The Association of Perioperative Glycemic Control with Postoperative Surgical Site Infection Following Elective Foot Surgery in Patients with Diabetes

Category: Midfoot/Forefoot Introduction/Purpose: Diabetes mellitus has been associated with an increased risk for postoperative surgical site infection (SSI) following foot and ankle surgery; however, among patients with diabetes, the level of perioperative glycemic control may affect the risk of postoperative SSI. There remains little evidence to support a perioperative hemoglobin A1c (HbA1c) level that could serve as a threshold for a significantly increased risk of postoperative SSI following foot surgery. The primary goal of the present study was to evaluate the association of perioperative glycemic control as demonstrated by hemoglobin a1c (HbA1c) in patients with diabetes with the incidence of postoperative SSI following elective foot surgery. Our secondary objective was to calculate a threshold level of HbA1c above which the risk of postoperative SSI after foot surgery increases significantly in patients with diabetes. Methods: A national administrative database was queried for patients who underwent common elective foot surgeries, including hallux valgus corrections, hallux rigidus correction and hammertoe corrections among others. Patients who underwent more complex procedures and patients with concomitant hindfoot procedures were excluded. Patients with diabetes mellitus who had a perioperative HbA1c level recorded within 3 months of surgery were identified; and were then stratified into thirteen mutually exclusive groups based on their hemoglobin a1c in 0.5 mg/dl increments from 11.5 mg/dl. The incidence of SSI was determined by either a diagnosis or procedure for SSI within 1 year postoperatively using CPT and ICD-9 codes, and was calculated for each HbA1c patient group. A receiver operating characteristic (ROC) analysis was performed to determine an optimal threshold value of the HbA1c above which the risk of postoperative SSI was significantly increased. Results: 4,744 patients who underwent forefoot surgery with diabetes and a perioperative HbA1c recorded within 3 months of surgery in the database were included in the study. The rate of deep SSI requiring irrigation and debridement within one year postoperatively stratified by HbA1c is pictured in Figure 1, which ranged from a low of 2.5% to a high of 11.8% and was significantly correlated with increasing HbA1c levels (P < 0.0001). The results of ROC analysis determined that the inflection point of the ROC curve corresponded to an HbA1c level above 7.5 mg/dL (P < 0.0001, AUC = 0.622, spec. = 75%, sens. = 44%). Conclusion: The risk of postoperative SSI following elective foot surgery in patients with diabetes mellitus increases significantly as the perioperative HbA1c increases. ROC analysis determined that a perioperative HbA1c above 7.5 mg/dL could serve as a threshold for a significantly increased risk of postoperative SSI following elective foot surgery

Arthroscopic Tenodesis of the Long Head Biceps Tendon Using a Double Lasso-Loop Suture Anchor Configuration

Multiple different techniques exist for performing a biceps tenodesis, and the literature has yet to define a particular technique as superior with respect to outcomes. Factors as the center of various clinical and biomechanical studies include analyzing arthroscopic versus open techniques, optimal fixation sites, and the use specific fixation devices (i.e., anchor, screw). This article details an all-arthroscopic approach for proximal tenodesis of the long head of the biceps tendon (LHBT) using a 2-portal method in a minimally invasive manner. Optimal biomechanical fixation of the LHBT is achieve by using 2 suture anchors in the creation of a dual lasso-loop configuration at the level of the bicipital groove. Technical pearls with respect to optimal arthroscopic viewing, efficient identification of the LHBT and subsequent release from the bicipital groove, and appropriate use of suture anchors for lasso-loop creation are presented for review. Two specific technical advantages of this technique include 2 fixation points for the LHBT to minimize failure risk, and smaller drill holes when compared with commonly performed tenodesis screw techniques to theoretically limit humeral fracture risk

Reconstruction Guide for the Measurement of Segmental Labral Insufficiency: An Alternative Technique for Acetabular Labral Reconstruction

The acetabular labrum is a dynamic structure important for both hip stability and functional motion. Given its importance, injuries to the labrum result in significant symptomatic dysfunction caused by altered hip kinematics. Although labral repair represents the standard for symptomatic labral tears with underlying bony deformity, complex labral tears or those with significant degeneration may not be amenable to repair and require labral reconstruction. Labral reconstruction has been shown to restore intra-articular fluid pressurization to levels similar to those in the intact state, and cohort studies have increasingly demonstrated significant improvement in patient-reported outcomes at midterm follow-up. A critical component of successful labral reconstruction is accurate measurement of the graft length to restore native anatomy and kinematics of the hip. The purpose of this Technical Note is to describe a way to accurately measure graft length required for labral reconstruction

Contemporary Hip Capsular Management and Closure Using a Suture Passing Device

Before comprehensive correction of femoroacetabular impingement syndrome, capsular management must be thoughtfully considered to ensure both adequate visualization for bony resection and prevention of iatrogenic microinstability. A number of biomechanical and clinical studies have shown the importance of performing comprehensive capsular closure to restore native hip biomechanical kinematics. The purpose of this Technical Note is to describe the technique of using a suture passing device for capsular plication by a fellowship-trained hip arthroscopist at a large-volume academic center

Endoscopic Repair of Proximal Hamstring Tear With Double-Row Suture Bridge Construct

Hamstring strains account for 25% to 30% of all muscle strains and are an exceedingly common injury in the athletic population. Although proximal hamstring avulsion injuries occur less commonly than strains at the myotendinous junction, they are more severe and debilitating. Proximal hamstring avulsions do not respond well to conservative treatment and are more likely to require surgical intervention. Surgical repair of proximal hamstring avulsions is indicated when the injury fails to respond to conservative treatment, in cases of osseous avulsion with retraction, and in cases of tearing of all 3 hamstring tendons. Endoscopic repair of proximal hamstring avulsions is a promising technique to repair these injuries while reducing morbidity. We describe our technique for endoscopic proximal hamstring repair, which uses a double-row suture bridge construct to reattach the tendons to the ischial tuberosity