Saying ‘No’ To Patients With Diabetes
Although these and other results push our profession closer to specific recommendations, they do not provide specific “cutoff” values. In our practice, we give serious pause and often cancel elective surgery in patients with preoperative hemoglobin A1c values more than 8% and/or blood glucose values higher than 200 mg/dL. Indeed, we often wonder if these cutoffs are too high. We hope that by educating our patients on the additional risks and complications inherent to uncontrolled diabetes, they may aim to better control their glucose prior to undertaking elective surgery.
Saying ‘No’ Because Of Smoking
Even with all the general knowledge today about smoking and its overall negative effects on human physiology, an estimated 45.3 million adults in the United States smoke.7 The adverse effects of smoking in the lower extremity are primarily a result of nicotine’s vasoconstrictive properties that subsequently lead to decreased tissue perfusion and oxygenation.8 Not only does smoking increase wound healing complications but it also affects bone healing.
There are multiple studies that demonstrate increased nonunion rates among smokers in various foot and ankle procedures.9-14 A prospective, multicenter study of 268 patients reported smokers to be 37 percent more likely to develop nonunions in comparison to nonsmokers.13 Chahal reported that smokers were 3.8 times more likely than nonsmokers to have a nonunion in regard to subtalar joint arthrodeses.14 Krannitz and colleagues found that not only was there increased time to radiographic healing among smokers in Austin bunionectomies, they also found a correlation between urine cotinine levels and increased time to healing.15
Although research definitively shows increased wound and bone complications in smokers, many foot and ankle surgeons continue to perform elective surgery on patients with diabetes who smoke. Smoking is an absolutely modifiable risk factor. One should educate patients on the effects of smoking and encourage them to quit. When the additional predisposition of micro- and macrovascular disease in patients with diabetes is compounded with the vasoconstrictive properties of smoking, it can cause devastating outcomes for elective surgery.
Saying ‘No’ Because Of Obesity
In the United States, there is a strong link between diabetes and obesity, objectively defined as an increased body mass index (BMI) over 30. With the rise of obesity and its own inherent risk factors, diabetes can only add to the list of a patient’s potential complications. Patients with diabetes already face an uphill battle with wound and bone healing. With the added effects of obesity come more complications including anesthesia difficulties, deep venous thrombosis (DVTs) and difficulty maintaining appropriate non-weightbearing status throughout the postoperative recovery period.
By itself, BMI is an objective patient finding that is known to correlate with perioperative and long-term patient morbidity and mortality.16-23 Obese patients have worse clinical and surgical outcomes following the development of lower extremity pathology.24-38 This is a modifiable risk factor that patients can change through dedicated diet, exercise and education.
The preoperative evaluation of patients with diabetes should include a BMI calculation as well as a goal BMI for surgical intervention in some cases. If diet and exercise are not sufficient or improbable, patients can seek medical attention from primary care physicians, bariatric surgeons and a host of support groups. The orthopedic community has relative obesity cutoffs for total joint arthroplasty procedures of the knee and hip. Why wouldn’t our profession follow suit for foot and ankle reconstructions?