Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_896_Библиотеки_им_академика_М_И_Перельмана

Foot ulceration with subsequent infection is one of the lead­ing causes of hospitalization for patients with diabetes mel­litus. Recent studies have placed the lifetime incidence of diabetic foot ulceration as high as 34% [1]. It is also esti­mated that the recurrence rate of ulceration is 65% in 3–5 years. The number of lower extremity amputations among diabetic patients has been well documented for years. Approximately 73,000 nontraumatic lower limb amputations were performed in 2010in people with diabetes [2]. While the amputation rate decreased from 11.2 to 3.9 per 1000 dia­betic patients between1996 and 2018, this is seven times higher than in non-diabetic patients [3]. More importantly, 85% of these amputations are preceded by a foot ulcer [4, 5].

One of the most important concepts for the surgeon and patient to understand are the goals of surgery. The goals of surgery in patients with foot deformities and a history of ulceration differ from those in patients with foot deformities and normal sensation. It is important that these are clearly delineated by the surgeon and the patient must demonstrate an understanding of these goals.

Diabetic patients, especially those with complications, are at increased risk for surgery. Therefore a detailed medical his­tory, surgical history, list of current medications and espe­cially identication of risk factors such as smoking, cardiac disease, and nephropathy is critical to proper preoperative risk assessment. Additionally an assessment of the patient’s diabetes control via HgbA1C can alert the surgeon to poten­tial complications postoperatively. It has long been believed that poor metabolic control is associated with higher postop­erative infection rates, delayed wound healing, and higher nonunion rates than in well controlled diabetic patients or non-diabetic patients. This is believed to be secondary to the inhibition of leukocyte migration by elevated glucose levels. Recent reports show that random blood sugars >200mg/dL are associated with increased rates of surgical site infections (SSI) [16]. Wound healing complications following foot and ankle surgery increased by a factor of 1.59 for every 1% ele­vation in HgbA1C. [17, 18] It has also been shown that peripheral neuropathy and poor metabolic control can affect bone healing in patients undergoing reconstructive surgery for Charcot joint disease. A preoperative discussion with the patient’s endocrinologist is warranted in order to optimize blood sugar management before surgery to minimize risks of complications, especially when elective or preventive sur­gery is contemplated. It may be prudent to delay these type of procedures until better glycemic control can be achieved. However, this is not possible in urgent or emergent surgery. These type of procedures should not be delayed in order to achieve optimum control.

Finally, a detailed social history has become increasingly important. More of the burden for the patient’s aftercare is being placed on the patient’s family. The majority of patients will require daily dressing changes and prolonged periods of nonweightbearing. For this reason, visiting nurses, home health aides, and physical therapists have become vital mem­bers of the multidisciplinary team. In situations where there is less than adequate support for these services at home, admission to a rehabilitative center should be considered. These factors should be identied early in the course of the patient’s hospitalization so that discharge planning can pro­ceed in a timely and stress free manner as there are increased pressures to reduce patients’ length of stay