A Guide To Foot Surgery For The Geriatric Patient

     In regard to traditional perceptions, we need to redefine our approach to geriatric patients. Somewhere along the way in our training, we are taught that once people reach 65 years old, they are given the demographic label “geriatric.” As a result, there is a tendency to shy away from presenting surgical options for these patients due to fears that they may not heal, their bones are too brittle or that they have too many medical problems. The common excuses that I hear include: “too old,” “too risky,” “won’t heal” and “just live with it.” It is not uncommon for geriatric patients to present to the office with homemade orthodigital appliances as a means of coping with pain.      However, in the new millennium, patients well into their 80s are active with swimming, golf, tennis and walking regimens. I can specifically remember an 80-something-year-old patient of mine, a retired physician, playing golf in a fracture boot because of tibialis posterior dysfunction. It seems to be a trend that people are generally living longer and trying to lead healthier lifestyles. In fact, we have seen the development of retirement communities nationwide that promote the active lifestyle.

Metatarsal Osteotomy: Should You Consider It In Active Geriatric Patients?

     I can recall the early days of my training studying the different procedures and parameters for performing bunion surgery. Certainly, one should consider criteria such as radiographic findings (angular measurements and joint condition) as well as the patient’s age. However, I clearly remember being taught that once the patient is in the 65-year-old range, I should be considering a Keller arthroplasty.      What is the reality? I rarely perform a Keller arthroplasty, even in my patients who are well into their 70s and 80s. I have found that this patient population does very well with a metatarsal osteotomy even if there is some degree of osteopenia. If the joint is not arthritic and one can perform a realignment osteotomy, why destroy the joint and destabilize the first ray? I reserve the arthroplasty procedures for sedentary geriatric patients who have a low demand for foot function. For the active patient, I am concerned that the arthroplasty may be the cause of a metatarsal stress fracture, lesser metatarsal overload with resulting sub-second metatarsalgia and/or a flail great toe.      When performing osteotomies and fusions in the geriatric patient, one must consider certain precautions such as osteotomy location, internal fixation and guarded postoperative protocol. Often when I perform a distal metatarsal osteotomy for bunion surgery, I will make the osteotomy slightly more proximal than I would in a patient with harder bone. This can prevent the more metaphyseal (spongy) bone from compacting and leading to shortening of the ray or causing instability of the osteotomy. Versatility is important in the operating room and one should have a backup plan if the planned internal fixation construct fails. One can always rely on K-wires if screws fail.      At times, one needs to make modifications to postoperative protocols. For instance, in a patient who has soft bone, I may have him or her use a fracture walker instead of a surgical shoe. There are times when I will tell my patients that the only way I will do their surgery is if they get a wheelchair and do not walk on the foot for a few weeks. A knee walker can be helpful in allowing some mobility while keeping these patients non-weightbearing.

Tackling Concerns With Patient History, Polypharmacy And Vascular Status

     Let us face it. The geriatric patient presents with baggage. Geriatric patients tend to have a myriad of pedal pathologies that may be combined with a whole host of special concerns. Some of these concerns include: general medical status, polypharmacy issues and vascular status. Other concerns are functional/activities of daily living (ADL) needs such as living alone, being the sole caretaker to a spouse, challenges of non-weightbearing, transportation issues, etc. The geriatric patient is also prone to traumatic events such as falling and twisting of the foot and ankle. In patients with osteopenia, there is risk of developing insufficiency stress fractures. Moreover, older patients are more likely to have had foot surgeries causing iatrogenic deformities that have had two or three decades to develop or become worse.      Most of us think of elective foot surgery for the young and healthy patient. Granted, geriatric patients and younger patients alike may have ailments such as bunions, hammertoes, neuromas and other common pedal pathologies. However, many geriatric patients have coronary artery disease, hypertension and atrial fibrillation. They may have had heart attacks, strokes, multiple angioplasties and bypasses, and are taking anticoagulants. Despite an extensive medical history that may include diabetes, heart disease, cancer and/or prior deep venous thrombosis (DVT), many of these patients are still active and want surgical correction of various deformities of the foot and ankle that are causing them pain and disability.      In order to put things into perspective, talk to an orthopedic surgeon who performs total joint replacements of the knee and hip. Most patients requiring this type of surgery are 70+ years old and have a long list of medical problems. Moreover, these patients usually have to donate blood for possible transfusion, are admitted to the hospital postoperatively for a few days and then go into a skilled nursing facility for rehabilitation. With this in mind, why do podiatrists shy away from foot surgery in the geriatric patient? Our surgeries are usually an hour or less, require little anesthesia (intravenous sedation and a local anesthetic field block) and an overnight stay is rarely necessary.      For geriatric patients who have multiple medical problems, I encourage you to get medical clearance from their primary care physician. Most surgeons, regardless of their specialty, obtain preoperative medical clearance unless it is an emergent surgery. Once the patient has been medically cleared for surgery, there are some special considerations.      Vascular status is of concern if there is not an easily palpable arterial pulse. Non-invasive Doppler studies are fairly routine in making initial assessments. A vascular surgeon referral may be needed if the non-invasive studies are significantly suboptimal. Patients will often undergo a vascular procedure and follow with podiatric surgery at a later date. In the case of a non-elective procedure, such as an incision and drainage or resection of bone for osteomyelitis, the reverse may be needed. The patient may need to undergo an endovascular procedure or arterial bypass after the podiatric surgery.      As a general rule, I do not use tourniquets for forefoot surgery. I use epinephrine in toes only if there is a palpable pulse with adequate capillary refill. If non-invasive studies are available and there are suboptimal results, one should avoid epinephrine. When in doubt, perform the surgery wet. Postoperatively, elevate the extremity without ice application to the foot. Give the patient postoperative instructions to check that the toes are pink and, if not, to call the doctor.      The geriatric patient will at times have an extensive podiatric surgical history. Multiple surgeries on the forefoot over the last 20 or more years can make it challenging to initiate an effective treatment plan. Occasionally, older patients may have implanted hardware that may be difficult to remove if the instrumentation is not readily available. In addition to bony pathologies such as hammertoes and/or aberrant metatarsal parabolas, there are inherent problems such as lack of adequate fat pad, thin and atrophic skin, and refusal to wear adequate shoe gear.

When Patients May Be At Risk For Embolic Events

     For anticoagulated patients undergoing elective podiatric surgery, it is important to weigh the risks and benefits for discontinuing coumadin. When it comes to forefoot surgical procedures, such as nail surgery, hammertoe correction, bunion repair and neuroma excision, surgeons can safely perform those procedures on patients who are anticoagulated. Major reconstructive surgeries, such as hindfoot fusions, pan metatarsal head resections and plantar foot surgeries, can be difficult to perform in the anticoagulated patient. It hard to achieve hemostasis and there is risk for postoperative hematoma. Consultation with the patient’s internist is recommended for these procedures.      When there is concern for an embolic event in high-risk patients, it may be necessary to admit the patient to the hospital prior to surgery. Give subcutaneous heparin (a mini-dose of 5,000 units every 12 hours) while stopping coumadin. After surgery, one can administer coumadin to achieve the appropriate protime level. The surgeon can then discontinue heparin.      In patients with low to moderate risk of an embolic event, it is acceptable to discontinue coumadin three to five days prior to surgery, administer a mini-dose of heparin in pre-op holding and then administer coumadin postoperatively. One may also utilize fractionated heparins per administration guidelines as a means of thrombolic/embolic prophylaxis. Additionally, clinicians may emphasize the use of antiembolic stockings, intermittent compression pumps and/or early postoperative range of motion/exercise of the hip and knee to augment any lapse in pharmaceutical anticoagulation.

Tailoring Reconstructive Surgery Principles To The Elderly

     Surgical principles for reconstructive foot surgery do not always pertain to the geriatric patients as they pertain to our younger, more active patients. For example, one would rarely consider a fifth metatarsal head resection in a young patient but it is ideal for an inactive geriatric patient with a painful tailor’s bunion or chronic pain and/or callus under the fifth metatarsal head.      Another common problem is the severely dislocated second metatarsophalangeal joint. An aggressive relocation can be compromising to the vascular supply of the toe. It may be heroic to perform an extensive hammertoe operation that includes a metatarsal osteotomy, flexor to extensor tendon transfer and arthroplasty of the toe. In this case, a proximal phalangeal base resection is often needed to relocate the toe. After performing the arthroplasty, the surgeon may use a K-wire to maintain position for up to six weeks and rarely is there a problem with instability of the toe. If there is a problem with instability in the future, one can perform a syndactyly.      In addition, for hammertoe repair in the young and active population, I will perform arthrodeses of the lesser toes (excluding the fifth) to provide long-term stability and enhance flexor tendon function. In certain cases, I perform arthroplasties in our older/sedentary patients who have problems such as ulceration or a corn on the dorsal toe and/or cannot wear a shoe. This is a prime example of the “less is more approach.”      This is an effective way to resolve ulceration or a corn without prolonged healing from a more extensive reconstruction. The older patient is concerned about one thing: pain relief. As surgeons, we strive for perfection in cosmesis and pain resolution. However, this may not be practical in this patient population. I cannot tell you how many times the older patient will tell me, “I don’t care what it looks like. Just get rid of the pain.”      Failed first metatarsophalangeal joint implants are commonplace in the older patient. It is a surgical dilemma to reconstruct the first ray when there are issues such as a short first ray with poor quality bone at the proximal phalanx and first metatarsal head. For a young, active patient, an autogenous iliac bone graft is often useful in augmenting an arthrodesis of the first metatarsophalangeal joint. However, this option is not practical for geriatric patients as most of this patient population cannot tolerate eight to 12 weeks of strict non-weightbearing.      In these cases, I will either remove the implant and replace it with a new one, or remove the implant, leave it as a joint resection and use a K-wire across the arthroplasty site for six weeks. Despite a short first ray, with retraction of the great toe, the foot is still functional for the needs of the less active geriatric patient.      One can then balance the foot with an orthotic device. In some cases, if the bone quality is good, one can then perform a fusion. The surgeon can evaluate the quality and quantity of bone intraoperatively. Typically, there is a significant amount of cortical shell without any cancellous bone.      After removing the implant, one should debride the bone margins of the proximal phalanx and metatarsal head until seeing bleeding cancellous bone. I am more likely to use multiple crossing K-wires for fixation versus screws. In many of these patients, however, a pan metatarsal head resection may be the only good option to restore the foot to a functional, pain-free state.

Conservative Care For Foot And Ankle Trauma: What You Should Know

     I have had good results with conservative management of foot and ankle trauma in the geriatric patient. Fractures of the metatarsals, calcaneus and fibula all heal well without surgery (assuming there is no gross displacement or dislocation). Light touch ambulation with a fracture walker and crutches/walker is generally adequate. Serial radiographs are important in the initial post-op weeks to make sure the fractures are not becoming displaced.      It is important to determine the patient’s activity level and lifestyle when making the decision for the type of treatment. Although one can offer surgical repair to patients as a treatment option, most patients elect conservative management over surgery when given a choice. When surgery is indicated, these patients generally do very well. Just think of how many hip fractures are repaired each year in older patients.

In Conclusion

     Forefoot reconstruction is in great demand for active geriatric patients. Generally speaking, patients well into their 80s tolerate foot surgery very well. In fact, most geriatric patients are compliant with the treatment plan and have very little postoperative pain.      It is paramount to complete all preoperative testing and obtain necessary consultations. As with all of our patients, regardless of age, it is crucial to have a thorough understanding of the surgical procedure(s), postoperative requirements and expected outcome. As long as one takes appropriate precautions, especially for vascularity, perioperative medical management and postoperative ADL, geriatric foot surgery can be successful and quite rewarding. Dr. Fishco is board-certified in foot surgery and reconstructive rearfoot and ankle surgery by the American Board of Podiatric Surgery. He is in private practice in Phoenix. He is also a faculty member of the Podiatry Institute. For related articles, see “How To Manage Surgical Pain In Elderly Patients” in the July 2005 issue of Podiatry Today, “How To Treat Severe Bunions” in the August 2005 issue or “How To Handle Complications Of Hammertoe Surgery” in the September 2005 issue. Also be sure to visit the archives at www.podiatrytoday.com.
 

References:

CE Exam #146 Choose the single best response to each question listed below. 1) Which of the following statements is false? a) According to the author, patients in their 70s do very well with Keller arthroplasties even if there is some degree of osteopenia. b) The author reserves arthroplasty procedures for sedentary geriatric patients who have a low demand for foot function. c) When it comes to active geriatric patients, the author is concerned that an arthroplasty may cause a metatarsal stress fracture. d) None of the above 2) When performing osteotomies and fusions in the geriatric patient, one must consider which of the following precautions? a) A guarded postoperative protocol b) Internal fixation c) Osteotomy location d) All of the above 3) In regard to geriatric patients who have been medically cleared for surgery, which of the following statements is true about vascular status? a) The lack of an easily palpable arterial pulse is not a significant deterrent to surgery. b) If non-invasive Doppler studies are significantly suboptimal, one should refer the patient to a vascular surgeon. c) In the case of non-elective procedures such as incision and drainage or resection of bone for osteomyelitis, geriatric patients often require an arterial bypass procedure prior to the podiatric surgery. d) All of the above 4) Which of the following can be an inherent problem with forefoot surgery for geriatric patients? a) A lack of adequate fat pad b) Thin and atrophic skin c) Refusal to wear adequate shoe gear d) All of the above 5) Which of the following procedures is difficult to perform in the anticoagulated patient? a) Nail surgery b) Neuroma excision c) Pan metatarsal head resection d) All of the above 6) When it comes to patients with a low to moderate risk of an embolic event … a) … one should give subcutaneous heparin (a mini-dose of 3,000 units every 12 hours) and discontinue coumadin. b) … one should discontinue coumadin the day before surgery and resume coumadin after surgery to achieve the appropriate protime level. c) … it is acceptable to discontinue coumadin three to five days prior to surgery, administer a mini-dose of heparin in pre-op holding and then administer coumadin postoperatively. d) None of the above 7) According to the author, a fifth metatarsal head resection … a) … is commonly performed in young, active patients b) … is ideal for an active geriatric patient with a painful tailor’s bunion c) … is ideal for an inactive geriatric patient who has chronic pain and/or a callus under the fifth metatarsal head d) None of the above 8) In regard to addressing failed first MPJ implants in geriatric patients … a) ... the author frequently opts for an autogenous iliac bone graft to augment a first MPJ arthrodesis. b) ... the author will either remove and replace the implant, or remove the implant, leave it as a joint resection and use a K-wire across the arthroplasty site for six weeks. c) ... one can usually perform a fusion after implant removal in most cases regardless of bone quality. d) None of the above 9) According to the author’s experience with conservative management of foot and ankle trauma in the geriatric patient, which of the following fractures heal well without surgery? a) Metatarsal fractures b) Calcaneus fractures c) Fibula fractures d) All of the above Instructions for Submitting Exams Fill out the enclosed card that appears on the following page or fax the form to the NACCME at (610) 560-0502. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam. Responses will be accepted up to 12 months from the publication date.