Efficacy of percutaneous surgery for digital deformities in older patients with comorbidities

Abstract

Introduction

Percutaneous forefoot surgery is a minimally invasive surgical technique with the advantages of lower morbidity and earlier recovery by allowing immediate weight bearing. These benefits represent an ideal indication for older patients with high comorbidity. This study presents the functional outcomes of this surgical technique in a series of patients with these characteristics at a tertiary-level university hospital.

Methodology

A retrospective observational study of a case series of patients who underwent this minimally invasive technique between 2022 and 2023. Epidemiological variables were collected, and the outcomes were analysed based on three parameters: resolution of ulcers, disappearance of keratoses, and the ability to wear shoes. The complete resolution of all three parameters evaluated was considered satisfactory, two resolved was acceptable, and the persistence of two or more was unsatisfactory. Given the characteristics of the series collected, only clinical follow-up was performed, with no radiological follow-up in any case.

Results

The first 30 cases operated on were collected. They had a mean age of 82.8 years and an average follow-up of 6.57 months, sufficient to evaluate medium-term postoperative results. The results were satisfactory in 83 % of cases. Half of the patients had two or more comorbidities—type 2 diabetes mellitus being the most prevalent—and the higher the number of comorbidities, the greater the risk of an unsatisfactory outcome. Surgical complications were few and mostly mild, affecting only 33 % of patients (10 cases). Those with ulcers before surgery presented the worst outcomes.

Conclusions

Percutaneous forefoot surgery for severe digital deformities in older patients with high comorbidity is an ideal minimally invasive technique with good functional outcomes and an acceptable percentage of complications.

Level of evidence

IV. Type of study: Case series.

1 Introduction

Digital deformities of the lesser toes (claw, hammer or mallet toes) are very common in daily practice and generally well tolerated, however, they can have a major functional impact with difficulty in independent ambulation, wearing regular footwear and the development of ulcers and infections ^,^, , especially in frail patients with associated comorbidities. In this group of patients, poor skin condition and compromised vascularisation of the toes are common, hence traditional techniques (open surgery) are excessively aggressive, leading to an increased risk of complications such as scarring problems, surgical wound dehiscence or infection ^, .

In recent years, the growing interest in minimally invasive surgery (MIS) has led to a radical transformation of many procedures in orthopaedics and traumatology of the foot and ankle ^,^, . Percutaneous forefoot surgery was first developed by podiatrists in the United States more than 50 years ago. However, it was quickly abandoned, probably due to a lack of solid theoretical or practical learning foundations. Nevertheless, the work initiated by Stephen Isham in the United States and expanded in Spain by Mariano de Prado and Pau Golano provided valuable knowledge and contributed to laying the anatomical and technical foundations for this type of surgery ^, . This contributed to its rapid expansion in Europe, and later Latin America and, more recently, the United States. An important milestone in the history of MIS was the creation of MIFAS (Minimally Invasive Foot and Ankle Society) in 2004 . The advantages of this type of surgery are mainly lower morbidity and earlier recovery by allowing immediate weight bearing, which makes it an ideal procedure in patients with high comorbidity ^, , however, surprisingly, we did not find in the literature any scientific article presenting the results of this technique in this subgroup of patients especially fragile, which is the premise of the research question of this work .

Table 1

Summary of the data.

Age (M±SD)	82.80 ± 4.73
Follow-up (M±SD)	6.57 ± 2.37
	N	%
Number of toes
f1	1	3.3
3	10	33.3
4	19	63.3
Results
Satisfactory	25	83.3
Acceptable	3	10.0
Unsatisfactory	2	6.7
Sex
Female	25	83.3
Male	5	16.7
Complications
Yes	10	33.0
Diabetes
Yes	15	50.0
Peripheral venous insufficiency
Yes	8	26.7
Peripheral arterial insufficiency
Yes	6	20.0
Dementia
Yes	12	40.0
No. of comorbidities
1	15	50.0
2	8	26.7
3	5	16.7
4	2	6.7
Clinical presentation
UL	5	16.7
K	6	20.0
UL/S	5	16.7
K/S	12	40.0
UL/K	2	6.7

M, mean; SD, standard deviation; UL, deformity ulcer; K, untreatable keratosis due to deformity; S, unable to wear shoes.

Table 2

Parameters according to result, n (%).

	Satisfactory	Acceptable	Unsatisfactory
Age (M±SD)	83.28 ± 4.89	79.67 ± 4.04	81.50 ± 2.12
Tracking (M±SD)	6.04 ± 2.13	9.00 ± 0.0	9.50 ± 3.56
Number of toes	25 (100.0)	3 (100.0)	2 (100.0)
– 1	1 (4.0)	0 (0.0)	0 (0.0)
– 3	8 (32.0)	0 (0.0)	1 (50.0)
– 4	16 (64.0)	3 (100.0)	1 (50.0)
Sex	25 (100.0)	3 (100.0)	2 (100.0)
-Female	21 (84.0)	2 (66.7)	2 (100.0)
-Male	4 (16.0)	1 (33.3)	0 (0.0)
Diabetes	25 (100.0)	3 (100.0)	2 (100.0)
-No	12 (48.0)	2 (66.7)	1 (50.0)
-Yes	13 (52.0)	1 (33.3)	1 (50.0)
Venous insufficiency	25 (100.0)	3 (100.0)	2 (100.0)
-No	18 (72.0)	2 (66.7)	2 (100.0)
-Yes	7 (28.0)	1 (33.3)	0 (0.0)
Peripheral vascular insufficiency	25 (100.0)	3 (100.0)	2 (100.0)
-No	22 (88.0)	2 (66.7)	0 (0.0)
-Yes	3 (12.0)	1 (33.3)	2 (100.0)
Dementia	25 (100.0)	3 (100.0)	2 (100.0)
-No	14 (56.0)	2 (66.7)	2 (100.0)
-Yes	11 (44.0)	1 (33.3)	0 (0.0)
No. of comorbidities	25 (100.0)	3 (100.0)	2 (100.0)
– 1	12 (48.0)	2 (66.7)	1 (50.0)
– 2	7 (28.0)	0 (0.0)	1 (50.0)
– 3	4 (16.0)	1 (33.3)	0 (0.0)
– 4	2 (8.0)	0 (0.0)	0 (0.0)
Clinical presentation	25 (100.0)	3 (100.0)	2 (100.0)
-UL	4 (16.0)	0 (0.0)	1 (50.0)
– K	4 (16.0)	2 (66.7)	0 (0.0)
– UL/S	4 (16.0)	0 (0.0)	1 (50.0)
– K/S	11 (44.0)	1 (33.3)	0 (0.0)
– UL/K	2 (8.0)	0 (0.0)	0 (0.0)
Complications	25 (100.0)	3 (100.0)	2 (100.0)
-No	22 (89.0)	0 (0.0)	0 (0.0)
-Yes	3 (11.0)	4 (100.0)	3 (100.0)

M, mean; SD, standard deviation; UL, deformity ulcer; K, untreatable keratosis due to deformity; S, unable to wear shoes.

The objective of this study is to present the functional outcomes of percutaneous forefoot surgery in a series of older patients with high associated comorbidity operated on in a tertiary-level hospital .

Table 3

Sample results.

	Age		Sex		ASA classification		Comorbidities		No. of toes		Clinical presentation*		Result**	Complications		Follow-up (months)
1	78		F		3		Diabetes, Venous insufficiency		4		UL/S		+	Resolved partial wound necrosis		18
2	82		F		3		Diabetes Alzheimer’s dementia		3		K/S		+			6
3	81		F		3		Diabetes Dementia		4		K/S		+			6
4	83		F		3		Rheumatoid arthritis		4		K/S		+			6
5	79		F		2		Peripheral arterial insufficiency		4		K/S		+/-	Residual pain		9
6	91		F		3		Diabetes Dementia		4		K		+			6
7	84		M		3		Diabetes Dementia		4		K		+/-	Partially resolved keratosis		9
8	86		M		3		Venous insufficiency		4		K		+			6
9	81		F		3		Venous insufficiency		4		K/S		+			6
10	82		M		3		Diabetes, Dementia, Venous insufficiency		4		K		+			6
11	76		F		3		Peripheral arterial insufficiency		4		K		+			3
12	89		F		3		Diabetes, Venous insufficiency Dementia		4		K/S		+			3
13	83		F		3		Diabetes, peripheral arterial insufficiency, Dementia		4		UL		–	Deep infection: amputation of two toes.		12
14	80		F		3		Peripheral arterial insufficiency		3		UL/S		–	Deep infection resolved		18
15	79		F		3		Arterial insufficiency, diabetes		4		UL		+			3
16	84		F		3		Diabetes, hypertension, ischemic heart disease		4		UL		+			3
17	81		F		3		Diabetes Dementia		3		K/S		+			6
18	77		M		3		Venous insufficiency, ischemic heart disease, COPD, hypertension.		4		K/S		+			3
19	76		F		3		Venous insufficiency, type 2 diabetes, Alzheimer’s dementia		4		K		+/-	Partially resolved keratosis		9
20	91		F		III		Poorly controlled diabetes, Blindness, Hypertension		3		UL		+			22
21	82		F		III		Moderate arterial insufficiency, Type 1 diabetes		4		UL/K/S		+			19
22	79		F		III		Nephropathy on dialysis, Type I diabetes, COPD, Moderate senile dementia		3		UL/S		+			11
23	85		F		III		Diabetes, COPD		1		UL		+			29
24	82		F		III		Hypertension, Systemic lupus, type 2 diabetes		4		K/S		+			18
25	79		F		III		Venous insufficiency, type 1 diabetes		3		K/S		+			31
25	93		F		III		Alzheimer’s dementia, bedridden		3		K/S		+			21
27	77		F		III		Hypertension, rheumatoid arthritis, senile dementia		4		K/S		+			18
28	89		F		III		Kidney transplant, Type 2 diabetes		3		UL/K/S		+			41
29	90		F		III		Hypertension, type 1 diabetes, COPD.		4		UL/S		+			23
30	85		M		III		Smoker, COPD, hypertension, stroke sequelae.		3		UL/S		+			28
Main Complications (6)
Age		Sex		ASA classification		Comorbidities		No. of toes		Clinical presentation*		Result**			Complications		Follow-up (months)
78		F		3		Diabetes. Venous insufficiency		4		UL/S		+			Resolved partial wound necrosis		18
79		F		2		Peripheral arterial insufficiency		4		K/S		+/-			Residual pain		9
84		M		3		Diabetes		4		K		+/-			Partially resolved keratosis		9
83		F		3		Diabetes, peripheral arterial insufficiency		4		UL		–			Deep infection: amputation of two toes.		12
80		F		3		Peripheral arterial insufficiency		3		UL/S		–			Deep infection, resolved		18
76		F		3		Venous insufficiency		4		K		+/-			Partially resolved keratosis		9