Complications We Don’t Talk About Enough

Aabha Suchak, DPM: I totally agree. Infection and healing are at the forefront of these conversations regarding complications postoperatively. However, I think nerve injuries do occur and they're likely more common than we realize and definitely more common than we discuss. Neuropraxia, which is just nerve irritation, it can cause burning and tingling, pins and needles and numbness, and sometimes patients will complain of increased sensitivity to touch. These things can improve over weeks and months, but oftentimes I think they get mistaken for normal postoperative pain. And the problem with that is as the surgical site heals, the neuropraxia also improves. So we think that this is part of the normal postoperative healing. I also think that nerve injuries during bunion surgery or hammer toe surgery can cause some numb areas or hypersensitivity. But again, as the surgical site is healing, this corresponds with the postoperative healing time. You can also get superficial nerve entrapment. 

I feel like these things tend to occur more with surgeries that have scar formation, which usually happens after traumatic injuries. So when we see ankle fractures, metatarsal fractures, ligament ruptures, a lot of times you'll get scar formation and you'll get that superficial nerve entrapment along with that. These things tend to be under-recognized just because standard imaging, we get our post-op X-rays, if we have to get a CT or an MRI after surgery, they typically don't show nerve issues. We usually see bone and joints and the structural deformities, but we really don't see any of the nerves on any of these imaging things. And then if we take it a step further, we order an EMG, we order a nerve conduction velocity testing. A lot of times those things tend to be normal also just because they're not checking for these small nerve fibers in the foot and the ankle. 

Jennifer Spector, DPM: Definitely, and I think it's something that deserves a lot more attention. Speaking of something that, at least for me, was a big experience in my clinical time was post-op stiffness. It was something that I know I tried to prepare patients for and definitely tried to address head on, but it doesn't always seem to get the same attention as say recurrence or non-union, but patients really see this as having a major impact on function. In your experience, what procedures do you think are most prone to having this type of problematic stiffness and do you have any pearls on how to prevent or manage it? 

Aabha Suchak, DPM: Yeah, I definitely think post-op stiffness can be a huge problem and it really can occur with any surgical procedure that impacts the joint or can have scar tissue formation or swelling that limits the range of motion of the joint. AO technique always teaches us to include early active range of motion. Within appropriate post-operative standards and post-operative guidelines, start early active range of motion. The more you limit range of motion, it can really cause stiffness to that area. And then again, postoperative edema control and swelling control, use rest, ice, elevation, make sure those patients are getting the inflammation down because again, the more swollen that surgical site is, the more swollen the joint is, it's going to really cause some issues with range of motion. I'm a huge advocate for sending patients to physical therapy postoperatively. Physical therapists can help with strengthening range of motion, flexibility, gait training, and they can help with scar tissue reduction and postoperative edema control, which again, those things are going to be really big in limiting the motion of that joint. 

So it's something that I've really learned through my career to start talking about during the preoperative evaluation and really just get patients mentally ready that you're going to be immobilized for X amount of weeks, but then we're really going to start focusing on you doing range of motion at home, getting you into a shoe, and then going to physical therapy to really help work on the strength and the flexibility of that joint. And I feel like that's really helped a lot.   

Jennifer Spector, DPM: I'm sure it has. And definitely preparing ahead of time, both ourselves and our patients probably goes a really long way with that. We spoke about recurrence previously or at least alluded to it. No matter what type of procedure we're talking about, recurrence is just so frustrating I'm sure for surgeons. In your experience, are we looking closely enough at biomechanical or other surgical factors or do you think that we're overlooking things once in a while when it comes to risk of recurrence?  

Aabha Suchak, DPM: I definitely think that there's a lot more biomechanical issues than we maybe take time to evaluate initially. And I think that's why our evaluation and management of patients is so important. First ray instability, excessive pronation, equinus deformity, underlying systemic conditions such as rheumatoid arthritis, metatarsalgia with plantar plate injury or plantar plate instability, all of these things are really biomechanical issues that can cause recurrence of the surgical site. And again, like I said, we really need a comprehensive evaluation and management of the patient. You want to pick the appropriate patient and the appropriate surgical procedure before you go into the operating room. And we really need to worry about what their x-rays look like, make sure that you're getting appropriate imaging, do some lab work if you need to, especially with these rheumatoid arthritis patients or patients who may have underlying systemic conditions. You really want to make sure that their lab work all looks appropriate before you take them to the OR. 

Do a full medication review, make sure you know if they're on immunosuppressant medications and things like that that may affect their bone quality intraoperatively. Do a full past medical history, do a gait analysis. Again, the gait analysis especially to make sure that the biomechanics are evaluated before you go into the operating room. Absolutely. And I would often tell patients, we're fixing this problem that you're here for, but we also need to address the foot type that got you here in the first place. So whether it's pre-op or post-op management with orthotics, I think you hit the nail on the head with making sure that we're paying attention to these things. So one more question for you today. I think we've all found ourselves in this situation where radiographs look perfect and you met every surgical objective during the perioperative period, but unfortunately the patient's function or symptoms don't quite improve in the way that we hope they would.  

Jennifer Spector, DPM: Can you share anything that you may have learned about what those cases might be able to teach us and should this impact how we define success surgically?   

Aabha Suchak, DPM: Of course. So I think that success is obviously defined by patient outcomes, but I think it's defined objectively and subjectively. So objectively, x-ray looks good, imaging is appropriate. Clinically, there's no infection, the incision's healed, and we think objectively we've really succeeded. We've done a great job with this surgical patient and the procedure. However, there's a deeper layer. So the actual patient outcome, so the patient comes back, they're not happy with the way the correction looks, their function has not improved, they're in more pain than they expected to be, or they're in more pain than they were prior to going to surgery. So in that situation, subjectively, it's really not a successful outcome. So when it's not successful subjectively from a patient standpoint, but it is objectively, I feel like we need to go back and reevaluate your options, whether that's conservative management or surgical management. 

And conservatively, we can talk about doing inserts or custom orthotics for that patient to help redistribute their gait and to help them with their biomechanics after surgery, or it may be sending them to physical therapy to really help work on that flexibility and that range of motion like we discussed earlier. But sometimes to have success from a patient standpoint, we do have to talk about returning to the OR and that may be an appropriate answer to get the success that we need both objectively and subjectively to optimize patient outcomes.  

Jennifer Spector, DPM: And thank you so much, Dr. Suchak, for sharing your insights on this very important topic with us today. I should also mention that this episode is published in partnership with the American Association for Women Podiatrists, and we are so grateful for the audience also joining us. We hope that you'll continue to tune into this past and future episodes on podiatrytoday.com and your favorite podcast platforms.