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Jardel HV, Keil AP, Martin CL, Richardson DB, Stenzel MR, Stewart PA, Christenbury KE, Engel LS, Sandler DP. Oil spill cleanup related exposures to benzene, toluene, ethylbenzene, xylenes, and n-hexane and incident diabetes mellitus. ENVIRONMENTAL RESEARCH 2025; 276:121487. [PMID: 40154786 DOI: 10.1016/j.envres.2025.121487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2024] [Revised: 03/04/2025] [Accepted: 03/25/2025] [Indexed: 04/01/2025]
Abstract
BACKGROUND AND OBJECTIVES Exposure to benzene, toluene, ethylbenzene, xylenes, and n-hexane (BTEX-H) may contribute to the development of diabetes. Oil spill response and cleanup (OSRC) workers are exposed to BTEX-H but there are few relevant studies. We studied incident diabetes over 10 years of follow-up among OSRC workers. METHODS This analysis includes 21,726 participants (82.2 % male, mean age 39.9 years; 66.5 % White race) in the Gulf Long-term Follow-up Study - a prospective cohort of Deepwater Horizon (DWH) oil spill OSRC workers followed from 2011 to 2013 through 2021. Individual estimates of cumulative work-related exposures to specific BTEX-H chemicals and an aggregate sum (total BTEX-H) were derived from a job-exposure matrix that linked exposure group estimates derived from exposure measurements to self-reported DWH work histories. We used Cox models to estimate associations of quartiles of exposure to individual BTEX-H chemicals and total BTEX-H with diabetes incidence. We used quantile-based g-computation, quantifying associations with exposure to the BTEX-H chemicals, treating them as separate components in a mixture. We examined differences in associations by neighborhood disadvantage using the Area Deprivation Index (ADI) and by self-classified race in stratified analyses. RESULTS Exposure to the BTEX-H chemicals was associated with diabetes, with elevated hazard ratios for third and fourth quartiles of exposure compared to the first quartile. For example, total BTEX-H, Q3 and Q4 HRs were 1.10 95 %CI (0.91, 1.33) and 1.27 95 %CI (1.05, 1.53), respectively. The HR associated with a three-quartile increase in the BTEX-H mixture was 1.31 95 %CI (1.07, 1.59). Stratified analyses showed little variation by race and suggestions of variation by ADI. CONCLUSION Exposures to BTEX-H chemicals were associated with incident diabetes among OSRC workers for the individual BTEX-H chemicals, total BTEX-H, and the BTEX-H mixture. The range of exposures in this study make these findings relevant to other low to moderate exposure settings.
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Affiliation(s)
- Hanna V Jardel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA.
| | - Alexander P Keil
- Occupational and Environmental Epidemiology Branch, National Cancer Institute Division of Cancer Epidemiology and Genetics, Bethesda, MD, USA
| | - Chantel L Martin
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - David B Richardson
- Department of Environmental and Occupational Health, Program in Public Health, University of California, Irvine, CA, USA
| | - Mark R Stenzel
- Exposure Assessment Applications, LLC, Arlington, VA, USA
| | | | | | - Lawrence S Engel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Dale P Sandler
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
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Pei X, Song Y. Standardized operating room nursing care is effective in preventing the occurrence of surgical wound infections. Am J Transl Res 2025; 17:1125-1134. [PMID: 40092092 PMCID: PMC11909554 DOI: 10.62347/mlli7876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Accepted: 01/16/2025] [Indexed: 03/19/2025]
Abstract
OBJECTIVE To analyze the clinical effectiveness of standardized operating room nursing care in preventing wound infections from orthopedic surgery. METHODS A total of 128 patients requiring orthopedic surgery were selected and divided into a control group and an observation group in accordance with the nursing care they received during surgery, with 64 patients in each group. Patients in the control group received conventional operating room nursing care, while those in the observation group received standardized operating room nursing care. The post-operative outcomes of patients in both groups, including wound healing rates, nursing management clinical indicators, incidence rates of wound infections and infection-associated complications, patients' mastery of infection-associated knowledge, patients' quality of life, and their satisfaction degree towards nursing care, were compared between groups. RESULTS Patients in the observation group showed a significantly higher wound healing rate compared to those in the control group (P < 0.01). The nursing management clinical indicators, such as the time to first eating and first ambulation after surgery, and the duration of hospital stay were all significantly shorter in the observation group than those in the control group (all P < 0.01). The incidence of postoperative wound infections in the observation group was 0.00%, which was significantly lower than the 21.88% observed in the control group (P < 0.001). After nursing care, the quality of life scores of patients in the observation group were significantly better than those in the control group (P < 0.01). The study also found that the overall satisfaction of patients in the observation group was 98.44%, significantly higher than 84.38% observed in the control group (χ2 = 27.349, P < 0.001). CONCLUSION Standardized operating room nursing care is an effective way to prevent the occurrence of surgical wound infections. This kind of care helps patients establish healthy lifestyles and assists in improving relevant clinical indicators, which is worthy of being promoted in clinical settings.
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Affiliation(s)
- Xuelei Pei
- Department of Surgical Anesthesiology, XD GROUP HOSPITAL Xi'an 710082, Shaanxi, China
| | - Yingming Song
- Operating Room, Shaanxi Provincial Tumor Hospital Xi'an 710061, Shaanxi, China
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Farnham C, Liu IZ, Agarwal AR, Parel P, Quan T, Durand WM, Raad M, Jain A. Preoperative Risk Assessment for Lumbar Fusion in Patients With Diabetes: Data-Driven Stratification of HbA1c and Same Day Glucose Levels that Predict 90-Day Complication Rates. Global Spine J 2025:21925682251315098. [PMID: 39829428 PMCID: PMC11748129 DOI: 10.1177/21925682251315098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2025] Open
Abstract
STUDY DESIGNS Retrospective Database Analysis. OBJECTIVES Pre-operative glycemic control in diabetic patients undergoing lumbar fusion (LF) is essential for evaluating complication risk. However, current thresholds for preoperative HbA1c and same-day-glucose (SDG) are either non-specific or have low predictive power. This study uses HbA1c and SDG to provide data-driven risk stratification for 90-day major and wound complications in LF patients. METHODS Using a national database, patients undergoing LF from 2013-2022 with a recorded preoperative HbA1c and SDG level were included for analysis. Multiple HbA1c and SDG strata were identified using stratum specific likelihood ratio analysis (SSLR). Each stratum was then propensity-score matched to the lowest strata and compared using risk ratios. Significance level was set at a P-value <0.05. RESULTS 12,026 patients met inclusion criteria. For 90-day major complications, SSLR identified 3 predictive HbA1c (4.5-5.4, 5.5-7.9, and 8.0+) and SDG strata (60-159, 160-239, and 240+). Following propensity-matching, the 90-day major complication risk sequentially increased for HbA1c: 5.5-7.9 (1.69; P = 0.001; 95% CI 1.24-2.30), 8.0+(2.31; P < 0.001; 95% CI 1.56-3.43). Following propensity-matching, the SDG strata similarly demonstrated sequentially increasing 90-day major complication risk: 160-239 (1.34; P < 0.001; 95% CI 1.18-1.54), 240+ (1.64; P < 0.001; 95% CI 1.31-2.05). Matched analysis demonstrated a higher relative-risk of 90-day wound complications for the 8.0+ HbA1c strata (2.23; P = 0.001; 95% CI 1.37-3.63) compared to the HbA1c 4.5-5.4 strata. No other strata were identified that predicted differences in 90-day wound complications. CONCLUSIONS This study identified data-driven HbA1c and SDG strata that better risk-stratify 90-day major complications following LF. Instead of current single-value thresholds, these multiple strata may be utilized for better preoperative guidance.
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Affiliation(s)
- Chloe Farnham
- Department of Orthopaedic Surgery, The Medical College of Georgia, Augusta, GA, USA
| | - Ivan Z. Liu
- Department of Orthopaedic Surgery, The Medical College of Georgia, Augusta, GA, USA
| | - Amil R. Agarwal
- Department of Orthopaedic Surgery, Johns Hopkins University, GA, USA
| | - Philip Parel
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA
| | - Theodore Quan
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA
| | - Wesley M. Durand
- Department of Orthopaedic Surgery, Johns Hopkins University, GA, USA
| | - Michael Raad
- Department of Orthopaedic Surgery, Johns Hopkins University, GA, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins University, GA, USA
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Conover BM, Johnson MJ, Frykberg RG, Raspovic KM, Wukich DK. Post-operative outcomes of talus fracture open reduction internal fixation in patients with diabetes mellitus. J Foot Ankle Surg 2025; 64:61-66. [PMID: 39288843 DOI: 10.1053/j.jfas.2024.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 07/23/2024] [Accepted: 09/07/2024] [Indexed: 09/19/2024]
Abstract
Little is known regarding outcomes of talus fracture management among patients with diabetes mellitus. This study aimed to compare post-operative outcomes after open reduction and internal fixation for talus fracture in patients with complicated diabetes, uncomplicated diabetes, and patients without diabetes. We used the PearlDiver database to identify patients who underwent operative repair of talus fractures from 2009 to 2021. Complications were evaluated at 30-days, 90-days, and 1 year of surgery. As we performed multiple separate analyses, to minimize the risk of type 1 error we employed the Bonferroni correction for statistical significance (p< 0.017). The PearlDiver identified 5,232 patients with talus fracture that underwent open reduction internal fixation. Stratified by diabetes status, the "complicated diabetes," "uncomplicated diabetes," and "no diabetes" groups contained 223, 418, and 4591 patients, respectively. Reoperation, acute kidney injury, and myocardial infarction were increased among diabetes patients compared to non-diabetes patients, irrespective of diabetes severity within 3 months of surgery. Furthermore, patients with complicated diabetes were more likely to develop sepsis and wound disruption compared to their non-diabetes counterparts within 3 months. While not statistically significant, complicated diabetes patients were diagnosed with talar non-union at higher rates compared with non-diabetes patients. Further analysis may reveal a clinically significant discrepancy in non-union between these groups. Complicated diabetes is associated with significantly higher risk of multiple adverse events following talus fracture repair.
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Affiliation(s)
- Benjamin M Conover
- University of Texas Southwestern Medical School, 1801 Inwood Road, Dallas, TX 75390, USA.
| | - Matthew J Johnson
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Cao S, Sun Y, Li S, Ma X, Wang C, Wang X. Efficacy of forefoot scrubbing with bristled brush during foot and ankle surgery. Foot Ankle Surg 2024:S1268-7731(24)00266-2. [PMID: 39689985 DOI: 10.1016/j.fas.2024.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2024] [Revised: 11/23/2024] [Accepted: 12/10/2024] [Indexed: 12/19/2024]
Abstract
BACKGROUND The utility of forefoot cleaning using bristled brush has been proposed by previous studies but has not been tested in any study. The aim of the current study is to investigate the antiseptic efficacy of additional forefoot scrubbing with bristled brush after a standard 2-step preparation with alcohol and chlorhexidine in foot and ankle surgery. METHODS One hundred patients underwent foot and ankle surgery by one orthopedic surgeon were included and categorized into one of two groups of different skin preparation procedure before surgery. Group 1 is the control group which received a standard 2-step preparation with alcohol and chlorhexidine. Group 2 is the forefoot scrubbing group which received a standard preparation with alcohol and chlorhexidine and an additional forefoot scrubbing in a sterile fashion. Positive culture results and microbe species were primary outcomes. A secondary outcome was the occurrence of any surgical site infection (SSI) 12 months following surgery. RESULTS The hallux nail fold positive rate of the forefoot scrubbing group was significantly lower than that of the control group after draping (forefoot scrubbing group, 0 %; control group, 12 %; p = 0.027) and after surgery (forefoot scrubbing group, 6 %; control group, 28 %; p = 0.003). The microbe species of hallux nail fold after surgery included Staphylococcus, coagulase negative, Staphylococcus aureus, Staphylococcus epidermidis, Micrococcus luteus, Neisseria, and Corynebacterium afermentans. There was no difference in the rate of SSI between the forefoot scrubbing group (10 %) and the control group (6 %). CONCLUSION Forefoot scrubbing with bristled brush before foot and ankle surgery reduces microbe growth rate after draping and after surgery at hallux nail fold. LEVEL OF EVIDENCE Level II, prospective cohort study.
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Affiliation(s)
- Shengxuan Cao
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuan Sun
- Department of Nursing, Huashan Hospital, Fudan University, Shanghai, China
| | - Shirong Li
- Department of Laboratory Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Ma
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China; Shanghai Sixth People's Hospital, Shanghai, China
| | - Chen Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China; Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - Xu Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China.
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Pallod S, Aguilera Olvera R, Ghosh D, Rai L, Brimo S, DeCambra W, Sant HG, Ristich E, Singh V, Abedin MR, Chang N, Yarger JL, Lee JK, Kilbourne J, Yaron JR, Haydel SE, Rege K. Skin repair and infection control in diabetic, obese mice using bioactive laser-activated sealants. Biomaterials 2024; 311:122668. [PMID: 38908232 PMCID: PMC11562812 DOI: 10.1016/j.biomaterials.2024.122668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 06/13/2024] [Indexed: 06/24/2024]
Abstract
Conventional wound approximation devices, including sutures, staples, and glues, are widely used but risk of wound dehiscence, local infection, and scarring can be exacerbated in these approaches, including in diabetic and obese individuals. This study reports the efficacy and quality of tissue repair upon photothermal sealing of full-thickness incisional skin wounds using silk fibroin-based laser-activated sealants (LASEs) containing copper chloride salt (Cu-LASE) or silver nanoprisms (AgNPr-LASE), which absorb and convert near-infrared (NIR) laser energy to heat. LASE application results in rapid and effective skin sealing in healthy, immunodeficient, as well as diabetic and obese mice. Although lower recovery of epidermal structure and function was seen with AgNPr-LASE sealing, likely because of the hyperthermia induced by laser and presence of this material in the wound space, this approach resulted in higher enhancement in recovery of skin biomechanical strength compared to sutures and Cu-LASEs in diabetic, obese mice. Histological and immunohistochemical analyses revealed that AgNPr-LASEs resulted in significantly lower neutrophil migration to the wound compared to Cu-LASEs and sutures, indicating a more muted inflammatory response. Cu-LASEs resulted in local tissue toxicity likely because of effects of copper ions as manifested in the form of a significant epidermal gap and a 'depletion zone', which was a region devoid of viable cells proximal to the wound. Compared to sutures, LASE-mediated sealing, in later stages of healing, resulted in increased angiogenesis and diminished myofibroblast activation, which can be indicative of lower scarring. AgNPr-LASE loaded with vancomycin, an antibiotic drug, significantly lowered methicillin-resistant Staphylococcus aureus (MRSA) load in a pathogen challenge model in diabetic and obese mice and also reduced post-infection inflammation of tissue compared to antibacterial sutures. Taken together, these attributes indicate that AgNPr-LASE demonstrated a more balanced quality of tissue sealing and repair in diabetic and obese mice and can be used for combating local infections, that can result in poor healing in these individuals.
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Affiliation(s)
- Shubham Pallod
- Center for Biomaterials Innovation and Translation, Biodesign Institute, Arizona State University, USA; Biological Design Graduate Program, School for Engineering of Matter, Transport, and Energy, Arizona State University, USA
| | - Rodrigo Aguilera Olvera
- Center for Bioelectronics and Biosensors, Biodesign Institute, Arizona State University, USA
| | - Deepanjan Ghosh
- Biological Design Graduate Program, School for Engineering of Matter, Transport, and Energy, Arizona State University, USA
| | - Lama Rai
- Center for Biomaterials Innovation and Translation, Biodesign Institute, Arizona State University, USA; College of Health Solutions, Arizona State University, USA
| | - Souzan Brimo
- Center for Biomaterials Innovation and Translation, Biodesign Institute, Arizona State University, USA; Biomedical Engineering, School for Biological and Health Systems Engineering, Arizona State University, USA
| | | | - Harsh Girish Sant
- Center for Biomaterials Innovation and Translation, Biodesign Institute, Arizona State University, USA; Chemical Engineering, School for Engineering of Matter, Transport, and Energy, Arizona State University, USA
| | - Eron Ristich
- School of Molecular Sciences, Arizona State University, USA; School of Computing and Augmented Intelligence, Arizona State University, USA
| | - Vanshika Singh
- Center for Biomaterials Innovation and Translation, Biodesign Institute, Arizona State University, USA; Biomedical Engineering, School for Biological and Health Systems Engineering, Arizona State University, USA
| | - Muhammad Raisul Abedin
- Center for Biomaterials Innovation and Translation, Biodesign Institute, Arizona State University, USA
| | - Nicolas Chang
- Center for Biomaterials Innovation and Translation, Biodesign Institute, Arizona State University, USA; Biomedical Engineering, School for Biological and Health Systems Engineering, Arizona State University, USA
| | | | - Jung Keun Lee
- Departments of Pathology and Population Medicine, Midwestern University, College of Veterinary Medicine, 5725 West Utopia Rd., Glendale, AZ, 85308, USA
| | | | - Jordan R Yaron
- Center for Biomaterials Innovation and Translation, Biodesign Institute, Arizona State University, USA
| | - Shelley E Haydel
- Center for Bioelectronics and Biosensors, Biodesign Institute, Arizona State University, USA; School of Life Sciences, Arizona State University, 501 E. Tyler Mall ECG 303, Tempe, AZ, 85287-6106, USA
| | - Kaushal Rege
- Center for Biomaterials Innovation and Translation, Biodesign Institute, Arizona State University, USA; Biological Design Graduate Program, School for Engineering of Matter, Transport, and Energy, Arizona State University, USA; Chemical Engineering, School for Engineering of Matter, Transport, and Energy, Arizona State University, USA.
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Nathe K, Bakaes Y, Giakas AM, Kung J, Gauthier C, Grabowski G, Smoker B, Boguski J, Toole W, Elliott M, Van Eck CF, Bowman E, Townsend C, Jackson JB. Open Ankle Fractures in Older Individuals: A Multi-center Study. J Foot Ankle Surg 2024; 63:631-636. [PMID: 38909963 DOI: 10.1053/j.jfas.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 05/06/2024] [Accepted: 06/08/2024] [Indexed: 06/25/2024]
Abstract
The purpose of this study is to identify demographics, etiology, comorbidities, treatment, complications, and outcomes for older patients with open ankle fractures. Patients ≥60 years old who sustained an open ankle fracture between January 1, 2004 and March 31, 2014 at 6 Level 1 trauma centers were retrospectively reviewed. Univariate analysis using chi-squared or Student's t test was performed to identify associations between preoperative variables and 2 postoperative outcomes of interest: amputation and 1-year mortality. Multivariate analysis was performed using stepwise logistical regression to identify independent predictors of postoperative amputation and 1-year mortality. Of the 162 total patients, the most common mechanism of injury was a ground-level fall (51.9%). The most common fracture types were bimalleolar fractures (52.5%) followed by trimalleolar fractures (26.5%), with 41.5% of the fractures classified as Gustilo Anderson Classification Type 2 and 38.6% classified as Type 3A. The average number of surgeries required per patient was 2.1. Complications included: 15.4% superficial infection rate, 9.9% deep infection rate, and 9.3% amputation rate. The 1-year mortality rate was 13.6% and the overall mortality rate was 25.9%. Male gender and fracture type were found to be independent predictors for amputation after surgery (p = .009, .005, respectively). Older age and having diabetes were independent predictors for 1-year mortality after surgery (p = .021, .005 respectively). Overall, open ankle fractures in older individuals were associated with high rates of amputation and mortality.
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Affiliation(s)
- Kristen Nathe
- Prisma Health Midlands Department of Orthopaedic Surgery, Columbia, SC
| | - Yianni Bakaes
- University of South Carolina School of Medicine Columbia, Columbia, SC.
| | - Alec M Giakas
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Justin Kung
- Prisma Health Midlands Department of Orthopaedic Surgery, Columbia, SC
| | - Chase Gauthier
- Prisma Health Midlands Department of Orthopaedic Surgery, Columbia, SC
| | - Gregory Grabowski
- Prisma Health Midlands Department of Orthopaedic Surgery, Columbia, SC
| | - Brice Smoker
- University of South Carolina School of Medicine Columbia, Columbia, SC
| | | | - William Toole
- University of Florida College of Medicine, Jacksonville, FL
| | - Mark Elliott
- University of Florida College of Medicine, Jacksonville, FL
| | | | - Erik Bowman
- University of Nebraska Medical Center, Omaha, NE
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Jahn J, Ehlen QT, Kaplan L, Best TM, Meng Z, Huang CY. Interplay of Glucose Metabolism and Hippo Pathway in Chondrocytes: Pathophysiology and Therapeutic Targets. Bioengineering (Basel) 2024; 11:972. [PMID: 39451348 PMCID: PMC11505586 DOI: 10.3390/bioengineering11100972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Revised: 09/24/2024] [Accepted: 09/24/2024] [Indexed: 10/26/2024] Open
Abstract
In this review, we explore the intricate relationship between glucose metabolism and mechanotransduction pathways, with a specific focus on the role of the Hippo signaling pathway in chondrocyte pathophysiology. Glucose metabolism is a vital element in maintaining proper chondrocyte function, but it has also been implicated in the pathogenesis of osteoarthritis (OA) via the induction of pro-inflammatory signaling pathways and the establishment of an intracellular environment conducive to OA. Alternatively, mechanotransduction pathways such as the Hippo pathway possess the capacity to respond to mechanical stimuli and have an integral role in maintaining chondrocyte homeostasis. However, these mechanotransduction pathways can be dysregulated and potentially contribute to the progression of OA. We discussed how alterations in glucose levels may modulate the Hippo pathway components via a variety of mechanisms. Characterizing the interaction between glucose metabolism and the Hippo pathway highlights the necessity of balancing both metabolic and mechanical signaling to maintain chondrocyte health and optimal functionality. Furthermore, this review demonstrates the scarcity of the literature on the relationship between glucose metabolism and mechanotransduction and provides a summary of current research dedicated to this specific area of study. Ultimately, increased research into this topic may elucidate novel mechanisms and relationships integrating mechanotransduction and glucose metabolism. Through this review we hope to inspire future research into this topic to develop innovative treatments for addressing the clinical challenges of OA.
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Affiliation(s)
- Jacob Jahn
- University of Miami Miller School of Medicine, Miami, FL 33136, USA; (J.J.); (Q.T.E.); (L.K.); (T.M.B.); (Z.M.)
| | - Quinn T. Ehlen
- University of Miami Miller School of Medicine, Miami, FL 33136, USA; (J.J.); (Q.T.E.); (L.K.); (T.M.B.); (Z.M.)
| | - Lee Kaplan
- University of Miami Miller School of Medicine, Miami, FL 33136, USA; (J.J.); (Q.T.E.); (L.K.); (T.M.B.); (Z.M.)
- Department of Orthopedics, University of Miami, Miami, FL 33136, USA
- UHealth Sports Medicine Institute, University of Miami, Miami, FL 33136, USA
| | - Thomas M. Best
- University of Miami Miller School of Medicine, Miami, FL 33136, USA; (J.J.); (Q.T.E.); (L.K.); (T.M.B.); (Z.M.)
- Department of Orthopedics, University of Miami, Miami, FL 33136, USA
- UHealth Sports Medicine Institute, University of Miami, Miami, FL 33136, USA
| | - Zhipeng Meng
- University of Miami Miller School of Medicine, Miami, FL 33136, USA; (J.J.); (Q.T.E.); (L.K.); (T.M.B.); (Z.M.)
- Department of Molecular and Cellular Pharmacology, Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Chun-Yuh Huang
- UHealth Sports Medicine Institute, University of Miami, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL 33146, USA
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Argyropoulos M, Wynell-Mayow W, Johnson O, Faroug R, Johal KS, Deol RS, Hakmi A, Mordecai S. Charcot neuro-osteoarthropathy: a review of key concepts and an evidence-based surgical management algorithm. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2024; 5:1344359. [PMID: 39219847 PMCID: PMC11362032 DOI: 10.3389/fcdhc.2024.1344359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 07/17/2024] [Indexed: 09/04/2024]
Abstract
Charcot neuro-osteoarthropathy (CNO), mainly as a result of diabetic neuropathy, is a complex problem which carries significant morbidity, and is an increasing burden on healthcare as demographics change globally. A multi-disciplinary team (MDT) is necessary to treat the multiple facets of this disease. The multifactorial and non-homogenous nature of this condition and its management, has prevented the development of comprehensive guidelines based on level 1 evidence. Although there is a trend to surgically treat these patients in tertiary centres, the increasing prevalence of CNO necessitates the capability of all units to manage this condition to an extent locally. This article conducted a thorough literature search of Pubmed and Embase from 2003 to 2023 including the following search terms; "Charcot" "neuroarthropathy" "diabetic foot" "management" "surgery" "treatment" "reconstruction". The results of this review have been summarised and synthesised into an evidence-based algorithm to aid in the surgical decision-making process, and improve the understanding of surgical management by the whole MDT.
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Affiliation(s)
| | - William Wynell-Mayow
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
- Imperial College Healthcare NHS Trust, Faculty of Medicine, Imperial College London, Stevenage, United Kingdom
| | - Oscar Johnson
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
| | - Radwane Faroug
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
| | | | | | - Atef Hakmi
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
| | - Simon Mordecai
- East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
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Shouman M, Brabant M, Rehman N, Ahmed S, Shahid RK. Perioperative Management of Patients with Diabetes and Cancer: Challenges and Opportunities. Cancers (Basel) 2024; 16:2821. [PMID: 39199594 PMCID: PMC11353093 DOI: 10.3390/cancers16162821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Revised: 08/08/2024] [Accepted: 08/08/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Both diabetes and cancer are major global health issues that are among the leading causes of morbidity and mortality. There is a high prevalence of diabetes among cancer patients, many of whom require a surgical procedure. This review focuses on the operative complications in patients with diabetes and cancer, and the perioperative management of diabetes in cancer patients. METHODOLOGY A literature search of articles in English-published between January 2010 and May 2024-was carried out using the databases PubMed, MEDLINE, Google Scholar, and the Cochrane Database of Systematic Reviews. The search primarily focused on the operative complications in patients with diabetes and cancer, and perioperative management strategies. RESULTS The relationship between cancer and diabetes is complex; cancer patients have a high risk of developing diabetes, while diabetes is a risk factor for certain cancers. In addition, various cancer therapies can induce or worsen diabetes in susceptible patients. Many individuals with cancer and diabetes require surgery, and due to underlying diabetes, they may have elevated risks for operative complications. Optimal perioperative management for these patients includes managing perioperative glycemia and other comorbid illnesses, adjusting diabetic and cancer treatments, optimizing nutrition, minimizing the duration of fasting, supporting early mobilization, and providing patient education to enable self-management. CONCLUSIONS While evidence is limited, optimal perioperative management for patients with both diabetes and cancer is necessary in order to reduce surgical complications. Future studies are needed to develop evidence-informed perioperative strategies and improve outcomes for these patients.
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Affiliation(s)
- Mohamed Shouman
- Saskatchewan Cancer Agency, Regina, SK S4W 0G3, Canada
- Department of Oncology, University of Saskatchewan, Saskatoon, SK S7N 4H4, Canada
- Department of Medical Oncology, National Cancer Institute, Cairo 11796, Egypt
| | - Michelle Brabant
- Department of Medicine, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada
| | - Noor Rehman
- College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada
| | - Shahid Ahmed
- Saskatchewan Cancer Agency, Regina, SK S4W 0G3, Canada
- Department of Oncology, University of Saskatchewan, Saskatoon, SK S7N 4H4, Canada
| | - Rabia K. Shahid
- Department of Medical Oncology, National Cancer Institute, Cairo 11796, Egypt
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11
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Ahluwalia R, Wek C, Lewis TL, Stringfellow TD, Coffey D, Tan SP, Edmonds M, Meloni M, Reichert ILH. Surgical Management of Complex Ankle Fractures in Patients with Diabetes: A National Retrospective Multicentre Study. J Clin Med 2024; 13:3949. [PMID: 38999511 PMCID: PMC11242888 DOI: 10.3390/jcm13133949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/03/2024] [Accepted: 07/02/2024] [Indexed: 07/14/2024] Open
Abstract
Objectives: Patients with ankle fractures associated with diabetes experience more complications following standard open reduction-internal fixation (ORIF) than those without diabetes. Augmented fixation strategies, namely extended ORIF and hindfoot nails (HFNs), may offer better results and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, we aimed to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes, including early post-operative weightbearing and surgical complications. Methods: A national multicentre retrospective cohort study was conducted between January and June 2019 in 56 centres (10 major trauma centres and 46 trauma units) in the United Kingdom; 1360 patients with specifically defined complex ankle fractures were enrolled. The patients' demographics, fixation choices and surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with and without diabetes. Results: There were 316 patients in the diabetes cohort with a mean age of 63.9 yrs (vs. 49.3 yrs. in the non-diabetes cohort), and a greater frailty score > 4 (24% vs. 14% (non-diabetes cohort) (p < 0.03)); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% an HFN, compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p < 0.02), but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications compared to non-diabetes patients, even though early-weightbearing rates were greater than for standard-ORIF. Conclusions: Ankle fractures in diabetes occur in older, frailer patients, whilst lower-than-expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weightbearing without increasing complications, in keeping with modern guidelines in ankle fracture management.
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Affiliation(s)
- Raju Ahluwalia
- Diabetic Foot Clinic, Kings College Hospital, London SE5 9RS, UK
- Department of Orthopaedics, Kings College Hospital, Bessemer Road, London SE5 9RS, UK
- The HARnT Collaborative King's College Hospital, London SE5 9RS, UK
| | - Caeser Wek
- Department of Orthopaedics, Kings College Hospital, Bessemer Road, London SE5 9RS, UK
- The HARnT Collaborative King's College Hospital, London SE5 9RS, UK
| | - Thomas Lorchan Lewis
- Department of Orthopaedics, Kings College Hospital, Bessemer Road, London SE5 9RS, UK
- The HARnT Collaborative King's College Hospital, London SE5 9RS, UK
| | - Thomas David Stringfellow
- Department of Orthopaedics, Kings College Hospital, Bessemer Road, London SE5 9RS, UK
- The HARnT Collaborative King's College Hospital, London SE5 9RS, UK
| | - Duncan Coffey
- Department of Orthopaedics, Kings College Hospital, Bessemer Road, London SE5 9RS, UK
- The HARnT Collaborative King's College Hospital, London SE5 9RS, UK
| | - Sze Ping Tan
- Department of Orthopaedics, Kings College Hospital, Bessemer Road, London SE5 9RS, UK
- The HARnT Collaborative King's College Hospital, London SE5 9RS, UK
| | - Michael Edmonds
- Diabetic Foot Clinic, Kings College Hospital, London SE5 9RS, UK
- The HARnT Collaborative King's College Hospital, London SE5 9RS, UK
| | - Marco Meloni
- Department of Diabetic Foot Unit, University of Tor Vergata, 00133 Roma, Italy
| | - Ines L H Reichert
- Department of Orthopaedics, Kings College Hospital, Bessemer Road, London SE5 9RS, UK
- The HARnT Collaborative King's College Hospital, London SE5 9RS, UK
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12
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Johnson MJ, Conover BM, Frykberg RG, Raspovic KM, Lavery LA, Wukich DK. Outcomes of open reduction and internal fixation of calcaneus fractures: A database study comparing patients with and without diabetes. Wound Repair Regen 2024; 32:437-444. [PMID: 38516794 DOI: 10.1111/wrr.13169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/22/2024] [Accepted: 02/11/2024] [Indexed: 03/23/2024]
Abstract
Treatment of calcaneal fractures in patients with diabetes mellitus (DM) is challenging. The purpose of this study was to compare post-operative outcomes after open reduction and internal fixation (ORIF) for calcaneus fracture in patients with complicated DM, uncomplicated DM, and patients without DM. A commercially available de-identified database was queried for all calcaneus fracture diagnoses undergoing ORIF from 2010 to 2021. The patients were separated into three groups for analysis: patients without DM (10,951, 82.6%), uncomplicated DM (1,500, 11.3%) and complicated DM (802, 6.1%). At 1 year, post-operative adverse events were assessed among the three groups. The odds of adverse event(s) for each group were compared between the three groups with and without characteristic matching. In the unmatched cohorts, patients with complicated DM, when compared with patients without DM and patients with uncomplicated DM, had significantly higher rates of all adverse events with exception of DVT. Rates of CNA were significantly higher in patients with complicated DM compared with no DM (OR 107.7 (CI 24.83-467.6) p < 0.0001) and uncomplicated DM (OR 44.26 (CI 3.86-507.93) p = 0.0002). After matching, non-union, AKI, sepsis, surgical site infection, and wound disruption were higher in patients with complicated DM compared with patients without DM. There were no significant differences in the three groups with regard to reoperation, DVT, MI, pneumonia, or below the knee amputation. Patients with DM who underwent ORIF for calcaneus fracture experienced higher rates of post-operative adverse events compared with those patients without DM.
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Affiliation(s)
- Matthew J Johnson
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | | | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lawrence A Lavery
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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13
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Suh YM, Fisher M, Hu D, Lin FC, Wukich D, Tennant J, Lalli T. Serum Fructosamine as an Indicator of Perioperative Complications in Patients Undergoing Foot and Ankle Surgery. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241263093. [PMID: 39086381 PMCID: PMC11289794 DOI: 10.1177/24730114241263093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024] Open
Abstract
Background Patients with poor glycemic control are at increased risk of postoperative complications. Hemoglobin A1c (HbA1c) has traditionally been used to assess preoperative glycemic control, but with limitations. More recently, fructosamine has been tested preoperatively in patients undergoing elective total joint arthroplasty. This study aims to assess whether preoperative serum fructosamine can be used to avoid adverse outcomes in patients undergoing foot and ankle surgery. Methods This was a retrospective chart review of all patients who underwent foot and ankle surgeries at 2 level 1 trauma centers from January 2020 to December 2021. Of those, 305 patients were tested for HbA1c and fructosamine levels preoperatively. Adverse outcomes were assessed over 30 and 90 days. Outcomes of interest were surgical site infection, wound dehiscence, unplanned return to the operating room, unplanned readmission, and death. Data were analyzed using independent 2-sample t tests. A mixed effects model was used for multivariate analysis. P values less than .05 were considered statistically significant. Results Preoperative serum fructosamine was significantly higher (P = .029) in those with complications within 90 days compared to those without. The mean preoperative fructosamine level was 269.2 µmol/L (SD = 58.85) in those who did have a complication vs 247.2 µmol/L (SD = 53.95) in those who did not. Clinically significant fructosamine threshold was determined using 2 different methods. Fructosamine was found to be non-inferior to HbA1c in accurately predicting postoperative complications. Conclusion Fructosamine is a serum marker that reflects nearer term glycemic control than HbA1c. Elevation in preoperative fructosamine is associated with increased perioperative complications after foot and ankle surgery within 90 days. Preoperative fructosamine may be used in patient optimization and risk stratification when determining candidacy and timing for elective foot and ankle surgeries. Level of evidence Level III, retrospective cohort study.
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Affiliation(s)
- Yu Min Suh
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Margaret Fisher
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Di Hu
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Feng-Chang Lin
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Dane Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Josh Tennant
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Trapper Lalli
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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14
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Shah AA, Devana SK, Lee C, SooHoo NF. A predictive algorithm for perioperative complications and readmission after ankle arthrodesis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1373-1379. [PMID: 38175277 DOI: 10.1007/s00590-023-03805-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/02/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE Ankle arthrodesis is a mainstay of surgical management for ankle arthritis. Accurately risk-stratifying patients who undergo ankle arthrodesis would be of great utility. There is a paucity of accurate prediction models that can be used to pre-operatively risk-stratify patients for ankle arthrodesis. We aim to develop a predictive model for major perioperative complication or readmission after ankle arthrodesis. METHODS This is a retrospective cohort study of adult patients who underwent ankle arthrodesis at any non-federal California hospital between 2015 and 2017. The primary outcome is readmission within 30 days or major perioperative complication. We build logistic regression and ML models spanning different classes of modeling approaches, assessing discrimination and calibration. We also rank the contribution of the included variables to model performance for prediction of adverse outcomes. RESULTS A total of 1084 patients met inclusion criteria for this study. There were 131 patients with major complication or readmission (12.1%). The XGBoost algorithm demonstrates the highest discrimination with an area under the receiver operating characteristic curve of 0.707 and is well-calibrated. The features most important for prediction of adverse outcomes for the XGBoost model include: diabetes, peripheral vascular disease, teaching hospital status, morbid obesity, history of musculoskeletal infection, history of hip fracture, renal failure, implant complication, history of major fracture. CONCLUSION We report a well-calibrated algorithm for prediction of major perioperative complications and 30-day readmission after ankle arthrodesis. This tool may help accurately risk-stratify patients and decrease likelihood of major complications.
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Affiliation(s)
- Akash A Shah
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 76-116 CHS, Los Angeles, CA, 90095, USA.
| | - Sai K Devana
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 76-116 CHS, Los Angeles, CA, 90095, USA
| | - Changhee Lee
- Department of Artificial Intelligence, Chung-Ang University School of Software and Computer Engineering, Seoul, South Korea
| | - Nelson F SooHoo
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 76-116 CHS, Los Angeles, CA, 90095, USA
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15
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Han X, Chu F, Jia D, Gao M, Zhang R, Zhang X, Wang H. Wound complication risk factors following open reduction and internal fixation of ankle fractures. Int Wound J 2024; 21:e14581. [PMID: 38112250 PMCID: PMC10961896 DOI: 10.1111/iwj.14581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/06/2023] [Indexed: 12/21/2023] Open
Abstract
This study was designed to identify risk factors for wound complications including surgical site infection (SSI) and wound healing issues following open reduction and internal fixation (ORIF) of ankle fractures. A retrospective analysis of individuals with ankle fractures treated with ORIF was undertaken. Study subjects were divided into a wound complications (WC) group and a no wound complication (NWC) group. The WC group was further divided into an SSI group and wound healing issues group. Twenty-one potential risk factors associated with wound complications after ORIF were tracked. Uni- and multivariate binary logistical regression analyses were used to identify risk factors associated with wound complications, ISS and wound healing issues. In total, 613 individuals, who had undergone surgery for ankle fractures formed the study cohort. The incidence of postoperative wound complications was 10.3% (63 cases), including 5.2% of SSI (32 cases) and 5.1% of wound healing issues (31 cases). The independent risk factors for wound complications were age 65 years or older, preoperative serum albumin level below 35 g/L, peripheral neuropathy, open fracture, fewer than seven cases per year in surgical volume, and attending surgeon level. The independent risk factors for SSI were age 65 years or older, preoperative serum albumin level below 35 g/L, open fracture and fewer than seven cases per year in surgical volume. The independent risk factors for wound healing issues were preoperative serum albumin level below 35 g/L, peripheral neuropathy, open fracture and attending surgeon level. Herein we found both factors inherent to the injury and individual and those pertaining to the surgical team affected the frequency of wound complications after ORIF of ankle fractures. Specifically, advanced age and low surgical volume were associated with a greater risk of SSI. Peripheral neuropathy and the low expertise level on the part of the surgeon were associated with a greater risk of wound healing issues. Hypoproteinaemia and open fracture were both associated with a greater risk of both SSI and wound healing issues.
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Affiliation(s)
- Xiuguo Han
- Department of Emergency SurgeryAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Fenglong Chu
- Department of Orthopedic TraumaAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Dailiang Jia
- Department of Emergency SurgeryAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Ming Gao
- Department of Orthopedic TraumaAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Rui Zhang
- Department of Orthopedic TraumaAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Xu Zhang
- Department of Emergency SurgeryAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Haibin Wang
- Department of Emergency SurgeryAffiliated Hospital of Jining Medical UniversityJiningChina
- Department of Orthopedic TraumaAffiliated Hospital of Jining Medical UniversityJiningChina
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16
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Lazzarini PA, Raspovic KM, Meloni M, van Netten JJ. A new declaration for feet's sake: Halving the global diabetic foot disease burden from 2% to 1% with next generation care. Diabetes Metab Res Rev 2024; 40:e3747. [PMID: 37997627 DOI: 10.1002/dmrr.3747] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/25/2023]
Abstract
The 1989 Saint Vincent Declaration established a goal of halving global diabetes-related amputation rates. A generation later, this goal has been achieved for major but not minor amputations. However, diabetic foot disease (DFD) is not only a leading cause of global amputation but also of hospitalisation, poor quality of life (QoL) and disability burdens. In this paper, we review latest estimates on the global disease burden of DFD and the next generation care of DFD that could reduce this burden. We found DFD causes 2% of the global disease burden. This makes DFD the 13th largest of 350+ leading conditions causing the global disease burden, and much larger than dementia, breast cancer and type 1 diabetes. Neuropathy without ulcers and amputations makes up the largest portion of the global DFD burden yet receives the least DFD focus. Future care focussed on improving safe physical activity in people with DFD could considerably reduce the DFD burden, as this incorporates increasing physical fitness and QoL, while simultaneously decreasing ulceration and other risks. Charcot neuro-osteoarthropathy is more prevalent than previously thought. Most cases respond well to non-removable offloading devices, but surgical intervention may further reduce the considerable burden of these neuropathic fracture dislocations. Ischaemia is becoming more common and complex. Most cases respond well to revascularisation interventions, but novel revascularisation techniques, medical management and autologous cell therapies may hold the key to more cases responding in the future. We conclude that DFD causes a global disease burden larger than most conditions and existing guideline-based care and next generation treatments can reduce this burden. We suggest the World Health Organization and International Diabetes Federation declare a new goal: halving the global DFD burden from 2% to 1% within the next generation.
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Affiliation(s)
- Peter A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Marco Meloni
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, The Netherlands
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17
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Aragón-Sánchez J, Víquez-Molina G, López-Valverde ME, Aragón-Hernández C, Aragón-Hernández J, Rojas-Bonilla JM. Outpatient Foot-Sparing Surgery Is Safe in Selected Patients with Diabetic Foot Infections. Adv Skin Wound Care 2024; 37:102-106. [PMID: 38241453 DOI: 10.1097/asw.0000000000000097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
OBJECTIVE To determine if outpatient foot-sparing surgery for patients with diabetic foot infections (DFIs) is associated with a higher rate of treatment failure or longer healing time. METHODS In this prospective observational study, the authors consecutively recruited a cohort of 200 patients with moderate and severe DFIs from the Diabetic Foot Unit of Hospital San Juan de Dios, Caja Costarricense de Seguro Social, San José de Costa Rica, Costa Rica from October 15, 2020 to December 15, 2021. They compared outpatients with those admitted. Cox univariate analysis was performed, with time to treatment failure and time to healing as dependent variables and outpatient management as the independent variable. RESULTS Seventy-one patients underwent surgery on an outpatient basis (35.5%), and 129 (64.5%) were admitted. Sixty of 111 patients (54.1%) with moderate infections were treated as outpatients versus 11 of 89 (12.4%) of those with severe infections. Twelve (16.9%) of the outpatients and 26 (20.2%) of those admitted presented failure (P = .57). The Cox univariate analysis with time to failure of treatment associated with outpatient management reported a hazard ratio of 1.26 (95% CI, 0.64-2.50; P = .50), and the analysis regarding healing time reported a hazard ratio of 0.91 (95% CI, 0.66-1.25; P = .56). CONCLUSIONS Foot-sparing surgery on an outpatient basis was safe in more than half the cases of moderate DFIs, especially in patients with osteomyelitis. This approach is not associated with treatment failure or a longer healing time. Patients with severe infections, penetrating injuries, necrosis, or high inflammatory response and those with peripheral arterial disease who require revascularizations should be admitted to the hospital.
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Affiliation(s)
- Javier Aragón-Sánchez
- Javier Aragón-Sánchez, MD, PhD, is Chief, Department of Surgery and Diabetic Foot Unit and Medical Director, La Paloma Hospital, Las Palmas de Gran Canaria, Spain. Gerardo Víquez-Molina, MD, is Head, Diabetic Foot Unit, Hospital San Juan de Dios, Caja Costarricense de Seguro Social, San José de Costa Rica, Costa Rica. María Eugenia López-Valverde, MD, is Specialist in Endocrinology and Nutrition, Hospital Juan Ramón Jiménez, Huelva, Spain Cristina Aragón-Hernández, MD, is Resident, Geriatrics Service, University Getafe Hospital, Madrid, Spain. Also at La Paloma Hospital, Javier Aragón-Hernández, MD, is Research Fellow, Surgery and Diabetic Foot Unit. José María Rojas-Bonilla, MD, is Physician, Diabetic Foot Unit, Hospital San Juan de Dios, Caja Costarricense de Seguro Social, San José de Costa Rica, Costa Rica
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18
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Zaboli Mahdiabadi M, Farhadi B, Shahroudi P, Mohammadi M, Omrani A, Mohammadi M, Hekmati Pour N, Hojjati H, Najafi M, Majd Teimoori Z, Farzan R, Salehi R. Prevalence of surgical site infection and risk factors in patients after knee surgery: A systematic review and meta-analysis. Int Wound J 2024; 21:e14765. [PMID: 38351472 PMCID: PMC10864688 DOI: 10.1111/iwj.14765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/25/2024] [Accepted: 01/28/2024] [Indexed: 02/16/2024] Open
Abstract
The present systematic review and meta-analysis aimed to determine the prevalence of surgical site infection (SSI) and risk factors in patients after knee surgery. A comprehensive and systematic search was carried out across various international electronic databases, including Scopus, PubMed and Web of Science, as well as Persian electronic databases like Iranmedex and the Scientific Information Database (SID). This search involved the utilization of keywords derived from Medical Subject Headings, such as 'Prevalence', 'Surgical wound infection', 'Surgical site infection' and 'Orthopaedics', spanning from the earliest records up to 1 October 2023. To assess the quality of the included studies, the Appraisal tool for Cross-Sectional Studies (AXIS tool) was utilized. The study encompassed a combined participant pool of 11 028 individuals who underwent knee surgery across seven selected studies. The collective prevalence of SSI in patients who underwent knee surgery, as reported in the seven included studies, was determined to be 3.0% (95% CI: 1.2% to 7.5%; I2 = 96.612%; p < 0.001). The combined prevalence of SSI in patients with DM, as reported in six studies, was 5.1% (95% CI: 1.7% to 14.5%; I2 = 79.054%; p < 0.001). Similarly, the pooled prevalence of SSI in patients with HTN, drawn from four studies, was 1.8% (95% CI: 0.7% to 4.5%; I2 = 63.996%; p = 0.040). Additionally, the collective prevalence of SSI in patients with a history of tobacco use, based on findings from six studies, was 4.8% (95% CI: 1.4% to 15.2%; I2 = 93.358%; p < 0.001). Subgroup analysis was conducted within six studies, categorizing them by two countries, namely China and the USA. These analyses revealed that the prevalence of SSI following knee surgery was 3.0% in China and 2.0% in the USA. It is noteworthy that variations in SSI prevalence across different studies may be attributed to a multitude of factors, particularly varying risk factors among patient populations. To address this issue and mitigate the impact of SSI on knee surgery patients, it is advisable to develop tailored interventions.
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Affiliation(s)
| | - Bahar Farhadi
- School of MedicineIslamic Azad University, Mashhad BranchMashhadIran
| | - Parinaz Shahroudi
- Department of Surgical TechnologyGuilan University of Medical SciencesRashtIran
| | - Mohsen Mohammadi
- Department of Medical Surgical NursingGuilan University of Medical SciencesRashtIran
| | - Amin Omrani
- Department of Physical Therapy, School of MedicineTehran University of Medical SciencesTehranIran
| | - Maryam Mohammadi
- Department of Physical Therapy, School of MedicineUniversity of Social Welfare and Rehabilitation SciencesTehranIran
| | - Nafiseh Hekmati Pour
- Department of NursingAliabad Katoul Branch, Islamic Azad UniversityAliabad KatoulIran
| | - Hamid Hojjati
- Nursing Research Center, Golestan University of Medical SciencesGorganIran
| | - Masoomeh Najafi
- Student Research Committee, School of Nursing and MidwiferyShahid Beheshti University of Medical SciencesTehranIran
| | - Zahra Majd Teimoori
- Shahid Beheshti School of Nursing and MidwiferyGuilan University of Medical SciencesRashtIran
| | - Ramyar Farzan
- Department of Plastic & Reconstructive Surgery, School of MedicineGuilan University of Medical SciencesRashtIran
| | - Reza Salehi
- Department of Anesthesiology, School of MedicineIran University of Medical SciencesTehranIran
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19
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Lachance AD, Giro ME, Edelstein A, Klos E, Lee W. Do We Need Routine Postoperative Prophylactic Oral Antibiotics in Elective Foot and Ankle Surgery? FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114231224796. [PMID: 38288286 PMCID: PMC10823856 DOI: 10.1177/24730114231224796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024] Open
Abstract
Background Previous studies about antibiotic prophylaxis in foot and ankle surgery have focused on perioperative intravenous administration, with few studies reporting on the efficiency of postoperative oral antibiotics. The purpose of this study is to investigate differences in the rate of postoperative infection and wound complications between patients with and without postoperative oral antibiotics and to identify independent risk factors for these complications following foot and ankle surgeries. Methods A retrospective review of all elective foot and ankle surgeries with at least a 6-month follow-up was performed over a 2-year time span. Patients were divided into 2 groups based on if they received postoperative oral antibiotics. We compared the rates of postoperative infections and wound complications between the 2 groups. The surgical site, the number of Current Procedural Terminology codes, and the number of surgical incisions were also noted. Multivariable logistic regression analysis was performed to identify independent risk factors of postoperative infection and wound complications. Results A total of 366 patients were included in this study-240 with antibiotics and 126 without antibiotics. There was no significant difference in the rates of postoperative infection and wound complications between the 2 groups. The rate of superficial infection, deep infection, and wound complications was 1.7%, 0.8%, and 5.8% in the antibiotic group vs 3.2%, 0.0%, and 4.0% in patients without antibiotics, respectively. Multivariable logistic regression analysis identified independent risk factors of postoperative infection and wound complications as follows: smoking (OR: 4.7), male (OR: 4.0), history of neoplasm (OR: 6.7), and multiple incisions (OR: 4.1). Conclusion Our results suggest that routine postoperative prophylactic oral antibiotics are not needed following elective foot and ankle surgeries. However, certain risk factors may increase the risk for postoperative infection and wound complications in foot and ankle surgery. Level of Evidence Level III, case-control study.
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Affiliation(s)
| | - Margaret E. Giro
- Department of Orthopaedic Surgery, Guthrie Clinic, Sayre, PA, USA
| | | | - Eliza Klos
- Department of Orthopaedic Surgery, Guthrie Clinic, Sayre, PA, USA
| | - Wonyong Lee
- Department of Orthopaedic Surgery, Guthrie Clinic, Sayre, PA, USA
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20
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McCann LJ, Dickinson JD. Considerations in Charcot Reconstruction. Clin Podiatr Med Surg 2024; 41:141-151. [PMID: 37951671 DOI: 10.1016/j.cpm.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Charcot deformity is a challenging condition often leading to foot and ankle deformity that subsequently causes decreased function, ulceration, infection, and limb loss. There are various treatment measures to take into consideration when managing these patients. Treatment approaches range from conservative casting to surgical reconstruction. The authors believe that when faced with deformity, aggressive reconstruction to maintain a plantigrade foot and prevent loss of function is critical. Because of the nature of the Charcot condition, timing and fixation are often debated. This article discusses the authors' approach to Charcot reconstruction in a large integrated health care system.
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Affiliation(s)
- Luke J McCann
- Kaiser South San Francisco Medical Center, 1200 El Camino Real, South San Francisco, CA 94108, USA.
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21
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Lawson MM, Stuart A, Ramsey KL, Friess DM, Working ZM. Outcomes of Fracture Surgery in Patients With Escalating Hemoglobin A1C in the Setting of Unmanaged Diabetes. J Orthop Trauma 2023; 37:586-590. [PMID: 37348040 DOI: 10.1097/bot.0000000000002655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVE To determine whether there is a threshold of elevated hemoglobin A1C (HbA1c) above which the complication risk is so high that fracture fixation should be avoided. DESIGN Retrospective cohort study. SETTING Academic Level I trauma center. PATIENTS/PARTICIPANTS A cohort of 187 patients with HbA1c values >7 and operatively treated extremity fractures. INTERVENTION Surgical fixation of extremity fractures. MAIN OUTCOME MEASUREMENTS Rate of major orthopaedic complication (loss of reduction, nonunion, infection, and need for salvage procedure). RESULTS 34.8% demonstrated HbA1c > 9% and 12.3% with HbA1c > 11. Major complications occurred in 31.4%; HbA1c values were not predictive. We found no evidence of a clinically or statistically significant relationship between HbA1c and risk of major complication. The odds ratio for a one-point increase in HbA1c was 1.006 ( P = 0.9439), and the area under the receiver operating characteristic curve, which reflects the average probability that someone with a major complication will have a higher HbA1c than someone without, was 0.51 (95% confidence interval 0.42-0.61), equivalent to random chance. CONCLUSION Diabetic patients with fracture demonstrated an extremely high overall rate of complications, with 30.5% experiencing a major complication. However, patients with extreme diabetic neglect did not have higher complication rates after extremity fracture fixation when compared with patients with controlled and uncontrolled diabetes. There was no correlation between rate of complication and level of HbA1c. In addition, there was no difference in complication rate between upper and lower extremity fractures or between fractures treated with open or percutaneous fixation. This suggests that fracture treatment decision-making should not be altered for patients with poor diabetic control, and that surgery is not contraindicated in patients with an extremely high HbA1c. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michelle M Lawson
- Department of Orthopedic Surgery, Oregon Health & Science University, Portland, OR; and
| | - Ariana Stuart
- Department of Orthopedic Surgery, Oregon Health & Science University, Portland, OR; and
| | - Katrina L Ramsey
- Biostatistics and Design Program, Oregon Health & Science University, Portland, OR
| | - Darin M Friess
- Department of Orthopedic Surgery, Oregon Health & Science University, Portland, OR; and
| | - Zachary M Working
- Department of Orthopedic Surgery, Oregon Health & Science University, Portland, OR; and
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22
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McArdle C, Coyle S, Santos D. The impact of wound pH on the antibacterial properties of Medical Grade Honey when applied to bacterial isolates present in common foot and ankle wounds. An in vitro study. J Foot Ankle Res 2023; 16:66. [PMID: 37784205 PMCID: PMC10544608 DOI: 10.1186/s13047-023-00653-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 08/13/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Diabetic foot ulcers (DFUs) and post-surgical wound infections are amongst the most troublesome complications of diabetes and following foot and ankle surgery (FAS) respectively. Both have significant psychosocial and financial burden for both patients and the healthcare system. FAS has been reported to have higher than average post-surgical infections when compared to other orthopaedic subspecialties. Evidence also indicates that patients with diabetes and other co morbidities undergoing FAS are at a much greater risk of developing surgical site infections (SSIs). With the growing challenges of antibiotic resistance and the increasingly high numbers of resilient bacteria to said antibiotics, the need for alternative antimicrobial therapies has become critical. AIM The aim of this study was to investigate the use of medical grade honey (MGH) when altered to environments typically present in foot and ankle wounds including DFUs and post-surgical wounds (pH6-8). METHODS MGH (Activon) was altered to pH 6, 7 and 8 and experimental inoculums of Pseudomonas aeruginosa (NCTC10782), Escherichia coli, (NCTC10418), Staphylococcus aureus (NCTC10655) and Staphylococcus epidermidis (NCTC 5955) were transferred into each pH adjusted MGH and TSB solution and the positive and negative controls. RESULTS MGH adjusted to various pH values had the ability to reduce bacteria cell survival in all pH variations for all bacteria tested, with the most bacterial reduction/elimination noted for Staphylococcus epidermidis. No correlations were noted among the pH environments investigated and the colony counts, for which there were small amounts of bacteria survived. CONCLUSION This research would indicate that the antibacterial properties of honey remains the same regardless of the pH environment. MGH could therefore potentially be considered for use on non-infected foot and ankle wounds to reduce the bacterial bioburden, the risk of infections and ultimately to improve healing outcomes.
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Affiliation(s)
- Carla McArdle
- Health Service Executive, St Clare's Integrated Care Centre, 502 Griffith Avenue, Glasnevin, D11 AT81, Dublin 11, Ireland.
| | - Shirley Coyle
- Queen Margaret University, Queen Margaret Drive, Musselburgh, EH21 6UU, Edinburgh, UK
| | - Derek Santos
- Queen Margaret University, Queen Margaret Drive, Musselburgh, EH21 6UU, Edinburgh, UK
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Messori M, Touloupakis G, Gilli A, Theodorakis E, Pozzi P, Ghirardelli S, Antonini G. The risk of infection in open distal tibial fracture: the DANGER score. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2965-2970. [PMID: 36917286 DOI: 10.1007/s00590-023-03517-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/02/2023] [Indexed: 03/15/2023]
Abstract
INTRODUCTION Open fractures of the distal tibia can be functionally devastating, and they remain one of the most challenging injuries treated by trauma surgeons usually burdened with a high rate of complications, including surgical site infections (SSI). Our aim is to analyze the most significant risk factors of SSI and propose a new scoring system-called the DANGER scale-potentially able to predict reliably and quantify the infection risk in distal tibia open fractures. METHODS We identified six variables summarized in the acronym DANGER where D stands for Diabetes, A for Antibiotic, N for Nature of trauma (high- or low-energy trauma), G represents Grade of fracture following the AO/OTA classification, E indicates Exposure of the fracture according to the Gustilo-Anderson classification, and R represents Relative risk of patient, including use of tobacco, alcoholism, and psychiatric disorders. Therefore, total score ranged from 1 to 14, with a lower score indicating less risk to develop SSI. RESULTS A total of 103 patients with open distal tibial fractures were enrolled, 12 patients (11.6%) developed SSI. Regarding DANGER score, a rating of 8.2 was calculated in SSI group and 4.8 in non-SSI group. Based on Fisher's test, diabetes (odds = 31.8 p < 0.05), grade of articular involvement (p < 0.05), severity of open fracture (p < 0.05), and dangerous behavior such as use of tobacco, alcoholism, and psychiatric disorders (p < 0.05) were significantly correlated with infection. Significant difference between total DANGER scores in SSI and non-SSI groups was found (p < 0.001). ROC curve was calculated founding a potential threshold of 7.5 (p < 0.001). CONCLUSION Based on the above well-accepted risk factors, DANGER scale represents an advantageous and practical tool in order to readily estimate the risk of surgical site infection of open distal tibial fractures.
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Affiliation(s)
- Matteo Messori
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy.
- University of Milan, 20122, Milan, Italy.
| | - Georgios Touloupakis
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
- University of Milan, 20122, Milan, Italy
| | - Antonio Gilli
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
- University of Milan, 20122, Milan, Italy
| | - Emmanouil Theodorakis
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
- University of Milan, 20122, Milan, Italy
| | - Pierrenzo Pozzi
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
- University of Milan, 20122, Milan, Italy
| | - Stefano Ghirardelli
- Women's College Hospital, University Toronto Orthopedic Sports Medicine, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Guido Antonini
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
- University of Milan, 20122, Milan, Italy
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24
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He C, Zhou F, Zhou F, Wang J, Huang W. Impact of type 2 diabetes on surgical site infections and prognosis post orthopaedic surgery: A systematic review and meta-analysis. Int Wound J 2023; 21:e14422. [PMID: 37775974 PMCID: PMC10828723 DOI: 10.1111/iwj.14422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 09/16/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND The escalating prevalence of type 2 diabetes raises concerns about adverse postoperative outcomes like surgical site infections (SSIs) and deep vein thrombosis (DVT) in orthopaedic surgeries. This meta-analysis aims to resolve inconclusive evidence by systematically quantifying the risks in type 2 diabetic patients compared to non-diabetic individuals. METHODS The meta-analysis was conducted adhering to the PRISMA guidelines and based on the PICO framework. Four primary databases were searched: PubMed, Embase, Web of Science and the Cochrane Library, with no temporal restrictions. Studies included were either prospective or retrospective cohort studies published in English or Chinese, which assessed orthopaedic surgical outcomes among adult type 2 diabetic and non-diabetic patients. The meta-analysis employed the Newcastle-Ottawa Scale for quality assessment and used both fixed-effect and random-effects models for statistical analysis based on the level of heterogeneity. RESULTS Out of 951 identified articles, nine studies met the inclusion criteria. The odds ratio (OR) for developing postoperative SSIs among diabetic patients was 1.63 (95% CI: 1.19-2.22), indicating a significantly elevated risk compared to non-diabetic subjects. Conversely, no statistically significant difference in the risk of postoperative DVT was found between the two groups (OR: 0.82; 95% CI: 0.55-1.22). Sensitivity analysis confirmed the stability of these outcomes. CONCLUSIONS Patients with type 2 diabetes are at a higher risk of developing SSIs post orthopaedic surgery compared to non-diabetic individuals. However, both groups demonstrated comparable risks for developing postoperative DVT.
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Affiliation(s)
- Chunyan He
- Department of EndocrinologyPuren Hospital Affiliated to Wuhan University of Science and TechnologyWuhanChina
| | - Feng Zhou
- Department of NutritionPuren Hospital Affiliated to Wuhan University of Science and TechnologyWuhanChina
| | - Fan Zhou
- Department of Medical BiomolecularPuren Hospital Affiliated to Wuhan University of Science and TechnologyWuhanChina
| | - Jin Wang
- Department of EndocrinologyPuren Hospital Affiliated to Wuhan University of Science and TechnologyWuhanChina
| | - Wei Huang
- Department of EndocrinologyPuren Hospital Affiliated to Wuhan University of Science and TechnologyWuhanChina
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25
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Bertelli HD, Aquino JLBD, Leandro-Merhi VÂA. Lower 25-hydroxyvitamin D (25OHD) levels, diabetes and age are associated with foot and ankle fracture treatment complications. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2023; 67:e220020. [PMID: 37738466 PMCID: PMC10665043 DOI: 10.20945/2359-4292-2022-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 07/11/2022] [Indexed: 09/24/2023]
Abstract
Objective This study investigated the nutritional status, 25-hydroxyvitamin D (25OHD), albumin and risk factors associated with complications in patients with foot and ankle fragility fractures. Subjects and methods Prospective study, developed with patients who suffered fractures due to fragility of the foot and ankle (n = 108); the type of fractured bone, fracture mechanisms and classification were studied and also pseudoarthrosis, treatment, surgical dehiscence, anthropometry, 25OHD and albumin. The Chi-square or Fisher's exact test, Mann-Whitney and Kruskal-Wallis tests were used in the statistical analysis and the multiple logistic regression analysis was used to identify the risk factors associated with complications. Results The factors that, together, were associated with treatment complications were the level of 25OHD (p = 0.0055; OR = 0.868 [1,152]; 95% CI = 0.786; 0.959 [1.043;1.272]) and diabetes (p = 0.0034; OR = 30,181; 95% CI = 3.087; 295.036). The factors that, together, were associated with the presence of any complication, were age (p = 0.0139; OR = 1.058; 95% CI = 1.011; 1,106) and 25OHD level (p = 0.0198; OR = 0.917; 95% CI = 0.852; 0.986). There was a complication probability above 0.40 associated with lower 25OHD levels (values below 20 ng/mL) and older age (over 50 years). Conclusion Lower or abnormal levels of 25OHD were associated with pseudoarthrosis, and age and 25OHD were both risk factors for treatment complications in patients with foot and ankle fractures.
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Affiliation(s)
- Hallan Douglas Bertelli
- Pontifícia Universidade Católica de Campinas (PUC-Campinas), Escola de Ciências da Vida, Programa de Pós-graduaçÃo em Ciências da Saúde, Campinas, SP, Brasil
| | - José Luis Braga de Aquino
- Pontifícia Universidade Católica de Campinas (PUC-Campinas), Escola de Ciências da Vida, Programa de Pós-graduaçÃo em Ciências da Saúde, Campinas, SP, Brasil
| | - VÂnia Aparecida Leandro-Merhi
- Pontifícia Universidade Católica de Campinas (PUC-Campinas), Escola de Ciências da Vida, Programa de Pós-graduaçÃo em Ciências da Saúde, Campinas, SP, Brasil, ,
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26
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McGregor PC, LeDuc R. Preoperative and Perioperative Management of Diabetics Undergoing Elective Foot and Ankle Surgery. Orthop Clin North Am 2023; 54:341-348. [PMID: 37271562 DOI: 10.1016/j.ocl.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
- Patrick Cole McGregor
- Loyola Medical Center, 2160 South 1st Avenue, Maguire Center, Suite 1700, Maywood, IL 60153, USA.
| | - Ryan LeDuc
- Loyola Medical Center, 2160 South 1st Avenue, Maguire Center, Suite 1700, Maywood, IL 60153, USA
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Rajab AAH, Hegazy WAH. What’s old is new again: Insights into diabetic foot microbiome. World J Diabetes 2023; 14:680-704. [PMID: 37383589 PMCID: PMC10294069 DOI: 10.4239/wjd.v14.i6.680] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/20/2023] [Accepted: 04/10/2023] [Indexed: 06/14/2023] Open
Abstract
Diabetes is a chronic disease that is considered one of the most stubborn global health problems that continues to defy the efforts of scientists and physicians. The prevalence of diabetes in the global population continues to grow to alarming levels year after year, causing an increase in the incidence of diabetes complications and health care costs all over the world. One major complication of diabetes is the high susceptibility to infections especially in the lower limbs due to the immunocompromised state of diabetic patients, which is considered a definitive factor in all cases. Diabetic foot infections continue to be one of the most common infections in diabetic patients that are associated with a high risk of serious complications such as bone infection, limb amputations, and life-threatening systemic infections. In this review, we discussed the circumstances associated with the high risk of infection in diabetic patients as well as some of the most commonly isolated pathogens from diabetic foot infections and the related virulence behavior. In addition, we shed light on the different treatment strategies that aim at eradicating the infection.
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Affiliation(s)
- Azza A H Rajab
- Department of Microbiology and Immunology, Faculty of Pharmacy, Zagazig University, Zagzig 44511, Egypt
| | - Wael A H Hegazy
- Department of Microbiology and Immunology, Faculty of Pharmacy, Zagazig University, Zagzig 44511, Egypt
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28
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Johnson MJ, Kandasamy S, Raspovic KM, Manchanda K, Liu GT, VanPelt MD, Lavery LA, Wukich DK. Fractures and dislocations of the foot and ankle in people with diabetes: a literature review. Ther Adv Endocrinol Metab 2023; 14:20420188231163794. [PMID: 37323164 PMCID: PMC10265356 DOI: 10.1177/20420188231163794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 02/27/2023] [Indexed: 06/17/2023] Open
Abstract
Diabetes (DM) increases fracture risk, and bone quality depends on type diabetes type, duration, and other comorbidities. Diabetes is associated with a 32% increased relative risk (RR) of total fractures and 24% increased RR of ankle fractures compared with patients without DM. Type 2 DM is associated with a 37% increased RR of foot fractures compared with patients without DM. The incidence of ankle fractures in the general population is 169/100,000 per year, while foot fractures occur less frequently, with an incidence of 142/100,000 per year. Biomechanical properties of bone are negatively impacted by stiff collagen, contributing to the increased risk of fragility fractures in patients with DM. Systemic elevation of proinflammatory cytokines, such as tumor necrosis factor-alpha (TNFα), interleukin-1β (IL-1β), and interleukin 6 (IL-6), impact bone healing in patients with DM. Fractures in patients with DM, can be associated with poorly regulated levels of RANKL (receptor activator of nuclear transcription factor kappa-b ligand) leading to prolonged osteoclastogenesis, and net bone resorption. One of the most salient factors in treating fractures and dislocations of the foot and ankle is to recognize the difference between patients with uncomplicated and complicated DM. Complicated diabetes is defined as 'end organ damage', and for the purposes of this review, includes patients with neuropathy, peripheral artery disease (PAD) and/or chronic renal disease. Uncomplicated diabetes is not associated with 'end organ damage'. Foot and ankle fractures in patients with complicated DM pose challenges, and surgery is associated with increased risks of impaired wound healing, delayed fracture healing, malunion, infection, surgical site infection, and revision surgery. While patients with uncomplicated DM can be treated like patients without DM, patients with complicated DM require close follow-up and robust fixation methods should be considered to withstand the anticipated prolonged healing period. The aims of this review are as follows: (1) to review pertinent aspects of DM bone physiology and fracture healing, (2) to review the recent literature on treatment of foot and ankle fractures in patients with complicated DM, and (3) to provide treatment protocols based on the recent published evidence.
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Affiliation(s)
- Matthew J. Johnson
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Suganthi Kandasamy
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Katherine M. Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kshitij Manchanda
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - George Tye Liu
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael D. VanPelt
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lawrence A. Lavery
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Alemayehu MA, Azene AG, Mihretie KM. Time to development of surgical site infection and its predictors among general surgery patients admitted at specialized hospitals in Amhara region, northwest Ethiopia: a prospective follow-up study. BMC Infect Dis 2023; 23:334. [PMID: 37198551 DOI: 10.1186/s12879-023-08301-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 05/03/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Surgical site infection is an infection occurring within 30 days after surgery. It is recently reported that evidence-based information on the specific time when the majority of surgical site infections would develop is a key to early detect the infection as well as to preventing and early intervene against their pressing and fatal complications. Therefore, the current study aimed to determine the incidence, predictors, and time to development of surgical site infection among general surgery patients at specialized hospitals in the Amhara region. METHOD An institution-based prospective follow-up study was conducted. The two-stage cluster sampling procedure was used. A systematic sampling technique with a K interval of 2 was applied to prospectively recruit 454 surgical patients. Patients were followed up for 30 days. Data were collected using Epicollect5 v 3.0.5 software. Post-discharge follow-up and diagnosis were done by telephone call follow-up. Data were analyzed using STATA™ version 14.0. Kaplan-Meier curve was used to estimate survival time. Cox proportional regression model was used to determine significant predictors. Variables with a P-value less than 0.05 in the multiple Cox regression models were independent predictors. RESULT The incidence density was 17.59 per 1000 person-day-observation. The incidence of post-discharge Surgical site infection was 70.3%. The majority of surgical site infections were discovered after discharge between postoperative days 9 to 16. Being male (AHR: 1.98, 95% CI: 1.201 - 3.277, diabetes Mellitus (AHR: 1.819, 95% CI: 1.097 - 3.016), surgical history (AHR: 2.078, 95% CI: 1.345, 3.211), early antimicrobial prophylaxis (AHR: 2.60, 95% CI: 1.676, 4.039), American Society of Anesthesiologists score ≥ III AHR: 6.710, 95% CI: 4.108, 10.960), duration of the surgery (AHR: 1.035 95% CI: 1.001, 1.070), Age (AHR: 1.022 95% CI: 1.000, 1.043), and the number of professionals in the Operation Room (AHR: 1.085 95% CI: 1.037, 1.134) were found to be the predictors of time to development of Surgical site infection. CONCLUSION The incidence of surgical site infection was higher than the acceptable international range. The majority of infections were detected after hospital discharge between 9 to 16 postoperative days. The main predictors of Surgical site infection were Age, Sex, Diabetes Mellitus, previous surgical history, the timing of Antimicrobial prophylaxis, American Society of Anesthesiologists score, pre-operative hospital stay, duration of surgery, and the number of professionals in the operation room. Hence, hospitals should give great emphasis on pre-operative preparation, post-discharge surveillance, modifiable predictors, and high-risk patients, as they found in this study.
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Affiliation(s)
- Meron Asmamaw Alemayehu
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Abebaw Gedef Azene
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Kebadnew Mulatu Mihretie
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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Aragón-Sánchez J, Víquez-Molina G, López-Valverde ME, Rojas-Bonilla JM, Murillo-Vargas C. Does Metabolic Control Have Any Influence on the Clinical Presentation and Short-Term Outcomes of Diabetic Foot Infections? Adv Wound Care (New Rochelle) 2023; 12:135-144. [PMID: 34078116 DOI: 10.1089/wound.2021.0072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: We hypothesized that patients with poor glycemic control undergoing treatment for diabetic foot infections (DFIs) would have a poorer prognosis than those with better metabolic control assessed by glycated hemoglobin (HbA1c). Approach: We analyzed a retrospective cohort of 245 patients with moderate and severe DFIs. HbA1c values were dichotomized (<7% or ≥7% and ≤75th percentile (P75) and >P75) to analyze patient outcomes regarding metabolic control. The present study adhered to the STROBE guidelines for cohort studies. Results: One hundred sixty-nine patients (69%) were men. Their mean age was 60.7 years (10.8). HbA1c ≥7% was detected in 203 patients (82.9%). P75 HbA1c was 10.9%. After performing univariate analysis, we found an association of HbA1c <7% with major amputations and mortality. However, after applying the logistic regression model, we did not find HbA1c <7% to be a predictive factor of major amputation. The risk factors for mortality following application of Cox's proportional hazards model were osteomyelitis (HR: 0.2, 95% CI: 0.07-0.62, p < 0.01), eGFR <60 mL/min/1.73 m2 (HR: 2.7, 95% CI: 1.0-7.5, p = 0.04), and HbA1c <7% (HR: 4.9, 95% CI: 1.8-13.2, p < 0.01). Innovation: The group with optimal glycemic control (HbA1c <7%) had a shorter survival time than those with worse metabolic control. Conclusions: We did not find a longer duration of hospitalization, a higher rate of amputations, or longer healing times in the groups with worse metabolic control. HbA1c <7% was a risk factor for mid-term mortality.
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Affiliation(s)
- Javier Aragón-Sánchez
- Department of Surgery, Diabetic Foot Unit, La Paloma Hospital, Las Palmas de Gran Canaria, Spain
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Hagedorn JM, Bendel MA, Hoelzer BC, Aiyer R, Caraway D. Preoperative hemoglobin A1c and perioperative blood glucose in patients with diabetes mellitus undergoing spinal cord stimulation surgery: A literature review of surgical site infection risk. Pain Pract 2023; 23:83-93. [PMID: 35748888 DOI: 10.1111/papr.13145] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/03/2022] [Accepted: 06/08/2022] [Indexed: 01/11/2023]
Abstract
AIMS The aim of our study was to review the surgical literature regarding the relationship between hemoglobin A1c (HbA1c), diagnosis of diabetes mellitus (DM), and risk of postoperative surgical site infection (SSI). METHODS A librarian-assisted literature search was performed with two goals: (1) identify surgical publications related to SSI and HbA1c values, and (2) identify publications reporting infection risk with DM in spinal cord stimulation (SCS), intrathecal drug delivery systems (IDDS), and cardiovascular implantable electronic device (CIED) implantation surgeries. Published guidelines on perioperative management of DM are reviewed. RESULTS We identified 30 studies reporting SSI and HbA1c values. The literature review indicated that for many surgical procedures, elevated HbA1c is not correlated to rate of SSI. We identified 16 studies reporting infection rates within DM cohorts following SCS, IDDS, and CIED implantation surgeries. The data reviewed did not indicate DM as an independent risk factor for SSI. CONCLUSION Preoperative HbA1c levels in patients with a history of DM is not a singularly sufficient tool to estimate risk of perioperative infection in SCS implantation surgery. Published guidelines on perioperative management of DM do not suggest a specific HbA1c above which surgery should be delayed; intentional perioperative glycemic control is recommended.
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Affiliation(s)
| | - Markus A Bendel
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Rohit Aiyer
- Richmond Interventional Pain Management, Zucker Hillside School of Medicine at Hofstra/Northwell, Staten Island, New York, USA
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32
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Czerwonka N, Yi A, Miller CP. Diagnosis and Treatment of Neuropathic Ankle Fractures. JBJS Rev 2022; 10:01874474-202212000-00002. [PMID: 36732284 DOI: 10.2106/jbjs.rvw.22.00122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
» Standard 3-view ankle radiographs are the first-line imaging modality for suspected neuropathic ankle fractures. Computed tomography is helpful to evaluate for concomitant osseous changes and soft-tissue infection. » Nonoperative management may be considered for low-demand, elderly, or comorbid patients for whom surgery and anesthesia are contraindicated. However, the presence of comorbidities alone should not necessarily preclude operative intervention. Given the overall poor results of nonoperative treatment in the neuropathic ankle fracture population, operative intervention may in fact be less risky to the patient. » The authors have 2 preferred treatment techniques. For cases in which the vascular supply and bone stock are adequate, open reduction and internal fixation (ORIF) with locking fixation for the fibula, a medial buttress/hook plate with lag screws for the medial malleolus, multiple syndesmotic screws for additional fixation even in the absence of a syndesmotic injury, and temporary transfixation Steinmann pins from the calcaneus into the tibia are used. For cases in which there is a concern for wound healing or previously failed ORIF, minimally invasive surgical tibiotalocalcaneal arthrodesis with a retrograde locked intramedullary nail is used.
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Affiliation(s)
- Natalia Czerwonka
- Columbia University Irving Medical Center, New York-Presbyterian, New York, New York
| | - Anthony Yi
- Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher P Miller
- Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Wukich DK, Liu GT, Johnson MJ, Van Pelt MD, Raspovic KM, Lalli T, Nakonezny P. A Systematic Review of Intramedullary Fixation in Midfoot Charcot Neuroarthropathy. J Foot Ankle Surg 2022; 61:1334-1340. [PMID: 35701302 DOI: 10.1053/j.jfas.2022.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/09/2020] [Accepted: 04/20/2022] [Indexed: 02/03/2023]
Abstract
Charcot neuroarthropathy can cause severe deformity of the midfoot, and intramedullary use of beams and bolts has been utilized as a method of definitive stabilization. This systematic review evaluated the outcomes of intramedullary beaming in patients with Charcot neuroarthropathy and determined the methodological quality of the studies. Four online databases were searched: PubMed, MEDLINE (Clarivate Analytics), CINAHL (Cumulative Index to Nursing and Allied Health) and Web of Science (Clarivate Analytics). To assess the methodological quality of the studies, the Coleman Methodology Score was used. The data was pooled into 2 outcomes groups for comparison: (1) Studies that reported on the outcomes of Charcot specific implants (study group). (2) Studies that reported on the outcomes using non-Charcot specific implants (control group). After screening, 16 studies were included. Compared to our control group, our study group had significantly higher rates of overall hardware complications, hardware migration, surgical site infection, reoperation, and nonunion. The study group had significantly lower rates of limb salvage compared to the control group. Our study and control groups did not differ in the rates of hardware breakage, wound healing complications, or mortality. The limb salvage rate was 92% and 97% of patients were still alive at a mean follow-up of 25 months. The mean Coleman Methodology Score indicated the quality of the studies was poor and consistent with methodologic limitations. The quality of published studies on intramedullary implants for Charcot reconstruction is low. Complications when utilizing intramedullary fixation for Charcot reconstruction are high, whether or not Charcot specific implants are used.
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Affiliation(s)
- Dane K Wukich
- Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - George T Liu
- Associate Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Matthew J Johnson
- Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael D Van Pelt
- Associate Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Katherine M Raspovic
- Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Trapper Lalli
- Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Paul Nakonezny
- Department of Clinical Sciences (Biostatistics), University of Texas Southwestern Medical Center, Dallas, TX
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Chen S, Miller JD, Steinberg JS. Management of the Charcot Foot and Ankle: Nonreconstructive Surgery. Clin Podiatr Med Surg 2022; 39:559-570. [PMID: 36180188 DOI: 10.1016/j.cpm.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Diabetic neuroarthropathy is a complication of diabetes mellitus that results in instability of the foot, structural deformity, and soft-tissue breakdown. Commonly, midfoot collapse of the medial, lateral, or both longitudinal arches may result in increased plantar pressures and subsequent midfoot ulceration. Many of these wounds can be successfully managed with local wound care and off-loading; however, surgical intervention becomes necessary in cases of osteomyelitis or when the wound fails to heal despite conservative efforts. In cases where surgical reconstruction may not be indicated, nonreconstructive surgical efforts have shown effectiveness in resolving wounds and allowing patients to return to ambulatory lifestyles. This article serves as an update to current treatment recommendations for the nonreconstructive surgical management of Charcot neuroarthropathy.
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Affiliation(s)
- Shirley Chen
- Department of Plastic Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center Podiatric Surgery Residency, Center for Wound Healing, MedStar Georgetown University Hospital, 3800 Reservoir Road Northwest, Bles Building 1st Floor, Washington, DC 20007, USA
| | - John D Miller
- Department of Plastic Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center Podiatric Surgery Residency, Center for Wound Healing, MedStar Georgetown University Hospital, 3800 Reservoir Road Northwest, Bles Building 1st Floor, Washington, DC 20007, USA
| | - John S Steinberg
- Department of Plastic Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center Podiatric Surgery Residency, Center for Wound Healing, MedStar Georgetown University Hospital, 3800 Reservoir Road Northwest, Bles Building 1st Floor, Washington, DC 20007, USA.
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Millonig KJ, Gerber R. Surgical Optimization for Charcot Patients. Clin Podiatr Med Surg 2022; 39:595-604. [PMID: 36180191 DOI: 10.1016/j.cpm.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Reconstruction of the Charcot foot and ankle demonstrates significant challenges to the foot and ankle surgeon. At present, there is limited clear consensus on the best approach for preoperative optimization. The primary aim of Charcot reconstructions is to limit the risk of ulceration by providing a stable plantigrade foot allowing ambulation. The focus of this article is the discussion of modifiable risk factors associated with Charcot reconstruction for preoperative optimization.
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Affiliation(s)
- Kelsey J Millonig
- East Village Foot & Ankle Surgeons, 500 East Court Avenue, Suite 314, Des Moines, IA 50309, USA.
| | - Rachel Gerber
- AMITA Health Saint Joseph Hospital Chicago, 2900 North Lake Shore Drive, Chicago, IL 60657, USA
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Hong CC, Rammelt S. Managing Acute Fore- and Midfoot Fractures in Patients with Diabetes. Foot Ankle Clin 2022; 27:617-637. [PMID: 36096555 DOI: 10.1016/j.fcl.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Choon Chiet Hong
- Department of Orthopaedic Surgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074
| | - Stefan Rammelt
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany.
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Mortality and Conversion to Transfemoral Amputation After Transtibial Amputation in the Veterans Affairs Health System. J Am Acad Orthop Surg 2022; 30:798-807. [PMID: 35858478 DOI: 10.5435/jaaos-d-22-00262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/25/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Transtibial below-knee amputation (BKA) is associated with considerable morbidity, particularly in the vasculopathic population. The purpose of this study was to determine the cumulative probability of undergoing transfemoral above-knee amputation (AKA) conversion within 5 years of BKA and associated risk factors while accounting for the competing risk of death. METHODS This is a retrospective, national database study with structured query of the Veterans Affairs (VA) database for patients who underwent BKA from 1999 to 2020, identified by Current Procedural Terminology codes. Above-knee amputation conversion was identified using Current Procedural Terminology codes in combination with natural language processing to match procedure laterality. After internally validating our patient identification method, risk factors were collected. Competing risk analysis estimated the cumulative incidence rate of AKA conversion and associated risk factors with death as a competing risk. RESULTS Our query yielded 19,875 patients (19,640 men, 98.8%) who underwent BKA with a median age of 66 years (interquartile range, 60 to 73). The median follow-up was 951 days (interquartile range, 275 to 2,026). The crude cumulative probabilities of AKA conversion and death at 5 years were 15.4% (95% confidence interval [CI], 14.9% to 16.0%) and 47.7% (95% CI, 46.9% to 48.4%), respectively. In the Fine and Gray subdistribution hazard model, peripheral vascular disease had the highest AKA conversion risk (hazard ratio [HR] 2.66; 95% CI, 2.22 to 3.20; P < 0.001). Other factors independently associated with AKA conversion included urgent operation (HR 1.32; 95% CI, 1.23 to 1.42), cerebrovascular disease (HR 1.19; 95% CI, 1.11 to 1.28), chronic obstructive pulmonary disease (HR 1.15; 95% CI, 1.07 to 1.24), and previous myocardial infarction (HR 1.10; 95% CI, 1.02 to 1.19) (All P < 0.02). DISCUSSION Within this predominantly male, VA population, BKA carries a high risk of conversion to AKA within 5 years, without reaching a steady risk of AKA conversion within 5 years. Peripheral vascular disease, chronic obstructive pulmonary disease, cerebrovascular disease, previous myocardial infarction, and urgent BKA increase the risk of AKA conversion. LEVEL OF EVIDENCE Level III.
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deMeireles AJ, Guzman JZ, Nordio A, Chan J, Okewunmi J, Vulcano E. Complications After Percutaneous Osteotomies of the Calcaneus. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221119731. [PMID: 36046552 PMCID: PMC9421033 DOI: 10.1177/24730114221119731] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Open hindfoot surgery is associated with a relatively high rate of complications, including neurovascular injuries and wound healing problems compared with percutaneous techniques. However, there is a scarcity of literature describing the outcomes of these percutaneous techniques given their relatively recent adoption. The present study aims to assess the rate of postoperative complications for 3 commonly performed percutaneous calcaneal osteotomies. Methods: One hundred eighteen patients (unilateral feet) were treated with one of 3 common percutaneous calcaneal osteotomies. Sixty-five patients (55.1%) were treated with a medializing calcaneal osteotomy for hindfoot valgus, 32 patients with a Zadek osteotomy (27.1%) for insertional Achilles tendinopathy, and 21 patients (17.8%) with a modified Dwyer osteotomy for hindfoot varus. Fisher exact test was used to assess for associations between categorical variables. Results: The mean age was 46.2 years and there was a mean follow-up of 16.1 months. The overall rate of postoperative complications was 3.4% (n = 4), and no significant differences were found between the different osteotomy types. Complications included 2 cases (1.7%) of transient neuritis, 1 case of prolonged wound drainage (0.8%), and 1 nonunion (0.8%). None of the complications were associated with any recorded preoperative comorbidity. Discussion: In this series, we found that percutaneous calcaneal osteotomies are a safe alternative method for the treatment of conditions involving the hindfoot. The rate of postoperative complications may be less when compared to the reported rates of open hindfoot correction and should be considered in patients with a traditionally high risk of developing a postoperative complication. Level of Evidence: Level IV, retrospective analysis.
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Affiliation(s)
- Alirio J. deMeireles
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Javier Z. Guzman
- Leni & Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrea Nordio
- Leni & Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jimmy Chan
- Leni & Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeffrey Okewunmi
- Leni & Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ettore Vulcano
- Columbia University Orthopaedics at Mount Sinai Medical Center, Miami Beach, FL, USA
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Complications of Lesser Toe Surgery: How To Avoid Them before Surgery and How To Assess and Treat Them When They Have Occurred. Foot Ankle Clin 2022; 27:233-251. [PMID: 35680286 DOI: 10.1016/j.fcl.2021.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Complications following lesser toe surgery are challenging to manage. The keys to treatment of any of these conditions are, first, to try to avoid them through identification of patient- and surgeon-related variables that contribute to their development and, second, following the occurance of a complication, to understand what can and cannot be corrected with surgical and nonsurgical management. This review provides a comprehensive assessment of current literature, demonstrates best practices and approaches to lesser toe complications, and provides an illustration of clinical examples.
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Abar B, Kwon N, Allen NB, Lau T, Johnson LG, Gall K, Adams SB. Outcomes of Surgical Reconstruction Using Custom 3D-Printed Porous Titanium Implants for Critical-Sized Bone Defects of the Foot and Ankle. Foot Ankle Int 2022; 43:750-761. [PMID: 35209733 PMCID: PMC9177519 DOI: 10.1177/10711007221077113] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Treating critically sized defects (CSDs) of bone remains a significant challenge in foot and ankle surgery. Custom 3D-printed implants are being offered to a small but growing subset of patients as a salvage procedure in lieu of traditional alternates such as structural allografts after the patient has failed prior procedures. The long-term outcomes of 3D-printed implants are still unknown and understudied because of the limited number of cases and short follow-up durations. The purpose of this study was to evaluate the outcomes of patients who received custom 3D-printed implants to treat CSDs of the foot and ankle in an attempt to aid surgeons in selecting appropriate surgical candidates. METHODS This was a retrospective study to assess surgical outcomes of patients who underwent implantation of a custom 3D-printed implant made with medical-grade titanium alloy powder (Ti-6Al-4V) to treat CSDs of the foot and ankle between June 1, 2014, and September 30, 2019. All patients had failed previous nonoperative or operative management before proceeding with treatment with a custom 3D-printed implant. Univariate and multivariate odds ratios (ORs) of a secondary surgery and implant removal were calculated for perioperative variables. RESULTS There were 39 cases of patients who received a custom 3D-printed implant with at least 1 year of follow-up. The mean follow-up time was 27.0 (12-74) months. Thirteen of 39 cases (33.3%) required a secondary surgery and 10 of 39 (25.6%) required removal of the implant because of septic nonunion (6/10) or aseptic nonunion (4/10). The mean time to secondary surgery was 10 months (1-22). Multivariate logistic regression revealed that patients with neuropathy were more likely to require a secondary surgery with an OR of 5.76 (P = .03). CONCLUSION This study demonstrated that 74% of patients who received a custom 3D-printed implant for CSDs did not require as subsequent surgery (minimum of 1-year follow-up). Neuropathy was significantly associated with the need for a secondary surgery. This is the largest series to date demonstrating the efficacy of 3D-printed custom titanium implants. As the number of cases using patient-specific 3D-printed titanium implant increases, larger cohorts of patients should be studied to identify other high-risk groups and possible interventions to improve surgical outcomes. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Bijan Abar
- Dept. of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC,Dept. of Mechanical Engineering and Materials Science, Duke University, Durham, NC
| | - Nicholas Kwon
- Dept. of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC
| | - Nicholas B. Allen
- Dept. of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC
| | - Trent Lau
- Dept. of Mechanical Engineering and Materials Science, Duke University, Durham, NC
| | - Lindsey G. Johnson
- Dept. of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC
| | - Ken Gall
- Dept. of Mechanical Engineering and Materials Science, Duke University, Durham, NC
| | - Samuel B. Adams
- Dept. of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC
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Drayton DJ, Birch RJ, D'Souza-Ferrer C, Ayres M, Howell SJ, Ajjan RA. Diabetes mellitus and perioperative outcomes: a scoping review of the literature. Br J Anaesth 2022; 128:817-828. [PMID: 35300865 PMCID: PMC9131255 DOI: 10.1016/j.bja.2022.02.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/04/2022] [Accepted: 02/08/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Diabetes mellitus (DM) is frequently encountered in the perioperative period. DM may increase the risk of adverse perioperative outcomes owing to the potential vascular complications of DM. We conducted a scoping review to examine the association between DM and adverse perioperative outcomes. METHODS A systematic search strategy of the published literature was built and applied in multiple databases. Observational studies examining the association between DM and adverse perioperative outcomes were included. Abstract screening determined full texts suitable for inclusion. Core information was extracted from each of the included studies including study design, definition of DM, type of DM, surgical specialties, and outcomes. Only primary outcomes are reported in this review. RESULTS The search strategy identified 2363 records. Of those, 61 were included and 28 were excluded with justification. DM was mostly defined by either haemoglobin A1c (HbA1c) or blood glucose values (19 studies each). Other definitions included 'prior diagnosis' or use of medication. In 17 studies the definition was unclear. Type 2 DM was the most frequently studied subtype. Five of seven studies found DM was associated with mortality, 5/13 reported an association with 'complications' (as a composite measure), and 12/17 studies found DM was associated with 'infection'. Overall, 33/61 studies reported that DM was associated with the primary outcome measure. CONCLUSION Diabetes mellitus is inconsistently defined in the published literature, which limits the potential for pooled analysis. Further research is necessary to determine which cohort of patients with DM are most at risk of adverse postoperative outcomes, and how control influences this association.
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Affiliation(s)
| | | | | | - Michael Ayres
- Leeds Institute of Medical Research, University of Leeds, UK
| | - Simon J Howell
- Leeds Institute of Medical Research, University of Leeds, UK
| | - Ramzi A Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
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Lin J, Huang T, Wei H, Bao B, Gao T, Zheng X, Zhu H. Does Preoperative Glycemic Control Restore Immune Defense Against Implant-related Infection in Mice With Diabetes? Clin Orthop Relat Res 2022; 480:1008-1017. [PMID: 34797251 PMCID: PMC9007187 DOI: 10.1097/corr.0000000000002041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 10/12/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The presence of Type II diabetes is a well-established risk factor for bone and joint infection, especially in patients with poor glycemic control. However, few studies have investigated the effect of the duration of preoperative glycemic intervention. For patients with poor glycemic control, the effect of the duration of preoperative glycemic intervention remains unknown. Many glycemic biomarkers including hemoglobin A1c (HbA1c), fructosamine, and 1,5-anhydroglucitol have different response rates to glycemic change. It is unclear which biomarker is more closely related to the decrease in infection proportion after preoperative glycemic intervention. QUESTIONS/PURPOSES (1) Is there an effect of the duration of preoperative insulin therapy in mice with diabetes receiving an experimental intra-articular implant? (2) Of the three commonly used biomolecules for monitoring blood glucose levels (HbA1c, fructosamine, and 1,5-anhydroglucitol), is one more closely related to decrease in infection proportion after presurgical insulin therapy? METHODS With a well-established protocol, Type II diabetes was modeled in female 10-week-old C57BL/6 mice by maintaining them on a high-fat diet (60% fat) for 8 months; control mice without diabetes received a normal low-fat diet (10% fat). Mice with Type II diabetes were randomized into groups to receive preoperative glycemic intervention with insulin for 0, 1, 3, 5, 7, 14, or 28 days, and investigators were blinded to the randomization. Mice with and without diabetes then received a surgically inserted wire into the femoral canal in a retrograde fashion and received a local or systemic challenge with Staphylococcus aureus or Escherichia coli (n = 20 for each bacteria challenge [systemic or local]/timepoint). The proportion of culture-positive joint samples was calculated. An additional 10 mice with Type II diabetes were treated with insulin for 28 days and the HbA1c, fructosamine, and 1,5-anhydroglucitol levels were consecutively monitored. Fisher exact tests and nonparametric Wilcoxon rank sum tests were used to analyze the different between different groups, with p < 0.05 taken as significant. RESULTS When insulin therapy was administered, the proportion of bone and joint infections decreased in mice with Type II diabetes, reaching asymptotic levels after 3 days of treatment for the systemic (S. aureus: 7 of 20 mice with diabetes on 3-day therapy, p < 0.001; 8 of 20 on 5-day, p = 0.002; 10 of 20 on 7-day, p = 0.01; 9 of 20 on 14-day, p = 0.006; and 8 of 20 on 28-day, p = 0.002 versus 18 of 20 in the no insulin therapy group; E. coli: 6 of 20 on 3-day therapy, p = 0.004; 7 of 20 on 5-day, p = 0.01; 7 of 20 on 7-day, p = 0.01; 6 of 20 on 14-day, p = 0.004; and 7 of 20 on 28-day, p = 0.01 versus 16 of 20 in the no insulin therapy group) or local bacterial challenge (S. aureus: 11 of 20 on 3-day therapy, p = 0.001; 12 of 20 on 5-day, p = 0.003; 10 of 20 on 7-day, p < 0.001; 12 of 20 on 14-day, p = 0.003; and 13 of 20 on 28-day, p = 0.008 versus 20 of 20 in the no insulin therapy group; E. coli: 10 of 20 on 3-day therapy, p = 0.003; 10 of 20 on 5-day, p = 0.003; 9 of 20 on 7-day, p = 0.001; 11 of 20 on 14-day, p = 0.008; and 10 of 20 on 28-day, p = 0.003 versus 19 of 20 in no insulin therapy group). Even after 28 days of insulin therapy, the proportion of bone and joint infections was still higher (statistically insignificant with large absolute difference, except for one instance) in mice with diabetes than in control mice without diabetes after systemic (S. aureus: 8 of 10 mice with diabetes on 28-day therapy versus 4 of 20 mice without diabetes, p = 0.30; E. coli: 7 of 20 on 28-day therapy versus 1 of 20 mice without diabetes, p = 0.04) or local challenge (S. aureus: 13 of 20 mice on 28-day therapy versus 8 of 20 mice without diabetes, p = 0.21; E. coli: 10 of 20 on 28-day therapy versus 5 of 20 mice without diabetes, p = 0.19). HbA1c and fructosamine levels were lagging indicators of the decrease in infection proportion after insulin treatment. In contrast, the 1,5-anhydroglucitol level increased quickly (reflecting lower blood glucose levels) in response to short-term glycemic control. Moreover, the time required for changes in 1,5-anhydroglucitol levels to be detected was no more than 3 days (3 days insulin therapy 1.86 ± 0.20 [95% CI -1.27 to -0.45]; p˂0.001 versus no insulin therapy 1.00 ± 0.11). CONCLUSION In a model of mice with Type II diabetes, prolonged preoperative glycemic intervention did not further reduce the proportion of bone and joint infections compared with that achieved with short-term intervention of 3 days. CLINICAL RELEVANCE Compared with HbA1c and fructosamine, 1,5-anhydroglucitol might be a better indicator for risk stratification and guiding the timing for elective surgery. Comparative study of these three biomarkers based on patient samples is warranted to further confirm this conclusion.
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Affiliation(s)
- Junqing Lin
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Tengli Huang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Haifeng Wei
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Bingbo Bao
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Tao Gao
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xianyou Zheng
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hongyi Zhu
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Wong LH, Chrea B, Meeker JE, Yoo JU, Atwater LC. Factors Associated With Nonunion and Infection Following Ankle Arthrodesis Using a Large Claims Database: Who Has Elevated Risk? FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221101617. [PMID: 35662901 PMCID: PMC9158424 DOI: 10.1177/24730114221101617] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Complications such as nonunion and infection following ankle arthrodesis can lead to increased patient morbidity and financial burden from repeat operations. Improved knowledge of risk factors can improve patient selection and inform post–ankle arthrodesis surveillance protocols. Methods: This is a large retrospective, database study with structured query of a national insurance claims database (PearlDiver Technologies) for patients treated with ankle arthrodesis from 2015 to 2019 as identified by International Classification of Diseases, Tenth Revision (ICD-10), codes. Patients with any operation 1 year prior to or following ankle arthrodesis were excluded from analysis to prevent attributing complications to another operation. Likelihoods of nonunion and infection within 1 year and 3 years following ankle arthrodesis were analyzed using Kaplan-Meier estimations. Patient characteristics associated with the identified complications following ankle arthrodesis were analyzed using multivariable logistic regression analyses. Results: Our query yielded 2463 patients in the 5-year period who underwent ankle arthrodesis. Nonunion occurred in 11% (95% CI 10-12) of patients within 1 year of ankle arthrodesis and 16% (95% CI 14-17) of patients within 3 years. Infection occurred in 3.9% (95% CI 3.1-4.7) of patients within 1 year of ankle arthrodesis and in 6.2% (95% CI 5.1-7.2) of patients within 3 years. Obese patients increased odds of nonunion on multivariable analysis (OR 1.6, 95% CI 1.3-2.0; P < .001). On multivariable analysis, diabetes (OR 1.7, 95% CI 1.2-2.6; P = .010) and each 1-unit increase in Elixhauser Comorbidity Index scores (OR 1.1, 95% CI 1.1-1.2; P < .001) contributed to increased odds of infection after ankle arthrodesis. Conclusion: Nonunion and infection following ankle arthrodesis have a 3-year probability of 16% and 6%, respectively. More than one-quarter of patients with nonunion following ankle arthrodesis experience a delay in diagnosis beyond 1 year. The risk of post–ankle arthrodesis nonunion is highest in patients with obesity; the risk of post–ankle arthrodesis infection is highest in patients with diabetes or an elevated Elixhauser Comorbidity Index score. Level of Evidence: Level III, prognostic study.
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Affiliation(s)
- Liam H. Wong
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Bopha Chrea
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - James E. Meeker
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Jung U. Yoo
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Lara C. Atwater
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
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Abstract
PURPOSE OF REVIEW Persons with diabetes are more likely to require orthopedic surgery and are at an increased risk of developing postoperative complications. Recognizing the impact of diabetes on musculoskeletal health provides an opportunity to educate healthcare professionals in standardizing the perioperative approach of persons with diabetes. RECENT FINDINGS Elevated hemoglobin A1C, fructosamine, and blood glucose levels have been associated with increased risk for complications in the orthopedic population. These risks can be mitigated by the early identification and optimization of these patients in the perioperative period. Intraoperative and postoperative glycemic management should support efforts to maintain glucose at safe levels while avoiding hyperglycemia and hypoglycemia. This paper considers factors surrounding diabetes care in the orthopedic surgical patient. Perioperative care discussed includes optimization, hospitalization to discharge, and special considerations such as steroids and diabetes wearable technology. Hospitals should consider these strategies towards enhancing the care of persons with diabetes requiring musculoskeletal care.
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Affiliation(s)
- Ruben Diaz
- Hospital for Special Surgery, New York, NY, 10021, USA.
| | - Jenny DeJesus
- Hospital for Special Surgery, New York, NY, 10021, USA
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45
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Klag EA, Fisk FE, Maier LM, Zeni F. Staged Percutaneous Treatment of a Complete Lisfranc Dislocation Secondary to Charcot Arthropathy: A Case Report. JBJS Case Connect 2021; 11:01709767-202112000-00070. [PMID: 35102063 DOI: 10.2106/jbjs.cc.21.00242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
CASE A 36-year-old woman with diabetic neuropathy presented with complete dorsal dislocation of the midfoot secondary to Charcot arthropathy. She was treated in a staged fashion with a Taylor spatial butt frame to distract and reduce the midfoot followed by percutaneous preparation of the tarsometatarsal (TMT) joints and fixator-assisted fusion. The arthrodesis healed successfully with maintenance of function at the 30-month follow-up. CONCLUSION Staged treatment with a Taylor spatial frame can be used successfully to treat complete TMT dislocations in the setting of Charcot arthropathy. Complications are not uncommon and must be addressed appropriately.
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Affiliation(s)
- Elizabeth A Klag
- Department of Orthopaedic Surgery, Henry Ford Health System Detroit, Michigan
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Lim S, Yeh HH, Macki M, Mansour T, Schultz L, Telemi E, Haider S, Nerenz DR, Schwalb JM, Abdulhak M, Park P, Aleem I, Easton R, Khalil J, Perez-Cruet M, Chang V. Preoperative HbA1c > 8% Is Associated With Poor Outcomes in Lumbar Spine Surgery: A Michigan Spine Surgery Improvement Collaborative Study. Neurosurgery 2021; 89:819-826. [PMID: 34352887 DOI: 10.1093/neuros/nyab294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 06/07/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Preoperative hemoglobin A1c (HbA1c) is a useful screening tool since a significant portion of diabetic patients in the United States are undiagnosed and the prevalence of diabetes continues to increase. However, there is a paucity of literature analyzing comprehensive association between HbA1c and postoperative outcome in lumbar spine surgery. OBJECTIVE To assess the prognostic value of preoperative HbA1c > 8% in patients undergoing elective lumbar spine surgery. METHODS The Michigan Spine Surgery Improvement Collaborative (MSSIC) database was queried to track all elective lumbar spine surgeries between January 2018 and December 2019. Cases were divided into 2 cohorts based on preoperative HbA1c level (≤8% and >8%). Measured outcomes include any complication, surgical site infection (SSI), readmission (RA) within 30 d (30RA) and 90 d (90RA) of index operation, patient satisfaction, and the percentage of patients who achieved minimum clinically important difference (MCID) using Patient-Reported Outcomes Measurement Information System. RESULTS We captured 4778 patients in this study. Our multivariate analysis demonstrated that patients with HbA1c > 8% were more likely to experience postoperative complication (odds ratio [OR] 1.81, 95% CI 1.20-2.73; P = .005) and be readmitted within 90 d of index surgery (OR 1.66, 95% CI 1.08-2.54; P = .021). They also had longer hospital stay (OR 1.12, 95% CI 1.03-1.23; P = .009) and were less likely to achieve functional improvement after surgery (OR 0.64, 95% CI 0.44-0.92; P = .016). CONCLUSION HbA1c > 8% is a reliable predictor of poor outcome in elective lumbar spine surgery. Clinicians should consider specialty consultation to optimize patients' glycemic control prior to surgery.
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Affiliation(s)
- Seokchun Lim
- Department of Neurological Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Hsueh-Han Yeh
- Department of Public Health Services, Henry Ford Hospital, Detroit, Michigan, USA
| | - Mohamed Macki
- Department of Neurological Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Tarek Mansour
- Department of Neurological Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Lonni Schultz
- Department of Neurological Surgery, Henry Ford Hospital, Detroit, Michigan, USA.,Department of Public Health Services, Henry Ford Hospital, Detroit, Michigan, USA
| | - Edvin Telemi
- Department of Neurological Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Sameah Haider
- Department of Neurological Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - David R Nerenz
- Department of Neurological Surgery, Henry Ford Hospital, Detroit, Michigan, USA.,Center for Health Services Research, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jason M Schwalb
- Department of Neurological Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Muwaffak Abdulhak
- Department of Neurological Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ilyas Aleem
- Department of Orthopedics, University of Michigan, Ann Arbor, Michigan, USA
| | - Richard Easton
- Department of Orthopedics, William Beaumont Hospital, Troy, Michigan, USA
| | - Jad Khalil
- Department of Orthopedics, William Beaumont Hospital, Royal Oak, Michigan, USA
| | | | - Victor Chang
- Department of Neurological Surgery, Henry Ford Hospital, Detroit, Michigan, USA
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Hyer CF, Berlet G, Philbin T, Bull P, Brandão R, Prissel M, Malay DS. Does Functional Neuromuscular Electrical Stimulation (NMES) Influence Calf Atrophy Following Achilles Tendon Surgery? Prospective Double-Blind Randomized Controlled Trial on the Use of Immediate Postoperative Electrical Muscle Stimulation to Preserve Muscle Function and Volume. J Foot Ankle Surg 2021; 60:683-688. [PMID: 33736944 DOI: 10.1053/j.jfas.2020.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 12/11/2020] [Accepted: 12/18/2020] [Indexed: 02/03/2023]
Abstract
Surgical repair of the Achilles tendon can lead to prolonged calf atrophy and functional limitations, even with early weightbearing. The use of neuromuscular electrical stimulation (NMES) has been studied in muscle rehabilitation programs following anterior cruciate ligament repair. Accelerated recovery and pain reduction were noted. The aim of the present study was to evaluate the use of electrical stimulation on maintaining calf muscle cross-sectional area volume and improving patient reported outcome measures following Achilles tendon surgery. Randomized controlled clinical trial. Forty patients were enrolled. All patients had undergone repair of the Achilles tendon. A 4 lead NMES device was applied at time of surgery with both patient and surgeon blinded to activity of the device. All patients followed a standardized postoperative protocol. Group 1 consisted of 20 patients who received protocol specific NMES. Group 2 was the "sham device" control group, receiving subtherapeutic electrical stimulation. Preoperative and postoperative calf circumference (2, 6, 12 weeks) and magnetic resonance imaging (MRI) scans (2, 6 weeks) were conducted. Patient-reported functional outcome scores were measured. Of the 40 patients, 23 (57.5%) were male and 17 (42.5%) were female. The mean age was 48.9 years (11.1 standard deviation [SD]) with a mean body mass index of 32.2 kg/m2 (5.7 SD). Calf measurements for Group 1 (39.3 cm and 39.7 cm) were slightly higher compared Group 2 (38.4 cm and 39.2 cm) at 6 and 12 weeks postoperative. Functional scores were similar between Groups 1 and 2 at final follow-up. Foot/Ankle Computer Adaptive Test scores were 55.1 (6.9 SD) versus 58.4(8.6 SD), and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scores were 82.3 (8.2 SD) and 83.9 (9.3 SD), respectively. The visual analog scale at 12-week visit for Groups 1 and 2 was 8.4 (9.3 SD) and 8.4 (9.1 SD), respectively. This prospective randomized controlled trial was undertaken to quantify and validate the effect and ability of NMES to minimize calf atrophy after acute or chronic repair. No statistically significant difference was found between active NMES and sham control group. There was a trend showing some maintenance of calf volume per MRI study.
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Affiliation(s)
| | - Gregory Berlet
- Attending Physician, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Terry Philbin
- Attending Physician, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Patrick Bull
- Attending Physician, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Roberto Brandão
- Fellow Foot and Ankle Surgery, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Mark Prissel
- Attending Physician, Orthopedic Foot and Ankle Center, Worthington, OH
| | - D Scot Malay
- Director of Podiatric Research and Staff Surgeon, Penn Presbyterian Medical Center, Philadelphia, PA
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Surgical Site Infection After Dermatologic Procedures: Critical Reassessment of Risk Factors and Reappraisal of Rates and Causes. Am J Clin Dermatol 2021; 22:503-510. [PMID: 33797060 DOI: 10.1007/s40257-021-00599-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
While rates are low, surgical site infections are the most common complication of dermatologic surgery. Surgical site infections have important consequences including impairment of wound healing, suboptimal cosmetic outcome, hospitalization, increased healthcare costs, and rarely, systemic infection. It is imperative to understand the risk factors and existing preventative measures to minimize the development of infection. This article reviews the available literature regarding surgical site infections following dermatologic procedures, to evaluate the standard of diagnosis and role of wound culture, risk factors, mimicking conditions, and significance of antibiotic prophylaxis. We offer a critical reassessment of the current literature on risk factors and reappraisal of infection rates to promote evidence-based patient care. We conclude that the strongest evidence suggests that diabetes mellitus is likely associated with increased surgical site infections. Immunosuppression is often clinically considered a risk factor; however, the evidence is mixed. In general the addition of antibiotics does not confer benefit except in high-risk sites. Conclusively, Mohs micrographic surgery has been proven safe in office and inpatient settings. We agree that sterile glove use for simple procedures is likely not a significant factor in the development of surgical site infections; however, we hypothesize that the overall sterile technique and setting may play a role in longer and/or more complex procedures.
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Bai Y, Su Y, Zheng Z. The clinical effect of nursing intervention in the operating room on the prevention of orthopedic wound infections. Am J Transl Res 2021; 13:3703-3709. [PMID: 34017554 PMCID: PMC8129312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/04/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To study the preventive effect of operating room nursing intervention on surgical incision infections in elderly patients undergoing orthopedic surgery. METHODS Altogether, 128 orthopedic patients were divided into an observation group and a control group according to the nursing method each patient underwent, with 64 patients in each group. RESULTS The grade A incision healing rate in the observation group was significantly higher than the rate in the control group (P<0.01). The eating and getting out of bed times, and the lengths of the hospital stays in the observation group were significantly shorter than the corresponding times in the control group (P<0.01). The incidences of postoperative wound infections in the observation group (0 cases) was significantly lower than the incidences in the control group (14 cases, accounting for 21.88%), and the difference was statistically significant (P<0.001). After the nursing, the prognoses and quality of life scores of the patients in the observation group were better than they were in the control group, and the differences were statistically significant (P<0.01). Our investigation indicated that, after the treatment, the overall patient satisfaction rate in the observation group (98.44%) was significantly higher than the patient satisfaction rate in the control group (84.38%), and the difference was statistically significant (χ2=27.349, P=0.000). CONCLUSION Operating room nursing intervention can effectively prevent postoperative wound infections and promote incision healing, so it is worthy of application.
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Affiliation(s)
- Yan Bai
- Department of Surgery and Anesthesiology, The Second Affiliated Hospital of Xi'an Medical University Xi'an, Shaanxi Province, China
| | - Yuqiang Su
- Department of Surgery and Anesthesiology, The Second Affiliated Hospital of Xi'an Medical University Xi'an, Shaanxi Province, China
| | - Zhonglei Zheng
- Department of Surgery and Anesthesiology, The Second Affiliated Hospital of Xi'an Medical University Xi'an, Shaanxi Province, China
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Increasing age and modifiable comorbidities are associated with short-term complications after open reduction and internal fixation of ankle fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:113-119. [PMID: 33759030 DOI: 10.1007/s00590-021-02927-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Ankle fractures are common orthopedic injuries with complication rates fixation of up to 40%. Limited evidence exists in the literature regarding complications in the elderly population, and moreover, these studies frequently define elderly arbitrarily at 60-65 years old. The purpose of the present study was to utilize a large, validated database to evaluate whether there is an inflection point of age when postoperative complications after an ankle fracture significantly increase. METHODS A retrospective review of all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent fixation of an ankle fracture between 2012 and 2018 was performed. Patients were identified within the database using the Current Procedural Terminology codes. Appropriate statistical analysis was performed with p value less than 0.05 considered statistically significant. RESULTS A total of 27,633 fractures were including and comprised of 221 posterior malleolar, 1567 medial malleolar, 8495 lateral malleolar, 10,175 bimalleolar, and 7175 trimalleolar. A total of 1545 complications were encountered (5.6%). There was a statistically significant association between increasing age and complications (OR = 1.03; p < 0.001). Further analysis shows the largest spike in complications within the age 78 + bracket. There were no overall interaction effects between age and fracture subtype (p = 0.223). CONCLUSION ORIF of ankle fractures is a common orthopedic procedure performed on patients of all ages, with complications ranging in severity. In order to best counsel patients on their individual postoperative risks, large datasets are often necessary to prognosticate. This study found that postoperative complications increase with advanced age. The incidence of complications did not spike for patients around the age of 65, but rather followed an incremental linear pattern with the largest increase in odds ratio occurring at age 78 and above. Complication rate was not associated with specific fracture type based off of ICD codes.
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