Postoperative Infection Rates Diabetic Patients Undergoing Foot and Ankle Surgery

NewsBot · Nov 20, 2013

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Trends in Postoperative Infection Rates and Their Relationship to Glycosylated Hemoglobin Levels in Diabetic Patients Undergoing Foot and Ankle Surgery.
Jupiter DC, Humphers JM, Shibuya N.
J Foot Ankle Surg. 2013 Nov 15.

The association of hyperglycemia with postoperative infectious complications after foot and ankle surgery has been well studied. However, many surgeons in their current practice use the somewhat arbitrary cutoff of 7% glycosylated hemoglobin (HbA1c) as the level above which surgery is considered unsafe and conducive to complications. Our goal in the present study was to assess the relationship between the HbA1c levels and the rate of postoperative infection to begin to determine whether 7% is a suitable cutoff or whether this level needs to be reevaluated. Furthermore, we were interested in the general trends relating to the infection rates and preoperative HbA1c levels. Our preliminary, subjective, analysis has indicated that infection rates increase steadily as the HbA1c increases toward 7.3%, increase rapidly at an HbA1c of 7.3% to 9.8%, and then level off. Additional study is warranted to better understand the role played by other covariates in determining the infection rate and to investigate whether patient selection has influenced the appearance of decreased infection rates at high HbA1c levels. Additional study could also assess similar relationships for other types of complication, such as nonunion, and perhaps examine different foot and ankle procedures in isolation.
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Admin2 · Nov 20, 2013

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NewsBot · Jul 2, 2015

Perioperative Glycemic Control and the Effect on Surgical Site Infections in Diabetic Patients Undergoing Foot and Ankle Surgery
David Sadoskas, DPM; Natalie C. Suder, MPH; Dane K. Wukich, MD
Foot Ankle Spec June 30, 2015

Introduction. Diabetes mellitus is one of the leading causes of hyperglycemia in the perioperative setting. Hyperglycemia has been shown to cause increased risk of surgical site infections (SSIs) in multiple surgical specialties, but to our knowledge it has not been investigated for orthopaedic foot and ankle surgery. The aim of this study was to determine if hyperglycemia increased the rate of SSI in elective, diabetic patients that required perioperative hospitalization.
Methods. A total of 348 consecutive inpatients after foot and ankle surgery were retrospectively evaluated. Patients who had a random serum glucose ≥200 mg/dL during the admission (Group 1) were compared to patients whose serum glucose never exceeded 200 mg/dL (Group 2).
Results. Our 2 groups were similar with regard to age, gender, and body mass index. Twenty-one of 176 patients (11.9%) whose serum glucose was ≥200 mg/dL during the admission developed an SSI as compared to 9 of 172 patients (5.2%) whose serum glucose remained <200 mg/dL (odds ratio = 2.45; 95% confidence interval = 1.09-5.52;, P = .03).
Discussion. Perioperative hyperglycemia ≥200 mg/dL is associated with increased rates of SSI after foot and ankle surgery. Communication with medical consultants is paramount in an effort to improve perioperative glycemic management and reduce the rate of SSI.
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NewsBot · Apr 3, 2016

Topically Applied Vancomycin Powder Reduces the Rate of Surgical Site Infection in Diabetic Patients Undergoing Foot and Ankle Surgery
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Fu? & Sprunggelenk; 3 April 2016
(no abstract)

NewsBot · May 20, 2017

Hemoglobin A1c as a Predictor of Postoperative Infection Following Elective Forefoot Surgery
Jourdan M. Cancienne, MD, Minton T. Cooper, MD, Kevin A. Laroche, MD, Dirk W. Verheul, BS, Brian C. Werner, MD
Foot & Ankle International May 15, 2017

Background:
There remains little evidence to support a perioperative hemoglobin A1c (HbA1c) level that could serve as a threshold for a significantly increased risk of postoperative surgical site infection (SSI) following forefoot surgery.

Methods:
A national database was queried for patients who underwent elective forefoot surgery with diabetes. Patients with a perioperative HbA1c level within 3 months of surgery were identified and stratified based on HbA1c level in 0.5 mg/dL increments. The incidence of SSI was determined by either a diagnosis or procedure for SSI within 1 year and a receiver operating characteristic (ROC) curve and area under the curve (AUC) analysis was performed to determine an optimal threshold value of HbA1c.

Results:
A total of 4630 patients who underwent forefoot surgery with diabetes with a perioperative HbA1c were included. The rate of SSI ranged from 2.3% to 11.8%. The inflection point of the ROC curve corresponded to an HbA1c level above 7.5 mg/dL (P < .0001; 95% confidence interval [CI] = 0.58-0.67; AUC = 0.631; specificity = 75%; sensitivity = 46%). After multivariate analysis, patients with an HbA1c level of 7.5 mg/dL or greater had a significantly higher risk for postoperative wound infection compared to patients below this threshold (OR = 1.92; 95% CI = 1.5-2.4; P < .0001).

Conclusions:
The risk of postoperative SSI following forefoot surgery increased as the perioperative HbA1c increased. ROC analysis determined that a perioperative HbA1c above 7.5 mg/dL could serve as a threshold for a significantly increased risk of postoperative SSI following forefoot surgery.
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NewsBot · Jun 28, 2017

The Association of Perioperative Glycemic Control with Postoperative Surgical Site Infection Following Elective Foot Surgery in Patients with Diabetes
Jourdan Cancienne, MD, Minton Cooper, MD, Brian Werner, MD
Foot & Ankle Orthopaedics June 23, 2017

Introduction/Purpose:
Diabetes mellitus has been associated with an increased risk for postoperative surgical site infection (SSI) following foot and ankle surgery; however, among patients with diabetes, the level of perioperative glycemic control may affect the risk of postoperative SSI. There remains little evidence to support a perioperative hemoglobin A1c (HbA1c) level that could serve as a threshold for a significantly increased risk of postoperative SSI following foot surgery. The primary goal of the present study was to evaluate the association of perioperative glycemic control as demonstrated by hemoglobin a1c (HbA1c) in patients with diabetes with the incidence of postoperative SSI following elective foot surgery. Our secondary objective was to calculate a threshold level of HbA1c above which the risk of postoperative SSI after foot surgery increases significantly in patients with diabetes.

Methods:
A national administrative database was queried for patients who underwent common elective foot surgeries, including hallux valgus corrections, hallux rigidus correction and hammertoe corrections among others. Patients who underwent more complex procedures and patients with concomitant hindfoot procedures were excluded. Patients with diabetes mellitus who had a perioperative HbA1c level recorded within 3 months of surgery were identified; and were then stratified into thirteen mutually exclusive groups based on their hemoglobin a1c in 0.5 mg/dl increments from < 5.49 mg/dl to > 11.5 mg/dl. The incidence of SSI was determined by either a diagnosis or procedure for SSI within 1 year postoperatively using CPT and ICD-9 codes, and was calculated for each HbA1c patient group. A receiver operating characteristic (ROC) analysis was performed to determine an optimal threshold value of the HbA1c above which the risk of postoperative SSI was significantly increased.

Results:
4,744 patients who underwent forefoot surgery with diabetes and a perioperative HbA1c recorded within 3 months of surgery in the database were included in the study. The rate of deep SSI requiring irrigation and debridement within one year postoperatively stratified by HbA1c is pictured in Figure 1, which ranged from a low of 2.5% to a high of 11.8% and was significantly correlated with increasing HbA1c levels (P < 0.0001). The results of ROC analysis determined that the inflection point of the ROC curve corresponded to an HbA1c level above 7.5 mg/dL (P < 0.0001, AUC = 0.622, spec. = 75%, sens. = 44%).

Conclusion:
The risk of postoperative SSI following elective foot surgery in patients with diabetes mellitus increases significantly as the perioperative HbA1c increases. ROC analysis determined that a perioperative HbA1c above 7.5 mg/dL could serve as a threshold for a significantly increased risk of postoperative SSI following elective foot surgery.
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NewsBot · Jan 17, 2022

Incidence and risk factors for poor perioperative blood glucose management in patients with diabetic foot: a retrospective study
Xia Chen et al
2021 Dec;10(12):12300-12309

Background: Diabetic foot (DF) is one of the most serious complications of diabetes mellitus (DM). In some cases of DF, life-saving amputation is necessary. This study set out to investigate the situation of preoperative blood glucose management in patients with DF.

Methods: A retrospective study was performed in two centers between January 2015 and June 2018. Adult patients who received surgical treatment for DF, including amputation, debridement, and flap or skin graft, were included. Demographic and clinical data of the patients were collected. All patients were followed up for at least 3 years, until June 2021. The study outcomes included postoperative mortality, and the incidences of postoperative renal impairment, surgical infection, complete wound closure within 3 months, and reamputation. Univariable and multivariable logistic regression analyses were performed to determine the risk factors for adverse outcomes and poor blood glucose management. Kaplan-Meier curves were generated to compare survival between patients with different preoperative levels of blood glucose.

Results: This study included 268 patients with DF, who were divided into four groups: normal (n=72), hyperglycemia (n=95), hypoglycemia (n=44), and mixed (n=57). Total mortality was much higher in the hyperglycemia, hypoglycemia, and mixed groups than in the normal group (P=0.030, 0.009, and 0.014, respectively). The incidences of surgical infection, complete wound closure within 3 months, and reamputation were significantly higher in the hyperglycemia, hypoglycemia, and mixed groups than in the normal group. Older age and a longer duration of DM were confirmed to be important risk factors for hyperglycemia, hypoglycemia, and mixed hyperglycemia and hypoglycemia. Having higher levels of glycosylated hemoglobin (HbA1c) and creatinine and a lower level of albumin was identified as a risk factor for hyperglycemia, hypoglycemia, or mixed hyperglycemia and hypoglycemia.

Conclusions: This study emphasizes the importance of perioperative blood glucose management for patients with DF and provides a basis for blood glucose management of these patients in the future.
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NewsBot · Jan 19, 2022

Incidence and risk factors for poor perioperative blood glucose management in patients with diabetic foot: a retrospective study.
Chen X et al
Annals of Palliative Medicine, 01 Dec 2021, 10(12):12300-12309

Background
Diabetic foot (DF) is one of the most serious complications of diabetes mellitus (DM). In some cases of DF, life-saving amputation is necessary. This study set out to investigate the situation of preoperative blood glucose management in patients with DF.
Methods
A retrospective study was performed in two centers between January 2015 and June 2018. Adult patients who received surgical treatment for DF, including amputation, debridement, and flap or skin graft, were included. Demographic and clinical data of the patients were collected. All patients were followed up for at least 3 years, until June 2021. The study outcomes included postoperative mortality, and the incidences of postoperative renal impairment, surgical infection, complete wound closure within 3 months, and reamputation. Univariable and multivariable logistic regression analyses were performed to determine the risk factors for adverse outcomes and poor blood glucose management. Kaplan-Meier curves were generated to compare survival between patients with different preoperative levels of blood glucose.
Results
This study included 268 patients with DF, who were divided into four groups: normal (n=72), hyperglycemia (n=95), hypoglycemia (n=44), and mixed (n=57). Total mortality was much higher in the hyperglycemia, hypoglycemia, and mixed groups than in the normal group (P=0.030, 0.009, and 0.014, respectively). The incidences of surgical infection, complete wound closure within 3 months, and reamputation were significantly higher in the hyperglycemia, hypoglycemia, and mixed groups than in the normal group. Older age and a longer duration of DM were confirmed to be important risk factors for hyperglycemia, hypoglycemia, and mixed hyperglycemia and hypoglycemia. Having higher levels of glycosylated hemoglobin (HbA1c) and creatinine and a lower level of albumin was identified as a risk factor for hyperglycemia, hypoglycemia, or mixed hyperglycemia and hypoglycemia.
Conclusions
This study emphasizes the importance of perioperative blood glucose management for patients with DF and provides a basis for blood glucose management of these patients in the future.
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