Bunion Surgery And The Geriatric Patient: What You Should Know

Performing bunion surgery in the elderly can help patients maintain a good quality of life but bunion surgery does come with potential risks due to age-related medical conditions. Accordingly, this author reviews key risk factors and shares insights on appropriate procedure selection in order to maximize the efficacy of hallux valgus procedures in this patient population.

Patients commonly ask if they are too old for bunion surgery. The answer to this complex question is largely based on individual risk factor assessment.

Advanced age alone does not preclude bunion surgery but certain age-related conditions can increase the likelihood of compromised healing and poor outcome. Examples include diabetes, peripheral neuropathy, peripheral vascular disease, age-related skin atrophy, obesity, poor bone health and mobility limitations. Age also brings the added risk of a blood clot with elective surgery and patients on oral anticoagulation are prone to excessive post-op bleeding.

A geriatric patient’s general health status in relation to anesthesia and anticipated longevity are also important considerations when discussing the potential risks versus benefits of elective surgery.

It would seem simple enough just to tell older patients to wear wider shoes in an effort to avoid surgery altogether. This approach may work for bump pain but shoe therapy may not be effective for cases involving painful arthritis, interdigital pressure, overlapping toes and severe deformity. Bunion deformity can also predispose patients to the development of open sores with high potential for bone and joint infection. The main determining factor regarding ideal procedure selection is the severity of deformity and some geriatric patients are not appropriate candidates for the type of procedure that would be necessary based on exams and X-ray findings.

How To Assess Risk Preoperatively
Pre-op screening is an important part of counseling an older patient about elective foot surgery. This includes the history of current anticoagulation medications, blood clot risk assessment, bone health screening, diabetes, peripheral neuropathy and other past medical history with a focus on cardiac disease.

Assessment of skin quality and distal extremity perfusion is important in this age group as some patients may have difficulty healing incisions after elective surgery. Uncontrolled lower extremity edema that extends to the forefoot is also a concern for wound healing.

A gait exam serves the dual purpose of a biomechanical exam plus assessment of how mobility limitations may affect recovery. Depending on the procedure and mobility limitations, pre-op discussions about a patient’s home situation and potential support group may be necessary.

For the most part, an active, healthy patient can recover from bunion surgery regardless of age.

Assessing The Risk For DVT And Pulmonary Embolism
Advanced age is an independent risk factor for the development of deep venous thrombosis (DVT) or pulmonary embolism after elective foot surgery. Blood clot risk assessment should focus on three major risk factors including active systemic cancer, a past history of DVT/pulmonary embolism and inherited clotting disorders like Factor V Leiden and protein S or C deficiency. Chemical prophylaxis with low molecular weight heparin or warfarin is common for those with major risk factors.

Bunion surgery rarely requires cast immobilization or inpatient bed rest, which makes the surgery itself relatively low risk for DVT/pulmonary embolism. The surgeon should look for minor risk factors that one can modify in an effort to minimize clot risk including the use of a removable brace that allows ankle range of motion and allows the patient to sleep without the brace if appropriate. One can also modify the fixation construct to allow immediate weightbearing for procedures that typically require non-weightbearing recovery. Pre-op patient education should focus on the risk factors that are relevant to the individual patient, signs and symptoms of DVT/pulmonary embolism, and a recommended action plan if problems develop.¹

Management Of Anticoagulation Medications With Foot Surgery
Continuous use of warfarin (Coumadin, Bristol-Myers Squibb) without bridging  for elective foot surgery is often appropriate if the patient’s condition calls for a therapeutic international normalized ratio (INR) range of between 2 and 3. It is ideal to communicate this plan to the primary medical team since this decision is highly procedure dependent and is usually up to the surgeon’s discretion.

I typically check the INR a few days before surgery and in pre-op to confirm that levels remain both therapeutic and appropriate for surgery. Patients with a history of heart valve replacement or other conditions that require a therapeutic INR between 2.5 and 3.5 may need bridging with low molecular weight heparin. However, this predisposes patients to postoperative bleeding risk similar to that of continuous use of warfarin without bridging. Control of bleeding during surgery is not an issue due to tourniquet use. However, patients on anticoagulation medications are more prone to postoperative hematoma. The surgeon and patient should be prepared for slightly higher risks of wound healing issues and infection. Careful hemostasis during dissection, tourniquet deflation prior to wound closure, close attention to postoperative elevation and prompt clinic follow-up can usually help avoid these problems.  

A Guide To Bone Health Assessment
Pre-op bone health assessment is a simple process that can help one avoid unnecessary risk of intraoperative or post-op problems. Patient history should focus on a personal or family history of osteoporosis, a history of low energy fracture suspicious for pathologic fracture and a history of vitamin D deficiency and current supplementation.^2,3 History and chart review can determine if the patient has ever been tested  for osteoporosis or a low vitamin D level. I typically address low vitamin D during the course of post-op recovery, avoiding the need to delay surgery waiting for normalization of lab values.

Alcohol, tobacco and steroid use also raise concern for poor bone health. X-rays may give clues regarding expectations for bone quality sufficient for osteotomy or joint fusion, but do not hesitate to get a dual energy X-ray absorptiometry (DEXA) scan if this is a concern.

Pertinent Insights On The Risks Related To Diabetes And Peripheral Neuropathy
A patient with well-controlled diabetes with intact protective sensation and adequate blood flow can likely recover after elective foot surgery without complications. Hemoglobin A1c below 7% is ideal and I do not hesitate to delay surgery until the patient is able to accomplish reasonable blood sugar control. The desire to have surgery will often motivate a patient to adhere to strict diabetes management.

A loss of protective sensation associated with peripheral neuropathy significantly increases the risk of postoperative complications.⁴ Semmes Weinstein monofilament testing is an easy pre-op screening tool. Elective bunion surgery can be successful despite the loss of protective sensation but one should consider longer and more aggressive post-op protection and stronger fixation. A good rule is to plan for three months of post-op protection for procedures that normally take six weeks to heal and non-weightbearing may be needed for procedures that normally allow immediate weightbearing in a boot. Past or current neuropathic ulceration are red flags for complications after elective bunion surgery.  

Considering Mobility Limitations And The Living Situation
Elective bunion surgery in the elderly would ideally allow immediate weightbearing during recovery but I do not hesitate to perform midfoot fusion when indicated. Some geriatric patients benefit from preoperative assessment and training by a physical therapist.

In-home assistance from family and friends is critical to successful post-op recovery, especially in the first two weeks after surgery. Having a family member or friend attend the preoperative visit is important to ensure they fully appreciate how best to assist the patient following surgery. Simply providing assistance with meals, mail, pets and transportation to office visits may be all that is necessary. Elderly patients are sometimes reluctant to ask for such help and it is ideal if this request comes directly from the surgeon.  

Procedure Selection Considerations In The Geriatric Population
Geriatric bunion surgery has historically involved lump and bump surgery and joint destructive procedures including the McBride or Keller procedures. This “geriatric” approach involved simple procedures that allowed immediate ambulation with the intention of avoiding prolonged recovery and non-weightbearing. Advances in bunion surgery allow a more reconstructive approach with the intention to optimally restore foot function, more fully correct the deformity and maintain an active person’s desired lifestyle.  

Distal metatarsal osteotomy versus midfoot fusion/Lapidus bunionectomy. Surgeons are frequently reluctant to perform midfoot fusion procedures in the geriatric population despite severe deformity, midfoot arthritis or progressive arch collapse. The perceived challenges with non-weightbearing and concern over bone health seem to be the primary causes for hesitation.

My observation is that bone quality at the base of the first metatarsal and medial cuneiform is usually better than bone quality at the first metatarsophalangeal joint (MPJ), especially in patients with longstanding hallux valgus deformity. Bone cyst formation in the subchondral bone of the metatarsal head is common with hallux valgus and associated degenerative joint disease. Premature loss of bone density in the medial half of the first metatarsal head is also common with severe valgus deformity due to disuse. The bone of the midfoot is largely unaffected by these factors and is commonly stronger, healthier and more amenable to internal fixation.

One can address concerns regarding osteoporosis or difficulty with complete non-weightbearing during the initial six weeks after midfoot fusion resulting in compromised fixation by adding a locking plate to the fixation construct. The combination of a compression screw and a medially applied locking plate is usually able to withstand the stress of protected weightbearing in a fracture boot. The patient may need to accept a slightly higher risk of delayed healing or nonunion with this approach.⁵

First MPJ fusion for geriatric bunion deformity. Geriatric patients undergoing bunion surgery often have fixed deformity, progressive arthritis or recurrent hallux valgus despite prior surgery, which may not be amenable to joint preservation procedures. First MPJ fusion is a very useful approach for geriatric bunion surgery as it affords permanent correction of first toe position and resolution of arthritic joint pain. First MPJ fusion allows a quicker return to mobility in comparison to midfoot fusion and is less impacted by early weightbearing. Incorporation of locking plate fixation provides further stabilization of the fusion site, especially with osteoporosis. Correction of the hallux valgus deformity substantially reduces the preoperative intermetatarsal angle and the surgeon can resect a large portion of the medial bump after applying fixation.  

When Gout Or Joint Infection Are Associated With Hallux Valgus
Both gout and joint sepsis tend to develop in joints that have inflammation of the synovial tissue and are commonly associated with preexisting hallux limitus and/or hallux valgus. The diagnosis of one is not exclusive of another as an individual patient could potentially have an arthritic bunion with secondary chronic gout that develops acute hematogenous joint sepsis. Intraoperative confirmation or unexpected findings of extensive gout during bunion surgery may tip the scale in favor of first MPJ fusion.

In Summary
My general rule of thumb for patients in their mid- to late 70s who are seeking advice about bunion surgery is to decide within the next few years if living with the condition will be tolerable. Waiting until patients are in their 80s often results in reluctance on the part of the surgeon to proceed with surgery. Careful assessment regarding what hurts, when it hurts, the impact on daily activities and what doctors have tried so far help to determine if bunion surgery will improve the patient’s quality of life. The surgeon’s job is to assist with shared decision making by giving a realistic picture of risk profile and expectations for post-op recovery. A focused and individualized risk/benefit assessment is the key to helping patients make these important decisions.

Dr. Boffeli is a Fellow and former member of the Board of Directors for the American College of Foot and Ankle Surgeons. He is also the Residency Director at Regions Hospital, a Level 1 trauma center in St. Paul, Minn.

References

1.     Fleischer A, Abicht B, Baker J, Boffeli T, et al. American College of Foot and Ankle Surgeons’ Clinical Consensus Statement: risk, prevention, and diagnosis of venous thromboembolism disease in foot & ankle surgery and injuries requiring immobilization. J Foot Ankle Surg. 2015; 54(3):497-507.
2.     Thacher T, Clarke B. Vitamin insufficiency. Mayo Clin Proc. 2011; 86(1):50-60.
3.     Holick M. Vitamin D deficiency. New Engl J Med. 2007; 357(3):266-280.
4.     Wukich D, Lowery N, McMillen R, et al. Postoperative infection rates is foot and ankle surgery: a comparison of patients with and without diabetes mellitus. J Bone Joint Surg Am. 2010; 92(2):287-95.
5.     Cottom J, Vora A. Fixation of Lapidus arthrodesis with a plantar interfragmentary screw and medial locking plate: a report of 88 cases. J Foot Ankle Surg. 2013; 52(4):465-9.