AFTER SURGERY

Congratulations, surgery is complete and you are now in the recovery phase. The hard part.

Again, YOU have to own your recovery. The surgery part is relatively easy, the recovery is the hard part. Your part includes being ready to recover. To do this, you need to be optimized while you recover.

More in depth information here (PDF).

DRESSING/SPLINT/BOOT/BRACE:

Leave in place until your first postoperative appointment, unless told otherwise. Keep clean and dry, wet and dark places breed bacteria and cause infections. Some strikethrough on the dressing is normal, if this happens then reinforce the dressing with additional gauze and a 6-inch ace wrap wrapped snugly, but not uncomfortably so. When bathing, put a cast cover or plastic bag and a lot of tape over your operative dressing.

WEIGHTBEARING/MOBILIZATION:

Make sure to follow instructions previously outlined to you. No weight means NO weight at all on the operative extremity. Regardless of your weightbearing status you should use your crutches or walker to get up once every hour to get the blood flowing in your legs to prevent blood clots. Do not do much more than going across the room and back.

PAIN CONTROL

Pain is part of the process and should be expected. Pain should not be unbearable; however, it likely will not be zero. A reasonable goal would be a 3 or 4/10 on the pain scale, something where you can sleep.

Medications are only part of the equation. Pain is connected with swelling and inflammation. Swelling/fluid goes downhill; you should be elevating your extremity more than 90% of the time with the foot/ankle above the knee and knee above the hip OR hand above the elbow and elbow above the shoulder. This reduces tension on the incision(s) and will decrease risk of an infection.

There are 3 pain waves to be aware of that are very normal and should not be alarming:

  1. 12 – 36 hours after surgery: the swelling is intense and the short acting pain “block” has worn off. Make sure your extremity is elevated and use more ice. If it is not working after 20 minutes then make sure you are taking your acetaminophen, celecoxib, duloxetine, and pregabalin as ordered, if you are then consider a rescue (PRN) pain medication – either your muscle relaxer or your narcotic if applicable.

  2. 3 – 5 days after surgery: the swelling has continued to increase even more so make sure you are elevating and icing. Follow similar steps to prior pain spike.

  3. 6 – 9 days after surgery: 1 in 10 will experience the melt down day – when all is going well and then it is SUDDENLY more painful without a specific inciting event. This is when maximum swelling has been reached. Follow similar steps to prior spike.

MEDICATIONS:

You will be prescribed a combination of or all of the medications in the table below. Tranexamic acid, cephalexin, and aspirin should be completed unless told otherwise; the other medications are for pain and so do not necessarily need to be completed. You may have also been prescribed a narcotic medication and/or a muscle relaxant, this is ONLY for breakthrough pain. The other medications are the main control.

You should also obtain over the counter Miralax (polyethylene glycol) and take 17g daily to prevent constipation while taking your other medications.

The Pain Control Pyramid:

You should have baseline control PRIOR to using your rescue medications. Listed in order are the medications/interventions you should be utilizing. Your regimen may not have all of these medications in it but the order still applies. When weaning off of pain medications the last on the list should be the first medication stopped. You do not have to take all pain medications if not needed.

  1. Ice and elevation - This is the first line. Toes above nose and make sure everything is going downhill towards the body (a pillow under the knee making the foot lower than the knee will make the swelling WORSE than a leg flat on the bed)

  2. Acetaminophen (Tylenol) - This is a non-addictive pain reliever

  3. Celecoxib (Celebrex) - This is an antiinflammatory that helps control both pain and swelling

  4. Duloxetine (Cymbalta) - This is a medication that helps decrease general musculoskeletal postoperative pain

  5. Pregabalin (Lyrica) - This is a medication that helps decrease postoperative nerve pain

  6. Cyclobenzaprine (Flexeril) - This is a muscle relaxant to be taken if having spasms

  7. Oxycodone (Roxicodone) - This is a narcotic medication that should be used as a rescue medication ONLY

Other Medications:

The first 3 medications should be taken and completed unless otherwise informed by your physician:

  1. Tranexamic Acid (TXA) Oral - This is to decrease bleeding after surgery. Bleeding is painful and causes swelling. This will not increase blood clot risk when taken as prescribed (an antifibrinolytic, NOT a prothrombotic)

  2. Cephalexin (Keflex) - This is an antibiotic for infection prevention

  3. Aspirin (ASA) - This is a mild blood thinner to prevent blood clots. If you are already on aspirin or another blood thinner at home you will likely restart your pre-surgery regimen after surgery

  4. Diosmin (MPFF) - This is a bioflavenoid made from citrus peels, it can be obtained over the counter and helps with swelling. If it does not interact with your normal home medications it should be taken 500mg twice daily for 6 months after surgery.

EDEMA (SWELLING) CONTROL:

Swelling leads to delayed healing and increased pain. The fluid in your body goes downhill to your legs.

DIET:

Mediterranean Diet – Focus on Whole Foods and Avoid Things that Come Pre-Packaged:

General rules to follow for at the minimum 6 weeks preoperatively to 3 months postoperatively. If you are on a special diet or have kidney problems, discuss with your primary care physician or nephrologist.

  • Stay Hydrated – Water, unsweetened tea or coffee. No sugar in your drinks. No alcohol. 

  • No Fried or Processed Foods – fries, burgers, chicken nuggets, chips, mac and cheese, salami

  • No Added Sugars – Look at the nutrition facts, most things in boxes have added sugars

  • DO EAT:

    • Beans (chickpeas, lentils, pintos, black, kidney, etc.)

    • Cruciferous vegetables (broccoli, Brussel sprouts, bok choy, kale, collard greens)

    • Other vegetables (artichokes, asparagus, mushrooms, okra, onions, sweet potatoes, tomatoes, garlic)

    • Nuts (walnuts, brazil nuts, cashews, chia, hazelnuts, macadamia, pecans, seeds)

    • Protein (aim for 100g daily, can supplement with whey or soy if needed)

    • Meat (tuna, salmon (white meats); avoid red meats and pork)

    • Whole grains (oatmeal, barley, quinoa, wild rice, buckwheat, brown rice)

    • Berries (acai, blackberries, raspberries, blueberries, cherries, strawberries, etc.)

    • Fruits (apples, apricots, avocado, melon, oranges, mangos, plums, pomegranates, etc.)

SUPPLEMENTATION:

While not mandatory, additional supplementation of nutrients below can help healing and decrease risk of complication in the healing process.

URGENT ISSUES:

For weekday, night, or weekend assistance: call your clinic’s number that you were seen at, if it is after hours you will be routed to the on-call physician. For emergency, call 911!