Does Patient Age Influence First Ray Procedure Selection?
For those aforementioned reasons, it is our opinion that the Lapidus bunionectomy is the procedure of choice for adolescent HAV in the presence of characteristics such as a higher intermetatarsal angle (greater than 14 degrees), hypermobility and an elongated first metatarsal. Given the presence of the open growth plate in the surgical site, we recommend allowing closure of the growth plate prior to surgical intervention. Proceeding in this manner ensures that one will perform the appropriate procedure for a durable correction with minimal complications.
Choosing A Procedure For Hallux Abducto Valgus In The Elderly
While surgical design for adolescent patients is influenced by hallmarks of development as well as cosmetic concern, surgical planning of hallux abducto valgus in adult or elderly populations differs depending on factors including recovery, home support and the goals of the procedure.
As a person ages and matures, drifting and contraction of soft tissues lead to an increased deformity. One can appreciate this in cases with overlapping second digits as well as intermetatarsal angles that have continually worsened over time with conservative care. Time not only influences the severity of the defect but bone density and other age-related arthritic conditions alter surgical options. With diminished bone quality, surgery utilizing plates, implants or grafts can cause an increased risk of negative outcomes such as nonunion, delayed union or failure of implants.
Finally, it is well documented that increasing age is an independent risk factor for postoperative complications such as pulmonary edema, heart attack, abnormal heart rhythms, bacterial pneumonia, respiratory failure and in-hospital mortality.10 As a result, it may be tempting to discourage surgical intervention in the elderly patient with HAV deformity.
However, this line of reasoning may unfairly and unnecessarily discount the benefits of surgical intervention in this group of patients. The Agency for Healthcare Research and Quality (AHRQ) evaluated the benefits of total knee replacement in its Patient Outcomes Research Team Reports.11 The report cited statistics that despite the risk of complications, quality of life improves for the elderly after knee replacement surgery.
We can extrapolate the findings of this report to HAV surgery and infer that improved function and reduction of pain symptoms following surgery may be worthwhile goals to attain in this specific patient population.
Another consideration to take into account when evaluating the elderly patient is the concept of chronologic versus physiologic age. Chronological age is simply age based on the year of birth. In contrast, physiologic age acknowledges the overall health of the individual and is based on function.
Miller and colleagues attempted to stratify HAV procedure recommendations based on age and severity of deformity.12 In elderly patients (defined as being over the age of 55) with minimal deformity, the authors recommended a Silver procedure and a Keller bunionectomy for more severe deformities. In patients under the age of 55, they recommended a Mitchell procedure.
While the authors’ recommendations are a good starting point, most surgeons would likely agree that hard age end points do not adequately take into account physiologic age or the individual goals of surgery. Not all patients over the age of 55 are likely to accept the apropulsive gait that ensues following a Keller procedure.
This highlights the need to accurately assess the patient's goals of the procedure when considering surgical options. Metatarsal head procedures have good results in populations that are relatively healthy and active. Joint destructive procedures such as fusions for more severe HAV cases or older patients also tend to have good results with a faster return to functionality and activity.