Pain is no longer the price of surgery—it is a problem to solve
Durante décadas, la cirugía de pie fue sinónimo de sufrimiento, una memoria colectiva transmitida de generación en generación. Hoy, gracias a técnicas percutáneas con incisiones de medio centímetro y una nueva filosofía que rechaza el dolor como precio inevitable de la intervención, el noventa por ciento de los pacientes no experimenta dolor alguno en las primeras veinticuatro horas. Lo que ha cambiado no es solo el bisturí, sino la manera en que la medicina concibe su responsabilidad hacia quien se pone en sus manos.
- La reputación histórica de la cirugía de pie —construida sobre técnicas agresivas y anestesias rudimentarias— frenaba a pacientes que preferían soportar el dolor antes que someterse a una operación.
- La presión de la vida moderna, que no tolera semanas de baja ni hospitalizaciones prolongadas, obligó a los cirujanos a replantear desde cero su forma de intervenir.
- La cirugía percutánea, que opera a través de incisiones de apenas medio centímetro guiadas por rayos X portátiles, logra corregir juanetes, dedos en martillo y otras deformidades sin dejar cicatriz visible.
- El noventa por ciento de los casos se resuelve de forma ambulatoria: el paciente llega por la mañana, regresa a casa en pocas horas y retoma el trabajo en días, no en semanas.
- El paradigma ha cambiado: el dolor postoperatorio ya no se gestiona, se previene; su presencia se considera ahora un fallo del proceso, no una consecuencia aceptable.
Durante la mayor parte del siglo XX, la cirugía de pie acumuló una reputación tan oscura que los pacientes la transmitían como un trauma familiar. El doctor Eduard Rabat, cirujano ortopédico al frente de la Unidad de Cirugía de Pie y Tobillo del Hospital Quirón Barcelona, sitúa el origen de ese miedo en las técnicas agresivas y las anestesias precarias que dominaron el campo hasta los años noventa: grandes incisiones, instrumentos rudimentarios y medicamentos que se desvanecían antes de que el dolor llegara a su pico.
Algo fundamental ha cambiado. La cirugía mínimamente invasiva —impulsada tanto por la evolución técnica como por las expectativas de una sociedad que no puede permitirse recuperaciones largas— ha transformado el campo. La filosofía también ha mutado: donde antes el dolor postoperatorio se aceptaba como inevitable, hoy se considera un problema que debe eliminarse antes de que aparezca.
Los datos son elocuentes. El noventa por ciento de los pacientes de Rabat no siente dolor alguno en las primeras veinticuatro horas tras la intervención. Las dos grandes herramientas de este cambio son la artroscopia y la cirugía percutánea, ambas practicadas a través de incisiones de medio centímetro. La segunda, preferida por Rabat en la gran mayoría de sus casos, permite corregir juanetes y otras deformidades reposicionando huesos y fijándolos con tornillos, todo ello sin dejar cicatriz visible.
Una operación de juanete típica comienza por la mañana: el paciente recibe sedación, el anestesiólogo bloquea el pie con dos o tres inyecciones en el tobillo, y el cirujano trabaja guiado por rayos X portátiles. En dos a cinco horas, el paciente regresa a casa. Durante la primera semana camina con un calzado especial; pasada esa semana, retoma el calzado habitual y, si su trabajo no exige esfuerzo físico, vuelve a él en días. Al mes, ya usa zapatillas y comienza la rehabilitación.
Rabat reconoce que no todas las patologías admiten un abordaje mínimamente invasivo, y que algunas siguen requiriendo cirugía abierta con al menos una noche de hospitalización. Pero incluso en esos casos, la anestesia moderna garantiza un postoperatorio sin dolor. El cambio de fondo es filosófico: el dolor ha dejado de ser el precio de la cirugía para convertirse en una señal de que algo puede y debe mejorarse.
For most of the twentieth century, foot surgery carried a reputation so dark that patients passed down stories of it like family trauma. The pain was legendary—not exaggerated, but genuinely terrible. Dr. Eduard Rabat, an orthopedic surgeon who runs the Foot and Ankle Surgery Unit at Hospital Quirón Barcelona, traces this reputation to its source: the aggressive surgical techniques and crude anesthesia that dominated the field through the 1990s. Surgeons worked with large incisions, crude tools, and anesthetics that wore off quickly, leaving patients in agony once the medication faded. Those experiences embedded themselves in the collective memory, passed from one generation to the next, until the very idea of foot surgery became synonymous with suffering.
But something fundamental has shifted. Rabat, who dedicates 90 percent of his practice to foot and ankle work, describes a radical transformation driven by two forces: evolving surgical technique and changing patient expectations. Modern life does not accommodate lengthy recoveries. People cannot afford weeks away from work or extended hospital stays. This pressure pushed surgeons to rethink their approach entirely. The result is minimally invasive surgery—a set of techniques designed to accomplish the same surgical goals while causing far less tissue damage. The philosophy has changed too. Where surgeons once accepted postoperative pain as inevitable and managed it with medication, the new standard is to prevent it altogether.
The numbers tell the story. Ninety percent of Rabat's patients report experiencing no pain whatsoever in the first twenty-four hours following surgery. This is not pain management through heavy medication; it is the absence of pain. The shift applies most dramatically to bunion surgery, the most common foot procedure. Where open surgery once required large incisions and weeks of immobility, percutaneous techniques now accomplish the same correction through incisions of half a centimeter—small enough that they leave no visible scars.
The two main minimally invasive approaches are arthroscopy and percutaneous surgery. Arthroscopy uses a half-centimeter incision to access the interior of joints, particularly useful for ankle work—treating cartilage damage, chronic ligament injuries in ankles that repeatedly twist, and tendon repairs common in athletes. Percutaneous surgery, Rabat's preferred method in roughly ninety percent of cases, works through similarly tiny incisions to access and reshape the bones of the forefoot. A surgeon can correct bunions, hammer toes, and other deformities by cutting and repositioning bone—osteotomies—and securing the corrections with screws, all through openings barely visible to the naked eye.
A standard bunion procedure unfolds like this: the patient arrives the morning of surgery. After preliminary checks, sedation is administered so the patient feels nothing as the anesthesiologist numbs the foot with two or three injections around the ankle. The surgeon then works under portable X-ray guidance, making half-centimeter incisions through which tendons and bone are accessed. Exostoses are shaved or cut away. Bones are repositioned. Screws—necessary in about eighty percent of cases, especially severe ones—are inserted through the tiny cuts. The entire procedure happens in an outpatient setting. Within two to five hours, the patient is sent home.
Recovery is measured in days, not weeks. For the first week, relative rest is recommended, though most patients can walk with support using a specialized forefoot surgery shoe. After that week, normal footwear resumes. Work can resume if it does not involve strenuous physical activity. The foot remains numb for the first twenty-four hours—the window when pain would historically strike. After that, because of the minimal tissue trauma, pain simply does not materialize. By one month, patients transition to comfortable or athletic shoes and begin rehabilitation. By comparison, open surgery of the past required weeks of immobility and months of recovery.
Rabat acknowledges that not all foot pathologies can be treated with minimally invasive techniques. Some conditions still require traditional open surgery, which may necessitate at least one night in the hospital. But even in those cases, modern anesthesia ensures a painless postoperative period. The fundamental change is philosophical: pain is no longer accepted as the price of surgery. It is treated as a problem to be solved, a sign that something in the surgical approach or pain management needs adjustment. A painless procedure, Rabat argues, is the foundation of genuine recovery. The foot no longer has to be sacrificed to fix the foot.
Notable Quotes
The change most important is in the mentality of professionals. Before, postoperative pain was considered normal and treated with drugs. Today, the goal is zero pain or, if impossible, minimal pain.— Dr. Eduard Rabat
A painless surgical procedure is the first step toward genuine recovery.— Dr. Eduard Rabat
The Hearth Conversation Another angle on the story
Why did foot surgery develop such a fearsome reputation in the first place? Was it just the pain, or something else?
It was the whole experience. The incisions were large, the tissue damage was extensive, and the anesthesia wore off quickly. Patients would wake up in extraordinary pain with no effective medication to manage it. Those stories—real stories—got passed down. People heard about their grandmother's bunion surgery and decided they'd rather live with the deformity.
And now ninety percent of patients report no pain in the first day. That seems almost too good to be true. What changed?
Two things. First, the techniques themselves became far less destructive. A half-centimeter incision instead of a large one means less tissue damage, less inflammation, less pain. Second, the anesthesia improved dramatically. We can now numb just the foot while keeping the patient sedated and comfortable, rather than putting them under general anesthesia.
But you still need to cut bone and move it, right? How does that not hurt?
Because the foot is completely numb. The anesthesiologist has essentially turned off sensation in that limb. The surgery happens while the patient is sedated and feels nothing. By the time sensation returns, the acute inflammatory phase has passed. The tissue damage is minimal, so there is simply less pain to feel.
What about the patients who do experience pain? Are they the ones with more severe deformities?
Sometimes, yes. If we anticipate a more complex procedure, we take special measures—better pain management protocols, sometimes an overnight hospital stay. But even then, the goal is zero pain, not pain management. That is the real shift in thinking.
So this is as much about changing how surgeons think as it is about changing the technique itself?
Exactly. For decades, surgeons accepted pain as inevitable. Now we see it as a failure. If a patient is in pain, we ask what we did wrong, not what medication we can give them. That mindset change might be the most important part of all.