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

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

The Effect of Obesity on Pediatric Tibia Fractures.

Background: Childhood obesity affects nearly one fifth of all children in the United States. Understanding the unique injury characteristics and treatment of tibia fractures in this population has become increasingly important. This study aims to explore the different injury characteristics between tibia fractures in obese and non-obese children. Methods: 215 skeletally immature children aged 2-18 who sustained tibia fractures between 2007.2019 were retrospectively reviewed. Patients were analyzed by weight group: underweight, normal weight, overweight, and obese as defined by body mass index (BMI) percentile based upon age. Analyses were performed on dichotomized groups: underweight and normal weight versus overweight and obese. Chi-square or Fisher's exact test was used to compare differences in categorical outcome between the 2-category BMI class variables; Wilcoxon test was used to compare continuous outcomes. A multivariate logistic regression model was used to evaluate BMI associations while controlling for age, sex, race, and mechanism of injury. Results: Distribution of BMI in the cohort included 6.5% underweight, 45.6% normal weight, 16.7% overweight and 31.2% obese. Overweight and obese children sustained fractures from low energy mechanisms at more than double the rate of normal and underweight children (20.5% versus 9.7%, p=0.028). Overweight and obese children sustained physeal fractures at a rate of 54.4% in comparison with 28.6% in their normal and underweight peers (p<0.0001, OR 2.50 (95% CI, 1.26-4.95)). Overweight and obese children sustained distal 1/3 tibia fractures at a higher rate of 56.9% compared to under and normal weight children at 33.9% (p=0.003, OR 2.24 (95% CI, 1.17-4.30)). Overweight and obese children underwent unplanned changes in treatment at a lower rate than normal and underweight children at 1% versus 8% rates of treatment change, respectively (p=0.013, OR 0.076 (95%CI, 0.009-0.655)). No significant differences were found in the rates of operative treatment, repeat reduction, post treatment complications, or physical therapy. Conclusion: Overweight children sustain tibia fractures from low energy mechanisms at higher rates than their peers. Similarly, obese and overweight patients have higher rates of physeal injuries and higher rates of distal 1/3 tibia fractures. Complication rates are similar between obese and non-obese children undergoing treatment for tibia fractures. Level of Evidence: III.

Quality of Life Improvement Following Reconstruction of Midtarsal Charcot Foot Deformity: A Five Year Follow-Up.

Background: There is increasing interest in reconstruction of diabetes-associated Charcot foot arthropathy with the goal of improving quality of life. Methods: Twenty-four patients who completed the Short Musculoskeletal Function Assessment (SMFA) at baseline and one year following Charcot foot reconstruction were contacted and asked to complete the survey at five years following surgery. Results: Fourteen of the 24 patients completed the SMFA preoperatively, one year following surgery and five years postoperatively. Two patients underwent below knee amputation in the interim. Improvement was noted in all domains measured by the SMFA, with a statistically significant improvement in difficulty with daily activities at five years. Conclusion: Correction of non-plantigrade Charcot foot arthropathy results in clinically meaningful improvement in health-related quality of life at both one and five years postoperatively, including independence with daily activities. The improvement is maintained when reevaluated at five years. This supports the modern paradigm shift towards reconstruction of this deformity. Level of Evidence: III.

Risk Reduction and Perioperative Complications in Patients With Diabetes and Multiple Medical Comorbidities Undergoing Charcot Foot Reconstruction.

BACKGROUND: Modern patient safety programs focus on medical optimization of patients prior to surgery, regional anesthesia when possible, and hospitalist-orthopedic co-management during the perioperative period. METHODS: Eighty-five consecutive patients with diabetes and multiple medical comorbidities underwent surgical reconstruction for acquired deformities secondary to Charcot foot arthropathy with circular ring fixation between 2016 and 2019. All patients participated in a standardized risk reduction program that included medical optimization prior to surgery, regional anesthesia whenever possible, and hospitalist-orthopedic co-management during the perioperative period. Charts were retrospectively reviewed for medical comorbidities, complications, and length of stay. The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Risk Calculator was used to retrospectively calculate their predicted perioperative risk. RESULTS: On multivariable analysis, longer lengths of stay were associated with low preoperative hemoglobin values (rate ratio [RR], 1.36; P = .01) and congestive heart failure (RR, 1.42; P = .02). There were 22 (26%) complications, though only 10 (12%) were serious. These included acute kidney injury (n = 6), sepsis (n = 2), 1 cardiac event, and 1 pulmonary embolism. Overall, the accuracy of predicting a complication using the ACS NSQIP Risk Calculator was 74% (95% CI, 63%-85%), which was comparable to the accuracy of predicting a complication using only patients' congestive heart failure and pin-tract infection statuses (c = 74%, 95% CI, 62%-86%). DISCUSSION: Medical optimization of patients with diabetes and multiple medical comorbidities prior to elective complex reconstruction orthopedic surgery allows the surgery to be performed with a predictable risk for perioperative complications. Preoperative anemia and congestive heart failure are associated with longer hospitalizations in this patient group. The ACS NSQIP Risk Calculator appears to be a reliable predictor of complications during the perioperative period. This study demonstrates that reconstructive surgery in this complex patient population can be accomplished with a reasonable exposure to perioperative risk. LEVEL OF EVIDENCE: Level IV, retrospective case series.