Foot and Ankle Surgery in the Diabetic Population

Incidence and associated factors of surgical site infection in patients undergoing foot and ankle surgery: a 7-year cohort study

Surgical site infections (SSI) constitute 31% of all hospital-acquired conditions, with ankle and foot surgical procedures showing an incidence of SSI ranging from 0.5% to 6.5%. This study aimed to assess the incidence of both superficial and deep surgical site infections in foot and ankle surgery, along with associated factors. Conducted as a retrospective cohort study, it included 2180 patients undergoing foot and ankle surgery in a private hospital between 2014 and 2020, encompassing elective and trauma cases. Outcome variables comprised SSI, while predictor variables encompassed sex, age, diabetes mellitus, systemic arterial hypertension, smoking, American Society of Anesthesiologists (ASA) score, and body mass index. Logistic regression models were employed to identify associations between study variables. The incidence of surgical site infections stood at 4% (83/2180), comprising a rate of 2.8% (57/2180) for superficial infections and 1.2% (26/2180) for deep infections. Smoking (OR 2.9, 95%CI 1.4-5.3) and ASA score >2 (OR 3.4, 95%CI 1.2-8.4) emerged as independent factors associated with surgical site infections. The group with deep infections exhibited higher proportions of smokers (p = 0.002), systemic arterial hypertension (p = 0.018), trauma surgery (p = 0.049), and an ASA score >2 (p = 0.011). Overall infection incidence in this cohort reached 4%, with trauma cases, smoking, hypertension, and an ASA score >2 independently linked to deep infections. Surgeons should be cognizant of these risk factors when managing prophylactic antibiotic regimens for patients.

Preoperative and Perioperative Management of Diabetics Undergoing Elective Foot and Ankle Surgery

Diabetics are a highly comorbid population with an elevated risk profile when undergoing surgery. Proper preparation and management of modifiable risk factors can optimize outcomes in diabetics. A multidisciplinary approach to preoperative optimization, including surgeons, primary care providers, and anesthesiologists, ensures diabetic patients receive comprehensive evaluation before elective surgery. Orthopedic surgeons must understand preoperative optimization goals as they pertain to nutrition, glycemic control, and cardiovascular disease in diabetic patients.

Swefoot - The Swedish national quality register for foot and ankle surgery

BACKGROUND

Population-based register data could be used to improve our knowledge of patients surgically treated for foot and ankle disorders. The quality register Swefoot was recently created to collect surgical and patient-reported data of foot and ankle surgery. This manuscript aims to describe the development and current use of the register.

METHODS

The development of Swefoot started in 2014 and currently, data on 16 different diagnoses are collected in 49 units performing foot and ankle surgery. Registrations are performed by the surgeon and the patient.

RESULTS

Between 2014 and 2020 approximately 20,000 surgical procedures have been registered. 75.1% of the registered patients were women, 9.3% were smokers, 9.3% had a concomitant rheumatoid disease, and 18.4% a BMI larger than 30 kg/m²_. CONCLUSIONS: The Swefoot is a unique national register for foot and ankle surgery. It is by now possible to present demographic, surgical, and outcome parameters based on Swefoot.

Managing Acute Fore- and Midfoot Fractures in Patients with Diabetes

Few is investigated about the management of acute fore- and midfoot injuries in diabetics. With well controlled diabetes, indications and techniques are similar to non-diabetics. With poorly controlled diabetes, medical optimization should be exercised. Stable internal fixation in case of surgical treatment and prolonged offloading independent of the choice of treatment are advised. With manifest Charcot neuroarthropathy, the goal is to achieve a plantigrade, stable foot that is infection- and ulcer-free and ambulant with orthopaedic shoes. If operative treatment is chosen, the concept of superconstructs in combination with prolonged protection in a well-padded total contact cast is applied.

Diabetic Kidney Disease Is Associated With Increased Complications Following Operative Management of Ankle Fractures

Background:

Diabetes mellitus and peripheral neuropathy are established risk factors for complications in operatively treated ankle fractures. Generally, the presence of peripheral neuropathy and diabetic nephropathy have been used as independent variables in studies of diabetic ankle fracture cohorts but are typically treated as binary risk factors. Our purpose was to quantify the effects of risk factors on complication rate specific to diabetic patients undergoing ankle fracture fixation.

Methods:

We identified 617 rotational ankle fractures treated operatively at a single academic medical center from 2010 to 2019, of which 160 were identified as diabetic. Of these, 91 ankle fractures in 90 diabetic patients met criteria for retrospective review of clinical and radiographic data. Criteria included perioperative laboratory studies, including glycated hemoglobin (HbA1c) and estimated glomerular filtration rate (eGFR), as well as follow-up radiographs in the electronic record. We defined complications in this surgical cohort as deep surgical site infection, unplanned return to the operating room, and failure of fixation. Logistic regression was performed and odds ratios (ORs) calculated.

Results:

The overall complication rate was 28.6% (26/91) in this cohort. Median follow-up was 29 weeks (range: 5-520 weeks). Mean perioperative HbA1c in patients who experienced postoperative complications was 7.6% (range: 5.1%-14.2%) compared with 7.8% (range: 5.6%-13.5%) who did not ( P = .69). Diabetic patients with chronic kidney disease (eGFR <60 mL/min per body surface area) (OR 5.29, P = .006) and peripheral neuropathy (OR 4.61, P = .003) were at significantly higher risk of all complications compared with diabetic patients without these comorbidities. Of note, we did not find an association between perioperative HbA1c or body mass index and complication rate.

Conclusion:

Patients with diabetes complicated by chronic kidney disease are at significantly higher risk of complications following operative management of ankle fractures. Our study also corroborated previous reports that within this high-risk cohort, the presence of peripheral neuropathy is a significant risk factor for complications. These sequalae of diabetic disease are manifestations of microvascular disease, glycosylation of soft tissues, and impaired metabolic pathways. Identifying these risk factors in diabetic patients allows for patient-specific risk stratification, education, and management decisions of ankle fractures.

Level of Evidence:

Level III, retrospective cohort study.

A systematic review of ankle fracture treatment modalities in diabetic patients

AIM

This systematic review evaluated the surgical outcomes of various ankle fracture treatment modalities in patients with Diabetes Mellitus as well as the methodological quality of the studies.

METHODS

For our review, four online databases were searched: PubMed, MEDLINE (Clarivate Analytics), CINAHL (Cumulative Index to Nursing and Allied Health) and Web of Science (Clarivate Analytics). The overall methodological quality of the studies was assessed with the Coleman Methodology Score. Data regarding diabetic ankle fractures were pooled into three outcomes groups for comparison: (1) the standard fixation cohort with management of diabetic ankle fractures using ORIF with small or mini fragment internal fixation techniques following AO principles, (2) the minimally invasive cohort with diabetic ankle fracture management utilizing percutaneous cannulated screws or intramedullary fixation, and (3) the combined construct cohort treated with a combination of ORIF and another construct (transarticular or external fixation).

RESULTS

The search strategy identified 2228 potential studies from the four databases and 11 were included in the final review. Compared to the standard fixation cohort, the minimally invasive cohort had increased risk of hardware breakage or migration and the combined constructs cohort had increased risk of hardware breakage or migration, surgical site infection and nonunion. Limb salvage rates were similar for the standard fixation and minimally invasive cohorts; however, the combined constructs cohort had a significantly lower limb salvage rate compared to that of the standard fixation cohort. The mean Coleman Methodology Score indicated the quality of the studies in the review was poor and consistent with its limitations.

DISCUSSION

The overall quality of published studies on operative treatment of diabetic ankle fractures is low. Treating diabetic ankle fractures operatively results in a high number of complications regardless of fixation method. However, limb salvage rates remain high overall at 97.9% at a mean follow-up of 21.7 months. To achieve improved limb salvage rates and decrease complications, it is critical is to follow basic AO principles, respect the soft tissue envelope or utilize minimally invasive techniques, and be wary that certain combined constructs may be associated with higher complication rates.

LEVEL OF EVIDENCE

2.

Prevention of Infection in Foot and Ankle Surgery

The literature for prevention of surgical infection related primarily to foot and ankle surgery is sparse, with most attention on total joint replacement and abdominal surgery. Attention should be paid to preoperative, intraoperative, and postoperative elements, which can have an effect on the development of postoperative infection. Although antibiotic prophylaxis typically is discussed in isolation, inclusion of this step into the process enhances the overall evaluation of surgery with respect to infection. This evolution provides for better patient outcomes and decreases the likelihood of an infection incurred after foot and ankle surgery.