A Guide To Foot Surgery For The Geriatric Patient

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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