Risk Reduction and Perioperative Complications in Diabetics with Multiple Medical Comorbidities Undergoing Charcot Foot Reconstruction

Abstract

Category: Diabetes; Other Introduction/Purpose: Modern Patient Safety Programs focus on medical optimization prior to surgery, regional anesthesia and hospitalist-orthopaedic co-management during the perioperative period. Methods: Eighty-five consecutive diabetic patients with multiple medical co-morbidities underwent surgical reconstruction for acquired deformities secondary to Charcot foot arthropathy with circular ring fixation between 2016 and 2019. All patients participated in a standardized perioperative medical optimization program, which included medical optimization prior to surgery, regional anesthesia whenever possible and hospitalist-orthopaedic comanagement during hospitalization. Charts were retrospectively reviewed for medical comorbidities, complications, and length of stay. The National Surgical Quality Improvement Program (NSQIP) Risk Calculator was used to retrospectively calculate their predicted perioperative risk. Results: On multivariable analysis, longer lengths of stay were associated with low preoperative hemoglobin values (RR = 1.36; P =.01) and congestive heart failure (RR = 1.42; P =.02). There were 22 (27%) complications, though only 10 (12%) were serious. These included acute kidney injury (n = 6), sepsis (n = 2), one cardiac event, and one pulmonary embolism. Overall, the accuracy of predicting a complication using the NSQIP risk calculator was 74% (95% CI: 63% - 85%) which was comparable to the accuracy of predicting a complication using only patients' congestive heart failure and pin-tract infection statuses (c = 74%, 95% CI: 62% - 86%). Conclusion: Medical optimization of diabetic patients with multiple medical co-morbidities prior to elective complex reconstruction orthopaedic surgery leads to improved clinical outcomes. Preoperative anemia and congestive heart failure are associated with longer hospitalizations in this patient group. The American College of Surgeons NSQIP Risk Calculator is a reliable predictor of complications in the perioperative period. This study demonstrates that reconstructive surgery in this complex patient population can be accomplished with a reasonable exposure to risk for complication.