In addition to optimal medical management, thorough preoperative preparation is the fundamental key to success in the surgical management of high-risk patients, such as those with diabetes. I have witnessed avoidable complications that have occurred due to a lack of attention in areas that may be mistakenly perceived as inconsequential.
During my fellowship, I learned several fundamental keys to success that minimize potential complications, increase patient satisfaction and foster the surgeon-patient relationship.
Informed consent occurs over several clinic visits and includes the patient’s support network. True informed consent should be an exchange of information over a period of time as opposed to a single event in time in which the patient signs a consent form. Studies have shown that patient expectations and postoperative outcomes are enhanced when informed consent occurs in this fashion.1,2 This is due to enhanced patient understanding of the procedure, potential risks and complications as well as an understanding of the expected postoperative recovery course.
It is valuable to reiterate the planned procedure, the most common potential risks, complications and their management should they occur, and the expected postoperative recovery course. Multiple visits give the patients time to process this information, ask questions and get answers to their satisfaction.
One or more of these visits should involve the patient’s support network that will be aiding during the postoperative recovery. Involving the patient’s support network is beneficial to the patient by having another person who can raise additional questions the patient may not have considered. It is beneficial to the surgeon to have another person who can provide insight into the patient’s expectations and ensure an understanding of what is required for an uncomplicated recovery. This person may also shed light on potential areas of non-adherent behavior.3 The patient should review the consent form and sign it during a separate dedicated visit to serve as a final review of the information presented over time.
Assessing The Patient’s Capacity For Postoperative Adherence
Involving other specialties preoperatively will be critical during the postoperative period. A thorough history and physical should include questions concerning the patient’s home environment. Does the patient live in a single story or multi-level home? Are there steps for entry and exit into the house? Is the patient’s house wheelchair accessible? These are important variables to consider, especially for patients who will require strict non-weightbearing for an extended period of time. Knowing this information will dictate what durable medical equipment they will require postoperatively.
Also consider a preoperative referral to physical therapy as physical therapists can simulate situations that the patient will encounter postoperatively, such as using a commode, getting in and out of a car, and going up and down steps. Physical therapists can determine if the patient is able to perform these activities while maintaining weightbearing restriction. This information may dictate the necessity of adjunctive surgical procedures such as the use of external fixation for “weight sharing” if the patient is incapable of remaining strictly non-weightbearing.4
The inability of the patient to perform these activities may also dictate the need for postoperative placement in a skilled nursing or acute rehabilitation facility. If one determines this to be a potential need, consultation to a social worker may be beneficial.
Discuss the reasons and importance for continued recovery at nursing or rehabilitation facilities with the patient and his or her support network. This is so both the patient and his or her supporters will “buy in” to the necessity of spending a period of time there to aid in the patient’s safe return home. One should also discuss the importance of involvement of the patient’s support network during the patient’s stay at these facilities.
When one does not assess these needs preoperatively but expects a patient to be able to perform these tasks postoperatively, the physician may be setting the patient up for complications that could have been prevented by assessing and addressing these needs upfront.3
Emphasizing The Value Of OR Preparation
If you are planning on using specific equipment for the surgery, prior to the day of surgery, review this equipment in detail and review the process in which this equipment works. Consider having the representative of the equipment manufacturer allow you and your surgical team to review use of the equipment prior to the day of surgery with a “hands-on” cadaveric or sawbones lab. This prior planning can minimize potential complications as the surgical team will be familiar with the use of the equipment and the steps of the procedure they will be performing.
Delegate specific tasks to each member of the surgical team to ensure each person knows his or her specific role on the day of surgery. This is particularly important when working with medical students, residents or assisting surgeons.
Several simple additions to the setup of the operating room can enhance the working space of the operative field. Prepping and draping of the operative extremity to expose the limb from above the knee to the toes allows increased space on the surgical field as exposure is not limited to the foot and ankle. This also allows for assessment of the positional relationship of the foot to the lower leg, which is essential during procedures involving realignment of the foot and ankle.
Be cautious in assessing this positional relationship if you are using an ipsilateral hip bolster to limit external rotation of the lower leg. Adding an arm board to the foot of the bed on the side of the non-operative limb also increases the working surgical space. This gives one the ability to move the non-operative extremity off to the side and creates a large working area between the lower legs. If intraoperative image intensification is necessary, place the imaging unit on the side of the non-operative extremity. This allows the surgeon to work without having the arm of the unit blocking him or her from the ideal portion of the operative field.
Other Pertinent Insights On Post-Op Strategies To Minimize Complications
One can minimize postoperative complications with the postoperative dressing, immobilization and activity restriction. Studies have found that postoperative use of a bulky, well padded, Jones-type compressive dressing aids in edema control and immobilization of the foot and ankle, and limits hematoma formation that could lead to infection or delayed healing.5,6
The addition of a sugar tong splint, with or without an anterior bolster, also helps limit motion about the foot and ankle, reducing tension and stress to incisions, which could lead to delayed healing or dehiscence. The surgeon should use a sugar tong splint as opposed to a posterior splint in order to avoid pressure-induced wounds to the posterior heel and plantar forefoot.6
The surgeon should cleanse the entire extremity at each postoperative visit and apply a new sterile dressing to limit the potential for infection and improve hygiene.7 Instruct patients to perform daily sponge baths while the dressings are in place in order to avoid the inner dressing from becoming wet from condensation or failed attempts to cover the dressing to take a shower. Moisture within the dressing can lead to maceration, skin breakdown and infection.
The successful outcome of elective surgery on a high-risk patient is based upon performing the proper procedure on a properly prepared patient at the proper time. A hastened review of a consent form and limited discussion of the expected postoperative recovery course could result in complications that proper informed consent could have avoided.
Preparing patients and their support network for what is expected of them postoperatively is essential to minimizing complications. Just like preparing for an exam in school, one obtains better results with a review of information over time as opposed to “cramming” the night before or walking into an exam cold and expecting to “wing it.” A patient will do better with adherence to postoperative weightbearing restrictions and will be more receptive to the necessity of postoperative skilled nursing or acute rehabilitation facility placement if one discusses these areas and addresses them preoperatively.
Ensuring sound procedure planning as well as operating room setup can help facilitate the procedure. Attention to detail should extend beyond the operating room and continue with proper postoperative dressing management and patient activity restrictions.
Implementing the aforementioned fundamental keys of success will become rote in your planning of elective surgery in the high-risk patient as the benefits will help facilitate better outcomes and fewer post-op complications.
Dr. Schade is the Acting Chief of the Limb Preservation Service, Vascular/Endovascular Surgery Service in the Department of Surgery at Madigan Army Medical Center in Tacoma, Wash. She is an Associate of the American College of Foot and Ankle Surgeons.
Dr. Steinberg is an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. Dr. Steinberg is a Fellow of the American College of Foot and Ankle Surgeons.
1. Brenner LH, Brenner AL, Horowitz D. Beyond informed consent educating the patient. Clin Orthop Relat Res 2009; 467(2):328-351.
2. Easley ME. Medicolegal aspects of foot and ankle surgery. Clin Orthop Relat Res 2005; 433(4):77-81.
3. Roukis TS, Stapleton JJ, Zgonis T. Addressing psychosocial aspects of care for patients with diabetes undergoing limb salvage surgery. Clin Pod Med Surg 2007; 24(3):601-610.
4. Roukis TS, Zgonis T. Post-operative shoe modifications for weightbearing with the Ilizarov external fixation system. J Foot Ankle Surg 2004; 43(6):433-435.
5. Lehnert B, Jhala G. The use of foam as a postoperative compression dressing. J Foot Ankle Surg 2005; 44(1):68-69.
6. Schweinberger MH, Roukis TS. Wound complications. Clin Pod Med Surg 2009; 26(1):1-10.
7. Schade VL, Roukis TS. Use of a surgical preparation and sterile dressing change during office visit treatment of chronic foot and ankle wounds decreases the incident of infection and treatment costs. Foot Ankle Specialist 2008; 1(3): 147-154.