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Forefoot Surgery in Elderly Compared With Younger Patient Populations: Complications and Type of Procedure
The Journal of Foot & Ankle Surgery 54 (2015) 586–590
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Forefoot Surgery in Elderly Compared With Younger Patient Populations: Complications and Type of Procedure Thibault Vermersch, MD 1, Michel Henri Fessy, MD, PhD 1, 2, Jean-Luc Besse, MD, PhD 1, 2 1 2
Service de Chirurgie Orthop edique et Traumatologique, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-B enite, France Universit e Lyon 1, IFSTTAR, LBMC UMRT-9406, Laboratoire de Biom ecanique et M ecanique des Chocs, Bron, France
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 3
In forefoot surgery, the presenting complaints and expected benefits differ between elderly and younger patients. The present study mapped forefoot procedures recommended to elderly patients compared with those recommended to the general population and assessed the complications according to age group and comorbidity. Consecutive patients were included in a single-center, continuous, retrospective case-control study. Three age groups were defined: <65 years, 65 to 74 years, and 75 years. All patients, regardless of age, underwent the same procedure; elderly-specific techniques such as the Keller procedure were not used. A total of 321 patients were included, with a mean age of 60.6 (range 16 to 86) years. A similar procedure was used in all 3 groups, but at differing frequencies, with arthrodesis and minor procedures increasing with increasing patient age. In all 3 groups, in the population as a whole, the incidence of delayed healing, deep infection, and nonunion was 9%, 1%, and 2%, respectively. These complications were independent of age group. In the <65-year-old group, just as in the study population as a whole, arthrodesis associated with resection arthroplasty resulted in greater rates of delayed healing and deep infection. The complications rates were equivalent among the 3 age groups. Major surgical procedures should be avoided in elderly patients, if possible. However, no particular procedure is contraindicated in the elderly, although the method of fixation must be robust owing to the frequency of osteoporosis. A first step would be to achieve consensus on the age threshold for “elderliness.” Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: age comorbidity complication elderliness fixation forefoot surgery osteoporosis
Forefoot surgery is the most frequent of all foot and ankle procedures (1). It concerns a broad population, peaking in females in their 50s (1). Few studies, however, have focused on forefoot surgery in the elderly. Management in this population was classically palliative, such as resection arthroplasty or arthrodesis. Some investigators have advised against surgery (2). Despite the obvious aging of the general population, few patients have complained of real difficulties caused by forefoot deformities, especially regarding function and gait (3). Elderly patients’ complaints and expectations differ from those of younger subjects (4), which might suggest a difference in procedures to be envisaged for the elderly or at least adapting the indications. For this, the concept of “elderly patient” needs to be defined, and no consensus has been reached in published studies (4–6). The present
Financial Disclosure: Jean-Luc Besse is a consultant for Biotech International. Conflict of Interest: None reported. Address correspondence to: Thibault Vermersch, MD, PhD, Department of nite CEDEX Orthopedic and Traumatologic Surgery, Lyon-Sud Hospital, 69495 Pierre-Be France. E-mail address: [email protected] (T. Vermersch).
study mapped the forefoot procedures implemented in elderly patients compared with the general population and assessed the complications according to age group and comorbidity. Materials and Methods Three age groups were defined in accordance with standard French practice: Group 1: Adult (<65 years) Group 2: Young elderly (65 to 74 years) Group 3: Old elderly (75 years)
Inclusion A single-center, continuous, retrospective case-control study consecutively included patients treated from January 1, 2010 to December 31, 2011. The follow-up period ranged from 12 to 24 months. All patients were treated by a single senior surgeon. The inclusion criteria were forefoot pathologic features managed surgically (including first-ray surgery for hallux valgus, hallux varus or hallux rigidus, and lateral ray surgery for quintus varus, metatarsalgia, or claw toe) and all surgery for rheumatoid arthritis because of the frequency of this etiology in forefoot surgery. The exclusion criteria were nonoperative management, pathologic features related to diabetic foot,
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.10.010
T. Vermersch et al. / The Journal of Foot & Ankle Surgery 54 (2015) 586–590
Table 1 General patient data stratified by age group Variable
Group 1 (<65 y; n ¼ 192)
Group 2 (65 to 75 y; n ¼ 99)
587
Table 3 Procedure types stratified by age group Group 3 (>75 y; n ¼ 30)
Total (n ¼ 321)
Mean age (y) 53.6 (16 to 64) 69 (65 to 75) 79 (76 to 86) 60.6 (16 to 86) Surgical revision 5 8 17 7 Diabetes 3 5 3 3 Osteoporosis 8 21 20 13 Pulmonary pathologic 9 11 10 9 features Severe cardiovascular 3 6 13 5 pathologic features Venous pathologic 19 24 40 22 features
Procedure Type Minor surgery (%) First ray (%) M1 and/or P1 osteotomy MTP1 arthrodesis Lateral rays (%) Weil DMMO Alignment resection
Group 1 (<65 y)
Group 2 (65 to 75 y)
Group 3 (>75 y)
All Patients
5
8
20
6
67 29
49 43
20 60
57 36
37 13 8
42 21 8
37 17 0
38 16 7
Abbreviations: DMMO, distal metatarsal mini-invasive osteotomy; MTP1, first metatarsophalangeal.
Data presented as percentages, unless otherwise noted.
and central or peripheral neurologic pathologic findings. Diabetic patients were eligible for inclusion only if they were without signs of associated perforating plantar ulcer.
venous thrombosis; pulmonary embolism was counted as a severe cardiovascular pathologic entity. Osteoporosis was considered only if the patient was receiving ongoing treatment. Since 2011, we have required our patients to stop smoking for 1 month before and 2 months after surgery.
Surgical Technique
Postoperative Complications
The same surgical techniques were used in all patients, regardless of age, with no procedure specific to the elderly subjects. We never performed Keller resection arthroplasty or Swanson implant, which have had a poor reputation in published studies. First ray procedures included scarf metatarsal osteotomy associated with Akin P1 osteotomy (7) (“joint-sparing first ray surgery”) using 2.5-mm screws (PyxisÒ, Biotech International, Worcestor, UK) and P1 staples (Biotech International) or metatarsophalangeal fusion with nonlocking plate fixation (FyxisÒ, Biotech International). Lateral ray procedures included Weil osteotomy of the metatarsal head (8), using 2.5-mm screws (PyxisÒ, Biotech International), or distal metatarsal mini-invasive osteotomy (DMMO) percutaneous osteotomy (9). Isolated minor procedures included interphalangeal arthroplasty or arthrodesis, tendon lengthening or sectioning, metatarsal prosthesis, arthrolysis, and so forth. The procedures were categorized by surgical “heaviness” from the patient’s viewpoint:
Three postoperative complications in particular were analyzed: delayed healing, deep infection, and dismantling of the material. Delayed healing was defined as any wound unhealed at 1 month postoperatively but not requiring antibiotic therapy. Deep infection was defined by clinical signs of forefoot sepsis (eg, redness, edema, effusion) associated with elevated inflammatory protein (C-reactive protein, erythrocyte sedimentation rate) levels. Antibiotic therapy was implemented with or without reintervention for lavage. Nonfusion was defined as unconsolidated osteotomy or arthrodesis at 6 months postoperatively.
Category 1: minor procedure (ie, without first ray involvement; eg, isolated claw toe or 1 lesser ray osteotomy, Morton neuroma) Category 2: moderate surgery (isolated first ray procedure; eg, scarf M1þP1 or first metatarsophalangeal [MTP1] arthrodesis) Category 3: major surgery (first ray procedure associated with second ray, with or without third ray osteotomy; eg, scarf M1þP1 osteotomy plus Weil M2 or M2-M3 or MTP1 arthrodesis plus Weil M2 or M2-M3) Category 4: complex major surgery (“complex foot” with first ray surgery plus second, third, and/or fourth ray osteotomy plus claw toe surgery; eg, scarf M1þP1 plus Weil M2, M3, or M4 or DMMO 2, 3, or 4 or MTP1 arthrodesis plus Weil M2, M3, M4 or DMMO 2, 3, 4 or MTP1 arthrodesis plus M2, M3, M4, or M5 alignment resection plus claw toe)
The data were analyzed using JMP, version 7.0, software (SAS Institute, Cary, NC) and Fisher’s exact test, with a significance threshold of p < .05.
Results A total of 321 patients were included for analysis, with a mean age of 60.6 (range 16 to 86) years. Of the 321 patients, 192 were in group 1 (60%), 99 in group 2 (31%), and 30 in group 3 (9%). General Data and Comorbidity The general patient data and comorbidities are listed in Tables 1 and 2. We found no differences in the type of anesthesia used or tourniquet time among the 3 groups. Procedures
Comorbidity Surgical revision was defined as surgery to a ray previously operated on at our center or elsewhere. Severe cardiovascular pathologic entities were defined as any treated cardiac or vascular pathologic features (other than high blood pressure) requiring regular medical follow-up. Venous pathologic features were defined as a history of varices or deep
Table 2 Perioperative data stratified by age group
Isolated nerve block (%) General anesthesia (%) Spinal anesthesia (%) Tourniquet time (min) Mean SD Range
Statistical Analysis
Group 1 (<65 y; n ¼ 192)
Group 2 (65 to 75 y; n ¼ 99)
Group 3 (>75 y; n ¼ 30)
All Patients (N ¼ 321)
44 34 22
35 44 21
36 47 17
41 38 21
39.2 14.3 10 to 80
41.5 13.8 0 to 70
40.5 15.3 10 to 65
40.0 14.2 0 to 80
Abbreviation: SD, standard deviation.
Significant differences (p < .05) were found in the distribution of the first ray procedures between groups 1 and 3 and groups 2 and 3 (Table 3). Also, twice as many minor procedures were performed in group 2 compared with group 1 and twice as many in group 3 compared with group 2 (p < .05 for both). We have preferred isolated minor procedure for patients >75 years because of balancing the surgery risk (more severe cardiovascular pathologic features; Table 2). In the 3 groups, Weil osteotomy was 2 to 3 times as frequent as DMMO, without a significant difference among the groups. Lateral ray surgery showed no significant differences in procedure according to age group (Table 3). In those undergoing first ray surgery, joint-sparing surgery was twice as frequent as arthrodesis in group 1 and 3 times as frequent in group 3. The 2 procedures were approximately equally frequent in group 2 (Fig. 1). We proposed more arthrodesis for severe hallux valgus in group 3 to avoid recurrence and therefore the potential risk of re-do surgery.
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T. Vermersch et al. / The Journal of Foot & Ankle Surgery 54 (2015) 586–590
Table 5 Postoperative complications stratified by age group Complication
Group 1 (<65 y; n ¼ 192)
Group 2 (65 to 75 y; n ¼ 99)
Group 3 (>75 y; n ¼ 30)
Total (n ¼ 321)
Delayed healing Deep infection Osteosynthesis dismantling Nonconsolidation
10 1 0.5 1
8 (8) 1 (1) 1 (1) 0
6 (2) 0 0 0
9 0.9 0.6 0.6
(19) (2) (1) (2)
(29) (3) (2) (2)
Data presented as % (n).
Fig. 1. First ray procedures by age group: Group 1 (<65 y, n ¼ 192); Group 2 (65–75 y, n ¼ 99); Group 3 (>75 y, n ¼ 30).
In terms of “heaviness,” fewer category 3 or 4 procedures were recorded for group 3 than for group 1, but this difference was not significant (Table 4). Complications Taking all age groups together, the incidence of delayed healing, deep infection, and nonconsolidation was 9%, 1% and 2%, respectively (Table 5). No significant intergroup differences were found. The 3 cases of deep infection secondary to healing disorder were associated with arthrodesis plus alignment resection: 2 in patients with rheumatoid polyarthritis (a 56-year-old and a 69-year-old patients, both presenting with a chronic healing disorder of the transverse dorsal approach), and 1 secondary to 67, grade IV hallux valgus (a 60-year-old patient with delayed healing of a medial approach). The complications were too few for multivariate analysis; thus, the incidence of the different comorbidities could not be correlated with the different age groups. Discussion The only procedure not used in “old elderly” subjects was arthrodesis associated with alignment resection. First ray surgery was more conservative in younger patients. The complications rates were equivalent among the age groups. The strong points of the present study were its continuous design, no loss to follow-up, and exhaustive inclusion of all patients treated by a single senior surgeon. The weak points possibly inducing bias were the retrospective design and the small number of patients in the >75-year-age group. However, no other comparative studies have highlighted the effects of patient age on surgical strategy and complications. It was difficult to set a threshold for elderliness. The published English-language data are sparse, without a consensus found, because the age criteria have varied greatly from study to study. The age limits found in studies concerning “the elderly” are listed in Table 6. The present findings showed a real difference in surgical procedures implemented in age groups 2 and 3, confirming our distinction between the “young elderly” and “old elderly.”
Table 6 Mean age and procedures used in published studies
Table 4 Procedural category stratified by age group Category
Group 1 (<65 y; n ¼ 192)
Group 2 (65 to 75 y; n ¼ 99)
Group 3 (>75 y; n ¼ 30)
1 2 3 4
5 39 35 21
8 26 38 28
20 33 33 14
(Minor surgery) (Moderate surgery (Major surgery) (Complex major surgery)
Data presented as percentages.
According to the published data, hallux valgus or rigidus is elderly patients is managed by arthroplasty using the Keller (10,11) or HueterMayo (12) procedure, with interposition (13) or a Swanson implant (5). These procedures have been considered the easiest and most reliable for first ray pathologic features in elderly subjects (11). Although some investigators have considered metatarsalgia to be less frequent in the elderly (14), resection of the metatarsal head or base of the first phalanx will inevitably lead to sesamoid retraction, impairing metatarsal weightbearing, with a risk of onset or aggravation of medial metatarsalgia (12). It also incurs a risk of insufficient correction of the hallux valgus. In patients who are still active, Marks (15) has recommended, as an alternative to MTP1 arthrodesis, a basal arthroplasty resection procedure, resecting 30% of the dorsal MTP1 surface and conserving the sesamoid complex and plantar plate, in contrast to the Keller procedure. O’Doherty (16), however, found no benefit in terms of first ray or metatarsal pain and recommended the Keller procedure. We consider these to be “old” techniques that have shown their surgical limitations and fail to provide improvement. Thus, we have decided not to use such procedures. The severity of hallux valgus increases considerably in elderly subjects (17). In most series focusing on the elderly, MTP1 fusion (Fig. 2) has been the technique of choice to treat hallux valgus or rigidus (18–20). In 20% of our “old elderly” group, the first ray was managed by joint-sparing surgery, with very good results (Fig. 3). Tollison (21) reported similar findings with associated chevron and Akin osteotomy. Tollison (21) did not consider joint-sparing surgery contraindicated in the elderly (age 55 to 81 years) and reported very good results. For chevron osteotomy, he recommended an intermetatarsal angle of <15 (21). Minor procedures were much more frequently used in the elderly (Fig. 4). Because the demand in terms of results were less exigent, the surgery tended to be as minor as possible. Minor procedures amounted to only 4% in group 1 compared with 20% in group 3 and 8% in group 2. However, these findings could not be compared with the published data, because none is available. No previous studies have focused on complications of forefoot surgery in elderly subjects. In the present series, the rate of deep infection was only 1% compared with 1% to 5% in the published data (22–25). Deep infection was restricted to those patients who had undergone arthrodesis with realignment resection but in context of rheumatoid arthritis or a very severe deformity.
Investigator
Mean Age (range) (y)
Type of Surgery/Radiographic Analysis
Miller et al (5), 1983 Majkowski et al (12), 1992 Tollison et al (6), 1997 Marks (15), 2009 D’Arcangelo (17), 2010 Ozan et al (13), 2010
61.3 66 62 (55 to 81) 72.7 70 (65 to 94) 61 (55 to 71)
Swanson implant Keller arthroplasty resection Chevron plus Akin Oblique basal arthroplasty resection Radiographic analysis of hallux valgus Keller arthroplasty resection
T. Vermersch et al. / The Journal of Foot & Ankle Surgery 54 (2015) 586–590
589
Fig. 2. Radiographs of 78-year-old female with (A) bilateral hallux valgus, treated by (B) arthrodesis on the right side.
Diabetes and surgical revision showed no significant correlation with delayed healing or deep infection. However, the present results for infection, delayed healing, and consolidation defects in group 3 could not be analyzed statistically, because the number of complications was too few and the patient numbers were too low. The rate of osteoporosis was greater in group 3 than in the other age groups, but this was not associated with a greater rate of nonconsolidation. Osteoporosis should not be considered a contraindication for surgery; however, we did use robust internal fixation or fusion, preferring plates rather than Kirschner wires (26). In the case of diabetes, surgery was reserved for well-balanced patients who were free of neuropathy or arteriopathy. Current techniques allow elderly patients to benefit from the same surgical procedures as the general population with no increased morbidity. Even so, we treat our elderly patients as fragile, adapting, not the surgery itself, but the postoperative care, including nutrition, pharmacology, cardiovascular and pulmonary precautions, and anesthesia (27). Particular attention must be given to the elderly patient’s cutaneous status, and dressings should be renewed by, or at least in the presence of, the surgeon. A significant correlation could be demonstrated between delayed healing and
lung disease in group 2. The present study did not include American Society of Anesthesiologists scores; however, it seems clear that they represent an essential factor in guiding surgical decisionmaking. In our own current practice, forefoot management in the very elderly (age group 3) has been primarily medical, with adapted footwear and orthoses. In the case of failure, surgery is not contraindicated and should not be seen as palliative treatment, although isolated minor procedures should be preferred, if possible. Otherwise, first ray arthrodesis is a good option, although jointsparing surgery should not be excluded. For the lateral rays, the findings from the present study could not be used to rate one procedure more highly than another. In conclusion, the forefoot surgical procedures available for elderly patients should be considered the same as those used in younger subjects, with an emphasis on arthrodesis. One can expect complications to be no more frequent than in the general population. Our study was, however, a case-control study. It would be interesting to conduct a prospective study to determine more precisely the role of surgery and the types of surgery that should be adapted to elderly patients. The first step toward this would be to achieve consensus on an age threshold for “elderliness.”
Fig. 3. Radiographs of a 71-year-old male with right hallux valgus, metatarsalgia, and second ray claw toe, treated 1 year previously by M1 scarf, M2M2 Weil, second proximal interphalangeal joint fusion.
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T. Vermersch et al. / The Journal of Foot & Ankle Surgery 54 (2015) 586–590
Fig. 4. Radiographs of an 80-year-old female with claw toes 40 years after the Keller procedure showing good result at 4 months after bilateral minor surgery (flexor tenotomies plus left and right proximal interphalangeal joint fusion).
References €nder-Tsai L. Surgical 1. Saro C, Bengtsson AS, Lindgren U, Adami J, Blomqvist P, Fella treatment of hallux valgus and forefoot deformities in Sweden: a population-based study. Foot Ankle Int 29:298–304, 2008. 2. Marcus RS, Rainieri JJ, Mussman M. Nonsurgical management of disorders of the forefoot. Clin Podiatr Med Surg 10:121–128, 1993. 3. Martınez-Gallardo Prieto L, Hermida Galindo LF, D’hyver de Las Deses C. Prevalence of foot conditions in a geriatric population and their impact on mobility, gait and tendency to falls. Rev Esp Geriatr Gerontol 47:19–22, 2012. 4. Baumhauer JF, McIntosh S, Rechtine G. Age and sex differences between patient and physician-derived outcome measures in the foot and ankle. J Bone Joint Surg Am 95:209–214, 2013. 5. Miller RJ, Rattan N, Sorto L. The geriatric bunion: correction of metatarsus primus varus and hallux valgus with the Swanson total joint implant. J Foot Surg 22:263– 270, 1983. 6. Tollison ME, Baxter DE. Combination chevron plus Akin osteotomy for hallux valgus: should age be a limiting factor? Foot Ankle Int 18:477–481, 1997. 7. Barouk LS, Barouk P, Baudet B, Toullec E. L’ost eotomie Scarf du premier m etatarsien et ost eotomie de la premi ere phalange pour la correction de l’hallux valgus. Chirurgie de l’avant-pied. Cahier d’Enseignement de la SOFCOT, Elsevier, Paris, 2005, pp. 59–82. otomie cervico-ce phalique de Weil dans les me tatarsalgies 8. Barouk LS. L’oste dianes. Med Chir Pied 10:23–33, 1994. me 9. De Prado M, Ripoll PL, Golano P. Cirurgia percutan ea del pi e, Masson, Barcelona, 2004. 10. Marcus RS. Review of 64 cases of hallux valgus surgically treated with the Kellervre technique. Minerva Med 81:121–122, 1990. Lelie 11. Sarda G, Bertini G, Celenza M, Guagnini M, De Tullio V. Review of 64 cases of hallux vie re technique. Minerva Med 81(7-8 valgus surgically treated with the Keller-Le suppl):121–122, 1990. 12. Majkowski RS, Galloway S. Excision arthroplasty for hallux valgus in the elderly: a comparison between the Keller and modified Mayo operations. Foot Ankle 13:317–320, 1992.
13. Ozan F, Bora OA, Filiz M. Interposition arthroplasty in the treatment of hallux rigidus. Acta Orthop Traumatol Turc 44:143–151, 2010. 14. Helfand AE. Lesser metatarsalgia in the geriatric patient. Clin Podiatr Med Surg 7:743–749, 1990. 15. Marks RM. Hallux rigidus: surgical treatment with the crescentic oblique basilar resection arthroplasty (COBRA). Foot Ankle Clin 14:23–32, 2009. 16. O’Doherty DP. The management of the painful first metatarsophalangeal joint in the older patient: arthrodesis or Keller’s arthroplasty? J Bone Joint Surg Br 72:839– 842, 1990. 17. D’Arcangelo PR. Radiographic correlates of hallux valgus severity in older people. J Foot Ankle Res 16:3–20, 2010. 18. Tourne Y. Hallux valgus in the elderly: metatarsophalangeal arthrodesis of the first ray. Foot Ankle Int 18:195–198, 1997. 19. Yu GV. First metatarsophalangeal joint arthrodesis. Clin Podiatr Med Surg 21:65– 96, 2004. se de la premie re 20. Groulier P, Curvale G, Piclet-Legre B, Kelberine F. L’arthrode tatarso-phalangienne. Rev Chir Orthop 80:436–444, 1994. articulation me 21. Tollison ME. Combination chevron plus Akin osteotomy for hallux valgus: should age be a limiting factor? Foot Ankle Int 18:477–481, 1997. 22. Hammel E, Abi Chala ML, Wagner T. Complications of first ray osteotomies: a consecutive series of 475 feet with first metatarsal scarf osteotomy and first phalanx osteotomy. Rev Chir Orthop 93:710–719, 2007. 23. Viehe R, Haupt DJ, Heaslet MW, Walston S. Complications of screw-fixated chevron osteotomies for the correction of hallux abducto valgus. J Am Podiatr Med Assoc 93:499–502, 2003. 24. Coetzee JC. Scarf osteotomy for hallux valgus repair: the dark side. Foot Ankle Int 24:29–33, 2003. 25. Roukis TS. Clinical outcomes after isolated periarticular osteotomies of the first metatarsal for hallux rigidus: a systematic review. J Foot Ankle Surg 49:553–560, 2010. 26. Faraj AA, Naraen A, Twigg P. A comparative study of wire fixation and screw fixation in arthrodesis for the correction of hallux rigidus using an in vitro biomechanical model. Foot Ankle Int 28:89–91, 2007. 27. Lee DK, Mulder GD. Foot and ankle surgery: considerations for the geriatric patient. J Am Board Fam Med 22:316–324, 2009.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Forefoot Surgery in Elderly Compared With Younger Patient Populations: Complications and Type of Procedure Thibault Vermersch, MD 1, Michel Henri Fessy, MD, PhD 1, 2, Jean-Luc Besse, MD, PhD 1, 2 1 2
Service de Chirurgie Orthop edique et Traumatologique, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-B enite, France Universit e Lyon 1, IFSTTAR, LBMC UMRT-9406, Laboratoire de Biom ecanique et M ecanique des Chocs, Bron, France
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 3
In forefoot surgery, the presenting complaints and expected benefits differ between elderly and younger patients. The present study mapped forefoot procedures recommended to elderly patients compared with those recommended to the general population and assessed the complications according to age group and comorbidity. Consecutive patients were included in a single-center, continuous, retrospective case-control study. Three age groups were defined: <65 years, 65 to 74 years, and 75 years. All patients, regardless of age, underwent the same procedure; elderly-specific techniques such as the Keller procedure were not used. A total of 321 patients were included, with a mean age of 60.6 (range 16 to 86) years. A similar procedure was used in all 3 groups, but at differing frequencies, with arthrodesis and minor procedures increasing with increasing patient age. In all 3 groups, in the population as a whole, the incidence of delayed healing, deep infection, and nonunion was 9%, 1%, and 2%, respectively. These complications were independent of age group. In the <65-year-old group, just as in the study population as a whole, arthrodesis associated with resection arthroplasty resulted in greater rates of delayed healing and deep infection. The complications rates were equivalent among the 3 age groups. Major surgical procedures should be avoided in elderly patients, if possible. However, no particular procedure is contraindicated in the elderly, although the method of fixation must be robust owing to the frequency of osteoporosis. A first step would be to achieve consensus on the age threshold for “elderliness.” Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: age comorbidity complication elderliness fixation forefoot surgery osteoporosis
Forefoot surgery is the most frequent of all foot and ankle procedures (1). It concerns a broad population, peaking in females in their 50s (1). Few studies, however, have focused on forefoot surgery in the elderly. Management in this population was classically palliative, such as resection arthroplasty or arthrodesis. Some investigators have advised against surgery (2). Despite the obvious aging of the general population, few patients have complained of real difficulties caused by forefoot deformities, especially regarding function and gait (3). Elderly patients’ complaints and expectations differ from those of younger subjects (4), which might suggest a difference in procedures to be envisaged for the elderly or at least adapting the indications. For this, the concept of “elderly patient” needs to be defined, and no consensus has been reached in published studies (4–6). The present
Financial Disclosure: Jean-Luc Besse is a consultant for Biotech International. Conflict of Interest: None reported. Address correspondence to: Thibault Vermersch, MD, PhD, Department of nite CEDEX Orthopedic and Traumatologic Surgery, Lyon-Sud Hospital, 69495 Pierre-Be France. E-mail address: [email protected] (T. Vermersch).
study mapped the forefoot procedures implemented in elderly patients compared with the general population and assessed the complications according to age group and comorbidity. Materials and Methods Three age groups were defined in accordance with standard French practice: Group 1: Adult (<65 years) Group 2: Young elderly (65 to 74 years) Group 3: Old elderly (75 years)
Inclusion A single-center, continuous, retrospective case-control study consecutively included patients treated from January 1, 2010 to December 31, 2011. The follow-up period ranged from 12 to 24 months. All patients were treated by a single senior surgeon. The inclusion criteria were forefoot pathologic features managed surgically (including first-ray surgery for hallux valgus, hallux varus or hallux rigidus, and lateral ray surgery for quintus varus, metatarsalgia, or claw toe) and all surgery for rheumatoid arthritis because of the frequency of this etiology in forefoot surgery. The exclusion criteria were nonoperative management, pathologic features related to diabetic foot,
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.10.010
T. Vermersch et al. / The Journal of Foot & Ankle Surgery 54 (2015) 586–590
Table 1 General patient data stratified by age group Variable
Group 1 (<65 y; n ¼ 192)
Group 2 (65 to 75 y; n ¼ 99)
587
Table 3 Procedure types stratified by age group Group 3 (>75 y; n ¼ 30)
Total (n ¼ 321)
Mean age (y) 53.6 (16 to 64) 69 (65 to 75) 79 (76 to 86) 60.6 (16 to 86) Surgical revision 5 8 17 7 Diabetes 3 5 3 3 Osteoporosis 8 21 20 13 Pulmonary pathologic 9 11 10 9 features Severe cardiovascular 3 6 13 5 pathologic features Venous pathologic 19 24 40 22 features
Procedure Type Minor surgery (%) First ray (%) M1 and/or P1 osteotomy MTP1 arthrodesis Lateral rays (%) Weil DMMO Alignment resection
Group 1 (<65 y)
Group 2 (65 to 75 y)
Group 3 (>75 y)
All Patients
5
8
20
6
67 29
49 43
20 60
57 36
37 13 8
42 21 8
37 17 0
38 16 7
Abbreviations: DMMO, distal metatarsal mini-invasive osteotomy; MTP1, first metatarsophalangeal.
Data presented as percentages, unless otherwise noted.
and central or peripheral neurologic pathologic findings. Diabetic patients were eligible for inclusion only if they were without signs of associated perforating plantar ulcer.
venous thrombosis; pulmonary embolism was counted as a severe cardiovascular pathologic entity. Osteoporosis was considered only if the patient was receiving ongoing treatment. Since 2011, we have required our patients to stop smoking for 1 month before and 2 months after surgery.
Surgical Technique
Postoperative Complications
The same surgical techniques were used in all patients, regardless of age, with no procedure specific to the elderly subjects. We never performed Keller resection arthroplasty or Swanson implant, which have had a poor reputation in published studies. First ray procedures included scarf metatarsal osteotomy associated with Akin P1 osteotomy (7) (“joint-sparing first ray surgery”) using 2.5-mm screws (PyxisÒ, Biotech International, Worcestor, UK) and P1 staples (Biotech International) or metatarsophalangeal fusion with nonlocking plate fixation (FyxisÒ, Biotech International). Lateral ray procedures included Weil osteotomy of the metatarsal head (8), using 2.5-mm screws (PyxisÒ, Biotech International), or distal metatarsal mini-invasive osteotomy (DMMO) percutaneous osteotomy (9). Isolated minor procedures included interphalangeal arthroplasty or arthrodesis, tendon lengthening or sectioning, metatarsal prosthesis, arthrolysis, and so forth. The procedures were categorized by surgical “heaviness” from the patient’s viewpoint:
Three postoperative complications in particular were analyzed: delayed healing, deep infection, and dismantling of the material. Delayed healing was defined as any wound unhealed at 1 month postoperatively but not requiring antibiotic therapy. Deep infection was defined by clinical signs of forefoot sepsis (eg, redness, edema, effusion) associated with elevated inflammatory protein (C-reactive protein, erythrocyte sedimentation rate) levels. Antibiotic therapy was implemented with or without reintervention for lavage. Nonfusion was defined as unconsolidated osteotomy or arthrodesis at 6 months postoperatively.
Category 1: minor procedure (ie, without first ray involvement; eg, isolated claw toe or 1 lesser ray osteotomy, Morton neuroma) Category 2: moderate surgery (isolated first ray procedure; eg, scarf M1þP1 or first metatarsophalangeal [MTP1] arthrodesis) Category 3: major surgery (first ray procedure associated with second ray, with or without third ray osteotomy; eg, scarf M1þP1 osteotomy plus Weil M2 or M2-M3 or MTP1 arthrodesis plus Weil M2 or M2-M3) Category 4: complex major surgery (“complex foot” with first ray surgery plus second, third, and/or fourth ray osteotomy plus claw toe surgery; eg, scarf M1þP1 plus Weil M2, M3, or M4 or DMMO 2, 3, or 4 or MTP1 arthrodesis plus Weil M2, M3, M4 or DMMO 2, 3, 4 or MTP1 arthrodesis plus M2, M3, M4, or M5 alignment resection plus claw toe)
The data were analyzed using JMP, version 7.0, software (SAS Institute, Cary, NC) and Fisher’s exact test, with a significance threshold of p < .05.
Results A total of 321 patients were included for analysis, with a mean age of 60.6 (range 16 to 86) years. Of the 321 patients, 192 were in group 1 (60%), 99 in group 2 (31%), and 30 in group 3 (9%). General Data and Comorbidity The general patient data and comorbidities are listed in Tables 1 and 2. We found no differences in the type of anesthesia used or tourniquet time among the 3 groups. Procedures
Comorbidity Surgical revision was defined as surgery to a ray previously operated on at our center or elsewhere. Severe cardiovascular pathologic entities were defined as any treated cardiac or vascular pathologic features (other than high blood pressure) requiring regular medical follow-up. Venous pathologic features were defined as a history of varices or deep
Table 2 Perioperative data stratified by age group
Isolated nerve block (%) General anesthesia (%) Spinal anesthesia (%) Tourniquet time (min) Mean SD Range
Statistical Analysis
Group 1 (<65 y; n ¼ 192)
Group 2 (65 to 75 y; n ¼ 99)
Group 3 (>75 y; n ¼ 30)
All Patients (N ¼ 321)
44 34 22
35 44 21
36 47 17
41 38 21
39.2 14.3 10 to 80
41.5 13.8 0 to 70
40.5 15.3 10 to 65
40.0 14.2 0 to 80
Abbreviation: SD, standard deviation.
Significant differences (p < .05) were found in the distribution of the first ray procedures between groups 1 and 3 and groups 2 and 3 (Table 3). Also, twice as many minor procedures were performed in group 2 compared with group 1 and twice as many in group 3 compared with group 2 (p < .05 for both). We have preferred isolated minor procedure for patients >75 years because of balancing the surgery risk (more severe cardiovascular pathologic features; Table 2). In the 3 groups, Weil osteotomy was 2 to 3 times as frequent as DMMO, without a significant difference among the groups. Lateral ray surgery showed no significant differences in procedure according to age group (Table 3). In those undergoing first ray surgery, joint-sparing surgery was twice as frequent as arthrodesis in group 1 and 3 times as frequent in group 3. The 2 procedures were approximately equally frequent in group 2 (Fig. 1). We proposed more arthrodesis for severe hallux valgus in group 3 to avoid recurrence and therefore the potential risk of re-do surgery.
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Table 5 Postoperative complications stratified by age group Complication
Group 1 (<65 y; n ¼ 192)
Group 2 (65 to 75 y; n ¼ 99)
Group 3 (>75 y; n ¼ 30)
Total (n ¼ 321)
Delayed healing Deep infection Osteosynthesis dismantling Nonconsolidation
10 1 0.5 1
8 (8) 1 (1) 1 (1) 0
6 (2) 0 0 0
9 0.9 0.6 0.6
(19) (2) (1) (2)
(29) (3) (2) (2)
Data presented as % (n).
Fig. 1. First ray procedures by age group: Group 1 (<65 y, n ¼ 192); Group 2 (65–75 y, n ¼ 99); Group 3 (>75 y, n ¼ 30).
In terms of “heaviness,” fewer category 3 or 4 procedures were recorded for group 3 than for group 1, but this difference was not significant (Table 4). Complications Taking all age groups together, the incidence of delayed healing, deep infection, and nonconsolidation was 9%, 1% and 2%, respectively (Table 5). No significant intergroup differences were found. The 3 cases of deep infection secondary to healing disorder were associated with arthrodesis plus alignment resection: 2 in patients with rheumatoid polyarthritis (a 56-year-old and a 69-year-old patients, both presenting with a chronic healing disorder of the transverse dorsal approach), and 1 secondary to 67, grade IV hallux valgus (a 60-year-old patient with delayed healing of a medial approach). The complications were too few for multivariate analysis; thus, the incidence of the different comorbidities could not be correlated with the different age groups. Discussion The only procedure not used in “old elderly” subjects was arthrodesis associated with alignment resection. First ray surgery was more conservative in younger patients. The complications rates were equivalent among the age groups. The strong points of the present study were its continuous design, no loss to follow-up, and exhaustive inclusion of all patients treated by a single senior surgeon. The weak points possibly inducing bias were the retrospective design and the small number of patients in the >75-year-age group. However, no other comparative studies have highlighted the effects of patient age on surgical strategy and complications. It was difficult to set a threshold for elderliness. The published English-language data are sparse, without a consensus found, because the age criteria have varied greatly from study to study. The age limits found in studies concerning “the elderly” are listed in Table 6. The present findings showed a real difference in surgical procedures implemented in age groups 2 and 3, confirming our distinction between the “young elderly” and “old elderly.”
Table 6 Mean age and procedures used in published studies
Table 4 Procedural category stratified by age group Category
Group 1 (<65 y; n ¼ 192)
Group 2 (65 to 75 y; n ¼ 99)
Group 3 (>75 y; n ¼ 30)
1 2 3 4
5 39 35 21
8 26 38 28
20 33 33 14
(Minor surgery) (Moderate surgery (Major surgery) (Complex major surgery)
Data presented as percentages.
According to the published data, hallux valgus or rigidus is elderly patients is managed by arthroplasty using the Keller (10,11) or HueterMayo (12) procedure, with interposition (13) or a Swanson implant (5). These procedures have been considered the easiest and most reliable for first ray pathologic features in elderly subjects (11). Although some investigators have considered metatarsalgia to be less frequent in the elderly (14), resection of the metatarsal head or base of the first phalanx will inevitably lead to sesamoid retraction, impairing metatarsal weightbearing, with a risk of onset or aggravation of medial metatarsalgia (12). It also incurs a risk of insufficient correction of the hallux valgus. In patients who are still active, Marks (15) has recommended, as an alternative to MTP1 arthrodesis, a basal arthroplasty resection procedure, resecting 30% of the dorsal MTP1 surface and conserving the sesamoid complex and plantar plate, in contrast to the Keller procedure. O’Doherty (16), however, found no benefit in terms of first ray or metatarsal pain and recommended the Keller procedure. We consider these to be “old” techniques that have shown their surgical limitations and fail to provide improvement. Thus, we have decided not to use such procedures. The severity of hallux valgus increases considerably in elderly subjects (17). In most series focusing on the elderly, MTP1 fusion (Fig. 2) has been the technique of choice to treat hallux valgus or rigidus (18–20). In 20% of our “old elderly” group, the first ray was managed by joint-sparing surgery, with very good results (Fig. 3). Tollison (21) reported similar findings with associated chevron and Akin osteotomy. Tollison (21) did not consider joint-sparing surgery contraindicated in the elderly (age 55 to 81 years) and reported very good results. For chevron osteotomy, he recommended an intermetatarsal angle of <15 (21). Minor procedures were much more frequently used in the elderly (Fig. 4). Because the demand in terms of results were less exigent, the surgery tended to be as minor as possible. Minor procedures amounted to only 4% in group 1 compared with 20% in group 3 and 8% in group 2. However, these findings could not be compared with the published data, because none is available. No previous studies have focused on complications of forefoot surgery in elderly subjects. In the present series, the rate of deep infection was only 1% compared with 1% to 5% in the published data (22–25). Deep infection was restricted to those patients who had undergone arthrodesis with realignment resection but in context of rheumatoid arthritis or a very severe deformity.
Investigator
Mean Age (range) (y)
Type of Surgery/Radiographic Analysis
Miller et al (5), 1983 Majkowski et al (12), 1992 Tollison et al (6), 1997 Marks (15), 2009 D’Arcangelo (17), 2010 Ozan et al (13), 2010
61.3 66 62 (55 to 81) 72.7 70 (65 to 94) 61 (55 to 71)
Swanson implant Keller arthroplasty resection Chevron plus Akin Oblique basal arthroplasty resection Radiographic analysis of hallux valgus Keller arthroplasty resection
T. Vermersch et al. / The Journal of Foot & Ankle Surgery 54 (2015) 586–590
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Fig. 2. Radiographs of 78-year-old female with (A) bilateral hallux valgus, treated by (B) arthrodesis on the right side.
Diabetes and surgical revision showed no significant correlation with delayed healing or deep infection. However, the present results for infection, delayed healing, and consolidation defects in group 3 could not be analyzed statistically, because the number of complications was too few and the patient numbers were too low. The rate of osteoporosis was greater in group 3 than in the other age groups, but this was not associated with a greater rate of nonconsolidation. Osteoporosis should not be considered a contraindication for surgery; however, we did use robust internal fixation or fusion, preferring plates rather than Kirschner wires (26). In the case of diabetes, surgery was reserved for well-balanced patients who were free of neuropathy or arteriopathy. Current techniques allow elderly patients to benefit from the same surgical procedures as the general population with no increased morbidity. Even so, we treat our elderly patients as fragile, adapting, not the surgery itself, but the postoperative care, including nutrition, pharmacology, cardiovascular and pulmonary precautions, and anesthesia (27). Particular attention must be given to the elderly patient’s cutaneous status, and dressings should be renewed by, or at least in the presence of, the surgeon. A significant correlation could be demonstrated between delayed healing and
lung disease in group 2. The present study did not include American Society of Anesthesiologists scores; however, it seems clear that they represent an essential factor in guiding surgical decisionmaking. In our own current practice, forefoot management in the very elderly (age group 3) has been primarily medical, with adapted footwear and orthoses. In the case of failure, surgery is not contraindicated and should not be seen as palliative treatment, although isolated minor procedures should be preferred, if possible. Otherwise, first ray arthrodesis is a good option, although jointsparing surgery should not be excluded. For the lateral rays, the findings from the present study could not be used to rate one procedure more highly than another. In conclusion, the forefoot surgical procedures available for elderly patients should be considered the same as those used in younger subjects, with an emphasis on arthrodesis. One can expect complications to be no more frequent than in the general population. Our study was, however, a case-control study. It would be interesting to conduct a prospective study to determine more precisely the role of surgery and the types of surgery that should be adapted to elderly patients. The first step toward this would be to achieve consensus on an age threshold for “elderliness.”
Fig. 3. Radiographs of a 71-year-old male with right hallux valgus, metatarsalgia, and second ray claw toe, treated 1 year previously by M1 scarf, M2M2 Weil, second proximal interphalangeal joint fusion.
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Fig. 4. Radiographs of an 80-year-old female with claw toes 40 years after the Keller procedure showing good result at 4 months after bilateral minor surgery (flexor tenotomies plus left and right proximal interphalangeal joint fusion).
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