Practice of Foot and Ankle Surgery

Practice of Foot and Ankle Surgery

Dear All,

Here is how and why I use the Orthoflex splints in my practice of foot and ankle surgery.
The why is simple: time saving and convenience of use in the Operating Room, Emergency Room, and ward; improved patient comfort and staff satisfaction. The splints avoid work intensive application, removal, or splitting of plaster casts or bandaged plaster slabs and the cleaning up afterwards. Their use is intended mainly as a temporary support starting in the Emergency Room or after an elective operation and ending with the surgeons decision on the long term immobilization required at discharge (often a one time definitive formal plaster cast when the swelling has gone down.). Sometimes their use is continued long term when rigid support is not necessary (for example a fracture of the calcaneus or minor foot fracture which is being treated conservatively by a non rigid support with early movement. The time saved in the Operating Room and in changing dressings and the management in the ward (adjustments for swelling or reduction of swelling, wound inspection etc.) makes for an overall saving and is therefore “cost effective”.
I always place a sheet in the splint to prevent soiling and provide a comfy wrap for the limb (a simple disposable hospital “nappy” sheet which is impervious to fluids on its splint side and cotton woolly and absorptive on the limb contact side.) The sheet is replaced whenever it is soiled by blood or secretions.

Splints can be re-used and disinfected by washing (and when necessary scrubbing with a soft brush) with Chlorehexidine surgical soap, or laundered in a washing machine at 30 degrees Celsius also using chlohexidine soap (close the buckles of the straps so they do not get entangled with the other laundry).

Examples of how and when:
Foot and Ankle fracture: the foot and ankle are placed in the inflated short splint (for Pylon fractures-a long splint) containing a sheet. The sheet is lightly wrapped around the sides of the foot, ankle, and leg and the straps are buckled and lightly tightened (the patient feel immediate support and pain is lessoned). He is sent for X-ray (no need to remove the splint because it is radiolucent). On admission the splint remains in position whilst waiting for operation. Inspection of the fracture is easy. He is scheduled for operation. If the swelling is too great to allow immediate internal fixation, the patient is discharged in the splint for a few days until the skin conditions are right for operation. Meanwhile he is instructed to tighten or loosen the straps for maximum comfort. He ambulates with a walker or crutches non-weight bearing keeping his leg raised up during the day to reduce swelling.
He is wheeled to the Operating Room for immediate or delayed operation in the splint. Following anesthesia the splint is removed. At the end of the operation a light non-circular dressing is applied to the wound and the limb is replaced into the same splint using a fresh sheet. I encourage early slight movements at the ankle joint if these are not very painful. In the ward the limb is inspected as needed and the tightness of the straps adjusted to comfort. The sheet is replaced as necessary. On discharge, if the swelling has gone down, the dressings are changed and a full circular well molded definitive Plaster of Paris BK is applied for 6 weeks non-weight bearing. I mostly use intra-cuticular stitching reinforced by Steris trips (unless the skin is contused or this was an open fracture) so there is no need to remove stitches. If there are stitches to be removed or the swelling is too great for a definitive cast, then the responsible disciplined patient is sent home for a few days in the splint until the stitches can be removed or the swelling has gone down, and then the Plaster of Paris is applied. I do not use the synthetic casts because they cannot be properly molded.
Elective Foot and Ankle Surgery:
I put on the short splint after the operation in the Operating Room for arthrodesis (sub-talar , ankle, triple, talo-navicular,etc), until the swelling has gone down and the stitches are out and then proceed to long term plaster of Paris and later to a walker as indicated.
The splint has the same advantages in the immediate post-operation period in elective operations as in the trauma group. I have no personal experience of total ankle replacement; however my colleague reports that the Orthoflex splint is very convenient and comfortable for the post-operation course of TAR.
Also for Hallux Valgus and first MT-P joint arthrodesis for the first post-operation period whilst the patient is at home, the Orthoflex splint gives better patient satisfaction than a Darco shoe. The splint is not suited for walking outdoors. Here the Darco shoe is suitable.
Plantar fasciitis
If the surgeon or podiatrist believes in night splint stretching of the plantar fascia and the Achilles tendon as a treatment for plantar fasciitis then the Orthoflex short splint is ideal. The oblique straps allow for a dynamic adjustment of the stretching force by the patient himself according to how much stretch the patient is able to suffer.
The splint allows ambulation at home whilst the stretching is taking place and there is no need to remove the splint at night if the patient has to get up to micturate.
Therefore the Orthoflex splint is superior to all the static night splints.

Yours sincerely,
Prof. Daniel Reis

N.B. Just a comment on my back pack. When I go trekking with friends or accompany a group I like to take a long Orthoflex splint with a couple of “well-leg-straps”.
This gives me a light weight solution for the first aid of any upper or lower limb injury.