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My apologies if you are looking for a quick get in and out post. This is a long item. It is a followup to an earlier post from 4 weeks ago. This long post is intended to help readers considering or planning toe fusion surgery. I looked for this sort of information before my own surgery and couldn't find it. Hopefully it will help others set realistic expectations and plan out their own recovery from toe fusion surgery.

Overall, my experience has been very good. My surgeon did a good job and I appear to have been a good candidate for the surgery. I am a healthy 5'11", 185 pound, 55 year old active guy. I'm a non smoker, light drinker who exercised 4-5 times a week before the surgery. I think my lifestyle contributed to my positive post-op experience. Small women who are out of shape and lifelong smokers are likely bad candidates for the operation. The bigger and healthier you are the more likely your experience will be a good one.

In the past three days have returned to wearing athletic shoes and walking without crutches. I expect to have some lingering swelling and stiffness for a while, but in six months I should be fully "healed". In six months, I'll try to remember to add one final post.

----- [B]FROM FIRST POST[/B] ------------------

[B]Why did I have the surgery?[/B] After first being diagnosed with degenerative arthritis in my toes in 1996 I stopped running. I started wearing orthotics in all my shoes. About 5 years ago I stopped dancing. About 3 years ago I started to gradually cut back on my hiking. About eight months ago I stopped walking around a lake near my house. Since I am just 55 years old, I decided that having surgery was a better option than living with limited mobility. I considered the costs/benefits and decided that the benefits outweighed the costs.

[B]
Was I concerned with having the surgery?[/B] Absolutely. An ortho specialist wanted me to consider surgery about five years ago. I decided that I wasn't in enough pain to consider the risks. Once I stopped walking more than a few 300 yards at a time I decided in the past year it was time to consider the risks. Surprisingly, the surgeon was not too positive on the benefits of the surgery. I believe he was conservative in estimating the success and satisfaction I would have experience with the surgery. I looked beyond his estimates to find studies online. Results of my search are summarized below:

In 2005, Brodsky, et. al., presented results of a retrospective study and indicated that “patients with a first MPJ fusion function extremely well and most athletic patients continue participating in sports with the advantage of greatly diminished discomfort.”2 Surgeons performed a first MPJ arthrodesis on 53 patients (60 feet), who ranged between 21 to 79 years old. These patients engaged in weightbearing activities ranging from activities of daily living to recreational sports and exercise.2 The researchers performed postoperative functional testing on 45 patients. Of those 45 patients, 64 percent could stand on their tiptoes, 94 percent could kneel, 87 percent could squat and 98 percent could pick up a small object from the floor.

The following are the results of patient answers to a functional questionnaire

• 100 percent could ascend stairs
• 96 percent could descend stairs
• 100 percent could walk less than one block
• 96 percent could walk one to six blocks
• 90 percent could walk over six blocks
• 75 percent returned to jogging
• 80 percent returned to golfing
• 92 percent returned to hiking
• 75 percent returned to tennis
• 98 percent returned to work
• 45 percent had no shoe limitations
• 47 percent required comfort shoes
• 8 percent required prescription insoles

In considering the above stats I focused on the "returned to" data. It was likely a small sample, but I found the data reassuring.

[B]How did I prepare for the surgery?[/B] Hindsight suggests I should have planned much better for the operation. This is one of the reasons I'm spending the time with this post. I waited until the last few days to develop a game plan. Rather than wait until last minute I suggest making a realistic assessment of the surgery's impact at least one week before the surgery. Start the assessment from the moment you wake up on a given day. Imagine that your foot will be in a cast and you can not allow it to touch the floor for the entire day while you attempt to complete a normal day. You'll find that from the moment you roll out of bed until the next morning when you wake up that your life will be dramatically changed.

Eventually I went through this effort, but it was once I was wearing the cast. As a result, I placed canes and stools strategically around the house. Other examples, In order to clean out my cat's litter box I staged a stool on the floor and kept a cane near by to help get up/down and to push the litter box around. In order to do my laundry I bought a "grabber" to pull clothes out of the dryer. In order to comfortable to get up/down from toilet I equipped my toilet seat with handrails (I did not go with the raised toilet seat, but some folks might want to consider that option).

Fortunately I rented a knee scooter as well as obtaining crutches for mobility around the house. The knee scooter is an ABSOLUTE NECESSITY. I found that I rarely used the crutches in the house and used the knee scooter almost exclusively. After two weeks they cut my cast off and provided a bulky aircast. The aircast allowed me to put pressure on my heel without risking pressure on the toe/foot. Once I had the aircast, I continued to use the knee scooter at the grocery store and for extended "walks" (mailbox, pick up news paper) at home. Depending on how big your doorways are you might find the crutches will be helpful for certain rooms.

Overall the knee scooter was the most important tool. With it, I was able to not only move around the house/neighborhood, but I was able to cook and clean. I hated shelling out $95 a month to rent the scooter, but it has been worth it.


[B]Things I wish the doc/nurses had told more (or told me more explicitly)[/B]

1. When I was released from the hospital, I rode home in the front seat of the car. DON'T MAKE THIS MISTAKE!! The foot should be elevated. Especially after the surgery. The blood pooled in my toe and I left a trail of blood through the house when I got home. The doc removed and replaced the cast to insure they had properly completed the operation. Sooo... ride home in the back seat with your foot elevated. It should have been common sense, but the orderly rolled me to the car and opened the front door for me. For the first two weeks, you will be far more comfortable if you keep your foot raised. The toe will swell and get uncomfortable otherwise.

2. It's OK to sleep without the boot! For the first two weeks you'll likely want to keep the cast/boot on constantly, but eventually you'll want to get a decent night's sleep. Check with your doctor to see when it's OK to sleep without the boot. My doc initially told me to keep the boot on at all times. I called him after a week of bad sleep and he agreed to let me take the boot off at night.

3. Stay on top of your meds, be aware of constipation and keep a close eye on your diet. I found that I was able to cut back on the pain killers after 3-4 days. However, there were sometimes when the pain was pretty bad because I delayed taking my pain killing meds. Take the prescribed amount at the prescribed times and cut back once you are comfortable.

Regarding constipation.. The more/longer you take painkillers the worse your constipation. You can't escape it. I took senna and dulcolax religiously after the surgery. That along with drinking a lot of water and eating a ton of fruit and vegetables prevented the constipation from being too painful.

[B]
How to stay sane? [/B]This has been more difficult than the physical recovery. I loaded up my Kindle with books, but found that during the first two weeks I could not focus for extended periods to read. Instead, I watched a lot of TV. Having friends visit and talking on phone were extremely helpful. Having a social visit each day has helped. Also, trying to stay somewhat fit has been important for me. I have continued to do situps and pushups. Not only does this help with overall health, but you'll find that having limited mobility requires strong core/back/abdominal muscles. Keep these in shape and you'll minimize the discomfort of wearing the cast/boot.

This is probably more than enough to start. I'll add one or two more updates over the next month.

-------[B]-SECOND POST -[/B]------------------------

Exactly 8 weeks ago, I had the surgery. I've just stowed my crutches, toilet seat armrest hardware and plastic aircast/boot. It's time to finish this post!

As noted at the beginning of the post I've returned to basic walking and routine activities. I have not returned to active sports (weights using my legs, cycling, etc). I will slowly return to those activities in the next few weeks. If I run into problems I'll post an update, but I'm confident things will go well.

[B]TRANSITION TO WEIGHT BEARING[/B]

I kept weight off the foot for six weeks. At the six week mark, I began to put partial weight onto the foot. That was a bit trickier than I expected. I was very unsure of how much weight to put onto the foot and how to put the weight on the foot. For the first few days I occasionally would step the problem foot on the scale to identify the appropriate amount of pressure (started off with 25% of my body weight and then increased to 50% and then 66% and then 100% over a 2 week period). Crutches are critically to increasing your weight bearing. More about crutches below.

The doc had suggested a slower pace increasing weight, but I suspect that was just standard conservative medical practice. I found that I was able to increase weight without observing an increase in pain or swelling. The pain and swelling will guide you in deciding how far to push the weight. You can't go wrong by taking it slow though.

[B]
USING CRUTCHES[/B]

During the first six weeks I rarely used crutches. I used the knee scooter much more. At two weeks, the doc replaced my cast with a hard plastic air cast. Once I was wearing the air cast I was very comfortable hobbling around and putting pressure on the heel of my foot. Between the knee scooter and the air cast I could go 2-3 days and not using the crutches.

I returned to the crutches once I started putting weight onto the foot at the six week point. I found it much easier to do this while using both crutches. BUT there will be times when you want to have a hand free to hold something. In those instances you can use one crutch or hold both crutches in one hand. Be sure to hold the one crutch in the hand opposite the problem foot. It sounds counter-intuitive, bit it works better. For me, I had my surgery on the right foot, so when I was just using one crutch I held it on the left side/left hand.

Using crutches around the house is a major pain in the neck. I had to force myself to use them. As a result, I hobbled around on the heel of the boot far more than I used the crutches. However, on a daily basis I would take my crutches out for a "walk". I eventually was walking about a mile a day.

I returned my rental scooter at about the six week mark to encourage use of the crutches. As long as I had the scooter, I knew I'd avoid the crutches.

A side note: You can take "walks" on your knee scooter on smooth asphalt/concrete paths. The scooter doesn't handle hills or rough surfaces though. I had hoped to use it in my backyard, but it never made it's way down the gravel path. A long walk can really play havoc with your muscles, but a short walk on a nice path could help you maintain your attitude.

[B]FITNESS[/B]

As mentioned in earlier post, I thought it was important to stay somewhat active. I used the knee scooter to get around at the gym where I would use the stationary equipment and dumbells. My gym had an upper body exerciser [manufacturer is SCIFIT] where you peddle with your hands. I could consistently break a sweat, but couldn't get a heart-thumping cardio workout. There are portable, table based peddle exercisers. I didn't try them, but they might be good to use at home.

After about six weeks, I tried swimming. I used leg floats (styrofoam which is wedged between legs) and only used my arms for propulsion. That minimizes pressure on the foot. I could get a better workout swimming than with the SCIFIT device but I was cautious not to push the swimming since my foot swelled a bit with each session. As a result I limited my time in the pool.

[B]DRIVING AND CONSERVATIVE MEDICAL ADVISE[/B]

The doc was pretty conservative. He was slow to let me sleep without the boot. He discouraged driving and wanted me to take a slow pace with putting weight on my foot. I'd encourage you to fully understand the doc, but push him to define what is allowed. I knew the doc wouldn't agree to letting me drive, so at about the five week mark I asked "It's OK to put weight on my foot as long as it's not on the front part of the foot. I can put weight on my heel and arch. Correct?" Once the doc said yes to that question, I felt comfortable increasing my activity level. I started to drive. It was uncomfortable and I relied on cruise control for long stretches. Take it slow and easy. I started off with short drives around the neighborhood until I was comfortable with the process. I'd take the boot off when I was in the driver's seat and either drive with my right foot barefoot OR I'd wear a post-op sandal on my right foot.

[B]GUIDING PRINCIPLES[/B]

As long as I kept the following principles in mind I think I kept to a safe path:

- I was always aware of how much weight I put on the front part of my foot.
- I backed off from any activity which resulted in an increase in swelling or pain in the foot.
- If I wasn't sure of an activity, I called the doc's office and push for clear guidance.
- Make adjustments as needed

Applying these principles kept me safe, advanced my healing and kept me sane. I never felt any pain in my foot.

If I had followed the conservative recommendations from my doc, I would have slept (tossed and turned is more like it) with the boot for two additional weeks. Instead I called the doc for clarification. Once I understood that the boot was more to protect my foot when I was walking I slept without the boot, BUT I adjusted my bedroom with a barrier to prevent me from inadvertently stepping onto my foot.

The decision to try out swimming, walking with the scooter, driving, etc... all reflect these principles to some extent.

[B]PLEASANT SURPRISES[/B]

At my final appointment with the doc I learned a few things which were pleasant surprises and alleviated some concerns I had. While sitting in the waiting room you hear all the horror stories from other patients. Try not to let them freak you out, but hearing about hardware failures reminds you that problems can arise.

Once the bone fuses, the screw/plate can be removed. I thought the process was irreversible. The doc suggests this should only be done if there is an unacceptable level pain. I don't plan on it or even want to consider it, but I like the idea that the screws/plate can be removed if necessary.

If there is a hardware failure BEFORE the bone fuses, the screw/plate an be removed and replaced. For example, if a plate or screw/breaks it can be repaired. The doc assured me that such failures and repair operations are rare.

MRIs are possible. I thought having the hardware would eliminate the possibility of MRIs in the future. The doc assured me that I could have an MRI if I needed one.

[B]THINGS I'D DO DIFFERENTLY[/B]

I intentionally scheduled my surgery when I wasn't working. I'm a teacher and could afford the luxury of scheduling this during my summer break. Knowing what I know now, I think I'd be willing to schedule the surgery during a winter break. Getting around with the knee scooter and crutches was easier than I imagined. Once I had the aircast, I was comfortable hobbling around without crutches or scooter.

I would ask the doc for more clarification at each visit to help set expectations. I was good before the surgery and at the end of the post op on preparing questions. Just after the surgery and for a few weeks I wasn't as disciplined. That could be just weariness, sleep-deprivation and just anxiety though. I would try to be more disciplined in having a list of questions/concerns each time I visited the doc.

I would have started to wear a post-op sandal earlier and more often. I might even try a different sandal with a higher heel. The higher heel sandals would allow a more even gait even while you're hobbling around the house on your heel. The selection at the local store was limited. The higher heel is available on the internet.

I learned late in my recovery about grocery shopping from home. I thought internet grocery shopping from home was a flop, but it evidently is making a comeback. I wish I had taken advantage of this from day one. Home delivery isn't available for my area, but I could pick up groceries at the store. I did this three times during my recovery. If I had thought of this earlier I would have done this from the get-go. It would have eased the burden on my friends who took me on my shopping trips. It was fun using the knee scooter at the grocery store, though!

[B]SUMMARY[/B]

I'm glad I did the surgery. But I don't want to go through it again! My other toe is arthritic as well. I will certainly not run or push my activity level and jeopardize needing the same surgery on the second toe. I feel like I gave up six-to-eight weeks of my life. It was necessary to return to walking and hiking, but I don't know if want to go through this recovery process again just so I can run. Especially since the running might not only require an operation in the other toe, it might jeopardize the original sugery!

That's all I can think of.

If you have read through this entire post, I hope it's been worth our mutual effort!

If you have any questions, please feel free to post them.

Good luck with your choices and planning!

Mark





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