Grambart Geriatric Foot and Ankle Pathology 2024-1.pdf

Geriatric Foot and Ankle Pathology Sean T. Grambart DPM FACFAS Assistant Dean of Clinical Affairs Attending Faculty, IMMC Foot and Ankle Surgical Residency Program Past-President, American College of Foot and Ankle Surgeons AO Trauma Fellow IOMA - UPPER MIDWEST OSTEOPATHIC HEALTH CONFERENCE 2020 1 O...

Geriatric Foot and Ankle Pathology Sean T. Grambart DPM FACFAS Assistant Dean of Clinical Affairs Attending Faculty, IMMC Foot and Ankle Surgical Residency Program Past-President, American College of Foot and Ankle Surgeons AO Trauma Fellow IOMA - UPPER MIDWEST OSTEOPATHIC HEALTH CONFERENCE 2020 1 Objectives Demonstrate knowledge of pathological conditions that affect the geriatric with the aging process Understand treatments for the infections/skin pathology Demonstrate knowledge of vascular disease 2 2 Plan… 3 3 Elective 4 4 Achilles Insertional Calcification Posterior Achilles Insertion Calcification 5/5 Muscle Strength Tendinosis with minimal erythema 5 5 Radiographic Examination 6 6 7 7 8 8 Ankle Arthritis 9 9 ESAA: A Unique Disease Etiology of arthritis Adjacent deformity Surrounding joint disease Age of the patient Expectations of treatment 10 10 Knee Arthritis: 10 OA Most is primary OA: Post traumatic OA – 9.8% Non-PTOA – 90.2% Brown et al, JOT 2006 Primary OA – 94% CJRR 2006-7 11 11 Ankle Arthritis: Trauma Most is post traumatic: PTOA – 79.5% Non-PTOA – 20.5% ❖ Brown et al, JOT 2006 ✓ PTOA – 78% ✓ Non-PTOA – 22% ❖ Valderrabano et al, CORR 2008 12 12 Traditional- Ankle Arthrodesis Advantage is access Both malleoli visible Better joint take down than lateral If congruent deformity tibial osteotomy easier 13 13 Ankle Arthrodesis 14 14 Flat Cut with Deformity Correction 15 15 Total Ankle Replacements ❖ Pros ❖ ROM closer to the normal ankle ❖ Provides a painless, plantigrade , stable foot ❖ Decreased chance of adjacent joint arthritis ❖ Viable intermediate solution prior to fusion ❖ Cons ❖ Polyethylene wear ❖ Talar subsidence ❖ Early failure rates ❖ Insurance reimbursement (implant) 16 16 Who is NOT the ideal patient? Neuroarthropathy Charcot Ischemia AVN of the talus Previous infection Severe malalignment Neuropathy Neuromuscular disorders 17 17 18 18 19 19 Non-Elective 20 20 Bacterial Infection Usually caused by Staph and Group A Strep species Cellulitis-infection of subcutaneous tissue Erysipelas-infection of dermis and upper subcutaneous tissue Distinct border Treatment Ladder?? 21 Circle the area Without “Open” Wound Topical Ineffective Oral Antibiotics Keflex, Clindamycin, Bactrim 21 Bacterial Infection No Abscess/Open Wounds Treatment Circle the area Topicals Ineffective Oral Antibiotics Keflex, Clindamycin, Bactrim 22 Circle the area Without “Open” Wound Topical Ineffective Oral Antibiotics Keflex, Clindamycin, Bactrim 22 Treatment of Lower Extremity Ulcers 23 What is a skin ulcer? A wound with complete loss of the epidermal layer of skin with extension into the dermis and possibly the subcutaneous tissues 24 24 Impact of Ulcerations “Foot ulcerations is the most common single precursor to lower extremity amputations among persons with diabetes.” JFAS, Diabetic Foot Disorders, Clinical Practice Guidelines 25 25 Wound Considerations Type of wound Arterial Venous Stasis Neuropathic Acute versus Chronic Limb Threatening versus non-limb threatening 26 26 Prevalence of PAD in the US 16 Prevalence (Millions) 14 12 13 8–12 10 8 PAD currently affects 8–12 million Americans. By 2050, the prevalence is expected to reach 19 million. 6 4 5.4 2 0 Stroke PAD CHD* CHD = coronary heart disease. PAD = peripheral arterial disease. * Includes myocardial infarction and angina pectoris. American Heart Association. Heart Disease and Stroke Statistics—2005 Update. 2005. 27 27 Common Sites of Claudication – Macro-vessel Disease Primary sites of involvement in symptomatic patients: Abdominal aorta and iliac arteries (30%) Femoral and popliteal arteries (80-90%) Obstruction in Aorta or iliac artery Ischemia in Buttock, hip, thigh Femoral artery or branches Thigh, calf Popliteal artery or distal Calf, ankle, foot Tibial and peroneal (40-50%) More in elderly and DM 28 Common 28 Diagnosis of PAD - Algorithm Risk Factor Identification Clinical Suspicion/Presentation ABI Measurement/TcPO2 Doppler, Duplex CTA/MRA Contrast Angiography 29 29 Non-invasive Tests- ABI Ankle-Brachial Index Ankle systolic blood pressure / Brachial SBP Technique Normal ABI 1-1.3 Borderline 0.91-0.99 Abnormal < 0.9 ABI >1.3 = non compressible artery (i.e. calcified) The lower the ABI, the less distance and lower speed in walking Ankle SBP