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It's Just a Toe Amputation

      The other day, one of our fourth year residents told me that the internist attending to one of our surgical patients seemed somewhat astonished at just how sick the patient actually was. The patient in question had been admitted to my service for a partial ray amputation in an effort to establish infection source control. Although relatively new to our institution, this particular internist was a seasoned veteran who had only recently worked consistently with our Foot and Ankle Surgery service. In fact, she expressed her sentiment with the statement: “..these foot surgery patients are some of the sickest people in the hospital.” Of course, with the SARS-CoV-2 pandemic still in effect, and many patients still in need of mechanical ventilation and medical intensive care, most of the patients requiring foot and ankle surgery do not qualify as the sickest in the hospital; nonetheless, many of them are plenty sick. The 66-year-old patient to whom the internist was referring was, in fact, very ill. His admitting diagnosis was diabetic foot infection with second toe gangrene (WBC count 14,000/mm3, PMNs 67%, ESR 54 mm/hr,), chronic renal failure on dialysis (creatinine 1.6 mg/dL, potassium 5.4 mmol/L, calcium 8.1 mg/dL), anemia (hemoglobin 6.8 g/100 mL, hematocrit 29%), peripheral arterial disease (ipsilateral ABI noncompressible), status post-CVA with right hemiparesis, previous myocardial infarction, previous congestive heart failure, uncontrolled diabetes mellitus (HbA1c 12%), hypertension (158/98 mm Hg), with a Charlson comorbidity index (
      • Needham DM
      • Scales DC
      • Laupacis A
      • Pronovost PJ.
      A systematic review of the Charlson comorbidity index using Canadian administrative databases: a perspective on risk adjustment in critical care research.
      ) of 12 points (≥5 points considered severely ill), and we were preparing to take him to the operating room. My thoughts were that this patient was representative of our usual diabetic foot infection patient, and one of many that we admit and who require a comprehensive team effort in order achieve a satisfactory outcome. Interestingly, when The Nationwide Inpatient Sample (2005-2010) was queried using International Classification of Diseases, 9th Revision (ICD-9) codes for a primary diagnosis of foot ulceration, it was shown that diabetic foot ulcer patients were sicker than foot ulcer patients without diabetes (Charlson comorbidity index > 3: 10.8% vs 5.8%) (
      • Hickes CW
      • Selvarajah S
      • Mathidoudakis N
      • Sherman RL
      • Hines KF
      • Black JH
      • Abularrage CJ.
      Burden of infected diabetic foot ulcers on hospital admissions and costs.
      ). So, I am not surprised to hear the internist who is comanaging my patients with me say that our patients are severely ill, and this is why interdisciplinary management of these patients is so important. I think, too, that foot and ankle surgeons should be familiar with the Charlson comorbidity index, and employ it to aid in the determination of prognosis when they admit patients to the hospital.
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      References

        • Needham DM
        • Scales DC
        • Laupacis A
        • Pronovost PJ.
        A systematic review of the Charlson comorbidity index using Canadian administrative databases: a perspective on risk adjustment in critical care research.
        J Crit Care. 2005; 20: 12-19
        • Hickes CW
        • Selvarajah S
        • Mathidoudakis N
        • Sherman RL
        • Hines KF
        • Black JH
        • Abularrage CJ.
        Burden of infected diabetic foot ulcers on hospital admissions and costs.
        Ann Vasc Surg. 2016; 33: 149-158