and resuming activity, except in the joints that were fused, where you will have permanent stiffness.

When to go to the emergency department or contact the office immediately:

• Fever >101° F (see above)
• Severe calf pain
• Drainage from wound
• Sudden increase in warmth, redness in the surgical area
• You should go to the nearest emergency department if you experience chest pain, profuse sweating, shortness of breath, or rapid heart rate