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Prophylactic Surgery In Patients With Diabetes: Timing Is Everything

There are a wide range of prophylactic lower extremity surgeries that may have an impact for patients with diabetes. Some are low-risk while others are complex and require careful consideration. 

In many cases, evaluation of the overall health and lower extremities of a patient with diabetes results in a prognosis-focused management plan without need for surgical intervention. This often includes a combination of patient education and appropriate follow-up. On the other hand, patients can present with a myriad of signs, symptoms and historical evidence requiring expeditious intervention to mitigate risks of end-stage lower extremity complications. 

Often, we overlook hammertoe corrections that can prevent both dorsal toe and plantar submetatarsal ulcerations.1 While bunion surgeries often require hardware, I feel one should not discourage these procedures in a properly selected patient. That said, when there is an indication for osseous fusion, complexity and risk of failure increase, so one must put precautions in place. 

However, surgeries do not have to be osseous to provide impressive pressure and ulceration risk reduction. Percutaneous flexor tenotomy and tendo-Achilles lengthening are both examples of potentially simple, yet highly effective procedures, whether performed as isolated procedures or adjuncts. The most complex of surgeries to mitigate risk of ulceration and limb loss are the myriad of Charcot reconstruction procedures. Needless to say, no matter which procedures you perform for patients with diabetes, there are inherent risks and benefits to uncover and discuss with each case. 

Prophylactic surgery to lessen biomechanical burden on the diabetic foot comes with inherent risk.1-4 Indeed, surgical goals in this population are infection prevention and decreasing future risk of amputation.3 However, in this high-risk group, it is hard to explain to patients that the usual risks of prophylactic surgery include infection, repeat surgery and even possible need for amputation when the goal of prophylactic surgery is prevention of these issues in the first place. This notion is off-putting enough that too many surgeons bypass surgical prevention. 

Establishing a patient’s surgical candidacy for prophylactic surgery requires a thorough attention to detail. Although the full list of considerations is extensive, there are a few things I always screen for that give me a good sense of the patient’s overall health. A thorough medication review offers insight on medical history and potential needs for optimization. I generally check for the use of anti-platelet therapy, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blocker therapy, and whether the patient is taking a statin. Patients that are require immunotheraputics are at higher risk for delayed and impaired healing. Each medication profile carries its own risks and warrants documentation and discussion with the patient and the doctor who prescribed them. For patients with a new diagnosis of diabetes or a history of suboptimal glycemic control, the medication profile becomes less helpful.2,4 

Optimization of modifiable risk factors prior to prophylactic surgery is important. This includes a maximum HbA1c of seven percent, absolute smoking cessation for at least one month prior to the procedure and evaluation of all other relevant comorbid states.2 Nutritional evaluation including albumin/prealbumin and various vitamin levels is a strong consideration for patients with multiple poorly controlled comorbidities. However, these targets may be fluid and/ or unattainable. Continuous reassessment of target goals over time is necessary.2 

Other factors to consider include end-stage renal disease, mobility challenges and/ or fall risk.2,3 In general, these are examples of non-modifiable risk factors or those which are not likely to change within the timeframe of an impending complication or duration of its planned management, but are still valuable to scrutinize. The overall gestalt of a patient’s condition is often best defined by these factors, and understanding how each patient’s health profile contributes to candidacy for prophylactic surgery helps guide treatment. 

While early intervention is always preferred, patient candidacy for prophylactic surgery is a moving target in regard to finding the sweet spot for optimal timing. Being proactive and engaging both the patient and the respective colleagues in other disciplines accelerates medical optimization, expands patient understanding and lessens risks for perioperative complications. 

I find it is wise to institute minimally-invasive procedures over open ones when indicated. Smaller incisions, especially in the presence of peripheral arterial disease (PAD), can decrease risks of non-healing and soft tissue infections, and may be advantageous when hardware is necessary. However, one must avoid compromising the robustness of the reconstructive construct in this population. Moreover, in my experience, one should extend the time expected for surgical healing in patients with diabetes significantly compared to that of average risk patients. Surgeons may need to combine percutaneous and open approaches. In these cases, healing time depends on the most invasive aspect of the procedure. 

Timing for surgical prophylaxis does not need to be complicated. A patient is either a candidate or not on a given day. We regularly help our patients take steps toward better surgical candidacy. Additionally, your personal comfort level will increase with each prophylactic surgery. After all, prevention is worth more than a thousand cures. 

Dr. Elmarsafi is a fellowship-trained foot and ankle surgeon in private practice in Woodbridge and Chantilly, Va 

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By Tammer Elmarsafi, DPM, MBBCh, AACFAS
References

1. Armstrong DG, Lavery LA, Stern S, Harkless LB. Is prophylactic diabetic foot surgery dangerous? J Foot Ankle Surg. 1996;35(6):585-589. 

2. Catanzariti AR. Prophylactic foot surgery in the diabetic patient. Adv Wound Care. 1999;12(6):312. 

3. Sayner LR, Rosenblum BI, Giurini JM. Elective surgery of the diabetic foot. Clin Podiatr Med Surg. 2003;20(4):783-792. 

4. Wukich DK, Lowery NJ, McMillen RL, Frykberg RG. Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus. J Bone Joint Surg. 2010;92(2):287-295. 

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