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

Surgical Considerations

Nutrition

Foot and ankle deformities, disorders, and arthritis may remain asymptomatic for years before becoming fixed, rigid, and painful among the aged population.[11] They are common in the geriatric patient and may lead to loss of lower extremity mobility and function, which in turn may contribute to deterioration of the cardiovascular system, a rapid decline in health, and a reduced life span. The musculoskeletal system undergoes significant change during the aging process as osteoarthritis and osteoporosis develop and progress, especially in women after menopause. Bone loses rigidity and strength and becomes more brittle. Joints and surrounding soft tissue become weak and less flexible with aging.[14,15] It is important to consider pharmacological and nutritional management pre- and postoperatively to enhance bone quality and healing.[16–19] Maintaining adequate protein levels as well as appropriate dietary supplementation may assist the healing process in patients considered nutritionally compromised. Patient's protein levels need to be assessed, along with a review of the patient's dietary habits. Special considerations need to be given to obese patients because obesity may be an indicator of poor nutritional status. Obesity also places excessive stress on the lower extremity and may contribute to poor healing and surgical outcomes. Laboratory tests recommended for determining to nutritional status include patient's body mass index (BMI; weight in kilograms/height in meters [BMI < 17 kg/m2 is associated with protein–energy undernutrition]); serum albumin (<3.5 mg/dL is a simple indicator of possible malnutrition); serum levels of vitamins A, B1, B12, C, D, E, iron, folic acid, zinc, and magnesium; serum creatinine levels; total urine nitrogen; complete blood count; comprehensive metabolic panel; liver function test; and lipid panel.

Preoperative Medical History

Preexisting medical conditions are of as much concern as nutritional status. Medications affecting cellular function and fibroblast activity are known to delay the closure process. It is not uncommon for elderly patients to be taking high levels of nonsteroidal - medications or possibly even steroidal medications for indications, including various arthritic or vasculitic conditions. A history of a previous deep venous thrombosis is important to determine because the risk of a postoperative deep venous thrombosis is increased if the patient has had one previously. Age, sedentary lifestyle, history of previous lower extremity trauma, hypercoagulability, and even family history of deep venous thrombosis are reasons for anticoagulant prophylaxis. Prophylaxis is a further consideration for patients who are expected to remain in bed for >48 hours or whose ambulation will be limited after discharge. Patients with a short hospital stay (<48 hours) and immediate ambulation still require the use of a compression device during the admission period to decrease risk of clot formation. There have been studies to evaluate these guidelines, but the incidence of venous thromboembolism after foot and ankle surgery has been rare (<1%) and the need for routine propylaxis postoperatively is not supported by any high level of evidence studies.[20–22]

Preoperative Examination

Planning for surgery in the geriatric patient involves all the requirements and criteria of the adult patient with special emphasis on preoperative cardiopulmonary precautions, appropriate surgical procedure selection, and proper postoperative management to maximize bone healing.[23] The surgeon should consider obtaining medical clearance for the planned procedure from the patient's primary care physician and cardiologist.

Indications of surgery in the medically cleared patient include the failure of previously attempted conservative management and pain, deformity, and/or functional disability that significantly impairs quality of life. When conservative management provides satisfactory results, surgery should not be encouraged. Postoperative compliance and a suitable postoperative living environment are additional preoperative considerations. Selected patients may require postoperative home care and physical therapy or short-term placement in a rehabilitative or skilled nursing facility. Preoperative considerations include the ability of the planned procedure to address pain, correct deformities, and to restore function, allowing patients to resume their activities of daily living and improve their quality of life.

Preoperatively, patients will require clinical, biomechanical, radiographic, social, and psychological evaluation and preparation. It is imperative to have a thorough discussion of the diagnosis, surgical treatment options, and prognosis with the patient and family involved. Patients may have unrealistic expectations about surgical procedures and may make the assumption that a normal "youthful" lower extremity will result from the intervention. Advantages and disadvantages of the procedure, expected levels of function and pain, level of postoperative care, and anticipated affect on ambulation require clear explanations and realistic expectations before obtaining a signature on an informed consent. Conservative options should have been tried and failed before surgical intervention.

Before scheduling procedures, it is imperative to obtain a medical clearance from the patient's geriatric physician. This is recommended to ascertain the cardiovascular and pulmonary status and risks of perioperative myocardial events, even among healthy geriatric patients.[12,24–27] Cardiovascular and pulmonary status are directly related to the rates of morbidity and mortality, and they can pose greater risks and complication when they are not managed properly.[7,28–30] Functional assessments using activities of daily living scales can predict perioperative rehabilitation requirements based on observations of their functions and multiple customary activity assessment.[31–33] The American Society of Anesthesiologists criteria are also useful guides in the surgical risk assessment and perioperative management of the geriatric patient.[8,11,34] When there is doubt concerning the patient's ability to tolerate a procedure, it is wise to choose the conservative option.

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