Natalie C. Suder

Prevalence of Diabetic Neuropathy in Patients Undergoing Foot and Ankle Surgery

Introduction: The aim of this prospective study was to determine the prevalence of neuropathy in diabetic patients undergoing foot and ankle surgery. It was hypothesized that the prevalence of diabetic neuropathy is higher among patients who undergo foot and ankle surgery compared with historical rates of neuropathy in diabetic patients in general. Methods: During a consecutive 42-month period, patient data were prospectively entered for 1859 consecutive patients undergoing foot and ankle surgery. Among the subjects, 394 had been previously diagnosed with diabetes mellitus (DM), and the remaining 1465 did not have DM. Results: The prevalence of neuropathy in patients with and without DM was 77.2% (304 of 394 patients) and 11.7% (172 of 1465 patients), respectively. Patients with diabetic neuropathy were older, had poorer glycemic control, had higher serum creatinine levels, and reported more significant tobacco use than diabetic patients without neuropathy. Conclusion: Nearly 80% of diabetic patients undergoing foot and ankle surgery at a large academic medical center had diabetic neuropathy. Preoperative recognition of this morbid complication of DM is important to appropriately stratify those diabetic patients into a high-risk category. Level of Evidence : Prognostic, Level IV

Noninvasive Arterial Testing in Patients With Diabetes A Guide for Foot and Ankle Surgeons

Background: This study was designed to compare the findings of noninvasive arterial testing in patients with and without diabetic foot pathology. Methods: The ABI (ankle brachial index), TBI (toe brachial index), and great toe pressures were measured in 207 patients. PAD (peripheral artery disease) was defined as an ABI < 0.91 on either extremity or a TBI < 0.7. Results: PAD was identified in 103 of the 207 patients (49.8%), 80 patients with diabetic foot pathology and 23 patients with nondiabetic foot pathology. Although patients with diabetic foot pathology were 1.4 times more likely to have PAD compared to patients without diabetic pathology, this increased risk was not statistically significant (OR 1.41 [95% CI 0.75-2.64], P = .28). Patients with PAD and diabetic foot pathology were 4.9 times more likely to have ischemia (toe pressure < 60 mm Hg) than patients with PAD and nondiabetic foot pathology (OR 4.93 [95% CI 1.35-17.94], P < .05). Patients on dialysis had a 7.3 times increased likelihood of having PAD compared to patients not on dialysis (OR 7.3 [95% CI 1.6-33.6], P < .01). Patients with absent pedal pulses were 4.9 more likely to have PAD than patients with normal pulses (OR 4.9 [95% CI 2.6-9.4], P < .0001). PAD was identified in 97 of 188 patients (51.6%) with peripheral neuropathy compared to 6 of 19 patients (31.5%) without peripheral neuropathy (OR 2.31 [95% CI 0.84-6.33], P = .10). Conclusions: Combining the ABI with TBI improved the ability to diagnose PAD in diabetic patients because the ABI has high specificity (low false positives) and the TBI has high sensitivity (low false negatives). The TBI was more reliable in patients with noncompressible arteries, medial artery calcinosis and/or neuropathy. Due to the relative incompressibility of calcified distal arteries in patients with DM, the ABI may be within normal limits in patients with PAD. This false negative result may lead surgeons to assume that normal perfusion is present. Level of Evidence: Level III, comparative study.

Topically Applied Vancomycin Powder Reduces the Rate of Surgical Site Infection in Diabetic Patients Undergoing Foot and Ankle Surgery

Background: The purpose of this study was to evaluate the efficacy of topically applied vancomycin powder in reducing the rate of surgical site infections (SSIs) in patients with diabetes mellitus (DM) undergoing foot and ankle surgery. Methods: Eighty-one patients with DM who underwent reconstructive surgery of a foot and/or ankle deformity and/or trauma and who received topically applied vancomycin were matched to 81 patients with DM who did not receive topically applied vancomycin. The mean age was 60.6 years in the vancomycin group and 59.4 years in the control group (P < .05). The 2 groups were similar with regard to gender, body mass index, duration of DM, short-term and longer term glycemic control, and length of surgery. Results: The overall likelihood of SSI was decreased by 73% in patients who received topically applied vancomycin (odds ratio [OR], 0.267; 95% CI, 0.089-0.803; P = .0188). The rate of superficial infection was not significantly different between the 2 groups (OR, 0.400; 95% CI, 0.078-2.062; P = .2734); however, deep infections were 80% less likely in patients who received vancomycin powder (OR, 0.200; 95% CI, 0.044-0.913; P = .0377). Conclusion: High-risk diabetic patients undergoing foot and ankle surgery were notably less likely to develop an SSI with the use of topically applied vancomycin powder in the surgical wound, particularly with regard to deep infections. Topically applied vancomycin was associated with a very low rate of complications and was inexpensive (

Patients With Diabetic Foot Disease Fear Major Lower-Extremity Amputation More Than Death

5 per 1000 mg). Based on this study, foot and ankle surgeons may consider applying 500 to 1000 mg of vancomycin powder prior to skin closure in diabetic patients who are not allergic to vancomycin. Level of Evidence: Level III, retrospective case control series.

Perioperative Glycemic Control and the Effect on Surgical Site Infections in Diabetic Patients Undergoing Foot and Ankle Surgery

Background. The aim of this study was to identify the most-feared complications of diabetes mellitus (DM), comparing those with diabetic foot pathology with those without diabetic foot pathology. Methods. We determined the frequency of patients ranking major lower-extremity amputation (LEA) as their greatest fear in comparison to blindness, death, diabetic foot infection (DFI), or end-stage renal disease (ESRD) requiring dialysis. We further categorized the study group patients (N = 207) by their pathology such as diabetic foot ulcer (DFU), Charcot neuroarthropathy, foot infection, or acute neuropathic fractures and dislocations. The control group (N = 254) was comprised of patients with diabetes who presented with common non–diabetes-related foot pathology. Results. A total of 461 patients were enrolled in this study and included 254 patients without diabetic foot complications and 207 patients with diabetic foot problems. When comparing patients with and without diabetic disease, no significant differences were observed with regard to their fear of blindness, DFI, or ESRD requiring dialysis. Patients with diabetic foot disease (61 of 207, 31.9%) were 136% more likely (odds ratio [OR] = 2.36; 95% CI = 1.51-3.70; P = .002] to rank major LEA as their greatest fear when compared with diabetic patients without foot disease (42 of 254, 16.5%) and were 49% less likely (OR = 0.51; 95% CI = 0.34-0.79; P = .002) to rank death as their greatest fear compared with patients without diabetic foot disease. Conclusion. Patients with diabetic foot pathology fear major LEA more than death, foot infection, or ESRD. Variables that were associated with ranking LEA as the greatest fear were the presence of a diabetic-related foot complication, duration of DM ≥10 years, insulin use, and the presence of peripheral neuropathy. Levels of Evidence: Level II: Prospective, Case controlled study

Relationship of femoral artery ultrasound measures of atherosclerosis with chronic kidney disease

Introduction. Diabetes mellitus is one of the leading causes of hyperglycemia in the perioperative setting. Hyperglycemia has been shown to cause increased risk of surgical site infections (SSIs) in multiple surgical specialties, but to our knowledge it has not been investigated for orthopaedic foot and ankle surgery. The aim of this study was to determine if hyperglycemia increased the rate of SSI in elective, diabetic patients that required perioperative hospitalization. Methods. A total of 348 consecutive inpatients after foot and ankle surgery were retrospectively evaluated. Patients who had a random serum glucose ≥200 mg/dL during the admission (Group 1) were compared to patients whose serum glucose never exceeded 200 mg/dL (Group 2). Results. Our 2 groups were similar with regard to age, gender, and body mass index. Twenty-one of 176 patients (11.9%) whose serum glucose was ≥200 mg/dL during the admission developed an SSI as compared to 9 of 172 patients (5.2%) whose serum glucose remained <200 mg/dL (odds ratio = 2.45; 95% confidence interval = 1.09-5.52;, P = .03). Discussion. Perioperative hyperglycemia ≥200 mg/dL is associated with increased rates of SSI after foot and ankle surgery. Communication with medical consultants is paramount in an effort to improve perioperative glycemic management and reduce the rate of SSI. Levels of Evidence: Prognostic, Level III: Case Control

Femoral Artery Atherosclerosis Is Associated With Physical Function Across the Spectrum of the Ankle‐Brachial Index: The San Diego Population Study

Background: Chronic kidney disease (CKD) is strongly associated with peripheral artery disease (PAD). Detection of subclinical PAD may allow early interventions for or prevention of PAD in persons with CKD. Whether the presence of atherosclerotic plaque and femoral intima‐media thickness (IMT) are associated with kidney function is unknown. Methods: We performed a cross‐sectional observational study of 1029 community‐living adults. We measured superficial and common femoral artery IMT and atherosclerotic plaque presence by ultrasound. Estimated glomerular filtration rate (eGFR; continuous) and eGFR <60 mL/min/1.73 m2 (binary) were evaluated as outcomes. Results: Mean age was 70 ± 10 years, mean eGFR was 78 ± 17 mL/min/1.73 m2, and 156 (15%) individuals had eGFR <60 mL/min/1.73 m2; 260 (25%) had femoral artery plaque. In models adjusted for demographics and cardiovascular risk factors, individuals with femoral artery plaque had mean eGFR approximately 3.0 (95% confidence interval, −5.3 to −0.8) mL/min/1.73 m2 lower than those without plaque (P < .01). The presence of plaque was also associated with a 1.7‐fold higher odds of eGFR <60 mL/min/1.73 m2 (95% confidence interval, 1.1–2.8; P < .02). Associations were similar in persons with normal ankle‐brachial index. The directions of associations were similar for femoral IMT measures with eGFR and CKD but were rendered no longer statistically significant with adjustment for demographic variables and cardiovascular disease risk factors. Conclusions: Femoral artery plaque is significantly associated with CKD prevalence in community‐living individuals, even among those with normal ankle‐brachial index. Femoral artery ultrasound may allow evaluation of relationships and risk factors linking PAD and kidney disease earlier in its course.

Extensor Digitorum Brevis Transosseous Transfer for MTPJ Instabilty A Pilot Study

Background The ankle‐brachial index (ABI) is inadequate to detect early‐stage atherosclerotic disease, when interventions to prevent functional decline may be the most effective. We determined associations of femoral artery atherosclerosis with physical functioning, across the spectrum of the ABI, and within the normal ABI range. Methods and Results In 2007–2011, 1103 multiethnic men and women participated in the San Diego Population Study, and completed all components of the summary performance score. Using Doppler ultrasound, superficial and common femoral intima media thickness and plaques were ascertained. Logistic regression was used to assess associations of femoral atherosclerosis with the summary performance score and its individual components. Models were adjusted for demographics, lifestyle factors, comorbidities, lipids, and kidney function. In adjusted models, among participants with a normal‐range ABI (1.00–1.30), the highest tertile of superficial intima media thickness was associated with lower odds of a perfect summary performance score of 12 (odds ratio=0.56 [0.36, 0.87], P=0.009), and lower odds of a 4‐m walk score of 4 (0.34 [0.16, 0.73], P=0.006) and chair rise score of 4 (0.56 [0.34, 0.94], P=0.03). Plaque presence (0.53 [0.29, 0.99], P=0.04) and greater total plaque burden (0.61 [0.43, 0.87], P=0.006) were associated with worse 4‐m walk performance in the normal‐range ABI group. Higher superficial intima media thickness was associated with lower summary performance score in all individuals (P=0.02). Conclusions Findings suggest that use of femoral artery atherosclerosis measures may be effective in individuals with a normal‐range ABI, especially, for example, those with diabetes mellitus or a family history of peripheral artery disease, when detection can lead to earlier intervention to prevent functional declines and improve quality of life.

Prevalence of Peripheral Arterial Disease in Patients With Diabetic Charcot Neuroarthropathy

Category: Lesser Toes Introduction/Purpose: Instability at the MTPJ of the lessor toes is challenging to treat, particularly when both transverse and sagittal plane deformity coexist. Previous studies have utilized a subligamentous transfer of the EDB for crossover toes. The purpose of this pilot study was to evaluate a transosseous transfer of the EBD to correct multiplanar instability of the lessor toe. Routine exposure of the MTP was performed through a dorsal approach and a Z lengthening of the EDL was performed. The median number of concomitant produres performed was 4 and included hallux valgus repair, neuroma excision, metatarsal osteotomy, hammertoe correction and capsulotomies of other toes as needed. 27 tendon transfers were performed in 25 patients (2nd MTPJ: 20, 3 rd MTPJ: 5, 4th MTPJ: 2) Methods: A capsular release was performed on the concave side (contracted) and the convex side (lax) of the proximal phalanx and metatarsal head were exposed. A tenotomy of the EDB was performed at the musculotendinous junction and its insertion remained intact. The EDB was then transferred through a 2.5 mm drill hole in the base of the proximal phalanx. The drill hole began on the concave side and exited on the convex side with a similar hole from the convex side of the metatarsal neck to the concave side. To correct sagittal deformity the drill hole was oriented from dorsal to plantar. A low profile 1.5 mm polyethylene suture tape augmented the EDB transfer in both the proximal phalanx and metatarsal neck. A 3.0 mm interference screw is placed distally and the tape and EDB were appropriately tensioned and proximal fixation was achieved with another interference screw. Results: Results Median age in years (25-75th interquartile range) Females (N,%) 24, 96% 64(58-85) BMI (25-75th interquartile range) Previous surgery (N,%) Smoking history (N,%) Inflammatory arthritis (N,%) 27.8(21-32) 8, 32% 7, 28% 5, 25% Median number of concomitant procedures (25-75th IQR) Preop AP MTPJangle in degrees (25-75th IQR) Postop AP MTPJ angle in degrees (25-75th IQR) % Transverse Plane Improvement Preoperative to Postoperative 4(3-6) 19(11.5-24.0) 13(4.5-20.5) 31.5% (p < 0.0001) Preop Lateral MTPJ angle in degrees (25-75th IQR) Postop Lateral MTPJ angle in degrees (25-75th IQR) 41(26-58) 29(22.5-36) % Sagittal Plane Improvement Preoperative to Postoperative 29.2%(p < 0.0001) Conclusion: At a median follow up 19 weeks (12-32 weeks), EDB transfer augmented by polyethylene tape resulted in significant improvement in the transverse (31.5%) and sagittal planes (29.2%) without using temporary K wire fixation across the MTPJ. Twenty of 25 patients (80%) were completely satisfied, 4 patients (16%) were partially satisfied and 1 patient (4%) was dissatisfied. One mild infection occurred which was treated with oral antibiotics. No fractures occurred. This study is limited by relatively short follow up and the need to confirm these findings by independent surgeons. A biomechanical study is underway to assess pull out strength of the construct