Dr. Jacobs has opened a very appropriate topic
for discussion. I am not aware of any papers
that specifically relate A1c to foot surgery
success elective or otherwise. The first thing
that I asked myself after considering his
question was: What is “elective” foot surgery?
Certainly, we all agree that the current trend
in “cosmetic” foot surgery is “elective.” I
think the line one draws between elective
surgery and necessary surgery can get grey.
Perhaps the terms emergent and non-emergent
surgery would be better. Non-elective cases
where one amputates an extremity to avoid
progressive life threatening complication are
clear cut but performing a surgery so that
someone can facilitate ambulation without pain
and maintain a healthy metabolic status and
lifestyle --I put in the grey area.
One of the things that I have learned since
school is that setting finite numbers on
anything usually is not advantageous in the real
world because the real world has so much
variation. Hard finite numbers are clear cut and
helpful for teaching but can get fuzzy in
reality. If anyone makes the statement that it
is wrong to do a non-emergent surgery on a
patient with a A1c of 6.8, and then I do one on
someone at 6.9-- what do you think the legal
system will do with that?
We learned that certain bunion procedures were
applicable for certain IM angles, but I can’t
tell you how many times I have broken those
rules in 23 years because of the multiple
variable that one has to consider. Years ago in
school at CCPM, one of the things that I was
lucky enough to learn is that one must weigh the
risks with the benefits in every case
individually. My training has taught me to
evaluate those risks from a medical stand point
with all those variables and my experience keeps
me learning that the “benefits” from a patients
stand point may not what I, as a podiatrist see
as the “benefit.”
So, all in all, I am not in favor of placing A1C
parameters on diabetic foot surgery. There are
standard values which internists deem good
control, moderate control, and poor control. I
believe that as podiatrists, we need to look at
A1C as only one of the factors in those myriad
of factors that go into pre-operative
evaluation. When it comes down to it, the
decision should be based on risk vs benefit
ratio, which is quite an individual assessment.
Tip Sullivan, DPM, Jackson, MS,
tsdefeet@MSfootcenter.net
