TAPE STARTS – [00:00]


Male Speaker: Our next speaker is Dr. Mike Trepal. He is Vice President for Academic Affairs, Dean and Professor of Department of Surgery in New York College of Podiatric Medicine. He serves as Residency Director for SUNY Downstate Podiatric Residency. Mike is obviously a constant educator, understands what we do from this platform, has major impact on patients' lives and how you practice. So today, Mike's going to be giving a few talks. The first one is going to be bunion surgery in the geriatric patients. So please welcome Mike.

Michael Trepal: Well, good morning everybody, and as you can tell, my voice is somewhere out in cyberspace, I think. The last two weeks, I've been – actually, two-and-a-half weeks, I went from Washington for the House of Delegates, to Italy for 10 days, came back, changed suitcases, and was out in Denver for the ABFAS Case Review Committee and just got back at midnight last night. So somewhere in some train station or airport, I picked up some – I don't know, if it was Italian bug or Washington bug, god forbid – or a Colorado bug. I didn't have a chance to visit any of the medicinal places out there though.

The things that I came away with, for the case review committee, we reviewed over 6,500 cases, and aside from reinforcing what a fair process it is, two things, one pertinent to this talk is we do some awesome work in this profession that we really need to pat ourselves on the back, the breadth, and the scope, and the quality of work that I saw, again, looking at, you know, not myself but over the committee of 6,500 cases, this profession s damn good at what it does. But a propos of this talk, it was impressing just how many geriatric, and I used that term sparingly, now as I approach that.

[02:06]

But just how many older individuals where you're actually doing surgery on in some sophisticated procedures. So this is real world stuff and we need to be adept at it. The disclosures that I have pertinent to this talk is I am Vice President at NYCPM. NYCPM is the academic sponsor for this meeting, and that's where you're going to be receiving your CME credits for. The learning objectives, we want to be able to describe aspects of the geriatric patient, describe treatment strategies, list and describe acceptable surgical options, and then, at the end of it, be able, given a given patient, come up with a rational treatment.

Now, we operate on all different age groups, kids, young adults, teenagers, middle-aged, and older individuals, and each has their own unique needs. Certainly, we have different ambulatory needs, we have different ambulatory capabilities. It's been said that the three stages of life, as kids have energy, have time but no money; adults have energy, have money, but no time; and elderly people have time, have money, but no energy. So depending upon where you sit in that spectrum.

The juvenile bunion on the other side, presents unique characteristics that we have to deal with, not the topic of this talk, but certainly if you're operating on a juvenile. And again, we saw a fair number of cases of juvenile bunions and how they were approached. Bunions come in all sizes, shapes, forms. Not every bunion is the same. And if you come away of nothing from this talk over than this following thing, is don't treat an X-ray, treat a patient. I tell the students at the college all the time, I hope you never treat a foot, and they look at me, like, you know, this guy's taking leave of the senses. And I said, "No, you treat a patient with a foot problem." And hence, you know, I think that, really, what I wanted to get out of this talk.

[04:06]

So the geriatric bunion is not just something of chronological age. It has been said 70 is the new 50. It's – yes, you need to take that into account. You need to – I was recently approached to defend a med mal case on a patient who had a lapidus, and was 87 years old, who underwent it. And you know what, I think the case was defensible, I mean, yes, 87 sounds a little bit outside the normal realm of things that you would be considering a lapidus on, but this patient was fairly active, played tennis, so it's not just chronological aid.

Certainly, the condition of the foot – what are the comorbidities associated with the patient? In case you haven't realized, we are an aging population for lots of reasons but you're going to be seeing more and more of these patients. It is predominantly female, skewed to the female side, but certainly, the pyramid is going up. If you practice, well, most of us are in the northeast and I think the migration is down south, but if you look at the southwest, down in the Florida areas, the part – percentage of the population where geriatrics is higher and higher.

One retrospective study by Matt Gould, it's a little bit dated but still, I think, probably accurate, is that patients who were admitted to a hospital for non-foot problem, right, 20% of them had bunions, not insignificant. If you look at age adjusted data for women, with hallux valgus, undergoing corrective surgery, you will see that those patients who are undergoing and having corrective surgery are generally healthier both psychologically and physiologically than patients who are not having surgery.

[06:07]

Foot problems impair balance and are a risk factor for falls. Falls are a big problem in this country. It is a PQRS indicator for risk prevention. I noticed many paper – many of our colleagues in their jobs were documenting in there, although that wasn't what we were reviewing, we're reviewing the surgical case but they were documenting fall risk prevention strategies. The New York State Podiatric Medical Association is embarking on a major initiative to educate on fall risk prevention and exactly what we do as a profession.

So foot pain, deformities such as bunions reduce plantar sensations, weaknesses of the muscles, and limitation of ankle dorsiflexion, all which occur with a greater degree of frequency and prevalence in the older individual are a major risk factor for falls. We know what happens when someone falls, they break hips. The morbidity rate and the mortality rate following a hip fracture is unbelievable. If you've had grandparents, or friends, or relatives who have had hip fracture, you know, for many, this is beginning of a slippery slope to their ultimate demise. So anything we can do to prevent it.

We need to be looking at their shoes. When we come into the treatment room, usually the patients got their behind on your chair. They're feet are up there and, you know, the shoes are thrown off into some corner. Look at the shoes, they can tell you shoe wear patterns. Many senior citizens can't afford to buy new stylish shoes. They're wearing shoes out. I don't think you need much. Any podiatrist worth their sole can look at that shoe and understand how that foot is functioning to a large extent just by looking at the wear pattern of the shoe.

Other risk factors for falls and this set of the views, many of these patients are taking psychotropic medicines, cognitive impairments, lower extremity problems.

[08:04]

They have pathologic reflexes, the foot problems, and the balance gait problems are renowned. Communication concerns, psychosocial – they don't hear well, they don't see well. Their level of independence may vary. Their cognitive status declines.

As we age, so does the volume and mass of the brain. In operating on the individual, you also have to know. I don't care what age group it is, you have to look at the expectation, what is it that someone is looking to do following your surgery. I surmise to you that in the older individual, these activities are not necessarily what they're looking for. This may be what your treatment goal.

Okay, the late Jim Ganley, who I think was one of our pioneers in this profession and just a brilliant individual used to talk about limited expectations, okay. You're not looking to cure the world. You're looking to have realistic reasonable expectations with minimal risk.

Financial concerns that they have. They're in limited incomes, they have to navigate through the healthcare environment. So these will have to be taken into consideration when you're going to operate on the individual. The morbidities or the comorbidities that they have, increased diabetes, coronary artery disease, congestive heart failure, cardiac arrhythmias. These all must be taken into consideration before you just turn – determine to operate on them.

Many are in A-fib. Now, the problem with A-fib, aside from the cardiac is it that most of these people are taking anticoagulants. Every other patient seems to be on Eliquis or one of DOACs medications for atrial fib. So these create comorbidities and bleeding factors that we need to take into consideration. Loss of sensation, ulceration, patients who are neuropathic, polypharmacy, these patients are taking multiple medications.

[10:02]

It's not uncommon to see a list of 20 medications that a patient is taking. They have other concerns in terms of generalized osteoporosis and osteoarthritis. Not only do they have osteoarthritis with the first MTPJ, they have osteoarthritis of the hip.

This may affect their ability to recuperate, to walk. If you're going to offload one leg and they have a contralateral degenerative arthritis of the hip, what effect is that going to have? Osteoporosis, again, how does that affect what treatment options we're going to do? Are you going to be able to put six screws into an osteoporotic bone and expect that they're going to hold? It's like putting a screw in a melted stick of butter.

Musculoskeletal gait, geriatric have a slower gait. They have decreased stride length and arm swing. They have forward flexions at the head and the torso. Increased flexion at the shoulders and knees and they have lateral sway that you can see. These balance issues will all affect what we do.

Sarcopenia is legendary in it. Okay, they do not have the muscle strength that may impact their ability to rehab following surgery. Arterial members, CAD and PAD go hand in hand or foot and foot or foot and heart or whatever you want to say.

Patients who have PAD invariably also have some degree of degeneration of the arteries, atherosclerosis of the coronary arteries. I refer a lot of patients to cardiology in my practice, tremendous amount to cardiology. When I identify PAD and that's not a hard thing to do, I refer them to cardiology and I can't tell you how many times it has ended up that they've had lesions that was significant and ended up with some coronary intervention.

So, again, there's lots of literature here that documented back and forth. A quick screening test that we do and you should be doing this on just about all of your geriatrics that you're considering surgery on is an ABI.

[12:04]

You don't necessarily have to refer out for a vascular consult or a vascular clearance. I mean, vascular surgeons don't want to get a patient from us that – that just say, patient's candidate for bunion surgery, please clear vascularly and I can feel the pulse on the roof.

All right, I mean if you can do – if you can feel pulses, and you do an ABI, and you document it, and that's good. That is generally sufficient. Venous problems, venous insufficiencies also need to be evaluated prior to undertaking it. Age and severity of illness affect length of stay in geriatric surgical patients.

Anesthesia levels, okay, is what the classification is. It's a concern if you're going to consider general anesthesia or what level of anesthesia you're going to do. Eighty, as I said, the chronological age is not an obstacle to surgical intervention.

And a few patients in this retrospective study of surgery and anesthesia and patients over 80and again, this was not necessarily podiatric lower extremity. It was more significant, more robust cases. But if you have a class II patient, less than 1% of class II patients ended up having a significant mortality in that. And again, these are from much robust and significant procedures than a bunion that we would do. So you can see, even from an anesthetic point of view and a class II individual, it's relatively safe.

Again, using local anesthesia, okay. It was found that no complications related specifically to use of a local anesthetic in over 127 foot and ankle procedures involving neuropathic ulcer debridement in close amputation. Okay, so use of local anesthesia is generally safe.

So taking all of these into consideration, the patients' needs, psychosocial, financial, level of independence, comorbidities, anesthetic risk, we're now faced with a foot with a bunion.

[14:07]

So what do we do? And many times, again, this is where I say, don't treat a foot. Treat a patient with a foot problem and you need to think outside the box sometimes. But remember, before you're think outside of the box, you've got to have a box.

Okay, you've got to have some type of treatment paradigms and type of protocols that you generally follow because if you have nothing and you scatter-brained in how you approach patients, thinking outside of the – every patient is thinking outside of the box.

Quick fix is not always the way to go. All right, so many times, you know, we're just going to take a – do a – I hate the term, bumpectomy or we're just going to do a little sternotomy or snap this or do that as the quick fix. Now, that may be appropriate in some patients and in others, we may be able to do a better job. So quick fix isn't always what works. The quick fix is this quote-unquote, "simple bunionectomy," doing an exostectomy of the medial imminence to remove a painful prominence there.

Now, again, this may be appropriate in a certain type of patient who has limited mobility to heal, to be offloaded to for doing an osteotomy, particularly a more robust osteotomy, someone who may have a fair degree of comorbidities, someone who may not – lives alone, someone who may not have the support mechanisms to repair. This is – and in these particular cases, you're not going to give them a ramrod straight bunion, but it's just enough to kind of take the edge off and then allow them to get into a shoe more comfortably.

Now, looking at a foot like that, one would not just treat that X-ray and just treat that foot. If you were in our surgery class at the college and we put this exam on these questions – on a question not knowing anything else about the patients, that here's a foot, what would you do? And you wrote simple bunionectomy, you would get an F on that because that's not appropriate for that X-ray in that foot.

[16:06]

But again, if you look at the entire patient together, it might just be adequate in that particular. More often than not, you're going to be doing a distal osteotomy. We'll be talking a lot more about distal osteotomies. One of the other things I came away with this past weekend – week out in Denver is the significant increase of lapidus procedures that our profession is doing.

We are now – the pendulum is clearly swinging in the direction of lapidus procedures. A lot of people are taking podiums around the country and advocating for the use of that procedure. We'll have a little bit more to say about the role distal osteotomies in the next talk.

Distal osteotomies, again, can be appropriate to reduce a deformity and in some cases, you can reduce it significantly to the point of a rectus first ray. You can push the limits of distal osteotomies. They certainly have less robust recovery period in terms of non-weight bearing needs on a patient. And again, this all needs to be considered. The X-ray may say proximal osteotomy, it may say lapidus but the patient is not going to be able to handle that.

Sometimes, you even got patients who are working and they can't be. You know, 65 is not the magic retirement age anymore. So I have many patients who are well into their 70s and even 80s who have full time jobs and have a need, whether it's financial, whether it's social, whether it's psychological to get back to work quick. So the distal osteotomy can give you very acceptable results.

[18:02]

Again, now, for example of distal osteotomies, well, that's not a perfect reduction of the intermetatarsal angle can be just enough for the individual patient. In patients who are able to withstand more aggressive procedures, the midshaft variety of osteotomies that we have here, your longus lumps, your scarves, your mals, your ludluv. Whatever your particular preference is can give you an enhanced stability to increase, but again as we talked about, you're still limited in the amount of lateral transposition of that metatarsal.

So, again, you can extend the dorsal arm. Personally, I'm not a particular fan of the scarf but we'll talk about that a little bit later. By increasing the length of the dorsal wing of that osteotomy, it doesn't necessarily allow you to transpose more but it gives you the ability to kind of push the limits and put more significant fixation in there to hold it into place.

And again, you can take fairly significant bunion deformities and get adequate results for your patient. Try to avoid where possible proximal osteotomies, whether it be a wedge osteotomy or lapidus fusion. Clearly they work and clearly from a mechanical – in engineering point of view, I mean, that's where you're going to get the biggest correction.

The more proximal you go, you have the lever on effect there to decrease it but remember, you're not just treating the X-ray, you're trying to treat the patient. And as I said, there are times that I'll do it and if I can have a choice and option in this patient population – I'm not talking about a 20-year-old here, we're talking about a 72-year-old.

The Keller, we talked – Dr. Rogers talked about the Keller and yes, absolutely I think the Keller – I've cured more plantar first metatarsal head ulcers by doing a Keller than probably any other means.

[20:07]

It certainly offloads the first MTPJ without question. However, that weight is going to go somewhere. It's going to go somewhere and it's going to go lateral. So depending upon the structure and the patient's gait because remember you're not just treating the foot.

If the patient has an abducted gait, for whatever super structural is, maybe not. If the patient has what would boys or mule would refer to as a low gear push off, where the patient has a rectus gait, that weight is going lateral and it's going underneath the second, third, fourth MTPJs, which if you expect it and you do something prophylactically on this, then you can prevent lateral strides because I've seen a fair amount of instances where status post-Keller, the first metatarsal also clears up but now, they get one step, two, three, or four, and that can be preventable.

We're fortunate at the college, they have Dr. Cusack, who is a pro at F-scanning and looking at this and he's going to give you a wonderful talk a little bit later. But, you know, on these patients, I will get preoperative F-scans and we can map out our procedure based upon how this patient is going to walk and predicting where that weight is going to transfer to but yes, Kellers are certainly something that should be in your toolbox to do it.

Fusion, here's a case, unstable foot. Clearly, that is a total unstable first MTPJ. Second and third is off – is subluxed. In this particular case, by fusing the MTPJ and you don't need $3,500 plates to fuse an MTPJ. In fact, I've been observing that some of the best fusions or some of the best lapidus fusions were simple two cross screws for $35 each as opposed to $3,500 for a plate.

[22:07]

In fact, some of the biggest complications I saw over the weekend were those using these newfangled plates, but another topic for another time. Fusing the first MTPJ in the patient, resecting the second and third metatarsal heads, K wiring it can give you a stable foot. It's not necessarily the prettiest looking foot but this is long-term durability and you can take a foot that looks on the left hand side to the right with minimum morbidity.

I mean you can put these patients in a Darco-type shoe, offload the forefoot. They don't need to be into a cast or maybe CAM walkers so they can have pretty good functional recuperations and do what you need to do. Again, another instance of a 68-year-old female, fairly active. That foot was not too functional for her.

This is not a cosmetic concern, there was some degree of brachymetatarsia there as well which we certainly were going to address. But again, in this particular woman, what we did here was interesting, I did the lapidus on again, two screws. Got pretty good fusion there and rather than try to restore that toe, what we did was amputate it.

Okay, again, cosmesis was not her concern. Her concern was functionality wearing into a shoe and she was perfectly happy with the result that that achieved over here. So you have a variety of surgical options available to you. More often than not, I think the distal osteotomies are the way to go. You need to be consistent in how these patients are going to ambulate post-operatively. Can they use a walker?

[24:00]

Are they going to need a wheelchair? What is there situation at home? Do they have ramps? What is their ability to bathe? If you're going to do a procedure that's going to take them, you know, six, eight weeks of immobilization, how are they going to bathe at home? They have to climb into a shower?

I have been called at the hospital by the nursing supervisor more than one time – Dr. Trepal, your service has a patient here, though they had a surgery and there's a cast on the patient, lives on the sixth floor walk-up. I think, how are they going to get up there? And who's going to take care of them? And how are they going to get back for your post-operative?

These are all part of your patient management that all too often, you know, is not really taken into consideration. Again, the ambient thing here that I want to get up to you is that this patient group, this population has unique characteristics. Financials, psychosocial, metabolic, radiographic, bone density, that all have to be looked at in totality in determining as to what you're going to do. So the bottom line is never treat a foot – treat a patient with foot problems.

We looked to the literature many times and that's me up there in that parachute and the point I want to make here is, yes, it's important to look at evidence-based medicine. I mean, it's, you know it would be heresy to say evidence-based medicine doesn't mean anything, but you have to evaluate the quality evidence and whether studies have really addressed the patient that you have in hand.

So when someone comes to you and says, look, here's an article that compared, you know, a scarf to an Austin or a lapidus to distal Austin and you can see you got much better IM correction in this.

[26:08]

Well, you've got to look at what type of patients they were doing it in. Was this – does this apply to you, a 72-year-old female with diabetes and limited capabilities? Or was the study done in 23 year old athletic individuals?

So the literature's important, but you have to analyze it carefully. The point I want to make from this slide is nobody has ever done the study to compare the survival rates of jumping of a plane with and without a parachute. Study's never been done, okay? Never been done, okay? But yet, okay, it's an obvious exaggeration and intuitive. I think there are many things that we do that make intuitive sense and even though there may not be a good randomized RCT out there that supports what we do, we've got to use common sense. And all too many times that I've seen, you know, looking at med mal cases or looking at patients who have been brought issues up before the State Podiatry Board or looking at case admissions to the Surgery Board and you see something that ended up in a disaster. And you're just going to say, what were you thinking? I mean, where did – what kind of common sense did you use?

So common sense should prevail. This is a patient population that is needy. We have the skills to provide it. We can do wonderful work for this population which is increasing and we will need to give ourselves a big pat on the back for the good work that we do in this area. So –

TAPE ENDS - [27:41]