Foot and Ankle Surgery: Considerations for the
Daniel K. Lee, DPM, and Gerit D. Mulder, DPM, MS
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, disor-
ders, and arthritis, which are not manifested until late in life, have become more common as more indi-
viduals attain longer lifespans. Although conservative therapies are a priority when addressing the geri-
atric 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 perioper-
ative management, including pharmacological and nutritional assessment, and cardiopulmonary precau-
tions. 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 surger-
ies 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. (J Am Board Fam Med 2009;22:316–24.)
Patients over the age of 65 are the fastest growing
segment of the population; this population num-
bers more than 30 million people (?12.5% of the
population).1–3Increased life spans have been pro-
moted by advances in medicine, science, and
healthy lifestyles. Promotion of physical activity
and ongoing exercise among the elderly has re-
sulted in these individuals being stronger and
healthier than previous generations. Increased ac-
tivity and increased lifespan both contribute to the
development of extensive lower extremity prob-
lems, 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.4Once inju-
ries 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 lim-
ited to medical history, physical and mental condi-
tion, and ambulatory status—must be considered
because age alone is not a direct contraindication
for surgical correction of foot and ankle deformi-
Advances in medicine and surgery are providing
more low-risk and sophisticated treatment options
that have not been previously available. Latest ad-
ing of biomechanics have allowed us to perform sur-
gery 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 al-
lowed for improved quality of life.
This article was externally peer reviewed.
Submitted 8 June 2008; revised 20 October 2008; accepted
3 November 2008.
From the Department of Orthopaedic Surgery (DKL) and
the Wound Treatment and Research Center and the De-
partment of Surgery, Division of Trauma (GDM), Univer-
sity of California, San Diego.
Conflict of interest: none declared.
Corresponding author: Daniel K. Lee, DPM, Assistant
Clinical Professor, Department of Orthopaedic Surgery,
University of California, 350 Dickinson Street, MC8894,
San Diego, CA 92103-8894 (E-mail: firstname.lastname@example.org).
May–June 2009Vol. 22 No. 3 http://www.jabfm.org
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 geriat-
ric patients.7–9The recent medical literature sug-
gests that there were neither increased complica-
tions or deaths with the use of general and local
anesthesia in the geriatric patient compared with
previously known data.8,10,11The medical litera-
ture suggests that the severity of the disease or
illness is a better indicator or predictor of surgical
and anesthesia outcome versus the patient’s chro-
nological age.12,13The following is a review of
considerations that may assist with referral of the
geriatric patient for possible lower extremity sur-
Foot and ankle deformities, disorders, and arthritis
may remain asymptomatic for years before becom-
ing fixed, rigid, and painful among the aged popu-
lation.11They are common in the geriatric patient
and may lead to loss of lower extremity mobility
and function, which in turn may contribute to de-
terioration of the cardiovascular system, a rapid
decline in health, and a reduced life span. The
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 sur-
rounding soft tissue become weak and less flexible
with aging.14,15It is important to consider pharma-
cological and nutritional management pre- and
postoperatively to enhance bone quality and heal-
ing.16–19Maintaining 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 de-
termining to nutritional status include patient’s
body mass index (BMI; weight in kilograms/height
in meters [BMI ? 17 kg/m2is associated with
protein–energy undernutrition]); serum albumin
(?3.5 mg/dL is a simple indicator of possible mal-
nutrition); 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 con-
cern as nutritional status. Medications affecting cel-
lular function and fibroblast activity are known to
delay the closure process. It is not uncommon for
elderly patients to be taking high levels of nonste-
roidal - medications or possibly even steroidal med-
ications 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 pre-
vious lower extremity trauma, hypercoagulability,
and even family history of deep venous thrombosis
are reasons for anticoagulant prophylaxis. Prophy-
laxis 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 imme-
diate ambulation still require the use of a compres-
sion device during the admission period to decrease
risk of clot formation. There have been studies to
evaluate these guidelines, but the incidence of ve-
nous thromboembolism after foot and ankle sur-
gery has been rare (?1%) and the need for routine
Figure 1. Forefoot arthritis. Preoperative (A) and
postoperative (B) clinical views after first
metatarsophalangeal joint and digital reconstruction.
doi: 10.3122/jabfm.2009.03.080122Foot and Ankle Surgery for the Geriatric Patient317
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