Foot and Ankle Surgery: Considerations for the Geriatric Patient

Daniel K. Lee; Gerit D. Mulder

Disclosures

J Am Board Fam Med. 2009;22(3):316-324. 

In This Article

Abstract and Introduction

Abstract

The growing number of lower-extremity abnormalities that are seen in inpatient and outpatient settings has paralleled the increased number of elderly in the population. Foot and ankle deformities, disorders, and arthritis, which are not manifested until late in life, have become more common as more individuals attain longer lifespans. Although conservative therapies are a priority when addressing the geriatric population, surgical options may be overlooked secondary to a misunderstanding of their ability to overcome perioperative management. Advanced minimally invasive surgical procedures for the foot and ankle have decreased the complications associated with foot surgery, making surgical intervention a viable option for many of the elderly. The newer procedures do not, however, minimize strict perioperative management, including pharmacological and nutritional assessment, and cardiopulmonary precautions. Outpatient surgical intervention may effectively address many ongoing problems associated with pain, decreased ambulation, and decreased quality of life. Current techniques in joint reconstruction in the forefoot and midfoot allow weight bearing from the day of surgery. Most hindfoot and ankle surgeries now permit minimal bone resection and incision through arthroscopy, resulting in improved muscle and tendon repair and early weight bearing. The changes in surgical approaches for the geriatric foot have permitted more effective and rapid intervention in problems affecting ambulation and quality of life in our aged population.

Introduction

Patients over the age of 65 are the fastest growing segment of the population; this population numbers more than 30 million people (>12.5% of the population).[1–3] Increased life spans have been promoted by advances in medicine, science, and healthy lifestyles. Promotion of physical activity and ongoing exercise among the elderly has resulted in these individuals being stronger and healthier than previous generations. Increased activity and increased lifespan both contribute to the development of extensive lower extremity problems, including degeneration of bone and joints. Ligaments, tendons, and muscles are more easily damaged or injured, and the lower extremity, foot, and ankle have been specially affected.[4] Once injuries or physical changes occur and impact quality of life, the question arises as to whether a conservative versus a surgical approach is in the patient's best interest. Numerous factors—including but not limited to medical history, physical and mental condition, and ambulatory status—must be considered because age alone is not a direct contraindication for surgical correction of foot and ankle deformities.

Advances in medicine and surgery are providing more low-risk and sophisticated treatment options that have not been previously available. Latest advances in surgical techniques and a better understanding of biomechanics have allowed us to perform surgery in the geriatric patient with functional results equivalent to those found among younger patients.[5,6] Figure 1 illustrates successful surgical results of a boney deformity attributed to progressive arthritic changes in the foot. In the absence of any significant contraindications, a forefoot correctional procedure was performed, which decreased patient pain and allowed for improved quality of life.

Figure 1.

Forefoot arthritis. Preoperative (A) and postoperative (B) clinical views after first metatarsophalangeal joint and digital reconstruction.

Surgery in the geriatric patient had been avoided because it was associated with high morbidity and mortality rates related to surgical procedures and general anesthesia. Currently more than 20% of all surgical admissions in the United States are geriatric patients.[7–9] The recent medical literature suggests that there were neither increased complications or deaths with the use of general and local anesthesia in the geriatric patient compared with previously known data.[8,10,11] The medical literature suggests that the severity of the disease or illness is a better indicator or predictor of surgical and anesthesia outcome versus the patient's chronological age.[12,13] The following is a review of considerations that may assist with referral of the geriatric patient for possible lower extremity surgery.

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