Charles Anderson, MD discusses techniques available to assess skin perfusion pre-operatively and intra-operatively as well as define the limitations of the different techniques that are used. Dr Anderson also discusses the outcome data demonstrating decreased suture line complications with pre-operative and intra-operative assessment of skin perfusion.
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Release Date: 12/26/2018 Expiration Date: 12/31/2020
Charles Andersen, MD
Chief of Vascular-Endovascular-Limb Preservation Service and Medical Director of the Wound Care Clinic at Madigan Army Medical Center
Clinical Professor of Surgery at the University of Washington and the Uniformed Services University of Health Sciences
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Speaker: So I have the next presentation. We are going to talk about the preoperative assessment of high-risk foot and ankle patients. Nothing to disclose. Again, I work for the army. What is going to hear is my opinion not the opinion of the army and not the opinion of the Veterans Affair and this presentation does not support or endorse any product. So our learning objectives, we are going to discuss the components of preoperative assessment, discuss the factors that can predict, postoperative complication, what factors for complications can be modified preoperatively and should surgical procedures be modified in patients with diabetes. So this is a publication that just came out. We put together this for the foot and ankle quarterly. Much of what I am going to say today is found in this publication that my partner and I just completed. So to put things in perspective, surgical techniques have continued to improve. However, perioperative complications continue to be a significant problem especially in patients with diabetes or associated vascular disease. A good example, TMA. TMA still has about 50% incidents of surgical site complications. This is a quote from Young back in 1977. A surgeon practicing TMA must be prepared to accept some failure and some instances of temporarily incomplete wound healing. Must be prepared to accept.
So the question, do we have the knowledge and/or the skills to decrease the perioperative or postoperative complications in foot and ankle surgery? And I hope following this presentation, the answer will be yes. So the preoperative assessment and management preoperative, the intraoperative plan and the perioperative management is critical to prevent complication. So I spend my time teaching residents and I often say the fun time is in the operating room. The work and the key to success is before you get to the operating room and after you leave the operating room. And it's really about attention to detail. So the work before you go to the operating room, the planning in the operating room over and above the technical detail and the postoperative care is the key to success. It's really about attention to detail. When we make rounds, we talk about high-risk vascular patients, high-risk limb preservation patients and we talk about the tight rope. So you picture patient walking across a tight rope. It takes just a little bit of wind to blow that patient off from the tight rope. And many of our patients they have zero margin of error or very little margin of error. If you take a young GI as we see in our hospital and you do ruptured appendix and somehow they don't get their antibiotics, you give them too much fluids, they get an infection, they have a margin of error. They are going to get through all of that very rapidly and they are going to go home.
You take that same patient now that has multiple comorbidities and you take them through just one of those perioperative complications and many times that's a downward spiral. We call that the domino effect. One domino tips, it tips the next one and oftentimes you end up with very bad outcome. We talk in our vascular patients, for example, fluid management, something that we tend to take for granted. However, you give our patients a little too much fluid postoperative day two, they mobilize that fluid, they give right heart stretch, they go into atrial fibrillation, they have an MI, they get pneumonia, they get intubated and they die. So margin of error, we have to manage that margin of error to really prevent the complications in our high-risk foot and ankle patients. So the preoperative assessment is critical to identify and potentially modify those factors that can lead to complications. When we talk about postoperative complications, there are systemic complications, i.e., MI, pneumonia, urinary tract infection or there are local complications, which can be surgical site infections, malunion, the need for reoperation, those are local complications. I have been fortunate to work in the center for over 20 years now where we work very closely together as a multidisciplinary limb preservation service. So same physical location, vascular surgeons, vascular lab, advanced podiatric care that works only in limb preservation fellow and advanced wound care.
And we meet every morning. We discuss patients every morning, we make rounds every day. So the key is what we have found in limb preservation is that multidisciplinary approach has really helped us prevent amputations. But that same approach has become very, very useful in our standard when we are talking about operating on high-risk patients. That is it's not one person's decision to manage that patient. It's a team approach both in preparing that patient, making sure if there is associated vascular disease, for example, that that's addressed, have an operative plan and have postop management, which can include internal medicine, infectious disease, certainly other specialties. When we look at the complication rate, it's significant. So 28% complication rate for ankle and hind foot reconstructive surgery, 8% re-operation rate, infection rate 2.8% in non-diabetic and 9.5% in patients with diabetes. So oftentimes, my residents will say, well, we send the patent to medicine for clearance and medicine says it's okay to operate. That's really something that we shouldn't think of preoperative medical clearance. We can get the team involved to gain additional information about the comorbidities and help in managing the comorbidities. But it's the surgeon that makes that decision about whether to operate or not operate.
It's not internal medicine. And it's the surgeon that is the lead in the preoperative, intraoperative and postop management of these patients. Maybe using a team but the surgeon has to be a significant part of that management team. The operations may be the same but the patients are different. So every patient has different risk factors, different comorbidities and when you are thinking about a complex foot and ankle procedure, not just procedure but a very in-depth analysis of the patient that's going to undergo that procedure is critical in preventing complications. Coordination, communication is critical. You can say we'd have done a complex foot and ankle procedure to sick diabetic patients, medicine is going to manage the diabetes. That's fine. They have the expertise. What they don't know is what the operation was that was performed, what the specific needs of that patient are for that operation. A good example is offloading, management of the dressing. PT what should have really entailed, how much can you push that. So again it has to be constant communication and that communication has to include the patient. I am old enough to remember when we put patients in the hospital preoperatively for most procedures and even for simple procedures they stayed in the hospital for sometimes a few days.
That's what patients expected and at the end of two days I knew they were going to be ready to go home. So when you communicate with the patients preoperatively, they clearly need to know what the expectations are, what the pathway is going to be, they buy into that, they know for example how long they are going to be immobilized, how long they are going to have an offloading device on. So they become a critical part of that team to help make decisions and help follow a pathway that will help prevent complication. When we look at a simple thing like the history, it's really a detective work. So you are looking for clues, disease history, previous hospitalizations where there are associated complications, previous infections, what were the organisms, previous revisions required, why? Functional status and expectations are critical in the history and making the decision for complex foot and ankle surgery. Medicine history, this is very interesting study looking at 99 patients of the age of 65 and limited number of patients really knew what medicines they were taking and why they were taking those medicines. And you think of the perioperative management, that's a red flag and that can include anticoagulation. So key to really find out what medicines the patients are taking and why they are taking those medications. Physical exam, certainly a general exam, vascular exam and neurological exam is critical.
Musculoskeletal exam should be performed both in the supine and weightbearing state and deformities may only be visible when the patients are in the weightbearing status. Vascular assessment, we have talked a lot in this meeting about identifying vascular disease. Every patient undergoing a complex foot and ankle procedure should have a vascular assessment. Now, if there are clearly palpable pulses and no history to support vascular disease, then that may be enough. But if that's not the state prior to undergoing any complex foot and ankle surgery, a vascular assessment is critical. If vascular disease is identified, not only is that a risk factor for local complications, it might be a trigger to do revascularization prior to the complex foot and ankle surgery. But it's also telling you that these patients have a systemic disease, atherosclerotic vascular disease, and they may be at increased risk for a perioperative MI. So that goes into the decision tree about the type of anesthesia, for example, and making anesthesia part of that team again to prevent the perioperative myocardial infarction. We have talked this morning already two talks that emphasized silent PAD especially important in the patients with diabetes. We talked about a high index of suspicion and ruling out vascular disease, especially in those patients with diabetes even if they don't have the typical symptoms of claudication or rest pain.
Demand versus supply, we talked a little bit as soon as you make an incision, as soon as there is trauma, as soon as there is a wound that increases the demand, if you can't meet that demand, then you don't heal or you heal slowly or you have a complication. Again, the importance of identifying those patients. I showed this in the previous talk and also this quote by my partner that looking in a regional MNM conference discussing foot and ankle surgery that at that particular MNM the most common cause of postoperative complications was failure to identify coexisting vascular disease prior to performing a podiatric procedure. Again, PAD not only a risk factor for local complications but systemic complications. Oftentimes, we forget about the venous exam. We wrote a chapter in Dr. Zgonis’ book and tried to emphasize the importance in foot and ankle surgery not only of the arterial but the venous system. If there is a history of venous disease that can put you at risk for DVT. So it may change the prophylactic measures that you take for DVT. In addition to that, venous disease is often associated with edema and edema causes increased pain and decreased healing. So management perioperatively, preoperatively and postoperatively of that edema again is critical in preventing postoperative complications.
Diabetes, again, we're at a limb preservation conference and many of the patients that we see and treat in a limb preservation center are diabetic. This is Dane Wukich that was very active in this program in the past, orthopedic surgeon, made the following statements across the spectrum of foot and ankle surgery. Diabetes is consistently associated with negative outcomes, less than ideal outcomes, higher risks of surgical site infection and systemic complications such as MI, PE or urinary tract infection and also a trend for longer hospital stay. So diabetes risk factor, management of diabetes critical in order to try to decrease the incidence of postoperative complication. Again, attention to detail, preoperative diabetic control, perioperative glucose control and modification of operative techniques, and perioperative and postoperative care in a patient with diabetes. We all know, for example, foot and ankle trauma in patients with significant diabetes, we manage differently than a young individual not diabetic. So it also modifies our operative technique. So this is data looking at preoperative control of diabetes looking at the hemoglobin A1c. This is a large study, 21,000 diabetic patients who underwent elective foot and ankle surgery.
Overall complication was 3.2%, but there was a steady 5% increase in the complication rate for every 1% increase in the hemoglobin A1c. So purely elective surgery is a worthwhile to attempt to get better diabetic control. This data would suggest that you can decrease the complication rate by paying attention to and working with your medical colleagues to get better control of the diabetes in these patients prior to undergoing elective complex foot and ankle surgery. This has to do with the perioperative glycemic control, again a series of patients undergoing elective foot and ankle surgery. The recommendations of the American Diabetes Consensus statement is to keep the glucose less than 180 and this series that was achieved in only 40% of patients, the patients that had values over 200 had 11.9% incidence of infection rate. Those that had glucose that stayed below 200, it was 5.2. So management of the perioperative glucose has a significant impact on the complications associated with complex foot and ankle surgery. That's something that can be managed. Cardiac assessment, certainly that have vascular disease have a history of any kind of cardiac event, have congestive heart failure, all benefit from preoperative cardiac optimization.
And that starts many times with just a preoperative EKG and at times full cardiac evaluation working with your cardiologist. The indications for a preoperative EKG certainly are patients over the age of 50 or the presence of PAD and I would add to that personally patients with diabetes. Neurological exam, very critical to do a very thorough preoperative neurological exam. Number one, that can alter the operative technique, it can alter the documentation of whether or not that is a postoperative complication. So again ensuring that you know exactly what the neurological state is before you undergo a complex foot and ankle procedure, especially a revisional foot and ankle procedure. Anemia is common and studies indicate that mortality increases with hemoglobin levels below 7. So anemia can be identified preoperatively. Again in elective surgery, you need to look for that not the day before surgery but the month before surgery. So once you are considering that patient for elective surgery, if they are anemic, then to find the etiology of that anemia. If possible treat that anemia and by elevating hemoglobin, potentially avoid the consequences of anemia, which are an increased perioperative complication rate.
So again, anemia can be treated especially for example in our patients with renal failure. Oftentimes, they are significantly anemic but can be prepared preoperatively that decrease the need for transfusion or the complications associated with anemia. Something I talked about in the first talk, fluorescence angiography, we also use that as part of our assessment of high-risk foot and ankle patients, again to look at the perfusion in the area where we are contemplating surgery, especially if that's any kind of amputation to make sure that there is adequate perfusion to heal that operative procedure and we also use that intraoperatively with any operations where we make a flap to assure that there is good perfusion of that flap and then after we close the flap, to relook at the flap so when we leave the operating room, we know we have a well perfused flap, which we found significantly decreases our incidence of postoperative incisional complications. Many of the surgical fields, especially general surgery, there is risk assessment tools. This is the NSQIP. This now has been utilized in foot and ankle surgery. So it allows you to look at data across the various centers and identify a risk calculator how likely the patients are to have complications. That can be very important in your decision making and also your counseling of your patients, and then you can also compare your outcomes to other outcomes as a quality measure.
So in conclusion, risk factors for postoperative complications can be identified and at times modified. Anticipate complications and use attention to detail to decrease the incidence. Patients with diabetes are at higher risk and may require special operative techniques, detail, detail, detail and attention to detail. Failure to identify and manage coexisting arterial or venous disease is a major cause of postoperative complications. Again, many of our patients, they walk a very fine line, very little margin of error to identify and manage the conditions that can lead to perioperative complications is critical. Thank you all very much.
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