Foot and Ankle Surgery: Considerations for the Geriatric Patient

Daniel K. Lee; Gerit D. Mulder


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

In This Article

Surgical Options for Eligible Candidates

Simple surgical procedures with local anesthesia may provide dramatic relief, permitting normal ambulation and resumption of daily activities while prolonging the length and quality of life. Selection of the most appropriate surgical procedure is paramount to the successful outcome of the surgery. Selection of the specific surgical procedure is based on the patient's health, the location of the problem, the level of severity/deformity, the need for single or multiple staged procedures, the length of rehabilitation, and postoperative course. New advanced procedures allow early weight-bearing and minimal to no use of any non-weight-bearing casts.[22] It is not our purpose to describe here the detailed surgical technique of the procedures that will be mentioned; however, a definition of the more common procedures described is given in Table 1.

Osteoarthritis and boney deformity are frequent findings in the forefoot and midfoot of the elderly.[38] The etiology can be multifactorial and include muscle imbalance, flat footedness, and trauma. Severity of deformities may be more pronounced with rheumatoid arthritis and other systemic arthritic conditions. Patients typically complain of pain and disability causing difficulty in ambulation, primarily with forefoot loading and propulsion phases of gait, as well as pain with shoe wear at the forefoot or distally from the midfoot. Corns and callouses are findings that may reflect an underlying osseous deformity.

Forefoot Procedures

The most common forefoot deforming arthritic conditions include hammertoes, hallux valgus ("medial bunion"), hallux rigidus ("dorsal bunion"), metatarsophalangeal joint derangement, metatarsalgia, first ray hypermobility and instability, tailor's bunion (fifth metatarsal bunion), and posttraumatic arthritis and deformity (Lisfranc injury, fractures of the phalanx, metatarsal, cuneiforms, cuboid, navicular, and Charcot foot). Figures 2, 3, and 4 These deformities are primarily addressed with less complicated osteotomies and minor bone excision.

Figure 2.

Hallux valgus. Note the severe contractures and deviations in the forefoot.

Figure 3.

Tailor's bunionette. Note the angular osseous malalignment of the 5th metatarsal.

Figure 4.

Diabetic Charcot deformity. Note the osseous destruction and collapse in the midfoot preoperatively (A) and the postoperative view of the reconstruction (B).

These procedures are usually performed under intravenous sedation (monitored anesthesia care) with regional local blocks (marcaine/lidocaine) in an outpatient setting[39,40] (Figure 5). Most patients are treated with a postoperative weight-bearing shoe or a temporary non-weight-bearing splint, which is eventually switched to a walking boot. Patients with gait instability may prefer a walker or Roll-A-Bout device (Roll-A-Bout Corporation, Frederica, DE; Figure 6) because they provide 3-point walking stability over the traditional cane or crutches.

Figure 5.

Regional blocks: (A) ankle and (B) popliteal.

Figure 6.

Non-weight bearing assistance devices as alternatives to traditional crutches and walkers.

Digital procedures including arthroplasties or arthrodeses correct multiplanar deformities of the proximal and distal interphalangeal joints. These corrections allow proper alignment of digits and the removal of painful joint surfaces for ease of shoe wear and prevention of arthritic ulcerations.

Midfoot Procedures

Procedures at the first metatarsophalangeal joints are divided into cheilectomy, osteotomy, implant arthroplasty, and arthrodesis.[41] They are either joint-sparing or joint-replacing procedures. Joint-sparing procedures (cheilectomy, osteotomy) have an excellent outcome in the presence of end-stage arthritis. Increased deformities have had better outcomes with joint-replacing procedures (implant arthroplasty and arthrodesis). Metatarsophalangeal joint resections and Keller-type procedures are usually reserved for end-stage conditions in which ambulation and flexibility are not a concern. Instability and posttraumatic arthritis in the tarsometatarsal joints require bone resection, which is the simplest approach, or arthrodesis to eliminate the source of pain and provide stability. Although bone resection does not require the use of fixation devices, arthrodesis requires joint preparation and fixation. These particular joints are not essential for gait. Their range of motion is minimal compared with the essential joints of the ankle, subtalar, midtarsal, and first metatarsophalangeal joints.

The fusion of tarsometatarsal joints provides significant pain relief and stability to the midfoot in stance and gait. With the introduction of external fixation they may now be used in combination with internal fixation for further added stability of these bone segments, allowing the patient to perform protected partial to full ambulation postoperatively, which previously required 4 to 8 weeks of non-weight-bearing immobilization.

Hindfoot Procedures

At the hindfoot and ankle levels, arthritis, deformity, and muscle imbalance can be common in the geriatric patient. Similar to the forefoot and midfoot, the causes can also be multifactorial and result from osteoarthritis or stroke. The arthritic events affecting the forefoot and midfoot can also affect the hindfoot and ankle. The ankle, subtalar, and midtarsal (talonavicular and calcaneocuboid) joints can be affected in isolation or combination. These joints are very complex and multiplanar in range of motion. Their 3-dimensional joint motion leads to a combination of arthritic events with joint crepitus at multiple levels. Neuromuscular conditions can affect the distal extrinsic muscles in the lower extremity leading to muscle imbalance, weakness, spasticity, and contractures.

The most common conditions include ankle arthritis, ankle valgum/varum deformity, drop foot, equinus, Achilles partial/full rupture, posterior tibial tendon dysfunction/insufficiency, subtalar arthritis, subtalar valgum/varum deformity, midtarsal joint arthritis, collapsed hindfoot complex, posttraumatic joints, and nonunion/malunion conditions. Typically patients with these conditions complain of pain around the heel and/or ankle. Disability is associated with difficulty standing and/or walking for long distances. It is not uncommon for muscle weakness and imbalance go unnoticed by the patient (Figure 7) During examination the clinician can determine the level of arthritis, misalignment, and deformity through muscle testing and evaluation of range of motion and gait.

Figure 7.

Chronic Achilles tendon rupture. Note (A) the clinical view of the interrupted integrity of the Achilles tendon; (B) T2-weighted images of the ruptured Achilles tendon; (C) intraoperative view of the ruptured Achilles tendon; and (D) Achilles tendon reconstruction with graft.

The goals for geriatric hindfoot and ankle surgery are focused on achieving a plantigrade foot, allowing full ground contact, ambulation with a brace, and elimination of the need for a brace.[38] Most of these procedures can now be performed under intravenous sedation (monitored anesthesia care) with regional popliteal, sciatic, or femoral local blocks in an outpatient setting. Unlike forefoot and midfoot procedures, most patients are protected with a temporary non-weight-bearing splint, which is then switched to a short-leg partial-walking cast after 2 to 4 weeks, and then to a full-walking cast during the following 3 to 4 weeks. In selected patients, an Ilizarov external fixation may be applied; this can allow postoperative weight bearing beginning in the first 1 to 2 weeks with a walking aid. Patients undergoing an Ilizarov procedure must be selected with special caution because strict compliance is needed (Figure 8). The daily postoperative care for these more complicated procedures are best addressed in a rehabilitative or skilled nursing facility.

Figure 8.

Severe ankle osteoarthritis. Note the Ilizarov external fixation for earlier postoperative weight-bearing tolerance.

Arthrodesis of the ankle and subtalar joints is still the gold standard in the treatment of end-stage arthritis (Figure 9). Although joint replacements that provide increased range of motion and flexibility are treatment options, the intermediate and short-term results are not as satisfactory and have higher complication rates compared with knee and hip joint replacements (Figure 10). Until this technology improves, extra-articular arthrodesis and joint resection with synovectomy and debridement are better options for geriatric patients. Isolated midtarsal joints arthrodesis reduces pain and disability as well as total range of motion of the subtalar joint. These procedures can proceed with early weight bearing compared with ankle and subtalar joint arthrodesis. There are currently no replacements available for these joints. Osteotomies in the ankle and hindfoot are viable extra-articular procedures, which preserve joints and provide realignment of the structures.

Figure 9.

Subtalar joint arthritis. A postoperative view after isolated subtalar joint arthrodesis.

Figure 10.

Ankle arthritis. A postoperative view of total ankle replacement. Note the complete bipolar components for the tibiotalar joint.

Tendinopathies associated the Achilles and posterior tibial tendon are the most frequently performed procedures. Although rupture repairs of the Achilles tendon is normally performed in isolation, repairs of the posterior tibial tendon in isolation without bone correction or realignment do not provide enough stability to hold the correction. Because most posterior tibial tendon conditions occur with progressive pes plano valgus and flatfoot deformity, the correction of bone pathology has priority over the tendon repair. Drop foot requires evaluation of in-phase and out-phase muscles because tendon transfer techniques can prevent ankle arthrodesis.[42,43]

Well-designed and well-controlled clinical trials among the geriatric population are still needed to validate the improvement in reported clinical outcomes and to assist the primary care provider in giving a more accurate description of outcome expectations to the patient. Advantages, disadvantages, benefits, risks, and time to recovery need to be clearly covered by the surgeon, although it is helpful for the primary care physician to inform the patient of options for which a educational visit and consult with the surgeon may be made. We strongly believe that the geriatric patient who is asymptomatic, able to ambulate without significant difficulty, and who is not in a limb threatening situation should not undergo a surgical procedure simply for cosmetic purposes. The primary care physician must carefully screen and the patient's current medical situation and medical and social history to determine whether surgical intervention should be considered. Patients, regardless of age, commonly anticipate that a surgical procedure will create an "anatomically normal," fully functional, and completely pain-free foot. Surgical procedures are meant to address problematic foot problems, improve ambulation, and to decrease pain. Patients may need to be educated postoperatively about ongoing, albeit decreased, pain, the need for special shoes, and limitations to daily activities. Patients will appreciate an honest and straightforward explanation of what to expect.

Currently, well-powered and controlled trials are not available to provide evidence-based and statistically significant data about the new and advanced surgeries that result in less pain, decreased recovery time, and improved function scores. The aforementioned lack of studies highlights the need for determining the correlation between perioperative medical management and treatment outcomes, as well as any relationship between newer techniques and surgeries on the elderly and common postoperative complications such as the incidence of deep venous thrombosis/pulmonary embolism (PE), postoperative pneumonia, or postoperative injuries (falls). The rise in numbers of senior patients and the parallel increase in surgeries performed on this population justify the need for such studies to be performed in the near future.