A Guide To Foot Surgery For The Geriatric Patient

Start Page: 76

CE Exam #146 — October 2006

I am pleased to introduce the latest article, “A Guide To Foot Surgery For The Geriatric Patient,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

While there may have been a general reluctance in the past to perform podiatric surgical procedures on older patients, geriatric patients are living longer and more active lives. Accordingly, William Fishco, DPM, discusses key considerations and precautions for ensuring optimal surgical outcomes in geriatric patients.

At the end of this article, you’ll find a nine-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 77 and successfully answering the questions on pg. 82. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Fishco has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
GRADING: Answers to the CE exam will be graded by NACCME. 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.
TARGET AUDIENCE: Podiatrists
RELEASE DATE: October 2006
EXPIRATION DATE: October 31, 2007
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss key precautions one should take when performing metatarsal osteotomies in geriatric patients;
• list potential considerations in the patient history when evaluating the surgical candidacy of geriatric patients;
• review keys to assessing the vascular status of geriatric patients;
• discuss appropriate pre-op and post-op drug administration and cessation in geriatric patients at risk for embolic events;
• describe how to resolve failed first MPJ implants in geriatric patients;
• review conservative care principles in managing foot and ankle trauma in geriatric patients.

Sponsored by the North American Center for Continuing Medical Education.

Older patients are more likely to have had foot surgeries causing iatrogenic deformities (as one can see above) that have had two or three decades to develop or become worse.
As one can see here, geriatric patients may sometimes have implanted hardware that may be difficult to remove if the instrumentation is not readily available.
In the case of a severely dislocated second metatarsophalangeal joint, the author notes that a proximal phalangeal base resection is often needed to relocate the toe. After performing an arthroplasty, he suggests using a K-wire (as shown above).
When older, sedentary patients have an ulceration or corn on the dorsal toe and/or cannot wear a shoe, the author will perform an arthroplasty in certain cases.
When older, sedentary patients have an ulceration or corn on the dorsal toe and/or cannot wear a shoe, the author will perform an arthroplasty in certain cases.
After removing a failed first MPJ implant, one should debride the bone margins of the proximal phalanx and metatarsal head until one encounters bleeding, cancellous bone. The author is more likely to use multiple crossing K-wires for fixation versus screw
After removing a failed first MPJ implant, one should debride the bone margins of the proximal phalanx and metatarsal head until one encounters bleeding, cancellous bone. The author is more likely to use multiple crossing K-wires for fixation versus screw
After removing a failed first MPJ implant, one should debride the bone margins of the proximal phalanx and metatarsal head until one encounters bleeding, cancellous bone. The author is more likely to use multiple crossing K-wires for fixation versus screw
In this AP view, one can see metatarsal neck fractures of the third, fourth and fifth metatarsals.
This oblique view depicts metatarsal neck fractures of the third, fourth and fifth metatarsals.
82
Author(s): 
By William D. Fishco, DPM, FACFAS

     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.

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