Risk Reduction and Perioperative Complications in Patients With Diabetes and Multiple Medical Comorbidities Undergoing Charcot Foot Reconstruction

Abstract

Background: Modern patient safety programs focus on medical optimization of patients prior to surgery, regional anesthesia when possible, and hospitalist-orthopedic co-management during the perioperative period. Methods: Eighty-five consecutive patients with diabetes and multiple medical comorbidities 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 risk reduction program that included medical optimization prior to surgery, regional anesthesia whenever possible, and hospitalist-orthopedic co-management during the perioperative period. Charts were retrospectively reviewed for medical comorbidities, complications, and length of stay. The American College of Surgeons (ACS) 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 (rate ratio [RR], 1.36; P = .01) and congestive heart failure (RR, 1.42; P = .02). There were 22 (26%) complications, though only 10 (12%) were serious. These included acute kidney injury ( n = 6), sepsis ( n = 2), 1 cardiac event, and 1 pulmonary embolism. Overall, the accuracy of predicting a complication using the ACS 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%). Discussion: Medical optimization of patients with diabetes and multiple medical comorbidities prior to elective complex reconstruction orthopedic surgery allows the surgery to be performed with a predictable risk for perioperative complications. Preoperative anemia and congestive heart failure are associated with longer hospitalizations in this patient group. The ACS NSQIP Risk Calculator appears to be a reliable predictor of complications during the perioperative period. This study demonstrates that reconstructive surgery in this complex patient population can be accomplished with a reasonable exposure to perioperative risk. Level of Evidence: Level IV, retrospective case series.