Saying ‘No’ To Patients With Diabetes
Patients with diabetes are no strangers to dealing with the complications associated with their disease. As foot and ankle surgeons, we also often face the challenge of treating the complications and sequelae of this pathologic process including lower extremity deformity, non-healing wounds, Charcot neuroarthropathy and infection to name a few.
However, what happens when we, as intervening medical professionals, are the cause of a relatively predictable complication? What about when a patient with diabetes at increased risk for complication requests elective surgery? Is it our obligation to treat these patients as we do those without diabetes or should we approach these patients with a more wary and conservative eye? In other words, when is it okay to say “no” to a patient with diabetes?
Although these are certainly questions without definitive answers, a review of recent literature may help podiatric surgeons make relatively judicious decisions. There are times when the medical profession may be a little too eager to please and when it seems like patients can always find a surgeon who will say “yes.” In a similar way, it can sometimes be difficult to remember that it is not our primary job to please our patients but instead to diagnose, educate and recommend. Just because a patient is willing to entertain increased perioperative surgical risk does not mean that we have to as well. It is okay to say “no.”
Saying ‘No’ Because Of Poor Glycemic Control
There is an increasing body of evidence that one should reconsider elective surgical intervention in the setting of uncontrolled hyperglycemia, both in terms of short-term and long-term control. Perhaps one can most easily appreciate this with long-term control of the hemoglobin A1c value. It can sometimes be frustrating in clinical practice when patients cannot recall their value or, even worse, have no knowledge of what it designates. At least in our practice, this laboratory test is part of the standard preoperative evaluation and we will not make a specific surgical recommendation to a patient with diabetes who does not have knowledge of this number.
A natural question that follows is “how high is too high?” in terms of the hemoglobin A1c. Although we do not have a definitive answer for this question, the literature continues to demonstrate a significantly increased risk of surgical complications with surprisingly small increases in the hemoglobin A1c.
Wukich and colleagues demonstrated that patients with diabetes with complications were 10 times as likely to develop a postoperative infection following foot and ankle surgery in comparison to patients without diabetes.1 The authors also found that patients with diabetic complications were six times as likely to develop postoperative infection in comparison to patients with diabetes without complications. Myers and colleagues subsequently found a significantly higher postoperative infection rate in patients with an A1c higher than 7% in comparison to patients lower than 7% in a series of ankle and hindfoot fusions.2
Shibuya and coworkers found that patients with a hemoglobin A1c higher than 7% were approximately three times as likely to have a bone healing complication in comparison to those with a hemoglobin A1c less than 7%.3 A recent investigation on over 1,700 patients undergoing total joint arthroplasty found that patients with an A1c value higher than 6.7% were nine times as likely to develop a postoperative wound complication.4
Short-term control of blood glucose also likely has an impact on perioperative results although this has not been as well investigated yet. A recent study from the University of Michigan found that preoperative blood glucose measurements above even 120 mg/dL in patients undergoing neurosurgical operative interventions led to an increased risk of postoperative complications and longer lengths of hospital stay.5 In the lower extremity, researchers found a statistically significant increased risk of wound dehiscence in those with preoperative glucose measurements higher than 200 mg/dL (and in patients with hemoglobin A1c higher than 6.5%).6