When I started out in practice, I was not prepared for the amount of surgery I would schedule in those initial months. I had hoped to ease in doing one case here and there. Instead, I had four every Friday. I realize this may not be a lot to some but it was plenty for me. While I have learned a lot since then, the biggest thing I have learned is that everybody walks.
It does not matter how specific you are or how serious you sound in your pre-surgical instructions, everybody will walk on their surgical foot. I performed my first Lapidus procedure on a young man with whom I stressed the importance of non-weightbearing. I gave him the option of a posterior splint versus a hard cast. He felt he could tolerate a posterior splint better and remain adherent.
On the first postoperative visit, he showed up with different dressings on and was walking without crutches. Of course, it is easy to blame the patient for this and some of this was absolutely his fault. However, it was also my fault for giving him the benefit of the doubt. My strategy has since changed.
I cast everyone who needs immobilization. I no longer give anyone the benefit of the doubt that they will be adherent to non-weightbearing instructions. This has greatly changed my post-op results.
My first patient did not have unfavorable results but there was some loss of correction. Initially, I thought that there would be pushback from patients. However, I am upfront and tell them all, “You will be in a cast from one to two weeks depending on how you are doing.” Believe me, every single one of those patients comes in walking but now I feel better. There is more protection with a cast. There is more of a chance that the surgical correction will be preserved.
Another issue that I encounter is that everyone falls. Almost every one of my surgical patients has fallen while they are on their crutches. I was beginning to think it was me. Maybe I have bad luck or I am cursed but these falls happen all the time. That’s where the cast comes in handy. It doesn’t matter how hard they fall or how many steps they fall down, my cast is usually pretty well intact and that surgical foot is protected.
I have also found a few extremely important aspects of casting that make the patient very comfortable and better able to tolerate the cast.
I tell every one of the residents to pad the heck out of the cast. Cast padding is very forgiving. Fiberglass is not. It is important to extend the cast padding beyond the toes distally and above where you plan to end the cast proximally. That way when you roll down the stockinette before adding that final decorative layer, there is an abundance of padding over those sharp fiberglass edges. Then you end your top layer or color just short of the padded stockinette edges.
This ensures that when the patient does walk on this cast, there are no sharp edges to cause a wound. This is extremely important with my patients with diabetes. A simple abrasion on the toes can turn into a giant problem. This is additional insurance to make sure that they have the least chance of having any subsequent issues from the cast. Again, it is easy to blame the patient. But I like to make sure I have done everything I can do so I can sleep at night knowing that I gave that patient a comfortable cast and the best chance of maintenance of surgical correction.
As an additional aside, for every surgical patient whom I put into a below-knee cast, I also ask for a popliteal block by anesthesia. This ensures that the patient is comfortable for between 12 to 72 hours depending on the effectiveness of the block. This helps that patient tolerate a cast for the first weekend. I typically operate on Fridays and call my post-op patients on Mondays. All have done well over the weekend due to their lasting popliteal block.
I have also found the majority of patients that have received this popliteal block require only one opioid pain medicine prescription. Very few request a second. I request popliteal blocks for anything that goes into a cast, which includes my Lapidus procedures. I know I could properly anesthetize this area with a local anesthetic plus monitored anesthesia care approach, However, I feel the patients do much better long-term with that extended extremity block.
The numb leg also discourages them from ambulating for those first few days. Very few people are going to walk on a leg they cannot feel. This does increase their chances for falling. However, in my experience, most end up just sitting in bed. It is a win-win.
In the very beginning, my philosophy was to “hope for the best” when it comes to postoperative surgical care. My philosophy has very much changed. It is now “prepare for the worst.” This has greatly decreased my anxiety for the patients as well as giving my patients more favorable results.
The addition of a popliteal block and a well constructed cast ensure that my patients experience a relatively benign and comfortable postoperative period. These few things made a huge difference in my practice. I hope young physicians who are getting ready to start practice this year are able to read this and hopefully learn from my early mistakes.
Dr. Bishop recently completed his residency at Alliance Community Hospital and is now in private practice in Alliance, Ohio.