Revision Surgery

Revision surgery is challenging.  When tissues and bones have already been exposed to surgical procedures, the quality of these tissues in area can be difficult to work with.  Often times the region is scarred heavily, and separation between anatomic regions is difficult to discern.

Revision surgery can also challenge the healing process.  Often times, tissues do not respond with the same vigor and quality of healing as the first time they are exposed to surgery.

And of course, the most common reason for the difficulties of revision surgery is deconstructing and reconstructing the effects of the previous surgery.  This can include a procedure that did not turn out as expected by the previous surgeon, or as a result of a post of complication that caused tissue loss, damage or implant failure.

Ultimately, dealing with the challenges as they are discovered is what your doctor is going to do, but understanding the increased level of difficulty of a revision surgery is a good foundation for moving forward, and hopefully to a successful resolution of your surgical endeavor.

We understand that this is lengthy document, but it was written as a labor of love.  We acknowledge the physical and emotional pain your prior surgery complication has caused you, and have crafted this detailed guide to help clarify the challenges ahead, and how we can manage them, should they arise.

We strongly suggest you read the entirety of this document, and ask questions should you have concerns about specific topics.

Procedure Variations

Due to the varying nature of complications and necessity for revision methods, every case will be unique and different.  In general however revision cases include the first steps of surgical dissection.  Once the tissues are dissected and separated to expose the base anatomy, the surgeon can then take steps to identify and remove implants that may have been placed the surgical site.

This step can be one of most precarious and difficult since there is a chance that the implant removal will fail.  Implants can break, or the threads and/or head of the screws “strip” leaving the surgeon with the choice of leaving the implant in the foot, or taking extra steps to remove them.  Sometimes the decision to take extra steps to remove a stripped screw would cause more harm and the unfortunate decision to leave the implants in place will have to be made.

There are times that the procedure would include the removal of infected, necrotic (dead) or damaged tissue.  This can include skin, tendon, muscle, bone or other findings.  One of the requirements of most revision surgeries is the freedom for the surgeon to respond to the findings as they arise and be able to resolve them to the best of their ability.  Removal of bad tissue is one such scenario.

During the procedure, if your surgeon notices that extra steps are required to improve the outcome of the procedure, these steps will be performed.  These can include a tendon transfers, bone removal, implant removal, implant placement, temporary fixation, and the use of bone or tissue grafts.

If you have questions about the potential steps your surgeon expects for your specific procedure, please discuss them before your surgery day.

Possible Complications Related to Revision Surgery

Scar Tissue and Altered Anatomy

Previous surgeries often leave behind scar tissue, which can alter the normal anatomy of the foot. Scar tissue is less flexible and more fibrous than normal tissue, making subsequent surgeries more challenging. Navigating through and around this scar tissue can be difficult, as it may obscure normal landmarks and make it harder to identify structures that need to be operated on.

Scar tissue forms as a natural part of the body's healing process after surgery. When the skin or deeper tissues are cut, the body responds by producing collagen fibers to mend the damage. This collagen-rich scar tissue is different from the original tissue in structure and function. It's denser, less elastic, and has fewer blood vessels, which can make it less responsive to subsequent surgical interventions. The altered tissue landscape poses a challenge for surgeons, as it can obscure the normal anatomical landmarks necessary for precision in surgery.

When operating in an area with extensive scar tissue, surgeons must navigate a changed topography. This altered anatomy can increase the risk of inadvertently damaging nearby structures, such as nerves or blood vessels. The presence of scar tissue also means surgeries are often longer and more complicated, as additional time is needed to carefully work through or around this tissue. Moreover, the reduced elasticity of scar tissue can limit the surgical options available, as it may not stretch or respond as healthy tissue would.

Weakened Bone Structure

Past foot surgeries, especially those involving bone cuts (osteotomies) or joint fusions, can lead to changes in the bone structure. Bones may become weakened or misshapen, affecting the foot's ability to bear weight and function normally. This weakening can be due to a number of factors, including changes in the distribution of stress across the bone, loss of bone density, or the presence of surgical hardware.

Operating on a foot with weakened bones presents unique challenges. There's an increased risk of intra-operative fractures or difficulty in securing surgical hardware like screws and plates. Surgeons need to plan meticulously, considering the altered biomechanics of the foot. In some cases, bone grafts or specialized hardware may be required to ensure structural integrity. Postoperatively, careful monitoring and possibly a longer period of non-weight-bearing may be necessary to allow for adequate bone healing.

Compromised Blood Supply

Previous surgeries can disrupt the normal vascular architecture of the foot, leading to compromised blood flow to certain areas. This disruption can be due to scar tissue compressing blood vessels or changes in the vascular pathways. Adequate blood flow is essential for delivering oxygen and nutrients necessary for healing post-surgery. When blood supply is compromised, there's a higher risk of complications like wound healing delays, tissue necrosis, and infection.

Planning surgery in a foot with compromised blood supply requires careful consideration. Surgeons must assess the vascular status of the foot to determine the safest approach. In some cases, procedures may need to be modified to minimize further disruption of blood flow. Postoperatively, managing blood supply is crucial for successful healing, which might involve strategies like optimizing patient nutrition, ensuring adequate hydration, and possibly using medications to improve circulation.

Chronic Pain

Some patients may continue to experience chronic pain in the foot, despite the fusion.  They can also be chronic numbness, pain or stiffness in the foot joint and difficulty walking.  Although it is rare, some patients can develop chronic pain conditions like CRPS, RSD.

Patients with a history of a bad surgical outcome may have chronic pain or increased sensitivity in the foot. This can make both the surgery and recovery more challenging, as managing pain becomes a key concern.  Chronic pain after foot surgery can arise from nerve damage, ongoing inflammation, or even the development of complex regional pain syndrome (CRPS), a chronic pain condition that can develop after surgery. Nerves that have been cut or compressed during the initial surgery may send constant pain signals to the brain, leading to a persistent pain experience.

Dealing with a patient who has chronic pain requires a sensitive and comprehensive approach. Surgeons must consider the potential for further nerve irritation or damage during the surgery. Pain management becomes a crucial part of the preoperative and postoperative plan, often involving a multidisciplinary team including pain specialists, physical therapists, and possibly psychologists.

Stiffness of Joint

There are instances that the joint can become stiff with limited mobility after surgery.  This can be due to a variety of reasons and usually manageable with physical therapy, and conservative treatment.  If the region remains stiff after treatment, surgical treatment could be an option.

Joint stiffness after surgery is often a result of scarring within the joint, changes in the articular cartilage, or alterations in the surrounding ligaments and tendons. These physiological changes can lead to decreased range of motion and flexibility. In the foot, which relies on a complex interplay of joints for movement, even minor stiffness can significantly impact function.

When revising a surgery in a stiff joint, surgeons face the challenge of needing to restore as much mobility as possible without causing further damage. This often involves carefully breaking down scar tissue, realigning bones, or even replacing damaged joint surfaces. The surgeon must balance the need to improve mobility with the risk of destabilizing the joint or causing additional scarring.

Altered Biomechanics

Previous surgeries can change the way forces are distributed across the foot, leading to altered biomechanics. This can put unusual stress on certain areas, leading to pain, difficulty in walking, and increased wear on joints and tissues. The altered biomechanics can also affect the outcome of subsequent surgeries, as they can change the load-bearing areas of the foot.

Understanding these biomechanical changes is crucial in planning revision surgery. The surgical approach may need to be tailored to correct or accommodate these altered force distributions. Postoperatively, rehabilitation might include physical therapy to help the patient adapt to these changes and prevent further complications.

Psychological Impact and Patient Responsibility in Revision Surgery

A negative experience from a previous surgery can lead to anxiety, fear, and lack of trust in medical procedures. This psychological impact can affect a patient’s approach to another surgery, their pain perception, and their overall recovery. Stress and anxiety can also physiologically impact healing by affecting the immune response and hormonal balance.

It’s important for the surgical team to acknowledge and address these psychological factors. Building a rapport, providing thorough and clear information about the procedure, and offering psychological support can help alleviate anxiety. In some cases, referral to a counselor or psychologist may be beneficial.

Understanding the Psychological Response

Experiencing a bad outcome from a previous surgery can lead to a range of psychological responses, including anxiety, fear, and distrust in medical procedures. These emotional responses are natural and valid, but they can also significantly impact the outcome of a revision surgery. It's essential for patients to acknowledge these feelings and understand how they can influence their recovery process. Recognizing the psychological impact is the first step towards managing it effectively.

Active Participation in the Healing Journey

The patient's commitment and active participation are crucial in the success of revision surgery. This includes following pre- and post-operative instructions, attending all scheduled appointments, and engaging in recommended rehabilitation activities. It’s also about being proactive in addressing any psychological concerns that may arise. Patients should feel empowered to communicate openly with their healthcare providers about their fears and anxieties. A clear and open dialogue can help tailor the surgical plan and recovery process to better suit the patient’s needs.

Tools for Managing Psychological Well-being

Psychological Counseling

Seeking psychological counseling can be a valuable tool for patients preparing for revision surgery. A counselor or psychologist specializing in dealing with medical trauma and anxiety can provide strategies to cope with fears and negative thoughts. Cognitive-behavioral therapy (CBT) is particularly effective in changing unhelpful patterns of thinking and behavior related to medical procedures.

Mindfulness and Relaxation Techniques

Techniques such as mindfulness, meditation, and deep breathing exercises can help manage anxiety and stress. These practices encourage a focus on the present moment and help in developing a more balanced perspective. They can be particularly useful before surgery and during the recovery period.

Patient Education and Informed Decision-Making

Being well-informed about the revision surgery, including understanding the risks, benefits, and expected outcomes, can help reduce anxiety. Knowledge empowers patients to make informed decisions about their care. Educational resources, support groups, or informational sessions can be instrumental in this process.

Building a Support System

Encouraging patients to build a strong support system is vital. This can include family, friends, support groups, or connecting with others who have gone through similar experiences. Having a network of support can provide emotional comfort and practical assistance during the recovery journey.

Setting Realistic Expectations

Helping patients set realistic expectations about the surgery and recovery process is essential. Understanding that recovery may be gradual and that challenges are part of the journey can help patients maintain a positive outlook.

Physical Activity and Rehabilitation

Engaging in recommended physical therapy and exercises not only aids in physical recovery but also has psychological benefits. Physical activity can improve mood, reduce anxiety, and enhance overall well-being.

By combining these tools and strategies, patients can be better prepared for revision surgery, both physically and psychologically. It’s about creating a holistic approach that addresses the entire spectrum of the patient’s needs and concerns, leading to a more positive surgical experience and outcome.