Dolfi Herscovici, Jr. DO

M. Nick Perenich, DO

Julia M. Scaduto, ARNP

Foot Ankle/Trauma Service Tampa General Hospital

Tampa, Florida

Disclosure Information The authors have not received anything of value from a

commercial company or institution related directly or indirectly to the subject of this presentation

Dr. Herscovici: SLACK Incorporated Royalties

Full Disclosure Online at AAOS.org

Introduction The 2014 National Diabetes Statistics reported that

29.1 million people (9.3% U.S. population) have diabetes

Patients with neuropathy, and at least one other co-morbidity Have higher rates of complications compared to

diabetics without neuropathy or another co-morbidity.

Nearly 89% have one additional co-morbidity Only 36-57% achieves adequate glycemic

control. No specific guidelines exist regarding the

evaluation of patients presenting with diabetic foot and ankle problems.

The purpose of this study was to use the experience and practice methods of the AOFAS membership to determine if preferences exist for the evaluation and approaches to the diabetic patient.

Methods and Materials

A multiple choice survey was developed and sent via e-mail to the 1373 active members of the AOFAS membership.

The survey consisted of twelve questions.

To ensure maximum response, e-mails were sent out at weekly intervals for 8 consecutive weeks.

Methods and Materials 1. How long have you been practicing?

a. <5 yrs

b. 6-10 yrs

c. 11-20 yrs

d. >20 yrs

2. Are you fellowship trained in Foot and Ankle: Yes/No

3. Foot and ankle surgery is what percentage of your practice?

a. <25%

b. 25-50%

c. 50-75%

d. >75%

4 . Do you treat diabetic fractures and charcot arthropathy: Yes/No

5. How many surgeries are performed on diabetic fractures or charcot arthropathy?

a.<10 per yr

b.11-30 per yr

c. 31-50 per yr

d. >50 per yr

Methods and Materials 6. Do you evaluate for neuropathy within the office Y/N-Yes?

a. Semmes-Weinstein

b. Pinwheel

c. Tuning fork

d. Temperature

e. Not evaluated

7. In a sensate patient do you evaluation circulation preoperative Y/N-Yes?

a. Only check for palpable pulses

b. Doppler-able pulses

c. ABI only

d. Toe pressures

e. Transcutaneous O2

f. Angiogram/MRI

g. Not evaluated

8. In a neuropathic pt do you evaluation circulation Preoperative Y/N- Yes?

a. Check for pal pulses

b. Doppler-able pulses

c. ABI only

d. Toe Psi

e. Transcutaneous O2

f. Angiogram/MRI

g. Not evaluated

Methods and Materials

9. Do you require preoperative medical evaluation: Yes/No

10. Do you evaluate HgbA1C preoperatively: Yes/No

11. What HgA1C level will you accept preoperatively?

a. <7.0

b. 7.1-8.0

c. 8.0-10.0

d. Does not concern you

12. Do you cancel scheduled surgery based on HgA1C levels: Yes/No

Results The data was compiled from 706 (51%)

completed responses. 60% have been in practice 11 or more years > 87% completed a Foot and Ankle fellowship Those with <10 years practice reported 73% of

their practice consisted of foot and ankle surgery (FAS), Those >11 years reported 60% of the practice devoted

to FAS.

72% with < 5 years practice checked for neuropathy with a monofilament Only 64% > 5 years used a monofilament. 22% respondents never evaluated for

neuropathy.

90% of respondents checked for palpable pulses in both sensate and

neuropathic patients 30% also used Dopperable pulses 34% also used an ankle-brachial index (ABI). <1% responded that circulation was not

evaluated.

5.07

6.10

6.45

Results

98% with < 5 years practice obtained preoperative medical evaluations

88% of the remaining respondents obtained preoperative medical evaluations.

88% with < 5 years practice and 84% > 20 years evaluated HgA1C

preoperatively.

Only 68% of the remaining respondents assessed HgA1C preoperatively.

Results A preoperative HgA1C value of <7.0 was

acceptable to 26% of respondents with <10 years practice and 31% for those >20 years.

24% of all respondents were not concerned with preoperative HgA1C values.

• Asked if elective surgery was canceled based on HgA1C levels: • 70% with <5 years practice responded

yes

• Only 55% of the remaining respondents responded that they cancelled surgeries.

Conclusions

The orthopedic management of the diabetic patient can be challenging.

Detecting neuropathy and peripheral arterial disease is important since they increase the risk of non-compliance and postoperative infections by a factor of four.

Responses to the survey have demonstrated some consistency exists however, the variability of some of the respondents has failed to demonstrate a “gold-standard” approach for the evaluation of these patients.

Conclusions

• Diabetic patients cannot be evaluated and treated similar to non-diabetic patients

• This survey has stimulated further questions for future study such as a need to set up a minimum, consisted standard for evaluating the diabetic patients who present with foot and ankle problems.