Can Preoperative Pain Assessment Scores Help Predict Post-Bunionectomy Pain?
In a recently published prospective study, researchers found that higher preoperative Visual Analogue Scale (VAS) scores and higher Mental Component Summary (MCS) scores of the Short-Form 36 (SF-36) questionnaire can help predict the degree of post-op pain after hallux valgus procedures.
The study in Foot and Ankle International involved 308 patients who had bunionectomies at a tertiary facility. The authors note that 94 patients had some degree of residual pain at six months after surgery. Researchers noted a higher preoperative VAS score increased the risk of having persistent pain at six months after surgery while a higher preoperative MCS score of SF-36 predicted a reduced risk.
“Predicting post-op pain is difficult to do. I have certainly been surprised by patients I thought would have more pain but did better than expected and those I thought would have little pain but did worse than expected,” says Michelle Butterworth, DPM, FACFAS, a Past President of the American College of Foot and Ankle Surgeons.
Dr. Butterworth says a lot of patients with post-op pain after bunion surgery have joint pain from stiffness and decreased motion of the joint, possibly due to decreased motion or degeneration of the joint to begin with, or scar tissue restricting motion.
H. John Visser, DPM, has found that younger patients and females with bunions can expect more post-op pain. More proximal procedures such as a Lapidus, opening wedge and closing wedge osteotomies tend to be more painful, according to Dr. Visser, the Director of the Foot and Ankle Surgery Residency Program within SSM Health DePaul Hospital in St. Louis. He believes the VAS and MCS scores can be “quite helpful” in gauging patients who may exhibit lower pain tolerance.
With distal bunion procedures, Dr. Visser has found that less than 5 percent of patients exhibit any significant pain six months postoperatively with pain usually stemming from delayed unions or compensatory pain not related directly to the surgery. He notes other factors for continued pain include undercorrection, overcorrection or hardware. With proximal bunion procedures, Dr. Visser estimates around 30 percent may have pain up to a full year after surgery.
Dr. Butterworth suggests that podiatrists prepare and educate patients with what to expect post-op in order to relieve some of their anxiety. As she notes, some are afraid they will wake up from surgery in pain or have heard from their friends or family members that foot surgery can be painful. For patients who are already taking narcotic medication preoperatively, it can be more difficult to manage post-op pain, according to Dr. Butterworth, who is in private practice in South Carolina.
To help address post-bunionectomy pain, in the first 72 hours, Dr. Visser suggests popliteal, regional and ankle blocks as well as narcotics. He finds physical therapy to be invaluable for edema reduction, pain relief and patient mobility. Dr. Visser also notes that adjunctive corticosteroid injections in the first web space (interosseous muscle) are helpful for edema and pain reduction. Dr. Butterworth’s suggestions for addressing post-op pain include physical therapy, non-steroidal anti-inflammatory drugs, injections and revisional surgery if needed.
Study Says Surgery Gets Athletes Up To Speed Quicker After An Acute Achilles Rupture
By Brian McCurdy, Managing Editor
A recent randomized controlled trial in the American Journal of Sports Medicine finds that surgical treatment of acute Achilles ruptures is more effective in restoring performance and quality of life than non-surgical treatment.
Sixty patients received either surgical or non-surgical treatment of acute Achilles tendon ruptures. Non-surgical treatment was a week of cast immobilization followed by a functional orthosis for six weeks.
According to the study, researchers said the conservative treatment course allowed full weightbearing after the first week and active plantarflexion after the fifth week. Surgery consisted of simple end-to-end open repair with the postoperative regimen being identical to non-surgical treatment. While surgical and non-surgical treatments of acute Achilles tendon ruptures had similar results as far as the Leppilahti Achilles tendon performance score goes, the study authors noted that surgery restored calf muscle strength earlier over the entire range of motion of the ankle joint. The study adds that surgery may also result in better health-related quality of life when it comes to physical functioning and bodily pain.
If magnetic resonance imaging (MRI) reveals a partial Achilles tendon rupture, Jeffrey Ross, DPM, MD, says the surgeon can make a more informed decision. If it is a partial tear and the patient is not a high-level athlete or exercise participant, Dr. Ross says immobilization to allow healing followed by aggressive physical therapy may be all that is required. However, if the tear/rupture is significant, there is a loss of function and a risk of the tear impairing future performance or activity, then surgical repair may be necessary, according to Dr. Ross, an Associate Professor at the Baylor College of Medicine in Houston.
Dr. Ross says surgical treatment will restore the Achilles tendon to nearly the strength and integrity it had before injury. He notes the Achilles tendon will lose tensile strength after a significant tear.
“Surgery can only afford a certain amount of restoration to the Achilles tendon. There will always be a certain amount of weakness post-injury, whether surgery or conservative care was the option choice,” says Dr. Ross. He adds that surgical repair is typically the better option for the performance athlete or adamant exerciser.
In regard to Achilles tendon surgeries, Dr. Ross says he commonly performs an end-to-end anastomosis, utilizing an autogenous section of tendon with advancement to act as a graft for a defect. Immediately post-op, he has the patient wear a cast and remain non-weightbearing for four to six weeks. Then the patient proceeds to a walking boot for two to four weeks and subsequently physical therapy for two to three months. Dr. Ross employs the walking boot and physical therapy steps as part of his conservative treatment regimen as well. With surgical or conservative treatment, he says patients return to activity when there is suitable strength and integrity in the Achilles tendon.
Does Unrestricted Non-Weightbearing Lead To Non-Union Following Jones Fractures?
By Brian McCurdy, Managing Editor
Although Jones fractures can be susceptible to non-union, a new study finds that a post-op protocol of unrestricted weightbearing is successful in attaining union.
The study in the Journal of Foot and Ankle Surgery focused on 27 consecutive patients treated for acute Jones fractures without restrictions on post-op weightbearing. Twenty-four patients achieved clinical union at a mean of eight weeks, according to the study. The authors note complete radiographic union occurred in 13 patients while another 13 made significant progress toward radiographic union and one patient had a non-union.
When treating Jones fractures, William Fishco, DPM, FACFAS, usually has patients non-weightbearing for at least six weeks, followed by protected weightbearing in a fracture boot for another two to four weeks. Once he sees substantial healing, he will have the patient begin weightbearing.
“With that protocol, I will typically get greater than a 90 percent union rate,” notes Dr. Fishco, a faculty member of the Podiatry Institute.
Dr. Fishco has not had any serious complications with non-weightbearing following fifth metatarsal fractures. He says all patients develop some atrophy, weakness and gait disturbance following immobilization, but he has avoided more serious complications such as blood clots.
The most important factor to address is foot shape, according to Dr. Fishco, who is in private practice in Anthem, Ariz. More often than not, he notes Jones fractures occur in patients with high arched and/or curved feet (metatarsus adductus). These foot types are susceptible to lateral column overload, like a chronic strain of the foot, and Dr. Fishco says one needs to address these types of deformities with foot orthotics to reduce lateral overload. He will walk patients earlier if they have a neutral foot type, noting that such patients have fewer mechanical influences that could undermine healing.
